Most "silent" gallstones are discovered when patients are undergoing other tests, often X-rays or imaging studies for other health problems. When someone is in pain as a result of gallstones, diagnosis is important, because the symptoms of a gallstone attack are similar to those of heart attack, appendicitis, ulcers, irritable bowel syndrome, and other serious disorders.
If someone goes to a doctor with pain and tenderness in the upper right portion of the abdomen, beneath the ribs, inflammation of the gallbladder is one likely cause. Routine laboratory tests may show elevated white blood cell counts if an infection is present. Elevation of liver and pancreatic enzymes may indicate inflammation of the gallbladder or ducts. But, generally, physicians rely on several other tests to accurately diagnose gallstones.
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Ultrasound is a painless method of visualizing the shape of tissues and organs in the body using high-frequency sound waves. It requires no special preparation by the patient and does not involve radiation, so it is safe during pregnancy. Sound waves are sent toward the gallbladder with a hand-held device that a technician slides over the abdomen. The sound waves bounce off the gallbladder and other organs, and their echoes are transformed into electrical signals that produce a picture of the organs on a video screen.
If there are stones in the gallbladder, the sound waves bounce off those as well, showing their size and location. Ultrasonography is considered the best test for detecting stones in the gallbladder because it produces images with 90 to 95 percent accuracy. It can also be used to visualize obstructions of the bile ducts inside and outside the liver. Ultrasound may not be able to establish that there is not a stone in the bile duct, however. Patients who continue to have symptoms after an ultrasound is negative might next move to magnetic resonance cholangiopancreatography (MRCP).
There are virtually no complications of ultrasound, but it is less useful in patients who are obese or who have a lot of air in their intestines.
During a computerized tomography scan, computerized X-ray pictures are taken by a machine that encircles the body like a giant doughnut. Computers generate cross-sectional images of the inside of the body and provide details of the organs. CT scans are less reliable than ultrasonography for diagnosis of gallstones but do show dilated bile ducts, which may indicate the presence of a stone. Their principal use is to detect complications such as fluid around the gallbladder, gas in the gallbladder wall, gallbladder perforations, or pus-filled areas inside the gallbladder that indicate infection. CT scans are effective for assessing whether a patient needs emergency surgery to remove the gallbladder.
Magnetic resonance imaging, or MRI, is a method of taking pictures of internal organs. The patient is scanned by a tubelike machine with a powerful magnet, which generates images from inside the body. Magnetic resonance cholangiopancreatography (MRCP) is a relatively new application of MRI technology using special software. The images it produces are similar to those produced during endoscopic retrograde cholangiopancreatography (ERCP), in which the doctor gets images by having the patient swallow a flexible tube—an endoscope. But in MCRP, the risks of sedation and perforation inherent in endoscopic techniques are avoided. The test is very helpful in assessing obstruction of the bile ducts, inflammation of the gallbladder, and the anatomy of the pancreatic ducts.
However, MRCP is only a diagnostic test and cannot be used for treatment if an obstruction is found. Also, the test is not advised for patients with certain metallic implants or devices, since high magnetic fields are involved.
ERCP is both a diagnostic procedure and a treatment technique. It is the gold standard for detection of gallstones in the common bile duct, which carries secretions from both the gallbladder and the pancreas into the small intestine. ERCP is also the best method for removing gallstones from bile ducts.
During the procedure, the patient is sedated enough to relax, then swallows a long and flexible lighted tube, called an endoscope, attached to a computer and video monitor. The physician puts the tube through the stomach into the duodenum, the first portion of the small intestine. The endoscope allows the physician to see the structures inside the intestine. The endoscope is also equipped with accessories, such as tiny brushes, forceps, baskets, balloons, and stents, which can be placed into the biliary and pancreatic ducts to find, remove, or break apart stones. A dye is injected into the pancreatic and bile ducts to obtain X-ray images of ducts. With this procedure, the physician is able to see two sets of images: the endoscopic view of the intestine and the X-ray images of the bile and pancreatic ducts. Pictures and video can be taken for later review of the patient's condition and options.
Possible complications of ERCP include inflammation of the pancreas (pancreatitis) and, less commonly, infection, bleeding, and perforation of the duodenum.
Also called a nuclear scan or HIDA, cholescintigraphy is helpful in diagnosing inflammation of the gallbladder. It requires the injection of a small amount of a radioactive tracing element into the blood. The tracer is rapidly absorbed by the liver, excreted into the bile, and accumulates in the gallbladder. A series of scans with a special camera show the trace element in the gallbladder, common bile duct, and small bowel. The test is useful to see abnormal contraction or obstruction of the gallbladder.
Endoscopic ultrasonography, or EUS, is a new, low-risk procedure using high-frequency sound waves during endoscopy (a procedure in which the patient swallows a long, flexible tube that transmits an image of structures inside the digestive tract). EUS can allow the physician to study the gallbladder, pancreas, and bile ducts and accurately detect gallstones in the common bile duct. Unlike endoscopic retrograde cholangiopancreatography (ECRP), endoscopic ultrasonography is not equipped to remove stones from the common bile duct. EUS might be performed if other tests are negative but the patient continues to have symptoms and there is still a suspicion of gallstone disease.
Last reviewed on 7/23/09
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