Grossman S J, Joyce J M
Nuclear Medicine, Western Pennsylvania Hospital, Pittsburgh.
Emerg Med Clin North Am. 1991 Nov;9(4):853-74.
A patient's clinical presentation should prompt an imaging evaluation that is cost effective for accurate diagnosis and leads to appropriate treatment of gallbladder inflammatory disease. In the setting of recurrent biliary colic, chronic cholecystitis is the main diagnostic consideration. Imaging hallmarks include gallstones and gallbladder wall thickening for which ultrasonography is uniquely suited. When a patient appears more toxic with right upper quadrant pain, one would more strongly consider acute cholecystitis. Because the morbidity and mortality of acute cholecystitis are reduced with early cholecystectomy, it is incumbent upon the clinician to make the diagnosis promptly and accurately. Hepatobiliary imaging with an IDA derivative has proven superior sensitivity, specificity, and accuracy for this condition. The examination has validity because it detects cystic duct obstruction, the primary pathophysiologic event responsible for most acute calculous and acalculous disease. Utilizing morphine augmentation when delayed filling is present has reduced the total examination time to less than 2 hours. Use of ancillary findings including gallbladder hyperemia and the "hot rim" sign help predict complicated cholecystitis, enabling more urgent intervention. The bulk of data presented in this review supports hepatobiliary imaging as the modality of first choice in the evaluation of acute cholecystitis. In the intensive care setting, where acalculous disease and atypical presentations are common, hepatobiliary imaging also plays a major role. We recommend liberal use of Sincalide pretreatment, morphine augmentation, and delayed images to promote gallbladder filling. If the gallbladder is nonvisualizing despite these maneuvers, sonography is often added as an aid to detect secondary signs of acute cholecystitis and help confirm the diagnosis with greater certainty prior to high-risk surgery.
患者的临床表现应促使进行具有成本效益的影像学评估，以实现准确诊断并指导对胆囊炎性疾病的恰当治疗。在复发性胆绞痛的情况下，主要诊断考虑为慢性胆囊炎。影像学特征包括胆结石和胆囊壁增厚，超声检查对此具有独特的适用性。当患者出现右上腹疼痛且中毒症状更明显时，则应更强烈地考虑急性胆囊炎。由于早期胆囊切除术可降低急性胆囊炎的发病率和死亡率，临床医生有责任迅速准确地做出诊断。对于这种情况，使用IDA衍生物进行肝胆成像已被证明具有更高的敏感性、特异性和准确性。该检查是有效的，因为它能检测出胆囊管梗阻，而胆囊管梗阻是大多数急性结石性和非结石性疾病的主要病理生理事件。当出现延迟显影时使用吗啡增强法可将总检查时间缩短至不到2小时。利用包括胆囊充血和“热边缘”征在内的辅助表现有助于预测复杂性胆囊炎，从而能够进行更紧急的干预。本综述中呈现的大量数据支持将肝胆成像作为评估急性胆囊炎的首选方式。在重症监护环境中，非结石性疾病和非典型表现很常见，肝胆成像也发挥着重要作用。我们建议广泛使用辛卡利特预处理、吗啡增强法和延迟图像以促进胆囊显影。如果尽管采取了这些措施胆囊仍未显影，通常会加做超声检查，以帮助检测急性胆囊炎的次要征象，并在进行高风险手术之前更确定地帮助确诊。
