Cholecystitis Diagnostic Test

Author: Michelle Lin, MD
Updated: 3/18/2011

Cholecystitis - Diagnostic tests

JAMA Clinical Rational Examination Series: Meta-analysis of 17 studies which evaluated role of history, physical, and lab tests in working up cholecystitis

History and Physical Exam

Finding (+) LR (-) LR
Anorexia 1.1-1.7 0.5-0.9
Emesis 1.1-2.1 0.3-0.9
Fever (>35C) 1.0-2.3 0.8-1.0
Guarding 1.1-2.8 0.5-1.0
Murphy sign 0.8-8.6 0.2-1.0
Nausea 1.0-1.2 0.6-1.0
Rebound 0.6-1.7 0.8-1.4
Rectal tenderness 0.5-2.3 1.0-1.3
Rigidity 0.3-0.7 1.0-1.2
RUQ mass 0.5-1.2 0.9-1.1
RUQ pain 0.9-2.5 0.3-1.6
RUQ tenderness 1.0-2.5 0.2-1.1

Laboratory tests

Finding (+) LR (-) LR
Alkaline phosphatase (AP) >120 U/L 0.4-1.6 0.6-2.0
ALT >40 U/L or AST >48 U/L 0.5-2.0 0.8-1.4
Total bilirubin >2 mg/dL 0.7-2.3 0.7-1.2
All 3 elevated: Total bili, AST, AP 1.0-2.8 0.8-0.9
Any 1 elevated: Total bili, AST, AP 1.0-1.5 0.6-0.9
WBC >10K 1.2-1.9 0.5-1.8
WBC >10K and fever (>35°C) 0.9-2.8 0.8-1.0
WBC ≤10K and no fever (≤35°C) 0.4-0.7 1.4-1.8

Use the Fagan nomogram

Note:

  • All likelihood ratios (LR) cross or almost cross 1.0.
  • This is no history, physical exam, or lab test that would comfortably allow you to rule- out or rule-in cholecystitis.
  • Murphy’s sign is perhaps the most useful sign because the +LR has been shown to be as high as 8.6.

Bottom line

Have a low threshold to perform a RUQ abdominal bedside ultrasonography for patients with upper abdominal pain or a fever from an unclear source (especially elder patients). Look for indirect signs of cholecystitis:

  • Murphy sign
  • Distended gallbladder
  • Pericholecystic fluid
  • Thickened gallbladder wall
  • Gallstones

Fagan nomogram

Fagan nomogram

Draw a connecting your pre-test probability and your likelihood ratio. This provides you with your post-test probability.

References

  • Trowbridge RL et al. Does this patient have acute cholecystitis? JAMA. 2003, 289(1): 80-6. [PubMed]