An audit of ultrasound diagnosis of gallbladder calculi

A Clinician's Guide to the Diagnosis and Management of Gallbladder Volvulus

INTRODUCTION

Gallbladder volvulus (GV), or torsion of the gallbladder, is an uncommon surgical emergency. This article reviews the world literature related to GV. We examine the history of gallbladder torsion and highlight the critical constellation of presenting signs and symptoms, which guide the acute care physician and surgeon to accurate and timely diagnosis of GV before surgical intervention.

METHODS

A comprehensive review of all published cases of GV was performed using the National Library of Medicine (PubMed) database.

RESULTS

Lists of typical symptoms and clinical presentations are provided to allow clinicians to establish an accurate preoperative diagnosis.

CONCLUSION

GV is frequently undiagnosed before surgical intervention. However, clinical presentation and associated radiographic findings can lead to an accurate diagnosis if the clinician is aware of this uncommon condition. When the diagnosis has been established before operative intervention, expeditious laparoscopic cholecystectomy can be performed safely. Delays in diagnosis may mandate open cholecystectomy if laparoscopic extraction is contraindicated because of undesirable sequelae of gallbladder necrosis, specifically perforation, bilious peritonitis, and hemodynamic instability.

Natural history of acalculous biliary symptoms

INTRODUCTION

The radiological criteria for the diagnosis of gallbladder disease rely largely on the detection of calculi using ultrasonography. Patients may, however, suffer symptoms typical of biliary pain without detectable gallstones. The aim of this study was to identify a cohort of patients presenting with recurrent episodes of biliary symptoms in the absence of identifiable pathology on ultrasonography and to record the outcome of subsequent imaging investigations.

METHODS

Records of patients having abdominal ultrasonography during a four-month period in 2006 were accessed retrospectively and those with symptoms suggesting biliary disease were identified. Radiology records were reviewed over a five-year follow-up period to identify patients undergoing further imaging for recurrent biliary symptoms and outcomes were recorded.

RESULTS

A total of 512 patients had ultrasonography for investigation of symptoms consistent with biliary disease. Almost half (41.2%) of these were found to have gallbladder pathology on ultrasonography and 4.7% of patients went on to have further investigations for similar symptoms without achieving a diagnosis. The median age of this group was 47 years and 75% of these patients were female. During the follow-up period, 2.6% of patients with biliary symptoms and initially normal ultrasonography developed gallstones and in 1.3% pancreatitis was demonstrated on imaging.

CONCLUSIONS

A small minority of patients who present with biliary symptoms and have no abnormality on ultrasonography present with recurrent symptoms or develop significant biliary pathology. These patients should be identified by interview at routine follow-up visits and further investigations should be considered.

Diagnostic utility of cholescintigraphy in emergency department patients with suspected acute cholecystitis: comparison with bedside RUQ ultrasonography

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.

Hepatobiliary ultrasound

The use of ultrasound technology in the emergency department(ED) is a recent and fast-growing phenomenon. Ultrasound is an extremely valuable tool for the evaluation of gallbladder (GB) dis-ease in the ED for several reasons: this disease is a common medical problem, cholecystitis can present in different ways clinically,the nature of the GB allows it to be well visualized by ultrasound,and ultrasound has many benefits and few complications associated with its use. This article reviews the focused examination of the GB, with specific attention to test characteristics (sensitivity,specificity, positive predictive value, and negative predictive value)when performed by emergency physicians in the ED.

Abdominal ultrasonography

This article focuses on ultrasonographic examinations of the abdomen and important intra-abdominal pathology. The liver and biliary tree are discussed first, followed by the use of ultrasonography in diagnosing appendicitis, ascites, and bowel obstruction. Pyloric stenosis and intussusception, important pediatric intra-abdominal problems, are also discussed.

An audit of a radiographer based ultrasound service

A general ultrasound service has evolved over several years. Radiographers undertake the general ultrasound lists, and show the request card and the hard copy films to a radiologist prior to the patient leaving the department. Whilst it is generally accepted for radiographers to carry the burden of obstetric scanning, this is less so for general work. This audit is of a sample of 100 patients out of the general ultrasound lists. These patients underwent the standard service examination by a radiographer and subsequent report by the radiologist. They also had a separate examination and report by an independent radiologist. 42 patients were agreed to have normal findings. 75 diagnoses or observations were made in the remaining 58 patients. Discrepancies arose between the two limbs of the audit in 20 of the observations. Review of the hard copy films and repeat scanning of patients where necessary identified one relevant error by the auditing radiologist and three relevant errors by the standard service. Whilst errors are made both by radiologists and radiographers, it is concluded that the existing radiographer based ultrasound service provides a satisfactory level of accuracy.