Clinically diagnosed cholecystitis: a case series.

In patients presenting with classic signs and symptoms of cholecystitis, the diagnosis is made based on confirmatory imaging studies. However, the most commonly utilized imaging studies lack accuracy, especially in the case of acalculous disease. Here we discuss four cases of patients presenting with symptoms of cholecystitis. All four patients underwent multiple imaging studies, which yielded negative results. Due to persistent symptoms, the decision was made to proceed with cholecystectomy. Each patient underwent uncomplicated cholecystectomy, with resolution of symptoms post-operatively, and continued symptoms relief 6-10 months post-operatively. Cholecystitis is a clinical diagnosis. Negative imaging studies should not influence the management in a patient presenting with classic signs and symptoms of cholecystitis.

INTRODUCTION

Cholecystitis most commonly occurs as a complication of gallstone disease but can also occur without gallstones, termed acalculous cholecystitis. In the great majority of cases, obstruction of the biliary tract from stones leads to acute cholecystitis. However, ~10% of all cases of cholecystitis are attributed to acalculous disease [1]. Both calculous and acalculous disease present with similar findings including abdominal pain, nausea and vomiting. The complaint of worsening of pain after high-fat containing meal is frequently present [2, 3]. Most often, patients presenting with these classic symptoms will then undergo imaging studies to make the diagnosis. Ultrasound (US) and cholescintigraphy (HIDA scan) are two commonly utilized imaging modalities for biliary disease[3]. But what about patients with classic signs and symptoms of cholecystitis, with normal imaging studies? Here we will discuss cases of classic symptomatology of cholecystitis and normal imaging studies, which were managed with cholecystectomy with complete resolution of symptoms. All final pathology reports confirmed the diagnosis of cholecystitis.

CASES

Case 1: A 28-year-old-female presented with abdominal pain, nausea and vomiting. Physical exam was significant for right-up-quadrant (RUQ) tenderness. Initial workup included abdominal US and computed tomography (CT), both of which were negative. She was admitted to the hospital for pain management and further workup. She subsequently underwent HIDA scan with cholecystokinin (CCK) which, like the previous imaging studies, was negative. Due to persistent pain, the decision was made to proceed with cholecystectomy for clinical cholecystitis. She underwent uncomplicated laparoscopic cholecystectomy with resolution of symptoms post-operatively. At 10 months post-operatively, she remains symptom free.

Case 2: A 49-year-old-female presented with 1-week history of RUQ pain, nausea and vomiting. She noted that pain initially began following high-fat meal. On physical exam, she exhibited epigastric tenderness and positive Murphy’s sign. She underwent extensive workup including US, CT abdomen/pelvis, CCK-HIDA scan, endoscopy and MRCP; all which resulted normal. Her abdominal pain persisted and the decision was made to proceed with cholecystectomy based on clinical diagnosis of cholecystitis. She underwent uncomplicated laparoscopic cholecystectomy. Post-operatively she recovered well with resolution of pain. At 6 months post-operatively, she remains symptom free.

Case 3: A 52-year-old-female presented with 6-month history of epigastric pain with radiation to the back. She reported some association with meals, but inconsistently. She underwent US and CCK-HIDA scan which both resulted normal. Due to persistent pain and symptomatology, the decision was made to proceed with cholecystectomy. She underwent uncomplicated laparoscopic cholecystectomy with resolution of symptoms. At 8 months post-operatively, she remains symptom free.

Case 4: A 54-year-old-female presented with a 3-month history of abdominal pain and nausea. She reported recent bought of pain associated with large Italian meal, but noted that she did experience pain unrelated to oral intake. In the emergency department, she underwent US and CT scan, both of which were negative for acute diseases. She was admitted to the hospital for pain management and further workup, including a CCK-HIDA scan which was also negative. The decision was made to proceed with cholecystectomy. She underwent uncomplicated laparoscopic cholecystectomy, with immediate resolution of symptoms post-operatively. At 6 months post-operatively, she remains symptom free.

DISCUSSION

In patients presenting with classic signs and symptoms of cholecystitis, the diagnosis is typically made based on confirmatory imaging studies. The most common symptom of cholecystitis is abdominal pain located in the RUQ or epigastrium. Pain may radiate to the back, specifically the right should blade, and is frequently associated with nausea and vomiting [4, 5]. Worsening of pain following high-fat meal may be present and is regarded as a classic symptom of acute cholecystitis, however, studies demonstrate that association of pain with meals is only present in 50% of all patients presenting with acute disease [5]. Depending on the degree acuity patients may appear ill, with fever and leukocytosis, or may be otherwise well appearing with pain only present on palpation of the abdomen. Patients may exhibit a positive ‘Murphy’s sign’, defined as RUQ tenderness on inspiration, studies quote the sensitivity and specificity of this finding to be 97 and 48%, respectively [6].

The most widely utilized imaging modality of biliary disease is the US, which has a sensitivity and specificity of 80 and 88%, respectively, for diagnosis of acute calculous cholecystitis. However, the accuracy of this test drops off dramatically in patients with acalculous disease. In this case the sensitivity and specificity is quoted to be as low as 36 and 17%, respectively [2, 7]. This demonstrates that US is an accurate diagnostic modality for the presence or absence of stone, but not for diagnosis of cholecystitis.

Cholescintigraphy (HIDA scan) is generally indicated if the diagnosis remains unclear after ultrasonography. Biliary dyskinesia can be evaluated with the addition of administration of CCK. The HIDA scan is both 95% sensitive and specific for acute calculous disease. As with US, the accuracy declines with acalculous disease with and sensitivity and specificity of 70 and 90%, respectively [7, 8]. Although abdominal CT is regarded as the single most informative radiographic imaging tool for examining intra-abdominal pathology, its overall value for assessment of the biliary tract is poor. The overall sensitivity and specificity of CT for the biliary pathology is low, 55 and 65%, respectively [9]. Based on these findings, one can see that no imaging modality is exact and leave considerable room for physician judgement.

The key issue we discuss here is when a patient presents with classic symptoms of cholecystitis in the face of normal imaging modalities. This often leads physicians to question the clinical picture at hand and search for other causes of pain. Our case series demonstrates resolution of symptoms with cholecystectomy in those patients presenting with only clinical symptoms of disease and lack of 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 exam, regardless of imaging studies.

CONCLUSION

Cholecystitis is a clinical diagnosis. Negative imaging studies should not influence the management in a patient presenting with classic signs and symptoms of cholecystitis.