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Make the Diagnosis: Acute Cholecystitis

No single clinical finding, or known combination of clinical history and physical examination findings, efficiently establishes a diagnosis of acute cholecystitis. Thus, clinicians must rely on their clinical gestalt. Bedside ultrasonography requires additional study, and clinicians must receive proper training, followed by demonstration of their proficiency.

Prior Probability

Approximately 5% of emergency department patients with abdominal pain have cholecystitis. Women and Native Americans have a higher risk of cholecystitis. Patients with increased risk of cholecystitis include those with chronic hemolytic disease (eg, sickle cell disease) or recent rapid weight loss.

Population for Whom Acute Cholecystitis Should Be Considered

Patients with abdominal pain.

Detecting the Likelihood of Acute Cholecystitis

Table 12-4Likelihood Ratios for Acute Cholecysitis

Reference Standard Tests

Surgical findings combined with pathology or clinical follow-up in patients who do not undergo surgery remain the reference standard for acute cholecystitis.

Original Article: Does This Patient Have Acute Cholecystitis?

Clinical Scenario

A 72-year-old woman with poorly controlled diabetes, coronary artery disease, and hypertension presents to the emergency department complaining of nausea and vomiting. As an emergency department resident, you elicit the history that the patient felt well until 24 hours ago, when she developed anorexia, followed rapidly by bilious emesis. She describes mild upper abdominal discomfort but is unable to further localize the pain. There have been no abnormal bowel movements, gastrointestinal bleeding, or chest pain.

The patient is febrile (39°C) and appears uncomfortable. Her lungs are clear, and cardiac examination reveals only a fourth heart sound. There is moderate epigastric tenderness and guarding throughout the abdomen, but no rigidity. Pelvic and rectal examination results are unremarkable. Electrocardiography shows no changes suggestive of ischemia. Laboratory testing shows a leukocytosis level of 17 500 × 103/μL, serum transaminase levels twice the upper limit of normal, and a total bilirubin level of 3.2 mg/dL. In considering the differential diagnosis for the patient's presenting complaint and laboratory results, you wonder whether the suspicion of acute cholecystitis is high enough to warrant further testing.

Why ...

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