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Acute cholecystitis - Diagnosis
Last reviewed: 03.07.2025
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Examination plan for suspected acute cholecystitis
The diagnosis of acute cholecystitis should be suspected in the presence of typical pain (biliary colic) in combination with the results of physical, laboratory and instrumental examination methods (ultrasound, FGDS, X-ray examination).
Laboratory diagnostics of acute cholecystitis
Mandatory laboratory tests
- Clinical blood test: leukocytosis, moderate shift in the leukocyte formula to the left, increased ESR.
- Serum glucose.
- Total protein and protein fractions.
- Serum cholesterol.
- Bilirubin and its fractions: in acute cholecystitis a slight increase is possible.
- Aspartate aminotransferase (AST), alanine aminotransferase (ALT): activity may be increased.
- Gamma-Glutamyl transpeptidase: its activity may be increased in the context of cholestasis syndrome in combination with increased alkaline phosphatase (ALP) activity.
- Alkaline phosphatase.
- Serum amylase: a significant increase of 2 times or more is important when conducting a differential diagnosis and is most often associated with pancreatitis due to a stone becoming trapped in the large duodenal papilla.
- General urine analysis.
Instrumental diagnostics of acute cholecystitis
Mandatory instrumental studies
- Ultrasound of abdominal organs: against the background of cholelithiasis, stones, thickening of the gallbladder wall (more than 3 mm), doubling of the gallbladder wall contour, accumulation of fluid around it are detected. Parietal inhomogeneity associated with inflammatory changes in the mucous membrane, deposition of fibrin, inflammatory detritus is possible. In case of empyema of the gallbladder, structures of medium echogenicity without acoustic shadow (pus) are detected in its cavity.
- FEGDS is performed to exclude peptic ulcer disease as a possible cause of pain syndrome; examination of the large duodenal papilla is necessary.
- X-ray examination of the chest organs to exclude pathology of the lungs and pleura.
Additional research methods
- Computed tomography as an alternative to ultrasound.
- MRI of the biliary tract.
- Endoscopic retrograde cholangiopancreatography (ERCP) to exclude choledocholithiasis, as well as if there is a suspicion of a tumor nature of the biliary tract lesion.
Differential diagnosis
Acute cholangitis is clinically characterized by Charcot's triad (pain in the upper right quadrant of the abdomen, fever, jaundice) or Raynaud's pentad (Charcot's triad + arterial hypotension and impaired consciousness). ALT and AST activity can reach 1000 U/L.
Acute appendicitis, especially with a high position of the cecum.
Acute pancreatitis: characterized by pain in the epigastric region radiating to the back, nausea, vomiting, increased activity of amylase and lipase in the blood.
Right-sided pyelonephritis: pain on palpation of the right costovertebral angle, signs of urinary tract infection.
Peptic ulcer of the stomach and duodenum: pain in the right hypochondrium or epigastric region; an ulcer complicated by perforation may resemble acute cholecystitis in its clinical manifestations.
Other diseases: lung and pleural pathology, acute viral hepatitis, acute alcoholic hepatitis, lower diaphragmatic myocardial infarction, ischemia in the mesenteric vascular basin, gonococcal perihepatitis, liver abscess or tumor.
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