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When upper right abdominal pain suggests gallbladder disease or obstruction of the common bile duct, the following blood tests may be performed:
Bilirubin and liver enzyme alkaline phosphatase (AP) are often elevated in cases of gallstones in the gallbladder and common bile duct (1) Aspartate aminotransferase (AST) and alanin aminotransferase (ALT) are often elevated in cases of gallstones in the common bile duct (1) White blood cells are usually elevated in the inflamed gallbladder or common bile duct (mostly due to gallstones) (1) Tumor marker CA 19-9 may be significantly elevated in gallbladder or common bile duct cancer, which are rare before 60 years of age (2)
NOTE. Gallstones in a non-inflamed gallbladder and early carcinoma of the gallbladder or bile duct may be present without any detectable changes in the blood.
Gallbladder Ultrasound
Ultrasonography is usually the first imaging investigation undertaken in suspected gallbladder disorder. Liver and pancreas are also usually investigated at the same time. Ultrasound can detect (1):
Gallstones in the gallbladder (but not reliably in bile ducts) as small as 2 mm Thickened gallbladder wall in a gallbladder inflammation with gallstones (not reliable if no stones) Cancer mass in the gallbladder can be detected in 50-75% of cases (3)
Combination of a normal ultrasound result and normal bilirubin and liver enzymes in the blood quite reliably excludes the possibility of stones in the common bile duct (1). Ultrasound of the gallbladder can be safely done in pregnancy but can not be done in severe cases of skin disease or in non-cooperative patient. In obese patients, obtained images may not be sufficiently clear to confirm a diagnosis. Ultrasound can not detect functional gallbladder or bile duct disorders, such as sphincter of Oddi dysfunction. Negative result of gallbladder ultrasound (no abnormalities detected) does not 100% exclude any gallbladder disorder.
ultrasound waves when they penetrate the abdominal wall. The doctor will guide the probe over your belly skin and observe the image of the gallbladder, liver and pancreas on the monitor. The procedure usually lasts about 15 minutes, is usually not painful and sedation or anesthesia is not necessary. You will be able to discuss the results immediately after the procedure and you will get a written report within a few days.
Complications
There is no known harmful effect of ultrasound waves. Transmission of infection from patient to patient through the use of a common ultrasound probe is rare.
Stones in the gallbladder (gallbladder is not completely filled with the dye) Obstruction in the cystic duct (dye does not enter the gallbladder at all) Obstruction of the common bile duct (dye is not excreted into the duodenum)
Bile leakage, if there is a perforation in the gallbladder or bile ducts (dye outside of biliary system) Biliary dyskinesia (improper painful contraction of the gallbladder containing no gallstones) may be detected by CCK-HIDA scan (5)
False positive results (gallbladder or bile ducts do not fill with contrast, even if there is no gallstones or obstruction) may occur in liver disease (alcoholic cirrhosis) or in those fasting or receiving all nutrients through an intravenous infusion (1). Normal HIDA scan does not exclude disorders of bile duct function (biliary dyskinesia, sphincter of Oddi dysfunction). The whole procedure takes about two hours. HIDA scan should not be done in pregnancy and in a known iodine allergy. Breast milk should be discarded for 48 hours after the test.
Complications
Side effects of HIDA scan are rare and include allergy to HIDA, pain during CCK injection, chills, nausea and rash. Cholescintigraphy for acute cholecystitis has sensitivity of 97%, Specificity of 94%. Imino-Diacetic Acid is rarely used currently, as better contrast materials have replaced it, but the term HIDA remains.
ERCP
ERCP (Endoscopic Retrograde Cholangio-Pancreatography) is a combination of endoscopic and X-ray investigation of the biliary tract; it can be performed when obstruction of cystic, common bile or pancreatic duct is suspected.
Complications
Possible complications of ERCP include pancreatitis (quite often but usually mild), perforation of the esophagus, stomach, duodenum or bile duct, bleeding, infection and side effects of sedation (6). Some complications may be life threatening, so detailed discussion about the benefits and risks with your doctor is recommended.
MRCP
MRCP (Magnetic Resonance Cholangio-Pancreatography) is an investigation of the cystic, common hepatic and pancreatic duct using MRI (magnetic resonance imaging). It is done for the same purposes like ERCP (see above) and can provide results of the same accuracy (7). The downside of MRCP is that unlike in ERCP, no treatment can be performed during the procedure.
Biliary sludge (condensed bile) or gallstones in the cystic or common bile duct Cancer in the gallbladder or bile ducts, or to evaluate its spread Complications, like rupture of the gallbladder or bile duct, or porcelain gallbladder Air in the gallbladder (in gallbladder infection)
X-Ray of Abdomen
X-ray of the abdomen, usually done for other purposes, can show big calcified gallstones in the gallbladder. In gallbladder infection, the air in the gallbladder can be sometimes seen.