Gallbladder Disease

Henry R. Kramer, MD

Joseph S. Wallins, MD, MPH

A 40-year-old woman with hypertension and obesity presents to the ED with three episodes of upper abdominal pain and mild nausea of increasing severity and length over 2 weeks. On examination, she is afebrile and her vital signs are within normal limits. She has mild epigastric tenderness but is not jaundiced and has a negative Murphy’s sign. Laboratory studies are unremarkable except for a left shift on her complete blood count with differential. She receives simethicone and viscous lidocaine, which partially improve her symptoms. You attribute her symptoms to mild gastritis and consider discharging her with primary care follow-up. However, you also weigh the potential diagnosis of acute cholecystitis and further imaging.

Are findings from a history and physical examination (H&P) sufficient for diagnosing or excluding acute cholecystitis?

Findings from the H&P alone are insufficient for diagnosing acute cholecystitis.

A 2017 systematic review and meta-analysis investigated the predictive power of various aspects of the diagnostic workup for acute cholecystitis.¹ The authors reviewed publications from 1965 to 2016 of patients presenting to the ED with a chief complaint of abdominal pain. Studies had to include findings of H&P, laboratory tests, or of ultrasound as well as a reference standard (either pathology or biliary
scintigraphy). Three prospective observational studies with H&P information met inclusion criteria (Table 8.1). Among these, acute cholecystitis prevalence was 7% to 64%. Main outcomes included sensitivity, specificity, and LRs (likelihood ratios).

TABLE 8.1 Summary of Test Characteristics of Diagnostic Findings

Symptom/Sign	Sensitivity	Specificity	+LR	−LR
Fever	31%-62%	37%-74%	0.71-1.24	0.76-1.49
Jaundice	11%-14%	86%-99%	0.80-13.81	0.87-1.03
Right upper quadrant pain	56%-93%	0%-96%	0.92-14.02	0.46-7.86
Murphy’s sign	53%-71%	95%-97%	11.48-21.31	0.32-0.50

Lack of fever, jaundice, or Murphy’s sign were not reliable to rule out acute cholecystitis, as the sensitivity of these signs was generally low. Notably, jaundice had very good specificity. The high specificity of Murphy’s sign is tempered by the fact that it is based on a single study in which only 10.1% of the population had acute cholecystitis, and therefore false negatives were rare. Given small sample sizes and wide variations in acute cholecystitis prevalence, all of these studies are likely subject to selection bias. As a result, the diagnostic utility of several of these findings are likely overestimated.

EASL guidelines note that characteristic clinical signs and symptoms should raise a strong suspicion for acute cholecystitis but do not make recommendations for ruling out acute cholecystitis by H&P alone.²

You order a right upper quadrant ultrasound (RUQ US), which is reassuringly normal, and discharge her home with PCP follow-up.

The ED pages you for another admission, a 41-year-old woman with hypertension, hyperlipidemia, and obesity who presented with sharp right upper quadrant pain that began after eating a fatty meal. Her vital signs are stable. Laboratory studies, including transaminases
and lipase, are within normal limits. At the time of your evaluation about 2 hours after her arrival, she reports nearly complete resolution of symptoms. She notes her symptoms lasted about 3 hours and came in waves of pain. She reports one prior episode, which occurred several weeks earlier. You consider testing with a RUQ US to evaluate for cholelithiasis.

How accurate is RUQ US for diagnosing cholelithiasis?

RUQ US is adequately sensitive and very specific at diagnosing cholelithiasis.

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