How Gallbladder Disease Is Diagnosed

Ultrasound Is the Key Diagnostic Test

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gallbladder disease diagnosis
© Verywell, 2018 

The term "gallbladder disease" encompasses medical conditions that affect the gallbladder, like gallstones, acute or chronic cholecystitis (gallbladder inflammation resulting from gallstones), and gallbladder cancer.

While symptom review, physical examination, and blood work all play a role in the diagnosis of gallbladder disease, obtaining an abdominal ultrasound (and possibly other imaging tests) is the most important aspect of the diagnostic process.

Medical History

If your doctor suspects gallbladder disease, he will inquire about your symptoms and whether you or any family members have ever had any gallbladder problems.

Examples of potential questions include:

  • Are you experiencing abdominal pain, and if so where? Pain in the upper right or upper middle side of the abdomen is suggestive of a gallbladder problem.
  • Is the abdominal pain associated with eating? With gallstones, an intense, dull pain may occur one or more hours after eating fatty foods and lasts at least thirty minutes.
  • Have you ever experienced this abdominal pain before? Episodes of gallstone pain generally get worse over time and may lead to complications like an infection of the bile ducts or inflammation of the pancreas.
  • Are you experiencing any other symptoms besides pain, like fevers, nausea, vomiting, or weight loss? These associated symptoms can help a doctor pinpoint whether gallbladder disease and other possible complications are present.

Physical Examination

Next, your doctor will perform a physical examination, focusing first on your vital signs. People with acute cholecystitis may have a fever and a high heart rate.

The presence of jaundice, signaled by yellowing of the whites of the eyes and/or skin, is worrisome for a gallstone complication called choledocholithiasis in which a gallstone leaves the gallbladder and blocks the main bile duct (where bile flows into the intestines).

During an abdominal exam, your doctor will note whether or not a finding called "guarding" is present. A person with acute cholecystitis may "guard" or place their hands on the right upper side of their abdomen where the gallbladder is located during the physical exam. 

Lastly, during the physical exam, your doctor will perform a maneuver called "Murphy's sign." With this test a person is asked to take a deep breath in, allowing the gallbladder to move down so the doctor can press on it. If a person experiences significant pain during this test (called a positive "Murphy sign"), it suggests he or she may have gallbladder disease.

Labs

People with gallbladder disease often have an elevated white blood cell count. Your white blood cells are your infection-fighting cells and when elevated signal some sort of inflammation or infection in the body. In addition to an elevated white blood cell count, a person may have elevated liver function tests.

While there may be a mild increase in liver enzymes, an elevation in the bilirubin level (also part of the liver function blood test) suggests a possible complication of gallbladder disease (for example, if a gallstone is impacted in the bile duct and/or there is an infection of the bile duct).

If your doctor suspects gallbladder cancer based on imaging tests (for example, ultrasound, CT scan, or MRI), he may order tumor marker blood tests, like CEA or CA 19-9. These markers, however, may also be elevated in the presence of other cancers, so they aren't a direct indication of gallbladder cancer. More often than not, these tumor markers are used to follow a person's response to cancer treatment (if elevated initially).

Imaging

While a medical history, physical examination, and labs may support a diagnosis of gallbladder disease, imaging is needed to confirm a diagnosis. In other words, the gallbladder needs to be visualized, and this is most often done with an ultrasound.

Ultrasound

An ultrasound is a quick and usually painless imaging test that uses sound waves to produce an image of the gallbladder. In addition to gallstones, gallbladder wall thickening or swelling and gallbladder polyps or masses may be seen.

During an ultrasound, the technician can also perform a "sonographic Murphy's sign." During this maneuver, the ultrasound transducer is pressed on the gallbladder while the patient takes a deep breath. If positive, the person will experience pain when the gallbladder is pressed down upon.

HIDA Scan

If a diagnosis of gallbladder disease is not certain after an ultrasound, a HIDA scan may be performed. This test allows for the visualization of bile movement through the bile duct system. During a HIDA scan, a radioactive tracer is injected through a person's vein. This substance is taken up by liver cells and removed into bile.

If the gallbladder cannot be visualized the test is "positive" because it means that there is some sort of obstruction (often from a gallstone, but possibly from a tumor) in the cystic duct, which is a tube that transports bile from the gallbladder to the common bile duct.

CT Scan

A CT scan of your abdomen may also reveal signs of gallbladder disease, like gallbladder wall swelling or fat stranding. It can be particularly useful for diagnosing rare, life-threatening complications of acute cholecystitis, like gallbladder perforation (when a hole develops in the gallbladder) or emphysematous cholecystitis (in which there is an infection of the gallbladder wall from gas-forming bacteria).

Magnetic Resonance Cholangiopancreatography (MRCP)

This non-invasive imaging test allows a doctor to evaluate the bile ducts both inside and outside the liver. It may be used to diagnose a stone in the common bile duct (a condition called choledocholithiasis).

Endoscopic Retrograde Cholangiopancreatography (ERCP)

An ERCP is both a diagnostic and potentially therapeutic test. During an ERCP, a gastroenterologist (a doctor who specializes in digestive system diseases) will place a thin, flexible camera called an endoscope into a person's mouth, down the esophagus, past the stomach, and into the small intestine.

A person is sedated during this procedure so there is no discomfort. Then, through the endoscope, a small tube is passed into the common bile duct. Contrast dye is injected into this small tube to light up the bile duct system, which can be seen through x-rays.

From an ERCP, a gallstone that is blocking the bile ducts can be visualized and removed at the same time. Narrowing of the bile ducts can also be seen with an ERCP, and a stent can be placed to keep the duct open. Lastly, during an ERCP, the doctor can take a tissue sample (called a biopsy) of any suspicious polyps or masses.

Differential Diagnosis

While it's sensible to suspect gallbladder disease if a person has pain in the right upper portion of their abdomen, other etiologies (mostly liver problems) must be considered. This is because your liver is also located on the upper right side of your abdomen and is connected to the gallbladder by a series of biliary ducts.

Examples of liver problems that may cause pain in the right upper side of the abdomen include:

  • Hepatitis (for example, viral hepatitis): Besides pain, other symptoms of hepatitis may include jaundice, clay-colored stools, and dark urine.
  • Fitz-Hugh-Curtis Syndrome (perihepatitis): This disease refers to inflammation of the liver coating that occurs in women who experience pelvic inflammatory disease.
  • Liver abscess: People with diabetes, who have undergone a liver transplant, or who have underlying liver, gallbladder, or pancreatic disease are most at risk of developing an abscess.
  • Portal vein thrombosis: This disease refers to a blood clot in the portal vein, which is the blood vessel that carries blood to the liver from the intestines.
  • Budd-Chiari syndrome: This is a very rare syndrome that occurs when there is obstruction of the veins that drain the liver.

Other than pain in the right upper part of the abdomen, a person with gallbladder disease may experience pain in the upper middle region of the abdomen (called epigastric pain).

Other potential causes of epigastric pain include:

  • Gastroesophageal reflux disease (GERD): In addition to epigastric pain, a person with GERD may note heartburn and problems swallowing.
  • Peptic ulcer disease: This condition describes sores that develop on the lining of the stomach or first part of the small intestines. Burning abdominal pain is the most common symptom.
  • Gastritis: This conditions refers to inflammation of the stomach lining and may be caused by a number of different factors like alcohol, nonsteroidal anti-inflammatories, or a virus.
  • Pancreatitis: People with pancreatitis often experience sudden, severe epigastric or left-sided pain that radiates to the back and is associated with nausea and vomiting.
  • Heart Attack (myocardial infarction): Epigastric pain may be the first symptom of a heart attack. A person may also have shortness of breath and cardiovascular risk factors.
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