Emergency Radiology (2004) 10: 256258 DOI 10.

1007/s10140-004-0325-8

O R I GI N A L A R T IC L E

Mohammad Alobaidi Rahul Gupta Syed Z. Jafri Darlene M. Fink-Bennet

Current trends in imaging evaluation of acute cholecystitis

Received: 14 November 2003 / Accepted: 26 December 2003 / Published online: 17 March 2004 ASER 2004

Abstract This study was designed to retrospectively determine recent clinical trends of initial radiological evaluation in patients pathologically proven to have acute cholecystitis (AC) and to assess the methodology that led to its diagnosis. Over a 28-month period, the medical records and imaging studies of 117 consecutive patients who had pathologically conrmed AC were retrospectively analyzed. The sensitivities of ultrasound (US) and hepatobiliary 99mTc-iminodiacetic acid (HIDA) were computed. The false-negative scans were retrospectively reviewed by a blinded radiologist to determine the limitations and advantages of each modality. The 117 patients were grouped into six categories based on the type of imaging examination they underwent prior to cholecystectomy: initial US evaluation only (n=80, 68.4%), initial US followed by HIDA (n=17, 14.5%), initial HIDA only (n=2, 1.7%), initial HIDA followed by US (n=3, 2.6%), initial CT (n=5, 4.3%), and no imaging evaluation (n=10, 8.6%). HIDA scan had a calculated sensitivity of 90.9% (20 truepositive, 2 false-negative) while US had a sensitivity of 62% (62 true-positive, 38 false-negative). Current practice in the initial radiological evaluation of acute cholecystitis remains outdated. The vast majority of patients in our study group were initially worked up using US, although HIDA scan has been shown to have greater sensitivity for the diagnosis of acute cholecystitis. Keywords Cholecystitis Gallbladder Ultrasound HIDA (hepatobiliary 99mTc-iminodiacetic acid) Gallstones
M. Alobaidi (&) R. Gupta S. Z. Jafri Department of Diagnostic Radiology, William Beaumont Hospital, 3601 West 13 Mile Road, Royal Oak, MI 48073, USA E-mail: mf7377@hotmail.com Tel.: +1-248-5515000 D. M. Fink-Bennet Department of Nuclear Medicine, William Beaumont Hospital, 3601 West 13 Mile Road, Royal Oak, MI 48073, USA

Introduction
The evaluation of a patient who presents with suspected acute cholecystitis (AC) requires the physician not only to understand the clinical presentation and laboratory data, but also to apply an appropriate radiological protocol to establish a standard of care. The diagnosis of AC can sometimes be a challenge, as both cholelithiasis and AC can present with right upper quadrant abdominal pain, particularly if other clinical ndings of AC such as fever and elevated white blood cell count are not present. No single clinical nding or laboratory test can suciently establish or exclude acute cholecystitis without further imaging. Generally, the use of imaging tools such as ultrasound (US), hepatobiliary 99mTc-iminodiacetic acid (HIDA) scan, computed tomography (CT), and magnetic resonance cholangiography has had a positive diagnostic impact on the evaluation of such patients. There is an abundance of published data comparing the diagnostic value of the various imaging modalitiesmost commonly US and HIDAin the evaluation of AC and the recommendations for initial work-up for patients with suggestive clinical ndings. However, discrepancies remain in practice. While Johnson and Cooper [1] suggested that HIDA oers high sensitivity (94%) but low specicity (36%), is costly, and should be eliminated as the initial evaluation of patients for AC, the majority of other studies overwhelmingly suggest the opposite. HIDA has been found to be 86100% sensitive and 94100% specic [2, 3, 4] for AC. When compared to US, with a reported accuracy of 77%, HIDA has been shown to provide 92% accuracy in diagnosing AC [5]. In particular, evidence suggests that HIDA is expeditious, safe, and simple, particularly in the initial emergency room evaluation, and should be used as the rst diagnostic modality [2, 6, 7]. We retrospectively reviewed our own institutions data to determine our own trend in evaluating gallbladder disease.

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This study was designed to provide a general scope of the current clinical practice in our institution regarding the initial radiological evaluation of patients who were retrospectively found to have pathologically proven AC, and to assess the methodology that led to its diagnosis.

Methods
A database consisting of patients pathologically proven to have AC was generated from our institution for a recent 28-month time period between 15 November 1999 and 20 March 2002. One hundred and seventeen patients had pathologically conrmed AC. Review of 110 patients who had documented symptoms recorded in their medical records revealed that the most common symptoms were right upper quadrant or middle abdominal pain (n=98), fever (n=90), and nausea/vomiting (n=72). The 117 patients were made up of 46 males and 71 females; age range was 693 years (mean age 59.7 years). The medical record of each patient was collected to retrospectively gather data on the patients age, sex, presenting symptoms, the imaging modality utilized initially and the timeframe, secondary imaging ndings, imaging diagnosis, and surgical/pathological ndings. The 117 patients were stratied into six categories based on the type of imaging modality they were evaluated with prior to surgery: initial US evaluation only, initial US followed by HIDA, initial HIDA only, initial HIDA followed by US, initial CT, and no imaging evaluation. Five US criteria were used to describe the presence of AC: sonographic Murphys sign, gallbladder wall thickening (gallbladder wall >3 mm), pericholecystic uid, intra- or extrahepatic biliary dilatation, and gallbladder hydrops (transverse diameter >5 cm). Major criteria are gallbladder wall thickening, sonographic Murphys sign, and pericholecystic uid; minor criteria are gallbladder distention and biliary dilatation. The diagnosis of AC was made using two major criteria or one major plus two minor criteria. The HIDA scan criteria of AC include persistent nonvisualization of the gallbladder 3 h after administration of radiotracer or 30 min after morphine sulfate (0.04 mg/kg) augmentation. As a control, the false-negative US scans were collected and given to a blinded radiologist to review together with 40 additional random true-positive scans of the 62 true-positives from the same study group. The 40 true-positives served as the control against bias of nal imaging diagnosis. The 78 interpretations were performed over a 2-day consecutive period with no distinction made between the two groups. Correlations to surgical and pathological outcomes were then compared to compute the sensitivity of US and HIDA, as well as determination of the initial clinical work-up methodology that led to the nal diagnosis of AC. The false-negative studies were then reviewed by a blinded radiologist without prior knowledge of the nal surgical or pathological outcomes, together with 40 truepositives as a control. A corrected sensitivity was then calculated based on limiting factors relating to the date of imaging versus the date of surgery and based on equivocal imaging reports by the use of disclaimers.

other ndings on US. Another patient was considered a true-positive in retrospect because he had an equivocal US report describing the presence of a calculus and gallbladder wall thickening but without a denite nal US diagnosis, and was recommended for follow-up study with HIDA. In this patient, the report should have been phrased more strongly for AC; thus, he too was not considered a true false-negative. Two patients were excluded because of the time interval between the imaging studies and the cholecystectomy. The rst of these had an initial negative US scan followed by a positive HIDA study and surgery 7 days later. The second had an initial negative US scan followed by cholecystectomy 1 month later. These 2 patients had to be excluded because the US scans were separated by a large time interval from the nal surgery, so there was no way of knowing whether the US scans were truly false-negative or whether the patients developed acute cholecystitis between the scan and their second presentation with symptoms. In total, 9 additional patients were considered true-positive for AC, while 2 were excluded from the calculation. The true US sensitivity was recalculated to be 70.4% (69 true-positive, 29 falsenegative). Therefore, even in retrospect, there were 29 patients who had pathologically proven AC but with no ndings to support the presence of AC on US.

Discussion
Accurate preoperative diagnosis of AC is important as early timing of laparoscopic cholecystectomy has been shown to reduce complications and rates of conversion to open cholecystectomy [8]. HIDA scan has repeatedly been shown to be the study of rst choice for evaluating a patient with AC as it is safe, simple, and highly accurate and sensitive [2, 3, 4, 5, 6, 9]. Yet, as a simple observation, we realized that emergency room clinicians and surgeons currently prefer US as the standard of practice for initial evaluation of suspected AC. In reviewing 117 patients with pathologically proven AC during a 28-month period, we retrospectively found that 97 (82.9%) were initially evaluated with US. Yet, in our study, US had a sensitivity of 62% and no better than 70.4%, even in retrospect. The sensitivity of HIDA scan, on the other hand, was 90.9%, which correlates well with earlier published studies [2, 3, 4] stating that HIDA has been found to be 86100% sensitive for AC. Patients who present with clinical ndings suggestive of AC often undergo one or more imaging studies prior to surgery. Only 10 (8.6%) of the 117 patients in this study underwent surgery based on clinical exam and laboratory data alone. This is not taking into account all the true-negative patients who underwent cholecystectomy in that 28-month time period on whom we did not collect data. The most common nding of the US scans that were false-negative for AC was the presence of a calculus (n=27) without other secondary ndings to support the diagnosis of AC. In retrospect, of the

Results
In the control group of 40 patients, there was 100% concordance to the 40 true-positive studies, retrospectively. In the study group, 7 additional cases of AC were diagnosed in retrospect from the 38 original false-negatives. One patient among the 38 with false-negative studies was considered a true-positive because he was a variant case, having a sonographic Murphys sign but no

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original 38, 9 false-negative studies were reclassied as true-positives and included in recalculating the sensitivity of US on the basis of presumed initial observer error. Of these 9, supporting signs for AC included wall thickening (n=5), positive sonographic Murphys sign (n=1), biliary dilatation (n=1), and hydrops (n=2). At best, even taking into account initial observer error, the recalculated US sensitivity was only 70.4%, compared to our calculated HIDA sensitivity of 90.9%. The remaining 27 patients (after 2 exclusions for time discrepancies) had only calculi (n=16) or no abnormal ndings (n=11). In retrospect, even in these 27 patients, US could not conrm AC even though it was proven clinically, surgically, and pathologically to be present. The study is inherently limited by uncontrolled variables. An obvious weakness is the retrospective, observational nature of the study. Additional possible sources of error are as follows. First, the presence of acalculous cholecystitis certainly contributes to the possible variability. Some patients with pathologically proven AC had other ndings on US to support the diagnosis of AC, but without the presence of gallstones. A second source of variation is the technicians ability to elicit a Murphys sign. It may be that knowledge varies as to what a Murphys sign is or how to perform it properly. Kendal et al. [10] reported that the emergency physicians detection of sonographic Murphys sign was more sensitive than the sonographers detection. Given that US exams are performed by multiple sonographers, the sensitivity of the Murphy sign and quality of exam can vary, especially in patients who receive pain medications prior to scanning. In addition, the actual technique of US is more operator-dependent, whereas the HIDA injection and imaging technique is more objective. In fact, the two study methods are very dierent in that US looks at purely anatomical features, whereas the HIDA scan is more a test of organ function. Obviously, a larger prospective, randomized study would be desirable to assess the statistical signicance of the results and ascertain whether the advantage of HIDA remains signicant in a larger group. Although the present results are impressive in favor of HIDA, they must be interpreted with caution as there were small numbers of patients in the HIDA arm. In addition, practical considerations remain as to the availability of a HIDA scan in after-hours emergency evaluation. Lastly, one should be cautious about using the HIDA scan in women of childbearing age, especially those who have recently missed a menstrual period, as it does involve radiation exposure. In the recent surgical literature, Kalimi et al. [2] state that the HIDA scan is more sensitive than US in diagnosing patients with AC. They recommend HIDA scan as the rst diagnostic modality for patients with suspected AC and that US may be used to conrm the presence of gallstones rather than to diagnose AC. Based on our study population and as a point of practicality, we recommend that if US is to be utilized rst as a screening test for gallstones, the presence of gallstones alone and lack of other ndings on US should not deter

the clinician from further pursuing the workup of suspected AC with a HIDA scan. Although HIDA scan has been in use for a long time and its higher sensitivity is well documented, our imaging trends show that its acceptance seems to be limited. In a review of 195 patients with suspected AC, Freitas et al. [11] concluded that scintigraphy has a sensitivity of 98.3%, compared to US which has a sensitivity of 81.4%, and that scintigraphy should be the procedure of choice for the rapid detection of AC. In a more recent study, Chatziioannou et al. [12] reviewed 107 consecutive patients who underwent studies by both imaging modalities. The accuracy of scintigraphy was 91% compared to 77% for US. Although the HIDA scan has some limitations, including the false-positive rate caused by chronic cholecystitis [13] and fasting, with regard to the timely and accurate diagnosis of cholecystitis in the patient who presents in the acute state, HIDA scan has been shown to outperform US time and time again. However, as a simple observation which was conrmed by studying our own recent imaging trends, US still appears to be the more popular initial choice for suspected AC.

References
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