Sharique Nazir, MD1, Alex Bulanov, MS, DO2, Anastasiya Nelyubina, BS3, Ishtiaque Aziz, BS3, Jordan K Magruder, BS3. 1NYU Lutheran Medical Center, 2NYIT College of Osteopathic Medicine, 3St. George’s University
The primary workup for right upper quadrant pain in the context of fever, nausea, vomiting, and leukocytosis is biliary ultrasound. Ultrasonography is a reliable diagnostic modality for cholelithiasis, but has a high false negative rate for acute cholecystitis, especially in diabetics and the elderly. Our goal was to investigate whether a negative biliary ultrasound unnecessarily delays surgery in the context of a clinical picture that is highly suggestive of cholecystitis.
We conducted a retrospective chart review of all laparoscopic cholecystectomies performed by three experienced minimally invasive surgeons at our 500-bed urban community teaching hospital, between 2011 and 2015. We included all cases with biliary ultrasounds negative for cholecystitis. Ultrasound reports were scored for the cardinal sonographic findings of acute cholecystitis: impacted stone in cystic duct or gallbladder neck, positive sonographic Murphy’s sign, thickened gallbladder wall (>3mm), distention of gallbladder lumen (> 4cm transverse and >9cm longitudinal), and pericholecystic fluid. The ultrasound report was then compared to the description of the gallbladder in the operative note and the final pathologic report. Additional data collected involved the initial clinical presentation, labs, additional preoperative imaging, time from clinical presentation to operation, length of hospital stay, and resolution of pain on post-operative follow-up.
Of the 453 laparoscopic cholecystectomies performed, 223 had ultrasounds negative for cholecystitis. In the negative ultrasound group the average cholecystitis ultrasound score was 0.78 and all but 31 of the ultrasounds showed gallstones. Subsequent preoperative workup included 8 HIDA scans, 64 MRCP, 63 CT scans. All cases mentioned gallbladder inflammation in the operative report. On pathology, 177 showed chronic cholecystitis, 22 showed combined chronic and acute cholecystosis, 16 showed necrotic/hemorrhagic cholecystitis, 19 showed mucosal ulceration, 4 with tubular adenoma, 4 with intestinal metaplasia and one each showed acute cholecystitis, porcelain gallbladder, antral metaplasia, low-grade dysplasia, and gallbladder adenocarcinoma. Average time from presentation to surgery was 1.1 days and length of stay was 1.7 days.
A negative billary ultrasound can confuse the picture of right upper quadrant pain. Most cases turned out to be chronic cholecystitis that could be managed electively; however, there was a 9% rate of necrotic cholecystitis, a true surgical emergency. Many studies have shown that early cholecystectomy leads to shorter length of stay and lower costs; therefore the need for additional workup versus directly proceeding to surgery must be closely examined.