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Figure 8. Partial filling of the gallbladder with obstruction distal to Hartmann's pouch (cystic duct sign). Anterior (a) and right lateral (b) images 30 minutes after 99mTc-IDA injection show a small focal collection of radiotracer in the gallbladder fossa. The inflamed gallbladder was enlarged on ultrasound (US) and is only partially filled by the radiotracer (arrow). A faint rim sign is also present (arrowheads).

Figure 8. Partial filling of the gallbladder with obstruction distal to Hartmann's pouch (cystic duct sign). Anterior (a) and right lateral (b) images 30 minutes after 99mTc-IDA injection show a small focal collection of radiotracer in the gallbladder fossa. The inflamed gallbladder was enlarged on ultrasound (US) and is only partially filled by the radiotracer (arrow). A faint rim sign is also present (arrowheads).

Morphine should not be given if there is no significant excretion or if there is a history of hypersensitivity. Hyperamylasemia is a relative contraindication as pancreatitis may be exacerbated. Naloxone should be available in the event of side effects, but these are rare with the low doses used. In patients that experience an acute exacerbation of pain following morphine, CCK-8 can also be used to relieve the sphincter of Oddi spasm.

Sensitivity and specificity with the morphine augmented protocol are 90-100% and 85-95%, respectively (Fig. 6).

Ancillary signs of acute cholecystitis are hyperperfusion in the gallbladder fossa on a flow study and the "rim" sign on later images (Fig. 7). The latter reflects extension of the inflammatory reaction into adjacent liver tissue with impaired excretion and prolonged retention resulting in a rim of relative increased activity around the gallbladder fossa after normal liver tissue has cleared. The sign is associated with an increased incidence of gangrenous wall perforation. On occasion a dilated cystic duct or gallbladder neck is visualized (cystic duct sign) with obstruction of the distal portion of the gallbladder (Fig. 8). Comparison of gallbladder size on US is helpful in avoiding a false negative diagnosis.

Although many episodes of acute cholecystitis may resolve with supportive care, the ease and low rate of complications from laparoscopic cholecystectomy have favored a more aggressive approach to treatment of patients who have a typical clinical presentation. US or CT tend to be the initial imaging procedures. Anatomic imaging can guide percutaneous drainage of pericholecystic fluid collections and cholecystostomy in patients at high operative risk. Cholecscintigraphy has been shown

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