Applied Hepatobiliary Scintigraphy in Acute Cholecystitis

Kenneth M. Montini, MD; Mark Tulchinsky, MD, FACNM


Appl Radiol. 2015;44(5) 

In This Article


Acute cholecystitis (AC) is severe inflammation of the gallbladder (GB) with intense abdominal pain dominating the clinical presentation. AC is divided into acute calculous cholecystitis (ACC) and acute acalculous cholecystitis (AAC). ACC represents over 90% of all AC cases,[1] initiated by a sentinel event of an obstructing gallstone in the gallbladder neck or cystic duct. The pathophysiology of AAC is multifactorial and not completely understood, except that an obstructing gallstone is absent. In both types, bile stasis in the GB is the centerpiece, leading to release of bile salts with detergent action that injures the GB. This precipitates release of inflammatory mediators and secretion of an inflammatory transudate by the GB wall that, in turn, elevates the pressure and causes GB distention – the key reason for the abdominal colic pain.[2] As edema and inflammation continue, ischemia and necrosis extend to include the entire thickness of the GB wall, creating a fertile ground for bacterial infection, which is found in 20-75% of bile from cholecystectomy specimens.[3–5] AC is often superimposed on chronic cholecystitis (CC), particularly in ACC cases.

ACC usually begins as post-prandial intermittent biliary type abdominal pain (biliary colic) that worsens over time. Symptoms progress to a generalized right upper quadrant abdominal pain with a palpable and painful GB that is commonly made worse with inspiration or cough to the point that it may provoke arrest of inspiratory effort (clinical Murphy's sign). Laboratory values usually demonstrate leukocytosis, mild hyperbilirubinemia, and modest elevation of serum aminotransferases. However, it is widely recognized that none of the clinical manifestations, individually or in combination, provide sufficient certainty for making the diagnosis or for proceeding with timely management decisions.[6,7] Diagnosis based on clinical and laboratory findings alone results in 16–20% error rates.[8,9] Given the evidence that early laparoscopic cholecystectomy offers outcome benefits,[10–12] diagnostic imaging should be employed as soon as clinicians suspect AC.[7]