Which of the following statements about the diagnosis of acute calculous cholecystitis are true?

A. Pain is so frequent that its absence almost precludes the diagnosis.

D. Cholescintigraphy is the definitive diagnostic test.

DISCUSSION: The presence of pain is the sine qua non of acute calculous cholecystitis. Chronic cholecystitis associated with cholelithiasis may develop in the absence of pain, and in critically ill patients pain may not be a prominent feature of acute acalculous cholecystitis. Only about 10% of patients with acute cholecystitis are jaundiced. Although an occasional patient may have concomitant bile duct obstruction, the jaundice associated with acute cholecystitis is probably due to absorption of bile pigments from the diseased gallbladder. The presence of jaundice in a patient with right-side upper quadrant pain should also suggest the possibility of acute cholangitis secondary to bile duct obstruction. Ultrasonography is very accurate in the detection of gallstones, but stones may be present in the absence of acute cholecystitis. Thickening of the gallbladder wall and a collection of fluid around the gallbladder are ultrasonographic findings in some patients with acute cholecystitis, but they are not always present and are not specific. Ultrasonography may be useful when the diagnosis is obscure because other conditions in the liver, pancreas, and kidney can be detected; however, it is not the definitive test for acute cholecystitis. Cholescintigraphy is specific for the diagnosis of acute calculous cholecystitis (accuracy over 95% in experienced hands). The rapidity, simplicity, and accuracy make cholescintigraphy the definitive diagnostic test in acute calculous cholecystitis; however, it must be interpreted cautiously in the context of another critical illness or recent surgery or trauma, because false-positives are not unusual in these situations.