Gallbladder Disease



Gallbladder Disease


Henry R. Kramer, MD

Joseph S. Wallins, MD, MPH





Are findings from a history and physical examination (H&P) sufficient for diagnosing or excluding acute cholecystitis?

Findings from the H&P alone are insufficient for diagnosing acute cholecystitis.

A 2017 systematic review and meta-analysis investigated the predictive power of various aspects of the diagnostic workup for acute cholecystitis.1 The authors reviewed publications from 1965 to 2016 of patients presenting to the ED with a chief complaint of abdominal pain. Studies had to include findings of H&P, laboratory tests, or of ultrasound as well as a reference standard (either pathology or biliary
scintigraphy). Three prospective observational studies with H&P information met inclusion criteria (Table 8.1). Among these, acute cholecystitis prevalence was 7% to 64%. Main outcomes included sensitivity, specificity, and LRs (likelihood ratios).








TABLE 8.1 Summary of Test Characteristics of Diagnostic Findings

































Symptom/Sign


Sensitivity


Specificity


+LR


−LR


Fever


31%-62%


37%-74%


0.71-1.24


0.76-1.49


Jaundice


11%-14%


86%-99%


0.80-13.81


0.87-1.03


Right upper quadrant pain


56%-93%


0%-96%


0.92-14.02


0.46-7.86


Murphy’s sign


53%-71%


95%-97%


11.48-21.31


0.32-0.50


Lack of fever, jaundice, or Murphy’s sign were not reliable to rule out acute cholecystitis, as the sensitivity of these signs was generally low. Notably, jaundice had very good specificity. The high specificity of Murphy’s sign is tempered by the fact that it is based on a single study in which only 10.1% of the population had acute cholecystitis, and therefore false negatives were rare. Given small sample sizes and wide variations in acute cholecystitis prevalence, all of these studies are likely subject to selection bias. As a result, the diagnostic utility of several of these findings are likely overestimated.

EASL guidelines note that characteristic clinical signs and symptoms should raise a strong suspicion for acute cholecystitis but do not make recommendations for ruling out acute cholecystitis by H&P alone.2



How accurate is RUQ US for diagnosing cholelithiasis?

RUQ US is adequately sensitive and very specific at diagnosing cholelithiasis.

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Feb 5, 2020 | Posted by in CRITICAL CARE | Comments Off on Gallbladder Disease

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