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Mahmoudzadeh F, Akhgar A, Mirfazaelian H. External validation of the bedside score for the diagnosis of acute cholecystitis. Heliyon 2024; 10:e25183. [PMID: 38322927 PMCID: PMC10844041 DOI: 10.1016/j.heliyon.2024.e25183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 01/19/2024] [Accepted: 01/22/2024] [Indexed: 02/08/2024] Open
Abstract
Objective: Acute cholecystitis usually presents with right upper quadrant (RUQ) abdominal pain. However, there are other conditions with similar findings which make the diagnosis difficult. The objective of this study is to prospectively validate the performance of the bedside score for the diagnosis of cholecystitis in patients presenting to the emergency department (ED) with possible acute cholecystitis. Study design We performed a prospective observational study of a convenience sample of patients with RUQ pain admitted to the ED of three academic hospitals. Symptoms (post prandial symptoms), physical signs (RUQ tenderness, murphy's sign) and ultrasound findings (Murphy's sign, gallstone, and gallbladder thickening) were scoring system items. The final diagnosis of cholecystitis was confirmed with a surgical pathology and/or discharge diagnosis of the patient in a 30-day follow-up. The treating physicians' clinical gestalt of acute cholecystitis was also assessed by 5-point Likert scale. Results One hundred thirty patients were followed up and were included in the analysis. 42 patients (32 %) had cholecystitis. The bedside clinical score of less than 4 had a sensitivity of 100 % (CI95 %: 91.60 %-100 %), negative predictive value (NPV) of 100 % (CI 95 %: 41.35 %-63 %), and negative likelihood ratio (-LR) of 0. Score of 6 and above had a specificity of 90.91 % (CI 95 %: 82.87 %-95.99 %), positive predictive value (PPV) of 83.67 % (CI 95 %: 72.55 %-90.86 %), and positive likelihood ratio (+LR) of 10.74 (CI95 %: 5.54-20.83). Physicians' clinical gestalt at the scale of 4 and 5 showed a specificity of 95.45 % (CI 95 %: 88.77 %-98.75 %), PPV of 90.91 % (CI 95 %: 79.29 %-96.31 %), and +LR of 20.95 (CI95 %: 8.02-54.71). At the same time at the scale of 1 and 2, the sensitivity was 95.24 % (CI 95 %: 83.84 %-99.42 %), NPV was 97.22 % (CI 95 %: 90.01 %-99.27 %), and the -LR was 0.06 (CI 95 %: 0.02-0.423). The area under the curve of bedside clinical score was not significantly higher than clinical gestalt (97.58 (CI 95 %: 95.31-99.85) vs. 95.37 (CI 95: 99.24-100))(p-value = 0.35). Conclusion This study showed while the bedside score would be helpful to rule out and rule in acute cholecystitis, physicians' gestalt had similar diagnostic performance.
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Affiliation(s)
- Fatemeh Mahmoudzadeh
- Emergency Medicine Department, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Atousa Akhgar
- Emergency Medicine Department, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Hadi Mirfazaelian
- Emergency Medicine Department, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Childs DD, Lalwani N, Craven T, Arif H, Morgan M, Anderson M, Fulcher A. A meta-analysis of the performance of ultrasound, hepatobiliary scintigraphy, CT and MRI in the diagnosis of acute cholecystitis. Abdom Radiol (NY) 2024; 49:384-398. [PMID: 37982832 DOI: 10.1007/s00261-023-04059-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 09/09/2023] [Accepted: 09/11/2023] [Indexed: 11/21/2023]
Abstract
PURPOSE To evaluate the recently reported relative diagnostic accuracy of US, CT, MRI, and cholescintigraphy for diagnosing acute cholecystitis. METHODS 2 radiologists independently performed systematic electronic searches for articles published between 2000 and 2021 and applied inclusion/exclusion criteria. 2 different radiologists extracted data from the articles and scored each with a methodological quality tool. Pooled estimates of sensitivity and specificity were calculated with a bivariate linear mixed model. A second analysis made head-to-head comparisons (US vs. CT, US vs. cholescintigraphy). Factors were also analyzed for potential confounding effects on diagnostic accuracy. RESULTS Of 6121 initial titles, 22 were included. The prevalence of cholecystitis varied widely across studies (9.4-98%). Pooled sensitivity and specificity estimates were 69% (confidence limit [CL] 62-76%) and 79% (CL 71-86%) for US, 91% (CL 86-94%) and 63% (CL 51-74%) for cholescintigraphy, 78% (CL 69-84%) and 81% (CL 71-88%) for CT, and 91% (CL 78-97%) and 93% (CL 70-99%) for MRI. Regarding head-to-head comparisons, the sensitivity of CT (87.6%, CL 70-96%) was significantly higher than US (66.8%, CL 43-84%), while specificities (81.7% with CL 54-95% for US, 91.9% with CL 67-99% for CT) were similar. The sensitivity of cholescintigraphy (87.4%, CL 76-94%) was significantly greater than US (61.6%, CL 44-77%), while the specificity of US (82%, CL 65-92%) was significantly higher than cholescintigraphy (68%, CL 47-84%). CONCLUSION Recent data suggests that CT may have a higher sensitivity than US for diagnosing acute cholecystitis, with similar specificity. Cholescintigraphy remains a highly sensitive modality with lower specificity than previously reported. MRI remains under studied, but with promising results.
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Affiliation(s)
- David D Childs
- Department of Radiology, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
| | - Neeraj Lalwani
- Department of Radiology, Virginia Commonwealth University Health, Richmond, VA, USA
| | - Timothy Craven
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Hina Arif
- Department of Medical Imaging, College of Medicine, The University of Arizona, Tucson, AZ, USA
| | - Mathew Morgan
- Department of Radiology, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Mark Anderson
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ann Fulcher
- Department of Radiology, Virginia Commonwealth University Health, Richmond, VA, USA
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Developing a Simple Score for Diagnosis of Acute Cholecystitis at the Emergency Department. Diagnostics (Basel) 2022; 12:diagnostics12092246. [PMID: 36140646 PMCID: PMC9497808 DOI: 10.3390/diagnostics12092246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/11/2022] [Accepted: 09/16/2022] [Indexed: 12/07/2022] Open
Abstract
We aim to develop a diagnostic score for acute cholecystitis that integrates symptoms, physical examinations, and laboratory data to help clinicians for timely detection and early treatment of this disease. We retrospectively collected data from our database from 2010 to 2020. Patients with acute abdominal pain who underwent an ultrasound or computed tomography (CT) scan at the emergency department (ED) were included. Cases were identified by pathological, CT, or ultrasound reports. Non-cases were those who did not fulfill any of these criteria. Multivariable regression analysis was conducted to identify predictors of acute cholecystitis. The model included 244 patients suspected of acute cholecystitis. Eighty-six patients (35.2%) were acute cholecystitis confirmed cases. Five final predictors remained within the reduced logistic model: age < 60, nausea and/or vomiting, right upper quadrant pain, positive Murphy’s sign, and AST ≥ two times upper limit of normal. A practical score diagnostic performance was AuROC 0.74 (95% CI, 0.67−0.81). Patients were categorized with a high probability of acute cholecystitis at score points of 9−12 with a positive likelihood ratio of 3.79 (95% CI, 1.68−8.94). ED Chole Score from these five predictors may aid in diagnosing acute cholecystitis at ED. Patients with an ED Chole Score >8 should be further investigated.
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Trauma-Angio score as a predictor of urgent angioembolization for blunt trauma: development and validation using independent cohorts. Eur J Trauma Emerg Surg 2022; 48:4837-4845. [PMID: 35674807 DOI: 10.1007/s00068-022-02008-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 05/15/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE This research aimed to establish a scoring system for selecting candidates for urgent angioembolization (AE). METHODS Patients with blunt trauma were retrospectively identified in a nationwide trauma registry. Patients aged ≥ 15 years with a systolic blood pressure of ≥90 mmHg were included. These individuals were then categorized into development and validation cohorts based on the date of admission. Next, an eight-point scaled system was developed using odds ratios obtained from the multivariate analysis of patients' clinical factors on their arrival at the hospital, with the implementation of urgent AE as a dependent variable. RESULTS The development cohort and validation cohort included 158,192 and 116,941 patients, respectively, and 3296 (2.1%) patients in the development cohort and 2,550 (2.2%) patients in the validation cohort underwent urgent AE. The frequency of transfusion within 24 h after arrival and the Injury Severity Score were similar between the two cohorts (16,867 [10.7%] vs. 11,222 [9.6%] and 10 [9-18] vs. 10 [9-17], respectively). The number of patients who were discharged and hospital-free days were comparable between the two cohorts (139,436 [94.4%] vs. 106,107 [95.6%] and 72 [53-84] vs. 73 [57-84] days, respectively). The probabilities and the observed rates of urgent AE increased proportionally from 2% at a score of ≤ 3 to almost 15% at a score of ≥ 7. In terms of predictive factors, no significant interaction was noted. CONCLUSION The Trauma-Angio scoring system can be used as a trigger to suggest the possibility of urgent AE. TRIAL REGISTRATION 20090087, 31st July 2009.
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Martin WT, Stewart K, Sarwar Z, Kennedy R, Quang C, Albrecht R, Cross A. Clinical diagnosis of cholecystitis in emergency department patients with cholelithiasis is indication for cholecystectomy: A comparison of clinical, ultrasound, and pathologic diagnosis. Am J Surg 2022; 224:80-84. [DOI: 10.1016/j.amjsurg.2022.02.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 02/07/2022] [Accepted: 02/16/2022] [Indexed: 12/07/2022]
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Daliparty VM, Amoozgar B, Razzeto A, Ehsanullah SUM, Rehman F. Cholecystitis Masquerading as Cardiac Chest Pain: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e932078. [PMID: 34548467 PMCID: PMC8477983 DOI: 10.12659/ajcr.932078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Patient: Male, 46-year-old
Final Diagnosis: Cholecystitis
Symptoms: Chest pain
Medication: —
Clinical Procedure: —
Specialty: General and Internal Medicine
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Affiliation(s)
- Vasudev Malik Daliparty
- Department of Internal Medicine, Jersey Shore University Medical Center, Perth Amboy Division, Perth Amboy, NJ, USA
| | - Behzad Amoozgar
- Department of Internal Medicine, Jersey Shore University Medical Center, Perth Amboy Division, Perth Amboy, NJ, USA.,Department of Biostatistics and Epidemiology, School of Public Health, University of California, Berkeley, CA, USA
| | - Alejandra Razzeto
- Department of Internal Medicine, Jersey Shore University Medical Center, Perth Amboy Division, Perth Amboy, NJ, USA
| | | | - Faseeha Rehman
- Department of Internal Medicine, Jersey Shore University Medical Center, Perth Amboy Division, Perth Amboy, NJ, USA
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Graglia S, Shokoohi H, Loesche MA, Yeh DD, Haney RM, Huang CK, Morone CC, Springer C, Kimberly HH, Liteplo AS. Prospective validation of the bedside sonographic acute cholecystitis score in emergency department patients. Am J Emerg Med 2021; 42:15-19. [PMID: 33429186 DOI: 10.1016/j.ajem.2020.12.085] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 12/29/2020] [Accepted: 12/30/2020] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Acute cholecystitis can be difficult to diagnose in the emergency department (ED); no single finding can rule in or rule out the disease. A prediction score for the diagnosis of acute cholecystitis for use at the bedside would be of great value to expedite the management of patients presenting with possible acute cholecystitis. The 2013 Tokyo Guidelines is a validated method for the diagnosis of acute cholecystitis but its prognostic capability is limited. The purpose of this study was to prospectively validate the Bedside Sonographic Acute Cholecystitis (SAC) Score utilizing a combination of only historical symptoms, physical exam signs, and point-of-care ultrasound (POCUS) findings for the prediction of the diagnosis of acute cholecystitis in ED patients. METHOD This was a prospective observational validation study of the Bedside SAC Score. The study was conducted at two tertiary referral academic centers in Boston, Massachusetts. From April 2016 to March 2019, adult patients (≥18 years old) with suspected acute cholecystitis were enrolled via convenience sampling and underwent a physical exam and a focused biliary POCUS in the ED. Three symptoms and signs (post-prandial symptoms, RUQ tenderness, and Murphy's sign) and two sonographic findings (gallbladder wall thickening and the presence of gallstones) were combined to calculate the Bedside Sonographic Acute Cholecystitis (SAC) Score. The final diagnosis of acute cholecystitis was determined from chart review or patient follow-up up to 30 days after the initial assessment. In patients who underwent operative intervention, surgical pathology was used to confirm the diagnosis of acute cholecystitis. Sensitivity, specificity, PPV and NPV of the Bedside SAC Score were calculated for various cut off points. RESULTS 153 patients were included in the analysis. Using a previously defined cutoff of ≥ 4, the Bedside SAC Score had a sensitivity of 88.9% (95% CI 73.9%-96.9%), and a specificity of 67.5% (95% CI 58.2%-75.9%). A Bedside SAC Score of < 2 had a sensitivity of 100% (95% CI 90.3%-100%) and specificity of 35% (95% CI 26.5%-44.4%). A Bedside SAC Score of ≥ 7 had a sensitivity of 44.4% (95% CI 27.9%-61.9%) and specificity of 95.7% (95% CI 90.3%-98.6%). CONCLUSION A bedside prediction score for the diagnosis of acute cholecystitis would have great utility in the ED. The Bedside SAC Score would be most helpful as a rule out for patients with a low Bedside SAC Score < 2 (sensitivity of 100%) or as a rule in for patients with a high Bedside SAC Score ≥ 7 (specificity of 95.7%). Prospective validation with a larger study is required.
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Affiliation(s)
- Sally Graglia
- Department of Emergency Medicine, UCSF-ZSFG, UCSF Medical School, San Francisco, CA, USA
| | - Hamid Shokoohi
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Michael A Loesche
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel Dante Yeh
- Ryder Trauma Center, Jackson Memorial Hospital, University of Miami, USA
| | - Rachel M Haney
- Department of Emergency Medicine, PeaceHealth Southwest Medical Center, Vancouver, WA, USA
| | - Calvin K Huang
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Christina C Morone
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Caitlin Springer
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Heidi H Kimberly
- Department of Emergency Medicine, Newton Wellesley Hospital, Newton, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Andrew S Liteplo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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