Which test is warranted to confirm a diagnosis of acute cholecystitis in this patient?
A 48-year-old African American woman presents to theemergency department with anorexia, nausea, vomiting,and abdominal pain over the last week. The pain wasinitially in the midepigastric area but has shifted to the rightupper quadrant. This most recent episode of pain hasprogressed over the last 5 hours. She has no past medicalhistory, takes no medications, and has never been pregnant.Her temperature is 38.3 C (100.9 F), blood pressureis 135/80 mm Hg, and pulse is 105 beats/min. She isanicteric and has diminished skin turgor. Her abdomen issoft, and she has voluntary guarding and inspiratory arrestwhen palpating the right upper quadrant. Pelvic and rectalexaminations are unremarkable. Her leukocyte count is14,000/cumm with a left shift, direct bilirubin is 2.4 mg/dL,alkaline phosphatase is 250 U/L, and the remainder of herliver function tests, electrolytes, and pancreatic enzymes arewithin normal limits.
A. CT of the abdomen and pelvis with intravenous contrast B. Transabdominal ultrasonography (TUS) C. Plain abdominal x-rays (KUB) D. Cholescintigraphy with intravenous injection oftechnetium-99m-labeled hepatoiminodiaceticacid (HIDA)
Cholescintigraphy with intravenous injection oftechnetium-99m-labeled hepatoiminodiaceticacid (hida)-key concept/objective: to reinforce that hida cholescintigraphy is the test of choice for confi rmation of a clinical diagnosis of acute cholecystitis tus is the diagnostic procedure of choice for a patientwith suspected gallstones and acute cholecystitis. ameta-analysis revealed that ultrasonography had asensitivity of 88 to 90% and a specifi city of 97 to 98% forthe diagnosis of gallstones greater than 2 mm in size.gallbladder ultrasonography should ideally be preceded byan 8-hour fast because gallstones are best visualized in adistended, bile-fi lled gallbladder. in addition to detectinggallstones, ultrasonography can be used to identify othercauses of right upper quadrant pain, such as hepatic abscessor malignancy, and it may reveal biliary duct obstruction.however, specifi c evidence of acute cholecystitis (i.e., thepresence of pericholecystic fl uid, edema of the gallbladderwall, or both) is found infrequently. occasionally, aso-called sonographic murphy sign is elicited when theultrasound probe is positioned below the right costalmargin. cholescintigraphy is the best method of confi rmingthe clinical diagnosis of acute cholecystitis. this procedure,which takes only 60 to 90 minutes, involves the intravenousinjection of technetium-99m-labeled hida (lidofenin),which is selectively excreted into the biliary tree and entersthe gallbladder. in the presence of acute cholecystitis,radiolabeled material enters the common bile duct andduodenum but not the gallbladder. a meta-analysissuggests that radionuclide scanning is the most accuratemethod of diagnosing acute cholecystitis. occasionally, thescan gives false positive results in patients who havealcoholic liver disease, in those who are fasting, or in thosereceiving total parenteral nutrition; however, false negativeresults are rare. radionuclide scanning may not be usefulfor patients with deep jaundice, because the labeled agentfails to enter the biliary tree.