1
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Portincasa P, Di Ciaula A, Bonfrate L, Stella A, Garruti G, Lamont JT. Metabolic dysfunction-associated gallstone disease: expecting more from critical care manifestations. Intern Emerg Med 2023; 18:1897-1918. [PMID: 37455265 PMCID: PMC10543156 DOI: 10.1007/s11739-023-03355-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 06/22/2023] [Indexed: 07/18/2023]
Abstract
About 20% of adults worldwide have gallstones which are solid conglomerates in the biliary tree made of cholesterol monohydrate crystals, mucin, calcium bilirubinate, and protein aggregates. About 20% of gallstone patients will definitively develop gallstone disease, a condition which consists of gallstone-related symptoms and/or complications requiring medical therapy, endoscopic procedures, and/or cholecystectomy. Gallstones represent one of the most prevalent digestive disorders in Western countries and patients with gallstone disease are one of the largest categories admitted to European hospitals. About 80% of gallstones in Western countries are made of cholesterol due to disturbed cholesterol homeostasis which involves the liver, the gallbladder and the intestine on a genetic background. The incidence of cholesterol gallstones is dramatically increasing in parallel with the global epidemic of insulin resistance, type 2 diabetes, expansion of visceral adiposity, obesity, and metabolic syndrome. In this context, gallstones can be largely considered a metabolic dysfunction-associated gallstone disease, a condition prone to specific and systemic preventive measures. In this review we discuss the key pathogenic and clinical aspects of gallstones, as the main clinical consequences of metabolic dysfunction-associated disease.
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Affiliation(s)
- Piero Portincasa
- Clinica Medica "A. Murri", Division of Internal Medicine, Department of Preventive and Regenerative Medicine and Ionian Area (DiMePrev-J), University of Bari Aldo Moro, p.zza Giulio Cesare 11, 70124, Bari, Italy.
| | - Agostino Di Ciaula
- Clinica Medica "A. Murri", Division of Internal Medicine, Department of Preventive and Regenerative Medicine and Ionian Area (DiMePrev-J), University of Bari Aldo Moro, p.zza Giulio Cesare 11, 70124, Bari, Italy
| | - Leonilde Bonfrate
- Clinica Medica "A. Murri", Division of Internal Medicine, Department of Preventive and Regenerative Medicine and Ionian Area (DiMePrev-J), University of Bari Aldo Moro, p.zza Giulio Cesare 11, 70124, Bari, Italy
| | - Alessandro Stella
- Laboratory of Medical Genetics, Department of Precision and Regenerative Medicine and Ionian Area (DIMEPRE-J), University of Bari Aldo Moro, Bari, Italy
| | - Gabriella Garruti
- Section of Endocrinology, Department of Preventive and Regenerative Medicine and Ionian Area (DiMePrev-J), University of Bari Aldo Moro, Bari, Italy
| | - John Thomas Lamont
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, 02215, USA
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2
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Kancheva M, Neychev V. Synchronous Acute Appendicitis and Acute Cholecystitis: A Case Report. Cureus 2023; 15:e40411. [PMID: 37456457 PMCID: PMC10348392 DOI: 10.7759/cureus.40411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023] Open
Abstract
Acute cholecystitis (AC) and acute appendicitis (AA), independently, are among the most commonly diagnosed conditions in the emergency department (ED). However, their synchronous presentation is very rare. Here, we present a 31-year-old man with worsening right flank abdominal pain, nausea, and vomiting. Physical examination results were significant for moderate to severe right upper abdominal quadrant pain with a positive Murphy's sign and right lower quadrant pain with rebound. Workup in the ED revealed leukocytosis with a left shift, and the abdominal ultrasound and computerized tomography scan showed AA and AC. A literature review revealed a paucity of publications on concomitant AA and AC. Reporting new cases will contribute to improving our understanding of the biology, natural history, and management of this rare pathological combination.
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Affiliation(s)
- Mihaela Kancheva
- Surgery, University of Central Florida College of Medicine, Orlando, USA
| | - Vladimir Neychev
- Surgery, University of Central Florida College of Medicine, Orlando, USA
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3
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Developing a Simple Score for Diagnosis of Acute Cholecystitis at the Emergency Department. Diagnostics (Basel) 2022; 12:diagnostics12092246. [PMID: 36140646 PMCID: PMC9497808 DOI: 10.3390/diagnostics12092246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/11/2022] [Accepted: 09/16/2022] [Indexed: 12/07/2022] Open
Abstract
We aim to develop a diagnostic score for acute cholecystitis that integrates symptoms, physical examinations, and laboratory data to help clinicians for timely detection and early treatment of this disease. We retrospectively collected data from our database from 2010 to 2020. Patients with acute abdominal pain who underwent an ultrasound or computed tomography (CT) scan at the emergency department (ED) were included. Cases were identified by pathological, CT, or ultrasound reports. Non-cases were those who did not fulfill any of these criteria. Multivariable regression analysis was conducted to identify predictors of acute cholecystitis. The model included 244 patients suspected of acute cholecystitis. Eighty-six patients (35.2%) were acute cholecystitis confirmed cases. Five final predictors remained within the reduced logistic model: age < 60, nausea and/or vomiting, right upper quadrant pain, positive Murphy’s sign, and AST ≥ two times upper limit of normal. A practical score diagnostic performance was AuROC 0.74 (95% CI, 0.67−0.81). Patients were categorized with a high probability of acute cholecystitis at score points of 9−12 with a positive likelihood ratio of 3.79 (95% CI, 1.68−8.94). ED Chole Score from these five predictors may aid in diagnosing acute cholecystitis at ED. Patients with an ED Chole Score >8 should be further investigated.
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4
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Tartaglia K. Can't Miss Infections: Endocarditis, Cellulitis, Erysipelas, Necrotizing Fasciitis, Cholecystitis. Med Clin North Am 2022; 106:537-543. [PMID: 35491073 DOI: 10.1016/j.mcna.2021.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
This article reviews the presentation, physical examination findings, and diagnosis of selective common acute infectious diseases. In this article, we review nonpurulent skin infections, infective endocarditis, and acute cholecystitis.
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Affiliation(s)
- Kim Tartaglia
- Department of Internal Medicine, The Ohio State University College of Medicine, M112 Starling Loving Hall, 310 W 10th Avenue, Columbus, OH 43210, USA.
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5
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Alkhurmudi M, Ali B, Alzaharani A. Incidental Finding of Acute Appendicitis During Laparoscopic Cholecystectomy for an Acute Calculous Cholecystitis. Cureus 2022; 14:e21973. [PMID: 35282553 PMCID: PMC8905659 DOI: 10.7759/cureus.21973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2022] [Indexed: 11/05/2022] Open
Abstract
Acute cholecystitis and appendicitis are among the most common conditions encountered by general surgeons; however, they are rarely described simultaneously. We are reporting a rare incidental finding of early acute appendicitis during laparoscopic cholecystectomy for a 36-year-old lady who presented to our emergency department with signs and symptoms of acute calculous cholecystitis. Laparoscopy has proved to be a highly useful and ideal tool in the diagnosis and treatment of such surgical situations.
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6
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Di Stefano M, Colombo C, De Leo S, Perrino M, Viganò M, Persani L, Fugazzola L. High Prevalence and Conservative Management of Acute Cholecystitis during Lenvatinib for Advanced Thyroid Cancer. Eur Thyroid J 2021; 10:314-322. [PMID: 34395303 PMCID: PMC8314780 DOI: 10.1159/000510369] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 07/22/2020] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Lenvatinib (LEN) is a multitarget tyrosine kinase inhibitor currently used for advanced, radioiodine refractory differentiated thyroid cancer (RAI-R DTC). Among adverse events (AEs), nausea, vomiting, and decreased appetite have been frequently described. We aimed to evaluate the prevalence, the clinical presentation, and the effectiveness of conservative treatment of gallbladder disorders in a consecutive series of patient treated with LEN. METHODS Patients with RAI-R DTC experiencing clinical symptoms suggestive for gallbladder disorders during LEN treatment were evaluated with laboratory investigations and contrast-enhanced abdominal computed tomography (CT) and ultrasound scan (US). RESULTS After a median time of 2 months from the start of treatment, 5/13 patients (38.4%) complained of gastrointestinal symptoms, with increased biliary enzymes levels, especially γGT, and CT/US suggestive of acute cholecystitis (AC). The onset of symptoms and the peak of γGT levels frequently corresponded to the highest reduction in body weight during the first months of treatment. All patients were treated with supportive care and, when appropriate, with ursodeoxycholic acid; in 4 patients, LEN dose reduction or short interruption was needed, too. CONCLUSIONS In patients with RAI-R DTC treated with LEN, a high prevalence of AC in the first months of treatment was documented. Mainly due to the low specificity of symptoms such as anorexia, nausea, and vomiting, this AE is likely to be frequently misdiagnosed. The onset of the disease was associated to the weight loss observed during the first months of treatment and contributes to further decrease in body weight. Therefore, particularly during the first months of treatment, or at any time of huge reduction of body weight, monitoring of γGT and US is crucial for prompt diagnosis and treatment. Conservative medical treatment and LEN dosage titration, together with dietary and rehabilitative supports, can limit or avoid the need for drug withdrawal and cholecystectomy.
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Affiliation(s)
- Marta Di Stefano
- Division of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Carla Colombo
- Division of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Simone De Leo
- Division of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Michela Perrino
- Division of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Mauro Viganò
- Division of Hepatology, San Giuseppe Hospital Multimedica IRCCS, Milan, Italy
| | - Luca Persani
- Division of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, Milan, Italy
- Department of Clinical Sciences and Community Health, Milan, Italy
| | - Laura Fugazzola
- Division of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- *Laura Fugazzola, Division of Endocrine and Metabolic Diseases, Department of Pathophysiology and Transplantation, University of Milan, Ospedale San Luca, IRCCS Istituto Auxologico Italiano, Piazzale Brescia, 20, IT–20149 Milan (Italy),
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7
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Navuluri R, Hoyer M, Osman M, Fergus J. Emergent Treatment of Acute Cholangitis and Acute Cholecystitis. Semin Intervent Radiol 2020; 37:14-23. [PMID: 32139966 DOI: 10.1055/s-0039-3402016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Acute pathology of the biliary tract including cholangitis and cholecystitis can lead to biliary sepsis if early decompression is not performed. This article provides an overview of the presenting signs and symptoms and role of interventional radiology in the management of patients with acute cholangitis or acute cholecystitis. It is especially important to understand the role of IR in the context of other treatment options including medical management, endoscopy, and surgery.
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Affiliation(s)
- Rakesh Navuluri
- Department of Radiology, The University of Chicago, Chicago, Illinois
| | - Matthew Hoyer
- The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Murat Osman
- George Washington University School of Medicine, Washington, District of Columbia
| | - Jonathan Fergus
- Department of Radiology, The University of Chicago, Chicago, Illinois
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8
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James TW, Baron TH. EUS-guided gallbladder drainage: A review of current practices and procedures. Endosc Ultrasound 2019; 8:S28-S34. [PMID: 31897376 PMCID: PMC6896434 DOI: 10.4103/eus.eus_41_19] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 06/18/2019] [Indexed: 12/18/2022] Open
Abstract
EUS-guided gallbladder drainage (EUS-GBD) is utilized for the treatment of acute cholecystitis and symptomatic cholelithiasis in patients who are poor operative candidates. Over the last several years, improved techniques and accessories have facilitated GBD. Recent literature demonstrated effectiveness and safety of EUS-guided GBD. Available data suggest at least similar results when compared to percutaneous cholecystostomy. EUS-guided GBD can be performed as a primary intervention in patients with cholecystitis who are unfit for urgent surgical intervention and as a secondary intervention to internalize biliary drainage in patients with indwelling percutaneous cholecystostomy catheters. Various stents can be used for -EUS-guided GBD. The optimal device and technique have yet to be determined, although at the present time, the use of luminal apposing stents is preferred. The purpose of this review is to provide the highlights of the most recent literature on EUS-guided GBD.
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Affiliation(s)
- Theodore W James
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
| | - Todd Huntley Baron
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
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10
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Faré PB, Allio I, Monotti R, Foieni F. Fitz-Hugh-Curtis Syndrome: A Diagnosis to Consider in a Woman with Right Upper Quadrant Abdominal Pain without Gallstones. Eur J Case Rep Intern Med 2019; 5:000743. [PMID: 30756005 PMCID: PMC6346932 DOI: 10.12890/2017_000743] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 09/23/2017] [Indexed: 11/29/2022] Open
Abstract
A young woman presented with right upper quadrant abdominal pain exacerbated by movement and breathing. Extensive evaluation revealed no gallstones or any other specific cause. Urine polymerase chain reaction results for Chlamydia trachomatis were positive, so the clinical diagnosis of Fitz-Hugh-Curtis syndrome was confirmed. This type of localized peritonitis is thought to be a complication of an ascending genital infection leading to pelvic inflammatory disease. The diagnosis is established on clinical grounds after excluding alternative, more common conditions. Proper antibiotic treatment usually leads to recovery and prevents long-term complications.
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Affiliation(s)
| | - Ileana Allio
- Internal Medicine Department, Ospedale La Carità, Locarno, Switzerland
| | - Rita Monotti
- Internal Medicine Department, Ospedale La Carità, Locarno, Switzerland
| | - Fabrizio Foieni
- Internal Medicine Department, Ospedale La Carità, Locarno, Switzerland
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11
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Portincasa P, Molina-Molina E, Garruti G, Wang DQH. Critical Care Aspects of Gallstone Disease. J Crit Care Med (Targu Mures) 2019; 5:6-18. [PMID: 30766918 PMCID: PMC6369569 DOI: 10.2478/jccm-2019-0003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 01/08/2019] [Indexed: 12/15/2022] Open
Abstract
Approximately twenty per cent of adults have gallstones making it one of the most prevalent gastrointestinal diseases in Western countries. About twenty per cent of gallstone patients requires medical, endoscopic, or surgical therapies such as cholecystectomy due to the onset of gallstone-related symptoms or gallstone-related complications. Thus, patients with symptomatic, uncomplicated or complicated gallstones, regardless of the type of stones, represent one of the largest patient categories admitted to European hospitals. This review deals with the important critical care aspects associated with a gallstone-related disease.
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Affiliation(s)
- Piero Portincasa
- Clinica Medica "A. Murri", Department of Biomedical Sciences & Human Oncology, University of Bari Medical School, Bari, Italy
- Piero Portincasa, Clinica Medica “Augusto Murri”, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School - Piazza Giulio Cesare 11; 70124 Bari – Italy
| | - Emilio Molina-Molina
- Clinica Medica "A. Murri", Department of Biomedical Sciences & Human Oncology, University of Bari Medical School, Bari, Italy
| | - Gabriella Garruti
- Section of Endocrinology, Department of Emergency and Organ Transplantations, University of Bari "Aldo Moro" Medical School, Piazza G. Cesare 11, 70124Bari, Italy
| | - David Q.-H. Wang
- Department of Medicine, Division of Gastroenterology and Liver Diseases, Marion Bessin Liver Research Center, "Albert Einstein" College of Medicine, Bronx, NY 10461, USA
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12
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Rastogi V, Singh D, Tekiner H, Ye F, Kirchenko N, Mazza JJ, Yale SH. Abdominal Physical Signs and Medical Eponyms: Physical Examination of Palpation Part 1, 1876-1907. Clin Med Res 2018; 16:83-91. [PMID: 30166497 PMCID: PMC6306141 DOI: 10.3121/cmr.2018.1423] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Revised: 06/02/2018] [Accepted: 07/17/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Abdominal palpation is a difficult skill to master in the physical examination. It is through the tactile sensation of touch that abdominal tenderness is detected and expressed through pain. Its findings can be used to detect peritonitis and other acute and subtle abnormalities of the abdomen. Some techniques, recognized as signs or medical eponyms, assist clinicians in detecting disease and differentiating other conditions based on location and response to palpation. Described in this paper are medical eponyms associated with abdominal palpation from the period 1876 to 1907. DATA SOURCES PubMed, Medline, on-line Internet word searches, textbooks and references from other source text were used as the data source. PubMed was searched using the Medical Subject Heading (MeSH) of the name of the eponyms and text words associated with the sign. CONCLUSION We present brief historical background information about the physician who reported the sign, original description of the sign, and its clinical application and implication in today's medical practice.
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Affiliation(s)
- Vaibhav Rastogi
- University of Central Florida, College of Medicine, Orlando, Florida, USA
| | - Devina Singh
- University of Florida, Department of Medicine, Gainesville, Florida, USA
| | - Halil Tekiner
- Department of the History of Pharmacy and Ethics, Erciyes University School of Pharmacy, Talas, Kayseri, Turkey
| | - Fan Ye
- University of Central Florida, College of Medicine, Orlando, Florida, USA
| | - Nataliya Kirchenko
- North Florida/South Florida Georgia Veterans Health System, Gainesville, Florida, USA
| | - Joseph J Mazza
- Marshfield Clinic Research Institute, Marshfield, Wisconsin, USA
| | - Steven H Yale
- Department of Internal Medicine, University of Central Florida College of Medicine, Orlando, Florida, USA
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13
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Yeh DD, Chang Y, Tabrizi MB, Yu L, Cropano C, Fagenholz P, King DR, Kaafarani HMA, de Moya M, Velmahos G. Derivation and validation of a practical Bedside Score for the diagnosis of cholecystitis. Am J Emerg Med 2018; 37:61-66. [PMID: 29724580 DOI: 10.1016/j.ajem.2018.04.051] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 04/20/2018] [Accepted: 04/23/2018] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE We sought to develop a practical Bedside Score for the diagnosis of cholecystitis and test its accuracy against the Tokyo Guidelines (TG13). METHODS We conducted a retrospective study of 438 patients undergoing urban, academic Emergency Department (ED) evaluation of RUQ pain. Symptoms, physical signs, ultrasound signs, and labs were scoring system candidates. A random split-sample approach was used to develop and validate a new clinical score. Multivariable regression analysis using development data was conducted to identify predictors of cholecystitis. Cutoff values were chosen to ensure positive/negative predictive values (PPV, NPV) of at least 0.95. The score was externally validated in 80 patients at a different hospital undergoing RUQ pain evaluation. RESULTS 230 patients (53%) had cholecystitis. Five variables predicted cholecystitis and were included in the scores: gallstones, gallbladder thickening, clinical or ultrasonographic Murphy's sign, RUQ tenderness, and post-prandial symptoms. A clinical prediction score was developed. When dichotomized at 4, overall accuracy for acute cholecystitis was 90% for the development cohort, 82% and 86% for the internal and external validation cohorts; TG13 accuracy was 62%-79%. CONCLUSIONS A clinical prediction score for cholecystitis demonstrates accuracy equivalent to TG13. Use of this score may streamline work-up by decreasing the need for comprehensive ultrasound evaluation and CRP measurement and may shorten ED length of stay.
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Affiliation(s)
- D Dante Yeh
- Ryder Trauma Center, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, United States.
| | - Yuchiao Chang
- Massachusetts General Hospital, Department of Medicine, United States
| | | | - Liyang Yu
- Massachusetts General Hospital, Department of Medicine, United States
| | - Catrina Cropano
- Massachusetts General Hospital, Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, United States
| | - Peter Fagenholz
- Massachusetts General Hospital, Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, United States
| | - David R King
- Massachusetts General Hospital, Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, United States
| | - Haytham M A Kaafarani
- Massachusetts General Hospital, Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, United States
| | - Marc de Moya
- Massachusetts General Hospital, Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, United States
| | - George Velmahos
- Massachusetts General Hospital, Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, United States
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14
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Bridges F, Gibbs J, Melamed J, Cussatti E, White S. Clinically diagnosed cholecystitis: a case series. J Surg Case Rep 2018; 2018:rjy031. [PMID: 29511527 PMCID: PMC5829721 DOI: 10.1093/jscr/rjy031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 01/29/2018] [Accepted: 02/07/2018] [Indexed: 11/12/2022] Open
Abstract
In patients presenting with classic signs and symptoms of cholecystitis, the diagnosis is made based on confirmatory imaging studies. However, the most commonly utilized imaging studies lack accuracy, especially in the case of acalculous disease. Here we discuss four cases of patients presenting with symptoms of cholecystitis. All four patients underwent multiple imaging studies, which yielded negative results. Due to persistent symptoms, the decision was made to proceed with cholecystectomy. Each patient underwent uncomplicated cholecystectomy, with resolution of symptoms post-operatively, and continued symptoms relief 6-10 months post-operatively. Cholecystitis is a clinical diagnosis. Negative imaging studies should not influence the management in a patient presenting with classic signs and symptoms of cholecystitis.
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Affiliation(s)
- Firas Bridges
- Division of General and Bariatric Surgery, Good Samaritan Hospital Medical Center, West Islip, NY, USA
| | - Jennifer Gibbs
- Division of Obstetrics and Gynecology, Good Samaritan Hospital Medical Center, West Islip, NY, USA
| | - Joshua Melamed
- Division of General Surgery, South Nassau Community Hospital, Oceanside, NY, USA
| | - Edward Cussatti
- Division of General and Bariatric Surgery, Good Samaritan Hospital Medical Center, West Islip, NY, USA
| | - Samantha White
- NYIT-COM, New York Institute of Technology, Westbury, NY, USA
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15
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Lahham S, Becker BA, Gari A, Bunch S, Alvarado M, Anderson CL, Viquez E, Spann SC, Fox JC. Utility of common bile duct measurement in ED point of care ultrasound: A prospective study. Am J Emerg Med 2017; 36:962-966. [PMID: 29162442 DOI: 10.1016/j.ajem.2017.10.064] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 10/19/2017] [Accepted: 10/24/2017] [Indexed: 12/07/2022] Open
Abstract
BACKGROUND Measurement of the common bile duct (CBD) is considered a fundamental component of biliary point-of-care ultrasound (POCUS), but can be technically challenging. OBJECTIVE The primary objective of this study was to determine whether CBD diameter contributes to the diagnosis of complicated biliary pathology in emergency department (ED) patients with normal laboratory values and no abnormal biliary POCUS findings aside from cholelithiasis. METHODS We performed a prospective, observational study of adult ED patients undergoing POCUS of the right upper quadrant (RUQ) and serum laboratory studies for suspected biliary pathology. The primary outcome was complicated biliary pathology occurring in the setting of normal laboratory values and a POCUS demonstrating the absence of gallbladder wall thickening (GWT), pericholecystic fluid (PCF) and sonographic Murphy's sign (SMS). The association between CBD dilation and complicated biliary pathology was assessed using logistic regression to control for other factors, including laboratory findings, cholelithiasis and other sonographic abnormalities. RESULTS A total of 158 patients were included in the study. 76 (48.1%) received non-biliary diagnoses and 82 (51.9%) were diagnosed with biliary pathology. Complicated biliary pathology was diagnosed in 39 patients. Sensitivity of CBD dilation for complicated biliary pathology was 23.7% and specificity was 77.9%. CONCLUSION Of patients diagnosed with biliary pathology, none had isolated CBD dilatation. In the absence of abnormal laboratory values and GWT, PCF or SMS on POCUS, obtaining a CBD measurement is unlikely to contribute to the evaluation of this patient population.
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Affiliation(s)
- Shadi Lahham
- University of California, Irvine, Department of Emergency Medicine, 333 The City Boulevard West Suite 640, Orange 92868, CA, USA.
| | - Brent A Becker
- York Hospital, Department of Emergency Medicine, York, PA, USA
| | - Abdulatif Gari
- University of California, Irvine, Department of Emergency Medicine, 333 The City Boulevard West Suite 640, Orange 92868, CA, USA
| | - Steven Bunch
- University of California, Irvine, Department of Emergency Medicine, 333 The City Boulevard West Suite 640, Orange 92868, CA, USA
| | - Maili Alvarado
- University of California, Irvine, Department of Emergency Medicine, 333 The City Boulevard West Suite 640, Orange 92868, CA, USA
| | - Craig L Anderson
- University of California, Irvine, Department of Emergency Medicine, 333 The City Boulevard West Suite 640, Orange 92868, CA, USA
| | - Eric Viquez
- University of California, Irvine, Department of Emergency Medicine, 333 The City Boulevard West Suite 640, Orange 92868, CA, USA
| | - Sophia C Spann
- University of California, Irvine, Department of Emergency Medicine, 333 The City Boulevard West Suite 640, Orange 92868, CA, USA
| | - John C Fox
- University of California, Irvine, Department of Emergency Medicine, 333 The City Boulevard West Suite 640, Orange 92868, CA, USA
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Jain A, Mehta N, Secko M, Schechter J, Papanagnou D, Pandya S, Sinert R. History, Physical Examination, Laboratory Testing, and Emergency Department Ultrasonography for the Diagnosis of Acute Cholecystitis. Acad Emerg Med 2017; 24:281-297. [PMID: 27862628 DOI: 10.1111/acem.13132] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 10/23/2016] [Accepted: 11/02/2016] [Indexed: 01/22/2023]
Abstract
BACKGROUND Acute cholecystitis (AC) is a common differential for patients presenting to the emergency department (ED) with abdominal pain. The diagnostic accuracy of history, physical examination, and bedside laboratory tests for AC have not been quantitatively described. OBJECTIVES We performed a systematic review to determine the utility of history and physical examination (H&P), laboratory studies, and ultrasonography (US) in diagnosing AC in the ED. METHODS We searched medical literature from January 1965 to March 2016 in PubMed, Embase, and SCOPUS using a strategy derived from the following formulation of our clinical question: patients-ED patients suspected of AC; interventions-H&P, laboratory studies, and US findings commonly used to diagnose AC; comparator-surgical pathology or definitive diagnostic radiologic study confirming AC; and outcome-the operating characteristics of the investigations in diagnosing AC were calculated. Sensitivity, specificity, and likelihood ratios (LRs) were calculated using Meta-DiSc with a random-effects model (95% CI). Study quality and risks for bias were assessed using the Quality Assessment Tool for Diagnostic Accuracy Studies. RESULTS Separate PubMed, Embase, and SCOPUS searches retrieved studies for H&P (n = 734), laboratory findings (n = 74), and US (n = 492). Three H&P studies met inclusion/exclusion criteria with AC prevalence of 7%-64%. Fever had sensitivity ranging from 31% to 62% and specificity from 37% to 74%; positive LR [LR+] was 0.71-1.24, and negative LR [LR-] was 0.76-1.49. Jaundice sensitivity ranged from 11% to 14%, and specificity from 86% to 99%; LR+ was 0.80-13.81, and LR- was 0.87-1.03. Murphy's sign sensitivity was 62% (range = 53%-71%), and specificity was 96% (range = 95%-97%); LR+ was 15.64 (range = 11.48-21.31), and LR- was 0.40 (range = 0.32-0.50). Right upper quadrant pain had sensitivity ranging from 56% to 93% and specificity of 0% to 96%; LR+ ranged from 0.92 to 14.02, and LR- from 0.46 to 7.86. One laboratory study met criteria with a 26% prevalence of AC. Elevated bilirubin had a sensitivity of 40% (range = 12%-74%) and specificity of 93% (range = 77%-99%); LR+ was 5.80 (range = 1.25-26.99), and LR- was 0.64 (range = 0.39-1.08). Five US studies with a prevalence of AC of between 10% and 46%. US sensitivity was 86% (range = 78%-94%) and specificity was 71% (range = 66%-76%); LR+ was 3.23 (range = 1.74-6.00), and LR- was 0.18 (range = 0.10-0.33). CONCLUSION Variable disease prevalence, coupled with limited sample sizes, increases the risk of selection bias. Individually, none of these investigations reliably rule out AC. Development of a clinical decision rule to include evaluation of H&P, laboratory data, and US are more likely to achieve a correct diagnosis of AC.
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Affiliation(s)
- Ashika Jain
- Department of Emergency Medicine SUNY‐Downstate Medical Center Brooklyn NY
| | - Ninfa Mehta
- Department of Emergency Medicine SUNY‐Downstate Medical Center Brooklyn NY
| | - Michael Secko
- Department of Emergency Medicine SUNY‐Downstate Medical Center Brooklyn NY
| | - Joshua Schechter
- Department of Emergency Medicine SUNY‐Downstate Medical Center Brooklyn NY
| | - Dimitri Papanagnou
- Department of Emergency Medicine Thomas Jefferson University Hospital Philadelphia PA
| | - Shreya Pandya
- Department of Emergency Medicine SUNY‐Downstate Medical Center Brooklyn NY
| | - Richard Sinert
- Department of Emergency Medicine SUNY‐Downstate Medical Center Brooklyn NY
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Jeans PL. Murphy's sign. Med J Aust 2017; 206:115-116. [PMID: 28208037 DOI: 10.5694/mja16.00768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 09/20/2016] [Indexed: 11/17/2022]
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DEĞERLİ V, KORKMAZ T, MOLLAMEHMETOĞLU H, ERTAN C. The importance of routine bedside biliary ultrasonography in the management of patients admitted to the emergency department with isolated acute epigastric pain. Turk J Med Sci 2017; 47:1137-1143. [DOI: 10.3906/sag-1603-12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Gandhi J, Tan J. Concurrent presentation of appendicitis and acute cholecystitis: diagnosis of rare occurrence. BMJ Case Rep 2015; 2015:bcr-2014-208916. [PMID: 26396122 DOI: 10.1136/bcr-2014-208916] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
A 67-year-old woman presented with a 2-day history of central abdominal pain migrating to the right upper and lower abdomen. On examination she was normothermic but tachycardic. Inflammatory markers were noted to be elevated with a white cell count of 18.5×10(9)/L and C reactive protein of 265 mg/L. A CT scan revealed dual pathology of appendicitis and acute cholecystitis, which was confirmed intraoperatively and histologically.
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Affiliation(s)
- Jamish Gandhi
- Department of General Surgery and Gynaecology, Hutt Hospital, Lower Hutt, New Zealand
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Abstract
Background The treatment of acute cholecystitis has been controversially discussed in the literature as there are no high-evidence-level data yet for determining the optimal point in time for surgical intervention. So far, the laparoscopic removal of the gallbladder within 72 h has been the most preferred approach in acute cholecystitis. Methods We conducted a systematic review by including randomized trials of early laparoscopic cholecystectomy for acute cholecystitis. Results Based on a few prospective studies and two meta-analyses, there was consent to prefer an early laparoscopic cholecystectomy for patients suffering from acute calculous cholecystitis while the term ‘early’ has not been consistently defined yet. So far, there is new level 1b evidence brought forth by the so-called ‘ACDC’ study which has convincingly shown in a prospective randomized setting that immediate laparoscopic cholecystectomy – within a time frame of 24 h after hospital admission – is the smartest approach in ASA I-III patients suffering from acute calculous cholecystitis compared to a more conservative approach with a delayed laparoscopic cholecystectomy after an initial antibiotic treatment in terms of morbidity, length of hospital stay, and overall treatment costs. Concerning critically ill patients suffering from acute calculous or acalculous cholecystitis, there is no consensus in treatment due to missing data in the literature. Conclusion Laparoscopic cholecystectomy for acute cholecystitis within 24 h after hospital admission is a safe procedure and should be the preferred treatment for ASA I-III patients. In critically ill patients, the intervention should be determined by a narrow interdisciplinary consent based on the patient's individual comorbidities.
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Affiliation(s)
- Jochen Schuld
- Department of General, Visceral, Vascular and Pediatric Surgery, University of Saarland, Homburg/Saar, Germany
| | - Matthias Glanemann
- Department of General, Visceral, Vascular and Pediatric Surgery, University of Saarland, Homburg/Saar, Germany
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Yazıcı P, Demir U, Bozdağ E, Bozkurt E, Işıl G, Bostancı Ö, Mihmanlı M. What is the effect of treatment modality on red blood cell distribution width in patients with acute cholecystitis? ULUSAL CERRAHI DERGISI 2015; 31:1-4. [PMID: 25931948 DOI: 10.5152/ucd.2015.2803] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 12/03/2014] [Indexed: 12/27/2022]
Abstract
OBJECTIVE The red blood cell distribution width (RDW) has recently been used as a marker to predict outcome in various patient groups. In this study, we aimed to examine how RDW is influenced during the treatment and follow-up of cases of acute cholecystitis which is a common inflammatory disease. MATERIAL AND METHODS Seventy-two patients who were treated for acute cholecystitis, were included into the study. The demographic data, leukocyte count, RDW, C-reactive protein (CRP) values and treatment protocols of these patients were prospectively recorded. The patients who received medical treatment for acute cholecystitis (Group A, n=33) and those who underwent surgery (Group B, n=39) were examined in separate groups. RESULTS There were 27 male and 45 female patients with a mean age of 50.1±18 years (min-max: 21-94). In Group B, 33 patients underwent laparoscopic cholecystectomy, whereas 6 patients underwent open cholecystectomy. The RDW values on admission were not significantly different between two groups. However the post-treatment/pre-discharge RDW values were significantly lower in the surgical group (14.4±1.9 to 13.6±1.1, respectively, p<0.05). Also, no significant RDW change was identified in the medical treatment group based on an intra-group assessment, whereas a significant decrease was observed in Group B (on admission and following surgical treatment: 14.3±1.3, 13.6±1.1, respectively, p=0.015). No significant differences were observed between groups in terms of CRP and leucocyte values. CONCLUSION There was a significant decrease in RDW values in patients who were treated with surgery for acute cholecystitis, while this response could not be observed with medical treatment.
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Affiliation(s)
- Pınar Yazıcı
- Clinic of General Surgery, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey
| | - Uygar Demir
- Clinic of General Surgery, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey
| | - Emre Bozdağ
- Clinic of General Surgery, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey
| | - Emre Bozkurt
- Clinic of General Surgery, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey
| | - Gürhan Işıl
- Clinic of General Surgery, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey
| | - Özgür Bostancı
- Clinic of General Surgery, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey
| | - Mehmet Mihmanlı
- Clinic of General Surgery, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey
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Woo MY, Taylor M, Loubani O, Bowra J, Atkinson P. My patient has got abdominal pain: identifying biliary problems. ULTRASOUND : JOURNAL OF THE BRITISH MEDICAL ULTRASOUND SOCIETY 2014; 22:223-8. [PMID: 27433223 DOI: 10.1177/1742271x14546181] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Right upper quadrant and epigastric abdominal pain are common presenting complaints in the emergency department. With increasing access to point-of-care ultrasound, emergency physicians now have an added tool to help identify biliary problems as a cause of a patient's right upper quadrant pain. Point-of-care ultrasound has a sensitivity of 89.8% (95% CI 86.4-92.5%) and specificity of 88.0% (83.7-91.4%) for cholelithiasis, very similar to radiology-performed ultrasonography. In addition to assessment for cholelithiasis and cholecystitis, point-of-care ultrasound can help emergency physicians to determine whether the biliary system is the source of infection in patients with suspected sepsis. Use of point-of-care ultrasound for the assessment of the biliary system has resulted in more rapid diagnosis, decreasing costs, and shorter emergency department length of stay.
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Affiliation(s)
- Michael Y Woo
- Department of Emergency Medicine, University of Ottawa and Ottawa Hospital Research Institute, Canada
| | - Mark Taylor
- Department of Emergency Medicine, University of Ottawa and Ottawa Hospital Research Institute, Canada
| | - Osama Loubani
- Department of Emergency Medicine, Dalhousie University, Canada
| | - Justin Bowra
- Department of Emergency Medicine, Sydney Adventist Hospital, Australia; Department of Emergency Medicine, Royal North Shore Hospital, Australia
| | - Paul Atkinson
- Department of Emergency Medicine, Dalhousie University, Canada; Discipline of Emergency Medicine, Memorial University, Canada; Department of Emergency Medicine, Saint John Regional Hospital, Canada
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Komindr A, Baugh CW, Grossman SA, Bohan JS. Key operational characteristics in emergency department observation units: a comparative study between sites in the United States and Asia. Int J Emerg Med 2014; 7:6. [PMID: 24499641 PMCID: PMC3922480 DOI: 10.1186/1865-1380-7-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Accepted: 01/11/2014] [Indexed: 11/22/2022] Open
Abstract
Background To improve efficiency, emergency departments (EDs) use dedicated observation units (OUs) to manage patients who are unable to be discharged home, yet do not clearly require inpatient hospitalization. However, operational metrics and their ideal targets have not been created for this setting and patient population. Variation in these metrics across different countries has not previously been reported. This study aims to define and compare key operational characteristics between three ED OUs in the United States (US) and three ED OUs in Asia. Methods This is a descriptive study of six tertiary-care hospitals, all of which are level 1 trauma centers and have OUs managed by ED staff. We collected data via various methods, including a standardized survey, direct observation, and interviews with unit leadership, and compared these data across continents. Results We define multiple key operational characteristics to compare between sites, including OU length of stay (LOS), OU discharge rate, and bed turnover rate. OU LOS in the US and Asian sites averaged 12.9 hours (95% CI, 8.3 to 17.5) and 20.5 hours (95% CI, -49.4 to 90.4), respectively (P = 0.39). OU discharge rates in the US and Asia averaged 84.3% (95% CI, 81.5 to 87.2) and 88.7% (95% CI, 81.5 to 95.8), respectively (P = 0.11), and the bed turnover rates in the US and Asian sites averaged 1.6 patients/bed/day (95% CI, -0.1 to 3.3) and 0.9 patient/bed/day (95% CI, -0.6 to 2.4), respectively (P = 0.27). Conclusions Prior research has shown that the OU is a resource that can mitigate many of problems in the ED and hospital, while simultaneously improving patient care and satisfaction. We describe key operational characteristics that are relevant to all OUs, regardless of geography or healthcare system to monitor and maximize efficiency. Although measures of LOS and bed turnover varied widely between US and Asian sites, we did not find a statistically significant difference. Use of these metrics may enable hospitals to establish or revise an ED OU and reduce OU LOS, increase bed turnover, and discharge rates while simultaneously improving patient satisfaction and quality of care.
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Affiliation(s)
- Atthasit Komindr
- Emergency Unit, King Chulalongkorn Memorial Hospital, 1873 Rama 4 Road, Pathumwan, Bangkok 10330, Thailand.
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24
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Yokoe M, Takada T, Strasberg SM, Solomkin JS, Mayumi T, Gomi H, Pitt HA, Garden OJ, Kiriyama S, Hata J, Gabata T, Yoshida M, Miura F, Okamoto K, Tsuyuguchi T, Itoi T, Yamashita Y, Dervenis C, Chan ACW, Lau WY, Supe AN, Belli G, Hilvano SC, Liau KH, Kim MH, Kim SW, Ker CG. TG13 diagnostic criteria and severity grading of acute cholecystitis (with videos). JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 20:35-46. [PMID: 23340953 DOI: 10.1007/s00534-012-0568-9] [Citation(s) in RCA: 261] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Since its publication in 2007, the Tokyo Guidelines for the management of acute cholangitis and cholecystitis (TG07) have been widely adopted. The validation of TG07 conducted in terms of clinical practice has shown that the diagnostic criteria for acute cholecystitis are highly reliable but that the definition of definite diagnosis is ambiguous. Discussion by the Tokyo Guidelines Revision Committee concluded that acute cholecystitis should be suspected when Murphy's sign, local inflammatory findings in the gallbladder such as right upper quadrant abdominal pain and tenderness, and fever and systemic inflammatory reaction findings detected by blood tests are present but that definite diagnosis of acute cholecystitis can be made only on the basis of the imaging of ultrasonography, computed tomography or scintigraphy (HIDA scan). These proposed diagnostic criteria provided better specificity and accuracy rates than the TG07 diagnostic criteria. As for the severity assessment criteria in TG07, there is evidence that TG07 resulted in clarification of the concept of severe acute cholecystitis. Furthermore, there is evidence that severity assessment in TG07 has led to a reduction in the mean duration of hospital stay. As for the factors used to establish a moderate grade of acute cholecystitis, such as leukocytosis, ALP, old age, diabetes, being male, and delay in admission, no new strong evidence has been detected indicating that a change in the criteria used in TG07 is needed. Therefore, it was judged that the severity assessment criteria of TG07 could be applied in the updated Tokyo Guidelines (TG13) with minor changes. TG13 presents new standards for the diagnosis, severity grading and management of acute cholecystitis. Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html.
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Affiliation(s)
- Masamichi Yokoe
- General Internal Medicine, Nagoya Daini Red Cross Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya, Aichi, 466-8650, Japan.
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Jang TB, Ruggeri W, Kaji AH. The Predictive Value of Specific Emergency Sonographic Signs for Cholecystitis. J Med Ultrasound 2013. [DOI: 10.1016/j.jmu.2013.01.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Douleurs épigastriques aiguës non traumatiques: prévalence des transaminases élevées. ANNALES FRANCAISES DE MEDECINE D URGENCE 2011. [DOI: 10.1007/s13341-011-0079-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Panebianco NL, Jahnes K, Mills AM. Imaging and laboratory testing in acute abdominal pain. Emerg Med Clin North Am 2011; 29:175-93, vii. [PMID: 21515175 DOI: 10.1016/j.emc.2011.01.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
When discussing which laboratory tests or imaging to order in the setting of acute abdominal pain, it is practical to organize information by disease process (eg, acute appendicitis, cholecystitis). Because studies on the accuracy of diagnostic tests are of necessity related to the presence or absence of specific diagnoses, and because clinicians frequently look to tests to help them rule in or rule out specific conditions, this article is organized by region of pain and common abdominal diagnoses. It focuses on the contributions that laboratory testing and imaging make in the emergency management of abdominal complaints.
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Affiliation(s)
- Nova L Panebianco
- Department of Emergency Medicine, University of Pennsylvania School of Medicine, Ground Ravdin, Philadelphia, PA 19104, USA.
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Privette TW, Carlisle MC, Palma JK. Emergencies of the Liver, Gallbladder, and Pancreas. Emerg Med Clin North Am 2011; 29:293-317, viii-ix. [DOI: 10.1016/j.emc.2011.01.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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29
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Jang TB. Bedside Biliary Sonography: Advancement and Future Horizons. Ann Emerg Med 2010; 56:123-5. [DOI: 10.1016/j.annemergmed.2010.03.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2010] [Revised: 03/09/2010] [Accepted: 03/19/2010] [Indexed: 11/28/2022]
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Gilani SNS, Bass G, Leader F, Walsh TN. Collins' sign: validation of a clinical sign in cholelithiasis. Ir J Med Sci 2009; 178:397-400. [PMID: 19685000 DOI: 10.1007/s11845-009-0404-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2009] [Accepted: 07/01/2009] [Indexed: 11/25/2022]
Abstract
BACKGROUND Cholelithiasis typically presents with right upper quadrant pain, as can pain from other right upper quadrant organs. Pain of cholelithiasis is often referred to tip of scapula. Professor Paddy Collins drew attention to fact that patients with gallstone pain would attempt to demonstrate this by placing their hand behind the back and thumb pointing upwards. This became known amongst his students as Collins' sign. AIM To evaluate accuracy of Collins' sign as indicator of cholelithiasis. PATIENTS AND METHODS Case-control study performed on 202 patients with symptomatic cholelithiasis and 200 control patients (with oesophagitis, gastritis or duodenal ulcer). Questionnaire examined pain pattern in both groups. The results analysed using t test and χ(2) test. RESULTS Collins' sign was positive in 51.5% of gallstone patients and 7.5% of control group (P < 0.001). CONCLUSIONS Collins' sign was positive in over half of all patients with cholelithiasis and was useful discriminator in diagnosis of gallstones.
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Affiliation(s)
- S N S Gilani
- Bon Secours Hospital, Glasnevin, Dublin, Ireland.
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Daniak CN, Peretz D, Fine JM, Wang Y, Meinke AK, Hale WB. Factors associated with time to laparoscopic cholecystectomy for acute cholecystitis. World J Gastroenterol 2008; 14:1084-90. [PMID: 18286691 PMCID: PMC2689412 DOI: 10.3748/wjg.14.1084] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine patient and process of care factors associated with performance of timely laparoscopic cholecystectomy for acute cholecystitis.
METHODS: A retrospective medical record review of 88 consecutive patients with acute cholecystitis was conducted. Data collected included demographic data, co-morbidities, symptoms and physical findings at presentation, laboratory and radiological investigations, length of stay, complications, and admission service (medical or surgical). Patients not undergoing cholecystectomy during this hospitalization were excluded from analysis. Hierarchical generalized linear models were constructed to assess the association of pre-operative diagnostic procedures, presenting signs, and admitting service with time to surgery.
RESULTS: Seventy cases met inclusion and exclusion criteria, among which 12 were admitted to the medical service and 58 to the surgical service. Mean ± SD time to surgery was 39.3 ± 43 h, with 87% of operations performed within 72 h of hospital arrival. In the adjusted models, longer time to surgery was associated with number of diagnostic studies and endoscopic retrograde cholangio-pancreatography (ERCP, P = 0.01) as well with admission to medical service without adjustment for ERCP (P < 0.05). Patients undergoing both magnetic resonance cholangiopancreatography (MRCP) and computed tomography (CT) scans experienced the longest waits for surgery. Patients admitted to the surgical versus medical service underwent surgery earlier (30.4 ± 34.9 vs 82.7 ± 55.1 h, P < 0.01), had less post-operative complications (12% vs 58%, P < 0.01), and shorter length of stay (4.3 ± 3.4 vs 8.1 ± 5.2 d, P < 0.01).
CONCLUSION: Admission to the medical service and performance of numerous diagnostic procedures, ERCP, or MRCP combined with CT scan were associated with longer time to surgery. Expeditious performance of ERCP and MRCP and admission of medically stable patients with suspected cholecystitis to the surgical service to speed up time to surgery should be considered.
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Blaivas M, Adhikari S. Diagnostic utility of cholescintigraphy in emergency department patients with suspected acute cholecystitis: comparison with bedside RUQ ultrasonography. J Emerg Med 2007; 33:47-52. [PMID: 17630075 DOI: 10.1016/j.jemermed.2007.02.044] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2006] [Revised: 02/07/2007] [Accepted: 02/19/2007] [Indexed: 11/17/2022]
Abstract
Tc-99m-HIDA cholescintigraphy studies of gallbladder (GB) emptying are considered to be the most accurate method to diagnose acute cholecystitis (AC). With increasing use of bedside ultrasound (US) by emergency physicians for the evaluation of GB pathology, it is important to determine the role of cholescintigraphy as an adjunct to emergency ultrasound of the gallbladder. The objective of this study was to determine the utility of cholescintigraphy as an adjunct to bedside ultrasound in the evaluation of Emergency Department (ED) patients with suspected acute cholecystitis. We retrospectively reviewed US studies of 102 patients being evaluated for AC at a large community ED with a residency program. All patients over 18 years of age presenting to the ED over a 1-year period who received an ED US of the GB followed by a cholescintigraphy were enrolled. Bedside ultrasonography was performed after an initial physical examination by a hospital-credentialed emergency sonologist. Criteria used to diagnose AC include the finding of gallstones with a sonographic Murphy sign, significant wall thickening over 5 mm, pericholecystic fluid, impacted stone, or a combination of these. US reports were compared to cholescintigraphy results, final diagnosis, disposition, and pathology results when applicable. Statistical analysis included descriptive statistics calculated using StatsDirect software. A total of 102 patients fit criteria for this study over a 1-year period. Three patients were dropped from data analysis due to incomplete data. ED US and cholescintigraphy examinations agreed for presence or absence of AC in 76 of 99 patients (77%; 95% confidence interval [CI] 68-84%) resulting in a correlation value of rs = 0.74. A total of 38 of 99 (38%; 95% CI 30-49%) patients were diagnosed with AC on cholescintigraphy and ED US agreed in 20 patients. ED US diagnosed 25 (25%; 95% CI 18-34%) patients with AC and cholescintigraphy agreed in 20 patients. Of 99 patients enrolled, 63 were admitted to the hospital (63%; 95% CI 53-72%). Of the admitted patients, 36 (36%; 95% CI 27-46%) went to the operating room (OR) for presumed AC. Of the 31 (79%; 95% CI 64-89%) with AC on cholescintigraphy who went to the OR, only 13 (42%; 95% CI 26-59%) had pathology-based diagnosis of AC; 15 (48%; 95% CI 32-65%) had chronic inflammation only and 3 (10%; 95% CI 4-25%) had a diagnosis of cholelithiasis only. In 12 of 15 OR cases (80%; 95% CI 62-98%), where cholescintigraphy diagnosed AC but ED US did not, operative diagnosis agreed with US. Five patients with normal cholescintigraphy but ED US diagnosis of AC were taken to OR; pathology agreed with ultrasonography in all. Three other patients diagnosed with AC on cholescintigraphy, but not on ED US, never required operative intervention based on consulting surgeon evaluation. Our study demonstrates that the utility of cholescintigraphy in the evaluation of ED patients with suspected acute cholecysitis after a negative ultrasound examination is very limited.
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Affiliation(s)
- Michael Blaivas
- Department of Emergency Medicine, Northside Hospital Forsyth, Cumming, Georgia 30041, USA.
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Roe J. Evidence-based emergency medicine. Clinical assessment of acute cholecystitis in adults. Ann Emerg Med 2006; 48:101-3. [PMID: 16791930 DOI: 10.1016/j.annemergmed.2006.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Jedd Roe
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
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Tung SP, Chern CH, Chen JD, How CK, Shih HC, Wang LM, Huang CI, Lee CH. Epigastraglia with tarry stools in a middle-aged female caused by jejunal intussusception due to a hamartoma. Emerg Radiol 2005; 11:298-300. [PMID: 16133626 DOI: 10.1007/s10140-005-0408-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2004] [Accepted: 01/24/2005] [Indexed: 12/15/2022]
Abstract
Upper gastrointestinal (GI) hemorrhage is a common presentation to an emergency department. Often, the diagnosis is peptic ulcer disease in which vague or sharp abdominal pain is associated with bleeding. In contrast, intussusception is a rare cause of abdominal pain and coincident GI bleeding. In this case, we report a 41-year-old woman who had an intussuscepting jejunal obstruction due to a hamartoma of the small bowel. The diagnosis was established by ultrasonography. In review of the literature, abdominal pain and bleeding are two common manifestations of intussusception when the lesion originates in the small bowel. Intussusception is frequently included in the differential diagnosis of pediatric patients with coincident abdominal pain and bleeding. However, it is rarely mentioned as an adult cause of these two findings. Because of the delayed and nonspecific presentations of abdominal discomfort in adult patients with intussusception, the diagnosis is often delayed. This case points out the need for considering intussusception even in middle-aged patients whose initial presentation is concomitant bleeding and pain.
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Affiliation(s)
- Shu-Ping Tung
- Emergency Department, Veterans General Hospital-Taipei, National Yang-Ming University, Taipei, Taiwan, Republic of China
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Affiliation(s)
- Kenneth Musana
- Department of Internal Medicine, Marshfield Clinic, Marshfield, WI 54449, USA
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Nelson BP, Senecal EL, Hong C, Ptak T, Thomas SH. Opioid analgesia and assessment of the sonographic Murphy sign. J Emerg Med 2005; 28:409-13. [PMID: 15837021 DOI: 10.1016/j.jemermed.2004.12.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2003] [Revised: 10/20/2004] [Accepted: 12/03/2004] [Indexed: 11/26/2022]
Abstract
Administration of intravenous opioid analgesia to patients with undifferentiated abdominal pain remains a controversial topic in many emergency departments. To determine whether opioid analgesia impacts assessment of the sonographic Murphy sign (SM) in evaluating acute gallbladder disease (GBD), a retrospective chart review was undertaken. The chart review encompassed 119 patients, 21% of whom, having received opioid analgesia before ultrasound, constituted the opioid group. Between the opioid and control (i.e., no opioid analgesia) groups, there were no significant differences in SM sensitivity (48.2%; CI 28.7-68.1% vs. 68.8%; CI 41.3-89%, respectively) or specificity (92.5%; CI 83.4-97.5% vs. 88.9%; CI 51.8-99.7%, respectively) for GBD. There was no association between opioid analgesia and false-positive SM (OR 0.74, CI 0.08-6.65), or false-negative SM (OR 1.42, CI 0.46-4.43). We conclude that the test characteristics of SM are unaffected by opioid analgesia.
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Affiliation(s)
- Bret P Nelson
- Division of Emergency Medicine & Harvard Affiliated Emergency Medicine Residency, Harvard Medical School, Boston, Massachusetts, USA
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Joshua AM, Celermajer DS, Stockler MR. Beauty is in the eye of the examiner: reaching agreement about physical signs and their value. Intern Med J 2005; 35:178-87. [PMID: 15737139 DOI: 10.1111/j.1445-5994.2004.00795.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Despite advances in other areas, evidence-based medicine is yet to make substantial inroads on the standard medical physical examination. We have reviewed the evidence about the accuracy and reliability of the physical examination and common clinical signs. The physical examination includes many signs of marginal accuracy and reproducibility. These may not be appreciated by clinicians and could adversely affect decisions about treatment and investigations or the teaching and examination of students and doctors-in-training. We provide a selected summary of the reliability and accuracy as well as important messages of key findings in the physical examination.
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Affiliation(s)
- A M Joshua
- Department of Medical Oncology, Sydney Cancer Centre, Sydney, New South Wales, Australia.
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Affiliation(s)
- Isaac George
- Department of Surgery, Columbia University College of Physicians and Surgeons, New York, New York 10032, USA
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Yusoff IF, Barkun JS, Barkun AN. Diagnosis and management of cholecystitis and cholangitis. Gastroenterol Clin North Am 2003; 32:1145-68. [PMID: 14696301 DOI: 10.1016/s0889-8553(03)00090-6] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Cholelithiasis is a prevalent condition in Western populations. Most cases are asymptomatic but complications can occur. Acute cholangitis, cholecystitis, and gallstone pancreatitis are the most common biliary tract emergencies and are usually caused by biliary calculi. Whenever possible, acute cholecystitis should be treated with early LC. AAC is an uncommon condition usually affecting patients with significant comorbidities. Treatment is usually with percutaneous cholecystostomy, which often is also the only required therapy. Endoscopic drainage is the preferred form of biliary decompression in acute cholangitis and these patients should subsequently undergo elective LC unless unfit for surgery. Effective and optimal management of biliary tract emergencies relies on close cooperation between gastroenterologist, surgeon, and radiologist.
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Affiliation(s)
- Ian F Yusoff
- McGill University Health Centre, 1650 Cedar Avenue, Montreal, Quebec H3G 1A4, Canada
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Abstract
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.
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Affiliation(s)
- Robert L Trowbridge
- Department of Medicine, University of California, San Francisco 94143-0120 , USA
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Durston W, Carl ML, Guerra W, Eaton A, Ackerson L, Rieland T, Schauer B, Chisum E, Harrison M, Navarro ML. Comparison of quality and cost-effectiveness in the evaluation of symptomatic cholelithiasis with different approaches to ultrasound availability in the ED. Am J Emerg Med 2001; 19:260-9. [PMID: 11447508 DOI: 10.1053/ajem.2001.22660] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Ultrasound is the imaging study of choice for the detection of gallstones, but ultrasound through medical imaging departments (MI Sono) is not readily available on an immediate basis in many emergency departments (EDs). Several studies have shown that emergency physicians can perform ultrasound themselves (ED Sono) to rule out gallstones with acceptable accuracy after relatively brief training periods, but there have been no studies to date specifically addressing the effect of ED Sono of the gallbladder on quality and cost-effectiveness in the ED. In this study, we investigated measures of quality and cost-effectiveness in evaluating patients with suspected symptomatic cholelithiasis during three different years with distinctly different approaches to ultrasound availability. The study retrospectively identified a total of 418 patients who were admitted for cholecystectomy or for a complication of cholelithiasis within 6 months of an ED visit for possible biliary colic. The percentage of patients who had gallstones documented at the first ED visit improved from 28% in 1993, when there was limited availability of ultrasound through the Medical Imaging Department (MI Sono), to 56% in 1995, when MI Sono was readily available, to 70% in 1997, when both MI Sono and ED Sono were readily available (P <.001). There were also significant differences over the 3 years in the mean number of days from the first ED visit to documentation of gallstones (19.7 in 1993, 10.7 in 1995, 7.4 in 1997, P <.001); the mean number of return visits for possible biliary colic before documentation of gallstones (1.67 in 1993, 1.24 in 1995, and 1.25 in 1997, P <.001); and the incidence of complications of cholelithiasis in the interval between the first ED visit for possible biliary colic and the date of documentation of cholelithiasis (6.8% in 1993, 5.9% in 1995, 1.5% in 1997, P =.049). The number of MI Sonos ordered by emergency physicians per case of symptomatic cholelithiasis identified increased from 1.7 in 1993 to 2.5 in 1995 and dropped back to 1.7 in 1997, when 4.2 ED Sonos per study case were also done. The cost of ED Sonos was more than offset by savings in avoiding calling in ultrasound technicians after regular Medical Imaging Department hours. The indeterminate rate for ED Sonos was 18%. Excluding indeterminates, the sensitivity of ED Sono for detection of gallstones was 88.6% (95% CI 83.1-92.8%), the specificity 98.2% (95% CI 96.0-99.3%), and the accuracy 94.8% (95% CI 92.5-96.5%). We conclude that greater availability of MI Sono in the ED was associated with improved quality in the evaluation of patients with suspected symptomatic cholelithiasis but also with increased ultrasound costs. The availability of ED Sono in addition to readily available MI Sono was associated with further improved quality and decreased costs. The indeterminate rate for ED Sono was relatively high, but excluding indeterminates, the accuracy of ED Sono was comparable with published reports of MI Sono.
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Affiliation(s)
- W Durston
- Kaiser Foundation Hospital, South Sacramento, CA 95823, USA
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Clinical policy: critical issues for the initial evaluation and management of patients presenting with a chief complaint of nontraumatic acute abdominal pain. Ann Emerg Med 2000; 36:406-15. [PMID: 11020699 DOI: 10.1067/mem.2000.109446] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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