Contribution of cholescintigraphy to the early diagnosis of acute acalculous cholecystitis in intensive-care-unit patients

Part 1: Current Concepts in Radiologic Imaging and Intervention in Acute Cholecystitis

Acute calculous cholecystitis and acute acalculous cholecystitis are encountered commonly among critically ill, often elderly, patients. Multidisciplinary management of these conditions is essential, with intensivists, surgeons, diagnostic radiologists, interventional radiologists, infectious disease physicians, gastroenterologists, and endoscopists able to contribute to patient care. In this article intended predominantly for intensivists, we will review the imaging findings and radiologic treatment of critically ill patients with acute calculous cholecystitis and acute acalculous cholecystitis.

The gallbladder: what's new in 2022?

This review focuses mainly on the imaging diagnosis, treatment, and complications of acute cholecystitis which is the most common benign disease of the gallbladder. The American College of Radiology appropriateness criteria for the imaging evaluation of patients with right upper quadrant pain and the Tokyo Guidelines for evaluating patients with acute cholecystitis and acute cholangitis are presented. The recent articles for using US, CT, MR, and HIDA in the evaluation of patients with suspected acute cholecystitis are reviewed in detail. The clinical management and postoperative complications are described. Because gallbladder polyps and adenomyomatosis can mimic gallbladder malignancies and acute cholecystitis, their imaging findings and management are presented. Finally, due the recent literature reporting better results with CT than US in the diagnosis of acute cholecystitis, a suggested approach for imaging patients with right upper quadrant pain and possible acute cholecystitis is presented in an addendum.

Acute acalculous cholecystitis and cardiovascular disease, which came first? After two hundred years still the classic chicken and eggs debate: A review of literature

The existence of a close association between disease of the biliary tract and disease of the heart is known from the mists of time.

Acute acalculous cholecystitis (AAC) can be defined as an acute necro inflammatory disease of the gallbladder in the absence of cholelithiasis.

AAC is a challenging diagnosis. The atypical clinical onset associated to a paucity and similarity of symptoms and to laboratory data mimicking cardiovascular disease (CVD) often results in under and misdiagnosed cases. Moreover, AAC has commonly a fulminant course compared to calculous cholecystitis and it is often associated with gangrene, perforation and empyema as well as considerable morbidity and mortality (up 50%). Early diagnosis is crucial to a prompt treatment in order to avoid complications and to increase survivability.

Even today, although scientific evidence dating two hundred years has shown a close association between AAC and CVD, due to the lack of RCT, there is still a lot of confusion regarding the relationship and consequently the clinical management AAC and CVD.

In addition, emergency physicians are not always familiar with transient ECG changes with AAC.

The aim of this review was to provide evidence regarding epidemiology, pathophysiology, clinical presentation and treatment of the complex association between AAC and CVD.

Our main findings indicate that AAC should be suspected after each general disease leading to hypoperfusion such as cardiovascular diseases or cerebrovascular diseases or major heart or aortic surgery. ECG changes in absence of significant laboratory data for IMA (Acute myocardial infarction) could be related to a misdiagnosed AAC.

US – Ultrasonography-plays a key role in the early diagnosis and also in the follow up of AAC.

Cholecystostomy and cholecystectomy as unique or sequential represent the two prevailing treatment options for AAC.

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AAC should be suspected after each general disease leading to hypoperfusion such as cardiovascular diseases or cerebrovascular diseases or major heart or aortic surgery.

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ECG changes in absence of significant laboratory data for IMA could be related to a misdiagnosed AAC.

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Cholecystectomy is an only definitive treatment for AAC.

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The first report on this theme after 20 years.

Necrotizing Cholecystitis in the Gallbladder: A Case Report

Infections caused by Candida species have shown a considerable increase in frequency in the recent past, and hence they are a cause of significant concern among medical practitioners. There are many factors that contribute to the occurrence of Candida-related infections in particular groups of patients. In this report, we present a case that highlights the causes and appropriate treatment methods of the condition. Patients with acute necrotizing cholecystitis often show poor outcomes after treatment, and hence physicians need to be alert when dealing with patients with this condition and should provide the best treatment method. We report a case of necrotizing cholecystitis in a 55-year-old female with a medical history of cholelithiasis, obesity, seizures, cocaine abuse, and anemia. She also reported lower abdominal pain, felt bloated, and complained of headache, dizziness, lack of appetite, shortness of breath, and vomiting. The patient underwent several lab tests as well as a CT scan of the abdomen, hepatobiliary iminodiacetic acid (HIDA) scan, endoscopy, and cholecystectomy.

Acute Acalculous Cholecystitis in the Setting of Negative Ultrasound and Computed Tomography Scan of the Abdomen

Acute acalculous cholecystitis (AAC) is most commonly seen after surgery in critically ill patients. Early diagnosis and treatment is the key in the management of AAC. Ultrasound is the commonly used first modality for right upper quadrant (RUQ) pain with sensitivity equal to or greater than 80% for AAC. Computed tomography (CT) scan is reported to have a sensitivity close to 90% and if both the ultrasound and CT scan are combined, it further increases the sensitivity for the diagnosis of AAC. It is unlikely for AAC to be present in the setting of both negative ultrasound and CT scan of the abdomen. Our case report presents a similar clinical scenario where the patient was found to have both negative ultrasound and CT scan abdomen but was positive on hepatobiliary iminodiacetic acid (HIDA) scan for AAC as stated below. A 32-year-old male presented to the emergency room with complaints of RUQ pain for two days which was associated with one episode of non-bilious and non-bloody vomiting as well as subjective fever and chills. On presentation, the patient's blood pressure was 87/54 mmHg. Other vitals were unremarkable. The patient had both CT scan abdomen and ultrasound of the RUQ done which reported non-specific findings but were grossly negative for AAC. On the first night of admission, the patient's blood pressure dropped to 84/32 mmHg. The patient was transferred to the intensive care unit (ICU) given the concern for sepsis and was started on intravenous (IV) vancomycin, IV metronidazole and IV levofloxacin (patient was allergic to penicillin). Given the high clinical suspicion, a HIDA scan performed which was positive for AAC. The patient then had a cholecystostomy tube placed by the interventional radiology team. The patient improved rapidly and was eventually discharged with a 14-day course of Bactrim DS (Roche Pharmaceuticals, Nutley, NJ) and metronidazole, and four weeks of outpatient follow up with general surgery. The patient underwent outpatient cholecystectomy in the eighth week from discharge. This leads to the conclusion that even if both the ultrasound and CT scan of the abdomen are negative and clinical suspicion is still high for AAC, the patient should undergo a HIDA scan as delay in treatment is associated with greater than 50% mortality in patients with AAC.

Nuclear medicine tests for acute gastrointestinal conditions

Acute cholecystitis (AC) and lower-gastrointestinal (GI) bleeding are 2 emergencies commonly encountered in nuclear medicine. Evidence of AC on hepatobiliary scintigraphy (HBS) allows for confident diagnosis and provides support for definitive surgical treatment. Proper patient preparation is essential for HBS including fasting and the use of pharmacologic adjuncts is sometimes required. Pharmacologic adjuncts may also be administered during HBS to shorten the length of the examination and increase its specificity. In the interpretation of HBS, there are several sources of false-positive results to be aware of, most commonly chronic cholecystitis. False-negative results on HBS are usually the result of mistaking another structure, such as a dilated cystic duct, for the gallbladder. Abdominal ultrasound is the appropriate initial test in patients with suspected AC, but HBS is an excellent second tier test for the diagnosis of AC in the work-up of indeterminate cases by sonography. GI bleeding scintigraphy plays an important role in the evaluation and management of patients with acute lower-GI bleeding. Scintigraphy serves to localize sites of active GI bleeding and stratify those patients who would benefit from aggressive treatment (surgery or arteriography) vs those who can be managed medically. Pretest involvement of respective services is critical for successful bleeding site confirmation and therapy by interventional radiology or surgery or both. Single photon emission computed tomography/computed tomography erythrocyte scintigraphy has demonstrated superior accuracy and precision over planar scintigraphy in the diagnosis of acute GI bleeding. Additionally, single photon emission computed tomography/computed tomography scintigraphy of GI bleeding provides useful supplemental anatomical information that benefits patient management.

Hepatobiliary scintigraphy in acute cholecystitis

Hepatobiliary scintigraphy is a mature imaging technique for evaluation of patients with acute cholecystitis (AC). It is effective in calculous and acalculous forms of AC. The test is used in contemporary medical practice as the arbiter when the findings from screening abdominal ultrasound do not fit a clinical picture. It is also performed in severely ill patients who have AC suspected on other testing, but whose frail condition and high operative risk demand the highest level of certainty. This review, therefore, examines all technique variations of hepatobiliary scintigraphy, offering an approach that may best fit a variety of clinical situations and philosophies on AC.

Acute acalculous cholecystitis: a review

Although recognized for more than 150 years, acute acalculous cholecystitis (AAC) remains an elusive diagnosis. This is likely because of the complex clinical setting in which this entity develops, the lack of large prospective controlled trials that evaluate various diagnostic modalities, and thus dependence on a small data base for clinical decision making. AAC most often occurs in critically ill patients, especially related to trauma, surgery, shock, burns, sepsis, total parenteral nutrition, and/or prolonged fasting. Clinically, AAC is difficult to diagnose because the findings of right upper-quadrant pain, fever, leukocytosis, and abnormal liver tests are not specific. AAC is associated with a high mortality, but early diagnosis and intervention can change this. Early diagnosis is the crux of debate surrounding AAC, and it usually rests with imaging modalities. There are no specific criteria to diagnose AAC. Therefore, this review discusses the imaging methods most likely to arrive at an early and accurate diagnosis despite the complexities of the radiologic modalities. A pragmatic approach is vital. A timely diagnosis will depend on a high index of suspicion in the appropriate patient, and the combined results of clinical findings (admittedly nonspecific), plus properly interpreted imaging. Sonogram (often sequential) and hepatic iminodiacetic acid scans are the most reliable modalities for diagnosis. It is generally agreed that cholecystectomy is the definitive therapy for AAC. However, at times a diagnostic/therapeutic drainage via interventional radiology/surgery may be necessary and life-saving, and may be the only treatment needed.

Acute cholecystitis: MR findings and differentiation from chronic cholecystitis

PURPOSE

To retrospectively determine the sensitivity and specificity of magnetic resonance (MR) imaging for differentiation between acute and chronic cholecystitis, with histopathologic analysis as the reference standard.

MATERIALS AND METHODS

Institutional review board approval with waived informed consent was obtained for this HIPAA-compliant study. Four reviewers blinded to the cholecystitis type but aware that cholecystitis was present retrospectively evaluated MR images for predetermined findings in 32 patients (15 male, 17 female; mean age +/- standard deviation, 55 years +/- 20) with histopathologically proved acute or chronic cholecystitis. The final MR diagnoses and MR findings in both groups were compared with each other and with the histopathologic diagnoses to determine the sensitivity and specificity of MR imaging. Chi(2) tests were used to detect differences in MR findings between the acute and chronic cholecystitis groups.

RESULTS

MR imaging sensitivity and specificity for detection of acute cholecystitis were 95% (18 of 19 patients) and 69% (nine of 13 patients), respectively. The sensitivities of increased gallbladder wall enhancement and increased transient pericholecystic hepatic enhancement were 74% (14 of 19 patients) and 62% (10 of 16 patients), respectively. Both findings had 92% (12 of 13 patients) specificity. Sensitivities of increased wall thickness, pericholecystic fluid, and adjacent fat signal intensity changes were 100% (19 of 19 patients), 95% (18 of 19 patients), and 95% (18 of 19 patients), respectively; specificities were 54% (seven of 13 patients), 38% (five of 13 patients), and 54% (seven of 13 patients), respectively. Pericholecystic abscess, intraluminal membranes, and wall irregularity or defect each had 100% (13 of 13 patients) specificity; sensitivities were 11% (two of 19 patients), 26% (five of 19 patients), and 21% (four of 19 patients), respectively. Increased gallbladder wall enhancement (P<.001) and increased transient pericholecystic hepatic enhancement (P=.003) were the most significantly different between acute and chronic cholecystitis.

CONCLUSION

Increased gallbladder wall enhancement and increased transient pericholecystic hepatic enhancement had the highest combination of sensitivity and specificity for the diagnosis and differentiation of acute and chronic cholecystitis.

Acute Acalculous Cholecystitis

Acute acalculous cholecystitis is defined as acute inflammation of the gallbladder in the absence of gallstones. Patients are usually critically ill with atherosclerotic heart disease, recent trauma, burn injury, surgery, or hemodynamic instability. The presentation of acute acalculous cholecystitis may be insidious, characterized by unexplained fever, leukocytosis, hyperamylasemia, or abnormal aminotransferases, and patients often lack right upper quadrant tenderness. Diagnostic evaluation includes ultrasonography, computerized tomography, and cholescintigraphy. Given the high mortality of untreated disease, definitive treatment consists of cholecystectomy or, in poor surgical candidates, cholecystostomy. Endoscopic therapy with nasobiliary drainage and lavage is an effective treatment option in patients unable to tolerate surgery or cholecystostomy.

Acute cholecystitis, biliary obstruction, and biliary leakage

The use of cholescintigraphy to diagnose acute cholecystitis, biliary obstruction, and biliary leakage dates back to the late 1970s. Today, despite the many advances in imaging instrumentation, radiopharmaceuticals, and methodology over these years, cholescintigraphy still plays an important role in confirming or excluding these diagnoses in acutely ill patients. Acute calculous and acalculous cholecystitis, gallbladder perforation, biliary obstruction, and biliary leakage often present as acute abdominal pain, and must be differentiated from other surgical and nonsurgical etiologies with similar symptoms and presentation. Understanding the pathophysiology of acute hepatobiliary diseases is vital for deciding on the most advantageous imaging work-up and for interpretation of the studies. To optimize the value of cholescintigraphy, up-to-date methology, proper use of appropriate pharmacologic interventions, and recognition of characteristic image findings are critical.

Does this patient have acute cholecystitis?

CONTEXT

Although few patients with acute abdominal pain will prove to have cholecystitis, ruling in or ruling out acute cholecystitis consumes substantial diagnostic resources.

OBJECTIVE

To determine if aspects of the history and physical examination or basic laboratory testing clearly identify patients who require diagnostic imaging tests to rule in or rule out the diagnosis of acute cholecystitis.

DATA SOURCES

Electronic search of the Science Citation Index, Cochrane Library, and English-language articles from January 1966 through November 2000 indexed in MEDLINE. We also hand-searched Index Medicus for 1950-1965, and scanned references in identified articles and bibliographies of prominent textbooks of physical examination, surgery, and gastroenterology. To identify relevant articles appearing since the comprehensive search, we repeated the MEDLINE search in July 2002.

STUDY SELECTION

Included studies evaluated the role of the history, physical examination, and/or laboratory tests in adults with abdominal pain or suspected acute cholecystitis. Studies had to report data from a control group found not to have acute cholecystitis. Acceptable definitions of cholecystitis included surgery, pathologic examination, hepatic iminodiacetic acid scan or right upper quadrant ultrasound, or clinical course consistent with acute cholecystitis and no evidence for an alternate diagnosis. Studies of acalculous cholecystitis were included. Seventeen of 195 identified studies met the inclusion criteria.

DATA EXTRACTION

Two authors independently abstracted data from the 17 included studies. Disagreements were resolved by discussion and consensus with a third author.

DATA SYNTHESIS

No clinical or laboratory finding had a sufficiently high positive likelihood ratio (LR) or low negative LR to rule in or rule out the diagnosis of acute cholecystitis. Possible exceptions were the Murphy sign (positive LR, 2.8; 95% CI, 0.8-8.6) and right upper quadrant tenderness (negative LR, 0.4; 95% CI, 0.2-1.1), though the 95% CIs for both included 1.0. Available data on diagnostic confirmation rates at laparotomy and test characteristics of relevant radiological investigations suggest that the diagnostic impression of acute cholecystitis has a positive LR of 25 to 30. Unfortunately, the available literature does not identify the specific combinations of clinical and laboratory findings that presumably account for this diagnostic success.

CONCLUSIONS

No single clinical finding or laboratory test carries sufficient weight to establish or exclude cholecystitis without further testing (eg, right upper quadrant ultrasound). Combinations of certain symptoms, signs, and laboratory results likely have more useful LRs, and presumably inform the diagnostic impressions of experienced clinicians. Pending further research characterizing the pretest probabilities associated with different clinical presentations, the evaluation of patients with abdominal pain suggestive of cholecystitis will continue to rely heavily on the clinical gestalt and diagnostic imaging.

Hepatic imaging. An overview

For optimal detection and characterization of focal or diffuse liver disease, it is essential to obtain the most appropriate imaging test in the correct clinical setting. Access to clinical information and medical history is, therefore, essential. Moreover, familiarity with currently available modalities for imaging the liver [figure: see text] allows the optimal use of the technical advances in ultrasound imaging, CT scanning, MR imaging, and nuclear scintigraphy technology and contributes to improved diagnostic accuracy.