All cholelithiasis patients who come to the Emergency Department (ED) with pain right upper abdomen of more than 4 hours duration and a clinical examination suggestive of cholecystitis require a cholecystectomy, suggests a study published in the American Journal of Surgery.¹

Researchers carried out a retrospective analysis of medical records of 308 patients, aged ≥18 years (mean age 40.3 years), visiting the ED with complaints of right upper quadrant pain and cholelithiasis and who subsequently underwent emergency cholecystectomy, from September 2017 to April 2020. Majority of the study subjects were female (73.4%). Their objective was to examine the accuracy of clinical examination by a surgeon vs USG assessment in suggesting the need for urgent cholecystectomy and with final pathological diagnosis.

The diagnosis of cholecystitis was based on the history of RUQ pain positive ± positive Murphy’s sign, TLC more than 11,000 cells per cu mm and presence of any two of USG features of GB wall thickening >4mm, pericholecystic fluid and GB distension > 40 mm. Majority (~96%) of patients who had presented to the ED secondary to prolonged RUQ pain with cholelithiasis had pathologic cholecystitis. Clinical diagnosis was found to be superior to USG for a pathologic diagnosis of cholecystitis; 96% vs 44% and 87% vs 18% for acute and chronic cholecystitis respectively.

The Tokyo criteria are used to triage patients with acute cholecystitis. Laboratory and USG findings are important components of these criteria in addition to the local signs and symptoms. Evidence however shows that the sensitivity of USG, which is often the first-line imaging test for acute cholecystitis, varies widely. Consequently, some patients may be discharged from the ED and advised OPD follow-up. However, many of these patients may come back to the emergency necessitating an urgent cholecystectomy.

RUQ pain for ≥4 hours in patients with known cholelithiasis is indicative of pathologic cholecystitis. These patients who present to the ED are candidates for cholecystectomy and should get a surgical consult. In this study, Martin et al showed that clinical examination was more predictive of pathologic diagnosis of acute cholecystitis than ultrasound assessment. The authors concluded that “this finding, even with the absence of sonographic evidence of cholecystitis, is indication for index encounter urgent cholecystectomy”.

Reference

1. Martin WT, et al. Clinical diagnosis of cholecystitis in emergency department patients with cholelithiasis is indication for urgent cholecystectomy: A comparison of clinical, ultrasound, and pathologic diagnosis. Am J Surg. 2022 Jul;224(1 Pt A):80-84. doi: 10.1016/j.amjsurg.2022.02.051.