Confirmatory imaging studies are used to make the diagnosis of cholecystitis in patients who present with classic signs and symptoms. However, the most commonly used imaging studies are inaccurate, particularly in cases of acalculous disease. We will look at four points of patients who presented with cholecystitis symptoms. All four patients had multiple imaging studies, all of which returned negative. The decision to proceed with cholecystectomy was made due to persistent symptoms. Each patient underwent an uncomplicated cholecystectomy, with symptoms resolved post-operatively and continued relief 6-10 months later. Cholecystitis is a clinical condition. Negative imaging studies should not be used to guide treatment in patients presenting with classic cholecystitis signs and symptoms.
Cholecystitis is commonly seen as a complication of gallstone disease, but it can also occur in the absence of gallstones, known as acalculous cholecystitis. Obstruction of the biliary tract by stones causes acute cholecystitis in most cases. However, acalculous disease accounts for 10% of all cholecystitis cases . The symptoms of the calculous and acalculous disease are similar, including abdominal pain, nausea, and vomiting. The complaint of pain worsening after eating a high-fat meal is common [2, 3]. Patients who present with these classic symptoms are frequently subjected to imaging studies to make a diagnosis. Two commonly used imaging modalities for the biliary disease are ultrasound (US) and cholescintigraphy (HIDA scan). But what about patients with classic cholecystitis symptoms and normal imaging studies? We will discuss cases of classic cholecystitis symptomatology and normal imaging studies that were treated with cholecystectomy with complete symptom resolution. All final pathology reports confirmed the diagnosis of cholecystitis.
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Case 1: A 28-year-old woman complained of abdominal pain, nausea, and vomiting. The physical examination revealed right-up-quadrant (RUQ) tenderness. Abdominal ultrasound and computed tomography (CT) were negative during the initial workup. She was admitted to the hospital for pain management and additional testing. She then had a HIDA scan with cholecystokinin (CCK), which returned negative like the previous imaging studies. The decision to proceed with cholecystectomy for clinical cholecystitis was made due to persistent pain. She had an uncomplicated laparoscopic cholecystectomy, and her symptoms were resolved post-operatively. She is still symptom-free ten months after surgery.
Case 2: A 49-year-old female presented with RUQ pain, nausea, and vomiting for one week. She mentioned that the pain started after a high-fat meal. She had epigastric tenderness and a positive Murphy’s sign on physical examination. She had a thorough workup that included an ultrasound, CT abdomen/pelvis, CCK-HIDA scan, endoscopy, and MRCP, all of which came back normal. Her abdominal pain persisted, so a cholecystectomy was scheduled based on a clinical diagnosis of cholecystitis. She had a simple laparoscopic cholecystectomy. She recovered well post-operatively, with pain relief. She is still symptom-free six months after surgery.
Case 3: A 52-year-old female presented with a 6-month epigastric pain and back radiation history. She reported some association with meals, but in varying degrees. She had a US and a CCK-HIDA scan, both of which came back normal. The decision to proceed with cholecystectomy was made due to persistent pain and symptomatology. She had an uncomplicated laparoscopic cholecystectomy, and her symptoms were resolved. She is still symptom-free eight months after surgery.
Case 4: A 54-year-old female presented with abdominal pain and nausea for three months. She reported recent pain associated with a large Italian meal, but she also said pain unrelated to oral intake. She was taken to the emergency room and had an ultrasound and a CT scan, both of which were negative for acute diseases. She was admitted to the hospital for pain management and further testing, including a negative CCK-HIDA scan. It was decided to proceed with the cholecystectomy. She had an uncomplicated laparoscopic cholecystectomy with immediate post-operative symptom relief. She is still symptom-free six months after surgery.
Confirmatory imaging studies are typically used to make the diagnosis of cholecystitis in patients who present with classic signs and symptoms. The most common symptom of cholecystitis is abdominal pain in the RUQ or epigastrium. Pain may radiate to the back, particularly to the right shoulder blade, and is frequently accompanied by nausea and vomiting [4, 5]. Pain worsening after a high-fat meal is a classic symptom of acute cholecystitis; however, studies show that the association of pain with meals is only present in 50% of all patients presenting with acute disease . Patients may appear ill, with fever and leukocytosis, or otherwise well, with pain only present on palpation of the abdomen, depending on their acuity level. Patients may exhibit a positive ‘Murphy’s sign,’ defined as RUQ tenderness on inspiration; studies claim a sensitivity and specificity of 97 and 48%, respectively .
In the United States, the most commonly used imaging modality for the biliary disease has a sensitivity and specificity of 80 and 88%, respectively, for the diagnosis of acute calculous cholecystitis. However, in patients with acalculous disease, the accuracy of this test drops dramatically. The sensitivity and specificity, in this case, are reported to be as low as 36 and 17%, respectively [2, 7]. This demonstrates that the US is an accurate diagnostic modality for determining the presence or absence of stone but not for cholecystitis diagnosis.
If the diagnosis is still unclear after ultrasonography, cholescintigraphy (HIDA scan) is usually recommended. With the addition of CCK administration, biliary dyskinesia can be evaluated. The HIDA scan is sensitive and specific for the acute calculous disease, with a sensitivity of 95%. As in the United States, the acalculous disease has a sensitivity and specificity of 70 and 90%, respectively [7, 8]. Although abdominal CT is considered the most informative radiographic imaging tool for examining intra-abdominal pathology, its overall value for evaluating the biliary tract is low. CT has low overall sensitivity and specificity for biliary pathology, with discounts of 55 and 65% . Based on these findings, it is clear that no imaging modality is perfect and leaves much room for physician discretion.
The key issue is when a patient presents with classic cholecystitis symptoms despite normal imaging modalities. This frequently causes physicians to question the clinical picture and look for other causes of pain. Our case series demonstrates that cholecystectomy relieves symptoms in patients presenting only clinical signs of disease and no confirmative diagnosis on imaging. Based on our observations, we hypothesize that cholecystitis is primarily a clinical diagnosis and that physicians should rely heavily on history and physical exams, regardless of imaging studies.
Cholecystitis is a clinical condition. Negative imaging studies should not be used to guide treatment in patients presenting with classic cholecystitis signs and symptoms.