Clinical Skills Pearl Vol 2 (#10): Gallbladder - Part 2

Gallbladder Part B...

Dr. Maynard Luterman

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What is Murphy's sign? What is the best set of lab tests to order to diagnose cholecytitis? What's better CT or Ultrasound to make the diagnosis?

Murphy sign, which is specific but not sensitive for cholecystitis, is described as tenderness and an inspiratory pause elicited during palpation of the RUQ. A retrospective study by Singer attempted to determine a set of clinical and laboratory parameters that could be used to predict the outcome of hepatobiliary scintigraphy (HBS) in all patients with suspected acute cholecystitis. The results of the study showed that, in 40 patients with pathologically confirmed acute cholecystitis, fever and leukocytosis were absent at the time of presentation in 36 (90%) and 16 (40%) of the patients, respectively. The study also found that no combination of laboratory or clinical values was useful in identifying patients at high risk for a positive HBS finding. And by the way an elevated alkaline phosphatase level is observed in 25% of patients with cholecystitis.

Ultrasonography provides greater than 95% sensitivity and specificity for the diagnosis of gallstones more than 2 mm in diameter. Ultrasonography is 90-95% sensitive for cholecystitis and is 78-80% specific.Studies indicate that emergency clinicians require minimal training in order to use right upper quadrant ultrasonography in their practice. The sensitivity and specificity of CT scan and MRI for predicting acute cholecystitis have been reported to be greater than 95%. Spiral CT scan and MRI (unlike endoscopic retrograde cholangiopancreatography [ERCP]) have the advantage of being noninvasive, but they have no therapeutic potential and are most appropriate in cases where stones are unlikely.