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von Felix C.

Describe teh approach.

Initial evaluation: laboratory studies and RUQ ultrasound (consider biliary POCUS if available)
If ultrasound findings are inconclusive, consider HIDA scan, abdominal MRI, or abdominal CT to confirm the diagnosis.
Assess for choledocholithiasis
Once the diagnosis is confirmed, determine the severity

Diagnostic criteria (table).

List lab studies to support the clinical diagnosis.

CBC: Leukocytosis is most common, but WBC count may be normal in up to 40% of patients.
CRP: elevated
Blood cultures: should be obtained, especially in patients with grade III acute cholecystitis
Bile cultures: should be obtained in patients undergoing laparoscopic cholecystectomy or gallbladder drainage

List tests to assess the severity of disease.

Blood gas analysis: PaO2/FiO2 ratio < 300 in severely ill patients
BMP: AKI, electrolyte derangements may be present in patients with severe disease
PT/INR: coagulopathy in patients with severe disease

List tests to rule out related biliary comorbidities.

should be obtained in all patients with suspected cholecystitis

LFTs [14][16]
- Mild elevations in AST and ALT are possible in acute cholecystitis.
- Signs of cholestasis (↑ bilirubin, ↑ ALP, ↑ GGT) are uncommon in cholecystitis; if present consider biliary obstruction (see ''Diagnosis of choledocholithiasis'' and ''Cholangitis'')
Lipase, amylase
- Mild elevation of amylase may be seen in acute cholecystitis [17]
- Elevation of lipase or amylase ≥ 3 times the normal is suggestive of acute biliary pancreatitis.

Describe the RUQ transabdominal ultrasound.

Indications: preferred initial imaging modality in suspected acute cholecystitis [9][10]
Characteristic findings [10]
- Gallbladder wall thickening > 3–5 mm [7]
- Gallbladder distention (8–10 x 4 cm) [10][18]
- Gallbladder wall edema (double-wall sign): The innermost and outermost layers appear hyperechoic; edematous tissue appears as a hypoechoic layer in between.
- Sonographic Murphy sign: Tenderness upon compression of the gallbladder with the ultrasound transducer
- Pericholecystic free fluid
- Presence of gallstones and/or biliary sludge
- In emphysematous cholecystitis, mural air appears as hyperechoic shadows within the gallbladder wall.
Important consideration: The CBD should be assessed for choledocholithiasis (see ''Diagnosis of choledocholithiasis” for further details).

Describe the cholescintigraphy.

Commonly referred to as hepatobiliary iminodiacetic acid scintigraphy or a HIDA scan.

Indications: preferred confirmatory test for suspected uncomplicated acute cholecystitis if ultrasound findings are inconclusive
Advantages
- High sensitivity (96%) and specificity (90%); considered the gold standard test to diagnose acute cholecystitis
- Can differentiate between acute and chronic cholecystitis
Characteristic findings
- Normal: gallbladder visualized within 4 hours of administration of radioactive tracer
- Acute cholecystitis: gallbladder is not visualized within 4 hours

Describe the MRI abdomen without and with IV contrast.

Indications
- Alternative to CT or HIDA scan in suspected acute cholecystitis with inconclusive ultrasound findings
- Either of the following in patients with contraindications to CT:
  - Suspected complications of cholecystitis
  - Clinical diagnosis of acute cholecystitis unclear
- Suspected choledocholithiasis (MRCP)
Characteristic findings: Similar to ultrasound findings

Describe the CT abdomen without and with IV contrast.

Indications
- An alternative to MRI or HIDA scan in suspected acute cholecystitis with inconclusive ultrasound findings [9][21]
- Suspected emphysematous cholecystitis [10]
- Suspected complications of acute cholecystitis [7][10]
- Clinical diagnosis of acute cholecystitis unclear [2][7]
Characteristic findings: similar to those on ultrasound and MRI

List DDs for RUQ with fever.

List DDs for RUQ without fever.

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Diagnostics