David Link, MS4
Article: Bingener, Juliane, et. al, “Does the correlation of acute cholecystitis on ultrasound and at surgery reflect a mirror image?”, The American Journal of Surgery 2004; 188: 703-707.
Background: For more than 40 years, ultrasound has been used as a tool to diagnose gallstones with high sensitivity. However, few studies have been done to evaluate its diagnostic value in cases of cholecystitis. This study compares preoperative findings on ultrasound to pathology seen in the operating room to determine the utility of ultrasound in the diagnosis of cholecystitis.
The Study: A prospective, single center study between February and September of 2002
Inclusion Criteria: Unrelenting RUQ pain or tenderness with or without, fever, elevated WBC count, or persistent nausea and vomiting that was clinically felt to warrant urgent cholecystectomy.
Exclusion Criteria: Pathology not felt to warrant urgent cholecystectomy
Methods: The presence of cholelithiasis, pericholecystic fluid, gallbladder distension, or a sonographic murphy’s sign were documented by trained radiologists reading still ultrasound images. The number of stones, wall thickness, and overall diagnosis of acute cholecystisis was also recorded. Surgery took place within 48 hours, and the operative findings were noted on a survey sheet in the operating room. The fresh gallbladder was opened for measurements. Pathology reports included values after dehydration in formaldehyde.
Primary Endpoints:
Sensitivity of ultrasound in diagnosis of acute cholecystitis when compared to surgical diagnosis.
Secondary Endpoints:
Sensitivity of ultrasound for cholelithiasis when compared to surgery and histology
Sensitivity of ultrasound for hydrops when compared to surgery
Correlation between wall thickening seen on ultrasound, at surgery, and on histology
Correlation between diagnosis of cholecystitis on ultrasound and on histology
Sensitivity of ultrasound in diagnosis of acute cholecystitis when compared to histology
Results: 55 patients completed the study (47 women and 8 men) with age ranging from 18 to 67 years. The US sensitivity for cholelithiasis was 98% and for hydrops was 24%. The sensitivity of ultrasound in diagnosis of acute cholecystits was 60%, however the correlation coefficient between ultrasound and surgery was 0.18 for wall thickness, and 0.35 for acute cholecystitis. Surgery and histology showed a coefficient of 0.6 for acute cholecystitis, and ultrasound and pathology had a coefficient of 0.23.
The Takeaway: As ultrasound is increasingly utilized in medical practice, we must be careful not to exclusively rely on it in cases of cholecystitis. While the sample size of this study is small, it indicates that due to low sensitivity (0.6) and even lower correlation coefficients (0.18), clinical judgment should be paramount in the diagnosis of acute cholecystitis, because depending on the clinical picture urgent operative intervention may be warranted despite negative ultrasound findings.