Does ultrasonography accurately diagnose acute cholecystitis? Improving diagnostic accuracy based on a review at a regional hospital

A novel preoperative score to predict severe acute cholecystitis

BACKGROUND

In a large multicenter trial, The Parkland Grading Scale (PGS) for acute cholecystitis outperformed other grading scales and has a positive correlation with complications but is limited in its inability to preoperatively predict high-grade cholecystitis. We sought to identify preoperative variables predictive of high-grade cholecystitis (PGS 4 or 5).

METHODS

In a six-month period, patients undergoing cholecystectomy at a single institution with prospectively graded PGS were analyzed. Stepwise logistic regression models were constructed to predict high-grade cholecystitis. The relative weight of the variables was used to derive a novel score, the Severe Acute Cholecystitis Score (SACS). This score was compared with the Emergency Surgery Acuity Score(ESS), American Association for the Surgery of Trauma (AAST) preoperative score and Tokyo Guidelines (TG) for their ability to predict high-grade cholecystitis. Severe Acute Cholecystitis Score was then validated using the database from the AAST multicenter validation of the grading scale for acute cholecystitis.

RESULTS

Of the 575 patients that underwent cholecystectomy, 172 (29.9%) were classified as high-grade. The stepwise logistic regression modeling identified seven independent predictors of high-grade cholecystitis. From these variables, the SACS was derived. Scores ranged from 0 to 9 points with a C statistic of 0.76, outperforming the ESS ( C statistic of 0.60), AAST (0.53), and TG (0.70) ( p < 0.001). Using a cutoff of 4 or more on the SACS correctly identifies 76.2% of cases with a specificity of 91.3% and a sensitivity of 40.7%. In the multicenter database, there were 464 patients with a prospectively collected PGS. The C statistic for SACS was 0.74. Using the same cutoff of 4, SACS correctly identifies 71.6% of cases with a specificity of 83.8% and a sensitivity of 52.2%.

CONCLUSION

The Severe Acute Cholecystitis Score can preoperatively predict high-grade cholecystitis and may be useful for counseling patients and assisting in surgical decision making.

LEVEL OF EVIDENCE

Diagnostic Test/Criteria; Level III.

Radiology Imaging Adds Time and Diagnostic Uncertainty when Point of Care Ultrasound Demonstrates Cholecystitis

BACKGROUND

Point of care ultrasound (POCUS) is specific for acute cholecystitis (AC), but surgeons request radiology imaging (RI) prior to admitting patients with POCUS-diagnosed AC.

OBJECTIVES

We sought to determine the test characteristics of POCUS for AC when performed and billed by credentialed emergency physicians (EPs), the accuracy rate of RI when performed after POCUS, and the time added when RI is requested after POCUS demonstrates AC.

METHODS

We performed a dual-site retrospective cohort study of admitted adult ED patients who had received biliary POCUS from November 1, 2020 to April 30, 2022. Patients with previously diagnosed AC, liver failure, ascites, hepatobiliary cancer, or cholecystectomy were excluded. Descriptive statistics and 95% confidence intervals for point estimates were calculated. Medians were compared using a Wilcoxon signed-rank test. Test characteristics of POCUS for AC were calculated using inpatient intervention for AC as the reference standard.

RESULTS

Of 473 screened patients, 143 were included for analysis: 80 (56%) had AC according to our reference standard. POCUS was positive for AC in 46 patients: 44 true positives and two false positives, yielding a positive likelihood ratio of 17.3 (95%CI 4.4-69.0) for AC. The accuracy rate of RI after positive POCUS for AC was 39.0%. Median time from ED arrival to POCUS and ED arrival to RI were 115 (IQR 64, 207) and 313.5 (IQR 224, 541) minutes, respectively; p < 0.01.

CONCLUSION

RI after positive POCUS performed by credentialed EPs takes additional time and may increase diagnostic uncertainty.

The Role of Different Systemic Inflammatory Indexes Derived from Complete Blood Count in Differentiating Acute from Chronic Calculus Cholecystitis and Predicting Its Severity

Purpose

This study aimed to evaluate the diagnostic value of the different Complete blood count-derived systemic inflammation indexes, including neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), systemic immune-inflammation index (SII), and neutrophil to lymphocyte × platelet ratio (NLPR) in differential diagnosing the chronic calculus cholecystitis (CCC) and the acute calculus cholecystitis (ACC), as well as determining the severity of ACC.

Patients and Methods

105 CCC and 88 ACC patients were enrolled. NLR, PLR, SII, and NLPR were evaluated in both cohorts as well as in different severity levels of ACC. The severity of ACC was determined based on the Tokyo Guidelines. Receiver operating characteristic (ROC) curve and Univariate/multivariate regression analyses were conducted.

Results

The levels of NLR, PLR, SII, and NLPR were significantly higher in the ACC group compared to the CCC group. The optimal cutoff values for NLR, PLR, SII, and NLPR were determined to be 3.89, 144.7, 896.8, and 0.031 respectively. NLR>3.89 demonstrates the highest predictive capability with an AUC of 0.801 and a sensitivity of 72.73%. Multivariate analysis showed that NLR>3.89 (OR: 4.169, p = 0.004) and NLPR>0.031 (OR: 4.304, p = 0.005) were dominant in distinguishing ACC from CCC. In ACC patients, the levels of NLR, SII, and NLPR were significantly higher in the Moderate to Severe-degree ACC (MS-ACC) group than in Mild-Degree ACC (M-ACC). NLPR > 0.044 exhibited the highest predictive ability with an AUC of 0.778 and a specificity of 91.67%. Multivariate analysis showed that NLR>6.399 (OR: 10.308, p = 0.000) was a possible independent prognostic factor for accessing the severity of ACC.

Conclusion

Systemic inflammation indexes can be useful in predicting the risk of ACC and MS-ACC. NLR demonstrates the best distinguishing power and sensitivity for distinguishing ACC from CCC, while NLPR shows the best predictive power and specificity for predicting the severity of ACC.

The role of ischemia-modified albumin, presepsin, delta neutrophil index, and inflammatory markers in diagnosing acute cholecystitis

BACKGROUND

The purpose of this study is to determine the significance of markers such as C-reactive protein, procalcitonin, complete blood count parameters, delta neutrophil index, ischemia-modified albumin, presepsin, and oxidative stress indicators, which are associated with inflammation, oxidative stress, and ischemia in the pathology and diagnosis of acute cholecystitis in adults.

METHODS

Patients diagnosed with acute cholecystitis in the emergency department and healthy individuals in the control group were included in the study. Routine blood count and biochemistry analyses were performed on the participants. Blood serum was used to measure ischemia-modified albumin, presepsin, and oxidative stress indicators.

RESULTS

White blood cell count, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, delta neutrophil index, C-reactive protein, procalcitonin, ischemia-modified albumin, ischemia-modified albumin to albumin ratio, presepsin, and oxidative stress indicators were significantly higher in patients with cholecystitis compared to the control group. Measurements of white blood cell count, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and delta neutrophil index can be included as part of the complete blood count. The complete blood count parameters are readily available and do not incur additional costs to the healthcare system.

CONCLUSION

The authors believe that the neutrophil-to-lymphocyte ratio, delta neutrophil index, ischemia-modified albumin, ischemia-modified albumin to albumin ratio, and presepsin values can be used as new markers in the diagnosis of acute cholecystitis due to their high sensitivity, specificity, and low negative likelihood ratio.

A meta-analysis of the performance of ultrasound, hepatobiliary scintigraphy, CT and MRI in the diagnosis of acute cholecystitis

PURPOSE

To evaluate the recently reported relative diagnostic accuracy of US, CT, MRI, and cholescintigraphy for diagnosing acute cholecystitis.

METHODS

2 radiologists independently performed systematic electronic searches for articles published between 2000 and 2021 and applied inclusion/exclusion criteria. 2 different radiologists extracted data from the articles and scored each with a methodological quality tool. Pooled estimates of sensitivity and specificity were calculated with a bivariate linear mixed model. A second analysis made head-to-head comparisons (US vs. CT, US vs. cholescintigraphy). Factors were also analyzed for potential confounding effects on diagnostic accuracy.

RESULTS

Of 6121 initial titles, 22 were included. The prevalence of cholecystitis varied widely across studies (9.4-98%). Pooled sensitivity and specificity estimates were 69% (confidence limit [CL] 62-76%) and 79% (CL 71-86%) for US, 91% (CL 86-94%) and 63% (CL 51-74%) for cholescintigraphy, 78% (CL 69-84%) and 81% (CL 71-88%) for CT, and 91% (CL 78-97%) and 93% (CL 70-99%) for MRI. Regarding head-to-head comparisons, the sensitivity of CT (87.6%, CL 70-96%) was significantly higher than US (66.8%, CL 43-84%), while specificities (81.7% with CL 54-95% for US, 91.9% with CL 67-99% for CT) were similar. The sensitivity of cholescintigraphy (87.4%, CL 76-94%) was significantly greater than US (61.6%, CL 44-77%), while the specificity of US (82%, CL 65-92%) was significantly higher than cholescintigraphy (68%, CL 47-84%).

CONCLUSION

Recent data suggests that CT may have a higher sensitivity than US for diagnosing acute cholecystitis, with similar specificity. Cholescintigraphy remains a highly sensitive modality with lower specificity than previously reported. MRI remains under studied, but with promising results.

Current Operative Approaches to the Diseased Gallbladder. Diagnosis and Management Updates for General Surgeons

Cholecystitis is a common diagnosis which requires management by general surgeons. Morbidity from cholecystitis is often life-threatening, especially in patients with underlying liver cirrhosis or other medical comorbidities. Diagnosis and management of this disease can vary among providers and hospitals. The decision to utilize a radiological or endoscopic temporizing maneuver in severe acute cholecystitis and the timing of later definitive cholecystectomy are relevant points of discussion within general surgery societies. In the last 5 years, the use of intraoperative ductal imaging by conventional vs fluorescence cholangiography had gained significant interest due to the widespread availability of indocyanine green. Finally, the operative strategies and how to manage intra-/postoperative complications are very important to optimizing patient outcomes. In this review paper, we discuss all treatment aspects of cholecystitis and provide updates in its management.

Diagnostic performance of ultrasound in acute cholecystitis: a systematic review and meta-analysis

BACKGROUND

An updated overview of ultrasound (US) for diagnosis of acute cholecystitis (AC) remains lacking. This systematic review was conducted to evaluate the diagnostic performance of US for AC.

METHODS

A systematic review was conducted following PRISMA guidelines. We meticulously screened articles from MEDLINE, Embase, and the Cochrane Library, spanning from inception to August 2023. We employed the search strategy combining the keywords "bedside US", "emergency US" or "point-of-care US" with "AC". Two reviewers independently screened the titles and abstracts of the retrieved articles to identify suitable studies. The inclusion criteria encompassed articles investigating the diagnostic performance of US for AC. Data regarding diagnostic performance, sonographers, and sonographic findings including the presence of gallstone, gallbladder (GB) wall thickness, peri-GB fluid, or sonographic Murphy sign were extracted, and a meta-analysis was executed. Case reports, editorials, and review articles were excluded, as well as studies focused on acalculous cholecystitis. The study quality was assessed with the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool.

RESULTS

Forty studies with 8,652 patients were included. The majority of studies had a low risk of bias and applicability concerns. US had a pooled sensitivity of 71% (95% CI, 69-72%), a specificity of 85% (95% CI, 84-86%), and an accuracy of 0.83 (95% CI, 0.82-0.83) for the diagnosis of AC. The pooled sensitivity and specificity were 71% (95% CI, 67-74%) and 92% (95% CI, 90-93%) performed by emergency physicians (EPs), 79% (95% CI, 71-85%) and 76% (95% CI, 69-81%) performed by surgeons, and 68% (95% CI 66-71%) and 87% (95% CI, 86-88%) performed by radiologists, respectively. There were no statistically significant differences among the three groups.

CONCLUSION

US is a good imaging modality for the diagnosis of AC. EP-performed US has a similar diagnostic performance to radiologist-performed US. Further investigations would be needed to investigate the impact of US on expediting the management process and improving patient-centered outcomes.

When Not to Operate on Acute Cases-A Surgeon's Perspective on Rapid Assessment of Emergency Abdominopelvic Computed Tomography

Clinical problem solving evolves in parallel with advances in technology and discoveries in the medical field. However, it always reverts to basic cognitive processes involved in critical thinking, such as hypothetical-deductive reasoning, pattern recognition, and compilation models. When dealing with cases of acute abdominal pain, clinicians should employ all available tools that allow them to rapidly refine their analysis for a definitive diagnosis. Therefore, we propose a standardized method for the quick assessment of abdominopelvic computed tomography as a supplement to the traditional clinical reasoning process. This narrative review explores the cognitive basis of errors in reading imaging. It explains the practical use of attenuation values, contrast phases, and windowing for non-radiologists and details a multistep protocol for finding radiological cues during CT reading and interpretation. This systematic approach describes the salient features and technical tools needed to ascertain the causality between clinical patterns and abdominopelvic changes visible on CT scans from a surgeon's perspective. It comprises 16 sections that should be read successively and that cover the entire abdominopelvic region. Each section details specific radiological signs and provides clear explanations for targeted searches, as well as anatomical and technical hints. Reliance on imaging in clinical problem solving does not make a decision dichotomous nor does it guarantee success in diagnostic endeavors. However, it contributes exact information for supporting the clinical assessments even in the most subtle and intricate conditions.

Accuracy of Ultrasound and Computed Tomography in Diagnosing Acute Cholecystitis Patients in a Tertiary Care Center in Saudi Arabia

Background Acute cholecystitis (AC) is a gallbladder inflammatory disease often associated with gallbladder stones. It accounts for up to 5% of emergency department visits. The majority of patients present with pain in the right upper quadrant, Murphy's sign, and fever. Furthermore, Saudi Arabia has been noted to have a significant prevalence of AC. According to the 2018 Tokyo Guidelines, imaging is an essential element, combined with local and systemic evidence of inflammation, for a confirmed diagnosis of AC. The definitive therapy is conducted surgically by cholecystectomy either urgently or electively. However, there are insufficient studies that focus on the accuracy of imaging in diagnosing AC patients in Saudi Arabia. Objective The aim of this study is to assess the accuracy of ultrasound (US) versus computed tomography (CT) in diagnosing AC patients at King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia. Methods and material A retrospective record review was conducted at KAUH during the period of June to July 2022. The study included 192 patients diagnosed with AC in the emergency department or outpatient department by US or CT or both and confirmed by laparoscopic cholecystectomy and histopathology between 2016 and 2022. Results The most common modality used was US (79.7%), followed by both US and contrast CT (10.9%). For CT, sensitivity was 81.3%, specificity was 62.5%, positive predictive value (PPV) was 59.1%, and negative predictive value (NPV) was 83.3%. For US, sensitivity was 37.9%, specificity was 81.7%, PPV was 50%, and NPV was 73.1%. A significant relationship was observed between both genders and high use of US (P = 0.0001). Conclusion We found that CT is more sensitive than US, while US is more specific in diagnosing AC.

Effectiveness of ultrasound screening in right upper quadrant pain: A comparative study in a basic emergency service

Background and Aims

The use of ultrasound screening is primarily facilitated by point-of-care ultrasound (POCUS) and its integration into healthcare systems is a result of the versatility of this imaging technique. This study intends to compare the accuracy and pertinence of sonographic findings obtained by a sonographer in a Basic Emergency Service (BES) with that of radiologists at referral hospital (RH) in Portugal.

Methods

Twenty patients with right upper quadrant (RUQ) pain and suspected cholecystitis or biliary pathology underwent sonography screening using POCUS in the BES. They were then forwarded to the RH where a radiologist performed a conventional ultrasound exam on the same patients. The results of both exams were compared to determine if the findings obtained in the BES were confirmed by the radiologist in the RH.

Results

In our sample, 60% of cases were related to biliary pathology, 20% were liver-related, 10% had hepatopancreatic biliary etiology, and 10% had unknown etiology. A strong association between the sonographic findings in the BES and the RH was found in the variables "Sonographic Murphy sign" (V = 0.859; p = 0.001), "Cholelithiasis/Gallbladder sludge" (V = 0.840; p = 0.001), and "Intrahepatic biliary tract dilatation" (V = 0.717; p = 0.006). Adequate measures of agreement between the findings of the radiographer and radiologist were obtained for the "Sonographic Murphy sign" (k = 0.664; p = 0.001) and the presence of "Cholelithiasis/Gallbladder sludge" (k = 0.712; p = 0.000).

Conclusion

Major biliary abnormalities were detected in patients with RUQ pain in BES using sonography. The correlation between the sonographic findings obtained by the sonographers at BES and those obtained by radiologists at the RH in Portugal was strong, showing that POCUS screening could be extended to other similar settings; however, more studies are needed.

Should Procalcitonin Be Included in Acute Cholecystitis Guidelines? A Systematic Review

Background and Objectives: Acute cholecystitis (AC) is a common surgical emergency. Recent evidence suggests that serum procalcitonin (PCT) is superior to leukocytosis and serum C-reactive protein in the diagnosis and severity stratification of acute infections. This review evaluates the role of PCT in AC diagnosis, severity stratification, and management. Materials and Methods: PubMed, Embase, and Scopus were searched from inception till 21 August 2022 for studies reporting the role of PCT in AC. A qualitative analysis of the existing literature was conducted. Results: Five articles, including 688 patients, were included. PCT ≤ 0.52 ng/mL had fair discriminative ability (Area under the curve (AUC) 0.721, p < 0.001) to differentiate Grade 1 from Grade 2-3 AC, and PCT > 0.8 ng/mL had good discriminatory ability to differentiate Grade 3 from 1-2 AC (AUC 0.813, p < 0.001). PCT cut-off ≥ 1.50 ng/mL predicted difficult laparoscopic cholecystectomy (sensitivity 91.3%, specificity 76.8%). The incidence of open conversion was higher with PCT ≥ 1 ng/mL (32.4% vs. 14.6%, p = 0.013). A PCT value of >0.09 ng/mL could predict major complications (defined as open conversion, mechanical ventilation, and death). Conclusions: Current evidence is plagued by the heterogeneity of small sample studies. Though PCT has some role in assessing severity and predicting difficult cholecystectomy, and postoperative complications in AC patients, more evidence is necessary to validate its use.

Focusing in on gallbladder disease. Do current imaging modalities accurately depict the severity of final pathology?

BACKGROUND

Accuracy of imaging modalities for gallbladder disease(GBD) remains questionable. We hypothesize ultrasonography(US), computed tomography(CT), and magnetic resonance imaging(MRI) poorly correlate with final pathologic analysis.

METHODS

This was a retrospective review of all patients who underwent cholecystectomy at our institution. Primary outcome was agreement between US, CT, and MRI, and final pathology report of the gallbladder. Cohen's Kappa statistic was used to describe the level of agreement (0 = agreement equivalent to chance, 0.1-0.2 = slight agreement, 0.21-0.40 = minimal/fair agreement, 0.41-0.60 = moderate agreement, 0.61-0.80 = substantial agreement, 0.81-0.99 = near perfect agreement, 1 = perfect agreement). Significance was set at p < 0.05.

RESULTS

1107 patients were enrolled. Average age was 48.6(±17.6); 64.2% were female. There was minimal agreement between the three imaging modalities and final pathology (US = 0.363; CT = 0.223; MRI = 0.351;p < 0.001).

CONCLUSION

Poor agreement exists between imaging modalities and final pathology report for GBD. Urgent surgical intervention for patients presenting with symptoms of GBD should be considered, despite imaging results.

Prediction of extensive necrotic change in acute gangrenous cholecystitis

PURPOSE

Gangrenous cholecystitis (GC) is a severe type of acute cholecystitis that implies higher mortality and morbidity rates than uncomplicated cholecystitis. The characteristics of GC are various for each case. However, preoperative predictors of GC with extensive necrotic change have not been investigated well.

METHODS

A total of 239 patients who were pathologically diagnosed with GC underwent laparoscopic cholecystectomy at our hospital between January 2013 and December 2021. Of these, 135 patients were included in this study and were subdivided into the extensive necrosis group (patients with necrotic change extending to the neck of the gallbladder, n = 18) and the control group (patients with necrotic change limited to the fundus or body, not extending to the neck, n = 117) according to each operation video. Patient characteristics and perioperative factors predicting extensive necrotic change were investigated.

RESULTS

Pericholecystic fat stranding (83.3 vs. 53.8%, p = 0.018) and absence of wall enhancement on preoperative CT images (50.0 vs. 24.7%, p = 0.026) were significantly associated with extensive necrosis. Seven of 18 patients in the extensive necrosis group showed necrotic changes beyond the infundibulum. The absence of wall enhancement on preoperative CT images (71.4 vs. 28.8%, p = 0.018) was significantly associated with necrotic changes beyond the infundibulum.

CONCLUSIONS

Pericholecystic fat stranding and absence of wall enhancement on preoperative enhanced CT are predictors of extensive necrotic change in patients with GC. In addition, the absence of wall enhancement also predicts the presence of necrotic changes beyond the infundibulum.

The Need for Standardizing Diagnosis, Treatment and Clinical Care of Cholecystitis and Biliary Colic in Gallbladder Disease

Gallstones affect 20% of the Western population and will grow in clinical significance as obesity and metabolic diseases become more prevalent. Gallbladder removal (cholecystectomy) is a common treatment for diseases caused by gallstones, with 1.2 million surgeries in the US each year, each costing USD 10,000. Gallbladder disease has a significant impact on the logistics and economics of healthcare. We discuss the two most common presentations of gallbladder disease (biliary colic and cholecystitis) and their pathophysiology, risk factors, signs and symptoms. We discuss the factors that affect clinical care, including diagnosis, treatment outcomes, surgical risk factors, quality of life and cost-efficacy. We highlight the importance of standardised guidelines and objective scoring systems in improving quality, consistency and compatibility across healthcare providers and in improving patient outcomes, collaborative opportunities and the cost-effectiveness of treatment. Guidelines and scoring only exist in select areas of the care pathway. Opportunities exist elsewhere in the care pathway.

Hotter Than It Looks: A Retrospective Review of Patients With Cholecystitis and With Negative Imaging

INTRODUCTION

Ultrasound is the gold standard for workup of cholecystitis in the emergency department, and findings heavily influence clinical decision-making. Patients with negative imaging for acute cholecystitis may be inappropriately sent home. The purpose of our study was to review the pathology and outcomes of patients presenting with biliary pain and negative ultrasound findings of acute cholecystitis.

MATERIALS AND METHODS

Emergency department patients who underwent laparoscopic cholecystectomy between January 2015 and February 2019 were reviewed retrospectively. Only patients with negative or equivocal imaging were included. The primary outcome was the incidence of cholecystitis on final pathology.

RESULTS

Two hundred fifty-seven patients underwent laparoscopic cholecystectomy. Pathology demonstrated cholecystitis in 84% of patients. Only 15% of patients had cholelithiasis without cholecystitis on pathology. The incidence of cholecystitis was similar in negative and equivocal imaging groups (84% versus 83%; P = 0.960). The median time from admission to the operating room was 12.1 h (interquartile range 7.1-18.3 h), and hospital length of stay was 1.2 d (interquartile range 0.8-1.7 d).

CONCLUSIONS

This study found that patients with negative or equivocal imaging had cholecystitis on pathology. On review of patient outcomes, those patients who underwent surgical intervention had a low rate of complications and short hospital stay.

A Potential Pitfall in POCUS of the Gallbladder: Beware of the Duodenum

It is estimated that 20 million people in the United States have gallbladder disease. Of the patients who present to the Emergency Department (ED) with abdominal pain, 3-10% have acute cholecystitis. Point-of-care ultrasound (POCUS) evaluation of the biliary system is a valuable tool to diagnose gallbladder disease and can greatly expedite the diagnostic evaluation of patients. One source of error in POCUS of the gallbladder is imaging nearby structures that can mimic the gallbladder, such as the duodenum.

The imaging diagnosis of cholecystitis in the adult ED: a comparative multi-reader, multivariable analysis of CT and US image features

PURPOSE

The purposes of this study are (1) to utilize multivariable logistic regression in order to evaluate which image feature combination is most predictive in the diagnosis of cholecystitis for computed tomography (CT) and ultrasound (US) in adult ED patients and (2) to use these results to compare the accuracy of CT and US.

METHODS

For RUQ pain patients undergoing US and CT at the same visit, multiple image features were evaluated independently by 2 radiologists blinded to additional data. Inter-reader variability was measured with the Kappa statistic. Sonographic Murphy's sign (SMS) information was obtained from original reports. Multivariable logistic regression was utilized to develop optimal predictive models for each modality. For US, models with/without SMS were compared to establish its relative value.

RESULTS

446 patients met inclusion criteria. For CT, the combination of cholelithiasis, short-axis gallbladder diameter > 3 cm, pericholecystic fluid or inflammation, and mural thickening > 3 mm provided the optimal model for both readers. For US, the optimal model included cholelithiasis, short-axis diameter > 3 cm, mural heterogeneity/striation, and sludge/debris for both readers. Kappa = 0.79-0.96 for included image features. For both readers, CT and US models had equivalent diagnostic performances; the SMS did not contribute significantly to US models.

CONCLUSION

For a diagnosis of cholecystitis in the ED, (1) the optimal image feature combination for CT is cholelithiasis, short-axis diameter > 3 cm, pericholecystic fluid or inflammation, mural thickening > 3 mm; and cholelithiasis, short-axis diameter > 3 cm, mural heterogeneity/striation, sludge/debris for US; (2) CT and US have equivalent diagnostic performance; (3) inter-reader reliability is substantial to excellent for utilized image features; (4) the SMS does not affect US model accuracy.

Cystic artery velocity as a predictor of acute cholecystitis

PURPOSE

To evaluate angle-corrected peak systolic cystic artery velocity (CAv) as a predictor of acute cholecystitis among patients presenting to the emergency department (ED) with right upper quadrant (RUQ) pain.

METHODS

In this IRB-approved and retrospective study, CAv was evaluated in 73 patients, 43 who underwent definitive treatment with cholecystectomy or percutaneous cholecystostomy and 30 control patients without clinical suspicion for cholecystitis. In addition to CAv, the following were reviewed by 3 radiologists: CBD diameter, cholelithiasis, impacted stone in the neck, sludge, gallbladder wall thickness > 3 mm, gallbladder transverse dimension ≥ 4 cm, longitudinal dimension ≥ 8 cm, tensile gallbladder fundus sign, pericholecystic fluid, pericholecystic echogenic fat, and sonographic Murphy sign.

RESULTS

Of the 43 patients who underwent definitive treatment, 25 had acute cholecystitis (34%) and 18 (25%) had chronic cholecystitis. Average CAv measurements were 50 ± 16 cm/s (acute), 28 ± 8 cm/s (chronic), and 22 ± 8 cm/s (control; p < 0.0001). In univariate analysis, among patients who underwent definitive therapy, CAv ≥ 40 cm/s, gallbladder wall thickness, stone impaction, GB long dimension ≥ 8 cm, and elevated WBC were associated with acute cholecystitis (p < 0.05). In multivariate analysis, CAv ≥ 40 cm/s was the only statistically significant variable (p = 0.016). CAv ≥ 40 cm/s alone had a PPV of 94.7% and overall accuracy of 81.4% in diagnosing acute cholecystitis.

CONCLUSION

CAv ≥ 40 cm/s is highly associated with acute cholecystitis in patients presenting to the ED with RUQ pain.

Point-of-care ultrasound for evaluating intra-abdominal calcification in the pediatric emergency department: case series and review of literature

Background

The presence of intra-abdominal calcification in the pediatric population can be due to a wide range of conditions. Calcification in the abdomen can be seen in normal or abnormal anatomical structures. In some patients, abnormal calcification points towards the pathology; whereas in others, calcification itself is the pathology. After a thorough history and clinical examination, point-of-care ultrasound (POCUS) would complement the assessment of acute abdominal pain, based on the list of differentials generated as per the abdominal region. The main objective of this article is to review commonly encountered causes of intra-abdominal calcifications in the pediatric population and help in clinical decision-making in a Pediatric Emergency Department.

Case presentation

We describe a series of pediatric patients who presented to the Pediatric Emergency Department with acute abdominal pain, in whom point-of-care ultrasound helped expedite the diagnosis by identifying varying types of calcification and associated sonological findings. For children who present to the Pediatric Emergency Department with significant abdominal pain, a rapid distinction between emergencies and non-emergencies is vital to decrease morbidity and mortality.

Conclusions

In a child presenting to the Pediatric Emergency Department with abdominal pain, POCUS and the findings of calcifications can narrow or expand the differential diagnosis when integrated with history and physical exam, to a specific anatomic structure. Integrating these findings with additional sonological findings of an underlying pathology might raise sufficient concerns in the emergency physicians to warrant further investigations for the patient in the form of a formal radiological ultrasound and assist in the patient's early disposition. The use of POCUS might also help to categorize the type of calcification to one of the four main categories of intra-abdominal calcifications, namely concretions, conduit wall calcification, cyst wall calcification, and solid mass-type calcification. POCUS used thoughtfully can give a diagnosis and expand differential diagnosis, reduce cognitive bias, and reduce physician mental load. By integrating the use of POCUS with the history and clinical findings, it will be possible to expedite the management in children who present to the Pediatric Emergency Department with acute abdominal pain.

Utility of ultrasound after a negative CT abdomen and pelvis in the emergency department

PURPOSE

The purpose of this study is to assess the utility of an abdominal and/or pelvic ultrasound (US) performed within 24 h after a negative CT of the abdomen and pelvis (CTAP) in the emergency department (ED). The secondary endpoint is to assess whether there is a significant increase in length of stay (LOS) in the ED due to immediate US reimaging.

METHOD

We reviewed the imaging reports of 335 patients over the course of 3 years in our ED who had an US within 24 h after a negative CTAP. We then assessed type of US and whether the US showed any acute findings. We also evaluated LOS in the ED.

RESULTS

Out of 335 patients, there were only three US cases suspicious for acute surgical pathology (3/335 or 0.9%). On 30-day clinical follow-up, only one of the three cases was confirmed as cholecystitis on pathology. The most common non-surgical findings on US not initially reported on CTAP were ovarian cysts (29/83) and gallstones (9/83). Additionally, the LOS for patients who received both a CTAP and US was 119 min longer than patients who only received a CTAP.

CONCLUSION

US abdomen and/or pelvis reimaging within 24 h following a negative CTAP is unlikely to change surgical management in the acute setting. US reimaging can still be useful in diagnosing non-surgical pathology, which could serve to explain the patient's pain. US reimaging after negative CTAP is associated with an average increase in the ED LOS.

General Pediatric Clinical Applications of POCUS: Part 1

The use of point-of-care ultrasound (POCUS) performed by non-radiologists has become more widespread and is entering new arenas of clinical care. Children in particular are prime candidates for ultrasound, as they are both usually thinner than adults and are particularly at risk from the harmful effects of ionizing radiation. In this two-part article, we propose 10 uses of POCUS that pediatricians can apply to their practice in both inpatient and outpatient settings. [Pediatr Ann. 2020;49(3):e147-e152.].

Accuracy of Right Upper Quadrant Ultrasound in Estimating Gallbladder Wall Thickness

OBJECTIVE

Ultrasound (US) evaluation of biliary pathology can be influenced by a variety of factors. This study examines the effect of patient specific factors on the accuracy of sonographic evaluation of gallbladder wall thickness (GBW).

METHODS

We performed a retrospective review of all patients who underwent cholecystectomy at a single institution from November 2012 to October 2015. GBW measured on US was compared with pathology results. Results were analyzed in relation to patient specific factors to include BMI, age, presence of diabetes, sex, and urgent versus elective cases.

RESULTS

In total 601 patients underwent cholecystectomy, 484 of which had paired preoperative US GBW measurement and postoperative pathologic specimen measurement. No significant difference in accuracy or precision of US measurement of the GBW based on BMI was found. Accuracy was not related to age, sex, urgency, or diabetes. Precision decreased with pathologic thickening, age, male sex, and urgent case performance.

CONCLUSIONS

US is accurate in measuring GB wall thickness regardless of patient specific factors. A nonsignificant trend exists with decreased precision with pathologic thickening, age, male sex, and urgently performed cases.

Deuxième niveau de compétence pour l’échographie clinique en médecine d’urgence. Recommandations de la Société française de médecine d’urgence par consensus formalisé

La Société française de médecine d’urgence a élaboré en 2016 des recommandations formalisées d’experts définissant le premier niveau de compétence en échographie clinique en médecine d’urgence. Ce niveau est maintenant complété par un deuxième niveau correspondant à une pratique plus avancée utilisant des techniques non envisagées dans le premier niveau comme l’utilisation du Doppler et nécessitant aussi une pratique et une formation plus poussées. Des champs déjà présents dans le premier référentiel sont complétés, et de nouveaux champs sont envisagés. La méthodologie utilisée est issue de la méthode « Recommandations par consensus formalisé » publiée par la Haute Autorité de santé et de la méthode Delphi pour quantifier l’accord professionnel. Ce choix a été fait devant l’insuffisance de littérature de fort niveau de preuve dans certaines thématiques et de l’existence de controverses. Ce document présente les items jugés appropriés et inappropriés par les cotateurs. Ces recommandations définissent un deuxième niveau de compétence en ECMU.

Clinical characteristics of patients with newly developed acute cholecystitis after admission to the intensive care unit

INTRODUCTION

Critical care patients have many risk factors for acute cholecystitis (AC). However, less data are available regarding newly developed AC in critically ill patients.

OBJECTIVES

To investigate the clinical features of AC occurring in critically ill patients after admission to an intensive care unit (ICU).

METHODS

We performed a retrospective cohort study from January 2006 to August 2016 at a tertiary care university hospital. We included patients diagnosed with AC with or without gallstones after ICU admission. All cases of AC were confirmed by gastroenterologists or general surgeons. We excluded patients with AC diagnosed before or at the time of ICU admission.

RESULTS

A total of 38 patients were diagnosed with AC after ICU admission between January 2006 and August 2016. Seventeen (44.7%) had acute acalculous cholecystitis, while 21 (55.3%) had acute calculous cholecystitis. The median age was 73 years (interquartile range = 63-81 years), and 22 (57.9%) patients were male. The most common reason for ICU admission was pneumonia or sepsis. The median interval from ICU admission to diagnosis of AC was 11 days (interquartile range = 4.8-22.8 days). Before AC diagnosis, almost 90% of patients used total parenteral nutrition, 68% used opioids, 76% were mechanically ventilated, and 42% received vasoactive drugs. More than half of patients underwent cholecystectomy, and all surgically resected gallbladders had pathology results for cholecystitis. Gangrenous cholecystitis was observed in five patients with acute calculous cholecystitis. The overall mortality was 42.1%, and 1/3 of these deaths were directly associated with AC. The average length of stay in the ICU and hospital was 26.5 and 44.5 days, respectively.

CONCLUSION

The development of AC in the ICU should be carefully monitored, especially in patients who have been infected and admitted to the ICU for more than 10 days. Proper diagnosis and treatment at a critical time could be lifesaving.

Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis (with videos)

The Tokyo Guidelines 2013 (TG13) for acute cholangitis and cholecystitis were globally disseminated and various clinical studies about the management of acute cholecystitis were reported by many researchers and clinicians from all over the world. The 1^st edition of the Tokyo Guidelines 2007 (TG07) was revised in 2013. According to that revision, the TG13 diagnostic criteria of acute cholecystitis provided better specificity and higher diagnostic accuracy. Thorough our literature search about diagnostic criteria for acute cholecystitis, new and strong evidence that had been released from 2013 to 2017 was not found with serious and important issues about using TG13 diagnostic criteria of acute cholecystitis. On the other hand, the TG13 severity grading for acute cholecystitis has been validated in numerous studies. As a result of these reviews, the TG13 severity grading for acute cholecystitis was significantly associated with parameters including 30-day overall mortality, length of hospital stay, conversion rates to open surgery, and medical costs. In terms of severity assessment, breakthrough and intensive literature for revising severity grading was not reported. Consequently, TG13 diagnostic criteria and severity grading were judged from numerous validation studies as useful indicators in clinical practice and adopted as TG18/TG13 diagnostic criteria and severity grading of acute cholecystitis without any modification. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

Role of Procalcitonin in Evaluation of the Severity of Acute Cholecystitis

OBJECTIVE

The aim of this study is to investigate the relationship between procalcitonin (PCT) level and the severity of acute cholecystitis.

MATERIALS AND METHODS

This study included 200 patients diagnosed with acute cholecystitis. To diagnose and assess the severity of acute cholecystitis; physical examination and abdominal ultrasound findings were evaluated and blood samples were taken to determine white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), and levels of coagulation factors, blood gas, C-reactive protein (CRP) and PCT. Patients were classified into three stages, namely, mild, moderate, and severe, according to the severity of acute cholecystitis using the Tokyo guidelines. The role of PCT level in the assessment of severity of acute cholecystitis and the correlation between the stages and PCT level were statistically analyzed.

RESULTS

Among patients with acute cholecystitis, 110 (55%) were classified as mild, 61 (30.5%) as moderate, and 29 (14.5%) as severe. Leukocytosis or leukopenia was positive in 48.5%, ESR elevation was found in 72.5%, CRP positivity in 55.5%, PCT elevation in 27%, and positive findings of ultrasonographic imaging in 54.5% of the patients. Serum WBC count, ESR, and CRP and PCT levels increased as the severity of disease increased (p<0.05). PCT could discriminate grade I from grade II-III with 95.45% sensitivity and 46.67% specificity at the best cut-off value of ≤0.52 (p<0.001). PCT could also discriminate grade III from grade I-II with 72.4% sensitivity and 90.06% specificity at the best cut-off value of >0.8 (p<0.001).

CONCLUSION

PCT level may be considered to be a parameter that could be added to the assessment of the severity of acute cholecystitis in the Tokyo guidelines, although further studies are needed to support our findings.

Signal Intensity of Superb Microvascular Imaging Correlates with the Severity of Acute Cholecystitis

Evaluation of the severity of acute cholecystitis is critical for the management of this condition. Superb microvascular imaging (SMI) enables the assessment of slow blood flow of small vessels without any contrast medium. An 84-year-old man visited our hospital with right upper abdominal pain. Computed tomography and abdominal ultrasonography showed a slight thickening of the gallbladder. White blood cell count and C-reactive protein levels were elevated. He was diagnosed with acute cholecystitis and treated conservatively with antibiotics. Two days later, his condition worsened and percutaneous transhepatic gallbladder drainage (PTGBD) was performed. The patient recovered and was discharged, and his drainage was withdrawn 7 days later. On admission, color-coded SMI (cSMI) showed pulsatory signals on the slightly thickened gallbladder wall. On the day of PTGBD, the intensity of the signal on cSMI had increased. Once the patient was cured, no further signal was observed on the gallbladder wall with either cSMI or mSMI. In conclusion, the strong pulsatory signal correlated with the severity of acute cholecystitis observed with cSMI and mSMI. Illustrating the signal intensity is useful for the evaluation of the severity of acute cholecystitis.

2016 WSES guidelines on acute calculous cholecystitis

Acute calculus cholecystitis is a very common disease with several area of uncertainty. The World Society of Emergency Surgery developed extensive guidelines in order to cover grey areas. The diagnostic criteria, the antimicrobial therapy, the evaluation of associated common bile duct stones, the identification of “high risk” patients, the surgical timing, the type of surgery, and the alternatives to surgery are discussed. Moreover the algorithm is proposed: as soon as diagnosis is made and after the evaluation of choledocholitiasis risk, laparoscopic cholecystectomy should be offered to all patients exception of those with high risk of morbidity or mortality. These Guidelines must be considered as an adjunctive tool for decision but they are not substitute of the clinical judgement for the individual patient.

Update on bedside ultrasound (US) diagnosis of acute cholecystitis (AC)

Acute cholecystitis (AC) represents a principal cause of morbidity worldwide and is one of the most frequent reasons for hospitalization due to gastroenteric tract diseases. AC should be suspected in presence of clinical signs and of gallstones on an imaging study. Upper abdominal US represents the first diagnostic imaging step in the case of suspected AC. Computed tomography (CT) with intravenous contrast (IV) or magnetic resonance imaging (MRI) with gadolinium contrast and technetium hepatobiliary iminodiacetic acid (Tc-HIDA) can be employed to exclude complications. US examination should be performed with right subcostal oblique, with longitudinal and intercostal scans. Normal gallbladder US findings and AC major and minor US signs are described. Polyps, sludge and gallbladder wall thickening represent the more frequent pitfalls and they must be differentiated from stones, duodenal artifacts and many other non-inflammatory conditions that cause wall thickening, respectively. By means of bedside ultrasound, the finding of gallstones in combination with acute pain, when the clinician presses the gallbladder with the US probe (the sonographic Murphy's sign), has a 92.2 % positive predictive value for AC. In our preliminary experience, bedside US-performed by echoscopy (ES) and/or point-of-care US (POCUS) demonstrated good reliability in detecting signs of AC, and was always integrated with physical examination and performed by a skilled operator.

Sonographic diagnosis of acute cholecystitis in patients with symptomatic gallstones

PURPOSE

The aim of the retrospective study was to assess the diagnostic ultrasound (US) criteria for acute cholecystitis in patients admitted for symptomatic gallbladder stones.

METHODS

The medical records of 186 patients who had undergone cholecystectomy within 24 hours after an US examination were reviewed. Acute cholecystitis was defined on the basis of pathology findings. The correlation between standardized US signs and final diagnosis of acute cholecystitis was assessed with univariate and multivariate analyses. The diagnostic values of US based on the correlated signs were then calculated.

RESULTS

The prevalence of acute cholecystitis was 52.7% (95% confidence interval [CI], 42.8-64.2). Three US signs were found to be predictive of acute cholecystitis: gallbladder distension, wall edema, and pericholecystic fluid collection. When none of the US signs were registered, sonography proved to have a 72.4% (95% CI, 59.1-83.3) negative predictive value. When registering two or three signs, sonography had positive predictive values of 78% (95% CI, 56.3-92.5) and 100% (95% CI, 58.9-100), respectively. With just one sign, the positive predictive value was 57.6% (95% CI, 47.2-67.4), and such a finding was furthermore observed in only 53.2% of the cases.

CONCLUSIONS

The sonografic diagnosis of acute cholecystitis may be achieved by registering only three standardized US signs. Nevertheless, in patients admitted for symptomatic gallstones, US is of some utility in less than half of those patients.

Computed Tomography Is More Sensitive than Ultrasound for the Diagnosis of Acute Cholecystitis

BACKGROUND

Ultrasound (US) is the first-line diagnostic study for evaluating gallstone disease and is considered the test of choice for diagnosing acute cholecystitis (AC). However, computed tomography (CT) is used widely for the evaluation of abdominal pain and is often obtained as a first abdominal imaging test, particularly in cases in which typical clinical signs of AC are absent or other possible diagnoses are being considered. We hypothesized that CT is more sensitive than US for diagnosing AC.

METHODS

A prospective registry of all urgent cholecystectomies performed by our acute care surgery service between June 2008 and January 2014 was searched for cases of AC. The final diagnosis was based on operative findings and pathology. Patients were classified into two groups according to pre-operative radiographic work-up: US only or CT and US. The US group was compared with the CT and US group with respect to clinical and demographic characteristics. For patients undergoing both tests the sensitivity of the two tests was compared.

RESULTS

One hundred one patients with AC underwent both US and CT. Computed tomography was more sensitive than US for the diagnosis of AC (92% versus 79%, p=0.015). Ultrasound was more sensitive than CT for identification of cholelithiasis (87% versus 60%, p<0.01). Patients undergoing both tests prior to surgery were more likely to be older, male, have medical comorbidities, and lack typical clinical signs of AC.

CONCLUSIONS

Computed tomography is more sensitive than US for the diagnosis of AC and is most often used in patients without typical clinical signs of AC.

C-reactive protein has a better discriminative power than white cell count in the diagnosis of acute cholecystitis

BACKGROUND

The diagnosis of acute cholecystitis (AC) is challenging and may result in a delay in surgery, hospital discharge, and increased mortality. To improve its diagnosis, C-reactive protein (CRP) has been proposed as a benchmark. The aim of this study was to evaluate discriminative power of CRP against white cell count (WCC) in AC.

METHODS

This was a retrospective cohort study. Over a 5-y period, 1959 patients were identified from the audit of cholecystectomies. The exclusion criteria were coexisting acute surgical conditions, absence of blood tests within 3 d before hospital admission for elective surgery, and private patients.

RESULTS

The eligibility criteria were met by 1843 patients. Comparison of the area under receiver operating characteristic (AUC) curve of CRP and WCC in acute on chronic, edematous, necrotic, suppurative, and gangrenous AC showed a better discriminative power of CRP. Both tests performed equally well in patients with pericholecystic abscess and gallbladder perforation. CRP was superior than WCC in mild AC, AUC = 0.93 (95% confidence interval [CI], 0.9-0.95) and 0.79 (95% CI, 0.74-0.84), P < 0.00005, in moderate and severe AC, AUC = 0.99 (95% CI, 0.97-1.0) and 0.92 (95% CI, 0.88-0.97), P = 0.009, and in all forms of AC combined, AUC = 0.94; (95% CI, 0.92-0.97) and 0.83 (95% CI, 0.79-0.87), respectively, P < 0.00005.

CONCLUSIONS

CRP has a better discriminative power than WCC in most forms of AC and is a useful diagnostic marker of AC.

Clinical effects of compound azintamide enteric-coated tablets in treatment of cholecystitis patients with post-surgery dyspepsia

AIM: To investigate the clinical effects of compound azintamide enteric-coated tablets in the treatment of cholecystitis patients with post-surgery dyspepsia.

METHODS: Sixty cholecystitis patients with post-surgery dyspepsia treated at our hospital were randomly divided into either a study group or a control group, with 30 cases in each group. The study group was given compound azintamide enteric-coated tablets, 150 mg each time, three times per day for 4 wk, and the control group was given matched placebo. The overall symptom score, the total rate of dyspepsia relief and the total score of SF-NDI scale were compared between the two groups before and after treatment.

RESULTS: The overall symptom score and dyspepsia score did not differ significantly between two groups of patients before treatment (P > 0.05). After 28 days of treatment, the scores of dyspepsia symptoms such as anorexia, early satiety, belching, abdominal pain or discomfort and the overall symptom were significantly lower in the study group than in the control group (P < 0.05). Although the total rate of dyspepsia relief at one week after treatment showed no significant difference between the two groups (P > 0.05), the rates at 2, 3, and 4 wk were significantly higher in the study group than in the control group (P < 0.05). The total score of the SF-NDI scale showed no significant difference between the two groups before treatment, 7 d or 14 d after treatment (P > 0.05), but was significantly lower on 21 d and 28 d in the study group than in the control group (P < 0.05).

CONCLUSION: Compound azintamide enteric-coated tablets can effectively improve symptoms and life of quality in cholecystitis patients with post-surgery dyspepsia.