Volume 5 Supplement 1
Accuracy of ultrasonography in the diagnosis of acute calculous cholecystitis: review of the literature
© Pinto et al; licensee BioMed Central Ltd. 2013
Published: 15 July 2013
To evaluate the accuracy of ultrasonography in the diagnosis of acute calculous cholecystitis in comparison with other imaging modalities.
The authors performed a search of the Medline/ PubMed (National Library of Medicine, Bethesda, Maryland) for original research and review publications examining the accuracy of ultrasonography in the diagnosis of acute calculous cholecystitis. The search design utilized a single or combination of the following terms : (1) acute cholecystitis, (2) ultrasonography, (3) computed tomography, (4) magnetic resonance cholangiopancreatography and (5) cholescintigraphy. This review was restricted to human studies and to English-language literature. Four authors reviewed all the titles and subsequent the abstract of 198 articles that appeared appropriate. Other articles were recognized by reviewing the reference lists of significant papers. Finally, the full text of 31 papers was reviewed.
Sonography is still used as the initial imaging technique for evaluating patients with suspected acute calculous cholecystitis because of its high sensitivity at the detection of GB stones, its real-time character, and its speed and portability. Cholescintigraphy still has the highest sensitivity and specificity in patients who are suspected of having acute cholecystitis. However, due to a combination of reasons including logistic drawbacks, broad imaging capability and clinician referral pattern the use of cholescintigraphy is limited in clinical practice. CT is particularly useful for evaluating the many complications of acute calculous cholecystitis. The lack of widespread availability of MRI and the relatively high cost prohibits its primary use in patients with acute calculous cholecystitis.
US is currently considered the preferred initial imaging technique for patients who are clinically suspected of having acute calculous cholecystitis.
Acute cholecystitis is defined as an acute inflammation of the gallbladder wall, regardless of the cause. In the many of cases, the underlying etiology is the obstruction of the cystic duct due to an impacted stone in either the neck of the gallbladder or the cystic duct (acute calculous cholecystitis). Acute cholecystitis can also develop without associated cholelithiasis (acute acalculous cholecystitis).
It is very uncommon that a patient without an history of biliary symptoms, such as colic pain, develop an acute cholecystitis. Conversely, < 15% of the patients with cholelithiasis experience clinical symptoms and < 5% an acute cholecystitis .
An estimated 25 million Americans have cholelithiasis. In 80% of cases, the cholelithiasis is primarily composed of cholesterol, with pigments, calcium bilirubinate, and calcium carbonate accounting for most of the remainder [2, 3].
Forty percent of patients with acute cholecystitis develop complications : the complications of cholecystitis most commonly result from the impaction of gallstones in the cystic duct or common bile duct and include gallbladder hydrops, emphysematous cholecystitis, which is seen more commonly in men and diabetic patients, gangrenous cholecystitis and perforation of the gallbladder. The gallbladder may perforate into the abdominal cavity, causing peritonitis, or the perforation may be contained by the omentum leading to an intra-abdominal abscess.
Emergency conditions involving the gallbladder and the bile ducts are common radiological challenging problems. Imaging provides valuable informations for the following reasons: (1) to ensure the final diagnosis, as up to 20% of patients clinically classified as having acute cholecystitis have another disease that does not require surgery; (2) to prevent the patient from complications in case of delayed diagnosis and (3) to detect complications which may urge the surgical treatment .
In this paper we evaluate the accuracy of ultrasonography in the diagnosis of acute calculous cholecystitis in comparison with other imaging modalities through a literature search.
The authors performed a search of the Medline/ PubMed (National Library of Medicine, Bethesda, Maryland) for original research and review publications examining the accuracy of ultrasonography in the diagnosis of acute calculous cholecystitis in comparison with other imaging modalities. The search design utilized a single or combination of the following terms : (1) acute cholecystitis, (2) ultrasonography, (3) cholescintigraphy, (4) computed tomography and (5) magnetic resonance cholangiopancreatography. This review was restricted to human studies and to English-language literature. Four authors reviewed all the titles and subsequent the abstract of 198 articles that appeared appropriate. Other articles were recognized by reviewing the reference lists of significant papers. Finally, the full text of 31 papers was reviewed.
Acute calculous cholecystitis: diagnosis with conventional radiography
Stonelike densities may be single or multiple. They may be irregular, show a marginal location or may exhibit dense, uniform calcification.
Plain abdominal film is of limited value in the setting of gallbladder disease because only 15–20% of gallstones are visible on a radiograph of the abdomen and little information about complicated gallbladder disease can be obtained using conventional radiography .
Acute calculous cholecystitis: diagnosis with ultrasonography
Ultrasound (US) is the preferred imaging examination for the diagnosis of acute cholecystitis and is the first method used when the clinical presentation is suggestive of biliary pathology. The main findings of acute calculous cholecystitis on US include in addition to the presence of stones: distension of the gallbladder lumen, gallbladder wall thickening, a positive US Murphy sign, pericholecystic fluid [5, 6] and a hyperemic wall upon evaluation with Color Doppler [7, 8].
Ultrasound has the best sensitivity and specificity for evaluating patients with suspected gallstones . As reported in the literature , some ultrasonographic findings are more strongly associated with acute cholecystitis than others: a positive Murphy’s sign (pain is provoked by either the transducer or the sonographer’s palpation under guidance, in the exact area of the gallbladder) is reported to have sensitivity as high as 88% [11, 12]. Ralls at al. report that one of the most important advantages of ultrasound over other imaging techniques in the investigation of acute cholecystitis is the ability to assess for a sonographic Murphy sign, which is a reliable indicator of acute cholecystitis with a sensitivity of 92% . An increased gallbladder wall thickness of > 3.5 mm has been found to be a reliable and independent predictor of acute cholecystitis .
Visualization of gallbladder wall thickening in the presence of gallstones using ultrasound has a positive predictive value of 95% for the diagnosis of acute cholecystitis .
Unfortunately, thickening of the gallbladder wall in the absence of cholecystitis may be observed in systemic conditions, such as liver, renal, and heart failure, possibly due to elevated portal and systemic venous pressures .
Moreover, as most patients are examined in the emergency setting, it has sometimes been questioned if the younger radiologists would perform as well as experienced radiologists, who are not always available at the time of examination. Grantcharov et al.  prospectively evaluated the interobserver agreement in US examination of the gallbladder and the biliary tract performed by an experienced and a novice radiologist: they report that the novice radiologist's expertise in the primary diagnosis of uncomplicated gallstone disease was as good as the one provided by the experienced colleague and the significant interobserver difference in the measurements of the thickness of the gallbladder wall and the common bile duct diameter might indicate that assessment of these parameters requires extensive practise.
Acute calculous cholecystitis: diagnosis with cholescintigraphy
Cholescintigraphy is a method widely used in some countries and completely ignored in others. The principle is to show that the radiopharmaceuticals (diisopropyl-iminodiacetic acid, or DISIDA) fills in the gallbladder within 30 minutes in normal subjects. In case of cystic duct obstruction, gallbladder will not enhance, even after hours.
In 1994, Shea et al  reported a systematic review of imaging studies published between 1978 and 1990. In this review, they concluded that cholescintigraphy had the best sensitivity (97%; 95% confidence interval [CI]: 96%, 98%) and specificity (90%; 95% CI: 86%, 95%) in the detection of acute cholecystitis, whereas US had a sensitivity of 88% (95% CI: 74%, 100%) and a specificity of 80% (95% CI: 62%, 98%). Recently Kiewiet et al  update the diagnostic accuracy summary estimates for imaging modalities described by Shea et al , by using state-of-the-art methods for the meta-analysis of diagnostic accuracy studies: in this systematic review, they observed that cholescintigraphy has the highest diagnostic accuracy of all imaging modalities in the detection of acute cholecystitis.
Acute calculous cholecystitis: diagnosis with Computed Tomography
As previoulsy reported, gallbladder sonography or cholescintigraphy is usually the first imaging study performed, because these modalities have been shown to be both sensitive and specific for this condition. However, some patients with acute cholecystitis have a confusing or complicated presentation and may be a diagnostic dilemma. In these patients, possible diagnoses include abscess, pancreatitis, ischemic bowel, or other abdominal inflammatory conditions. Many of these patients may be referred for a CT of the abdomen[18, 19]. CT is particularly useful for evaluating the many complications of acute cholecystitis, such as emphysematous cholecystitis, gangrenous cholecystitis, hemorrhage, and gallstone ileus [20, 21]. Moreover CT is also useful in making the specific diagnosis when obesity or gaseous distention limit the use of US.
Acute calculous cholecystitis: diagnosis with Magnetic Resonance Imaging
Both conventional magnetic resonance imaging (MRI) [22–24] and magnetic resonance cholangiopancreatography [23, 24] have been evaluated in the diagnosis of acute calculous cholecystitis and its complications . When compared to ultrasonography, some have found MRI to be equivalent  and some have found it to be superior . Park et al. report that in the assessment of acute cholecystitis, US is superior to MR cholangiography in the evaluation of gallbladder wall thickening. However, MR cholangiography is superior to US in the depiction of cystic duct and gallbladder neck calculi at the evaluation of cystic duct obstruction . The lack of widespread availability of MRI and the relatively high cost prohibits its primary use for now [29–31].
Acute cholecystitis accounts for 3–10% of all patients with abdominal pain and is the most common cause of acute abdominal pain in the right upper quadrant, especially in the elderly patients . Sonography is still used as the initial imaging technique for evaluating patients with suspected gallbladder (GB) disease because of its high sensitivity at the detection of GB stones, its real-time character, and its speed and portability .
Cholescintigraphy still has the highest sensitivity and specificity (96% and 90%) in patients who are suspected of having acute cholecystitis. However, due to a combination of reasons including logistic drawbacks, broad imaging capability and clinician referral pattern (especially in the emergency setting) the use of cholescintigraphy is limited in clinical practice  and US has emerged as the first-line imaging modality for the diagnosis of acute calculous cholecystitis. There is a lack of availability of equipment and/or personnel and the examination time takes up to several hours, whereas a full abdominal US examination is readily available, can be performed in 10–15 minutes, and allows for assessment of pain localized to the gallbladder region (sonographic Murphy sign). Furthermore, cholescintigraphy provides information confined to the hepatobilliary tract, whereas US can be useful in diagnosing other pathologic conditions responsible for the abdominal complaints. Cholescintigraphy also carries the burden of ionizing radiation whereas US and MR imaging do not .
There are several limitations to our study. Some relevant to this review include: accuracy, unobtainable texts and timeframe restrictions. In this review we do not used statistical techniques for combining results of the eligible studies. Another important limitation is the limited number of recent studies in which a head-to-head comparison has been performed.
US is currently considered the preferred initial imaging technique for patients who are clinically suspected of having acute calculous cholecystitis. US is preferred by the majority of radiologists because of lower costs, better availability after hours, and more evidence regarding its accuracy for cholecystitis. In current practice, in the emergency setting, CT is being used increasingly especially in elderly patients with abdominal pain even when they are suspected of having acute cholecystitis.
This article has been published as part of Critical Ultrasound Journal Volume 5 Supplement 1, 2013: Topics in emergency abdominal ultrasonography. The full contents of the supplement are available online at http://www.criticalultrasoundjournal.com/supplements/5/S1. Publication of this supplement has been funded by the University of Molise, University of Siena, University of Cagliari, University of Ferrara and University of Turin.
- Menu Y, Vuillerme M-P: Non-traumatic abdominal emergencies: imaging and intervention in acute biliary conditions. In Emergency Radiology. Edited by: Marincek B, Dondelinger RF. Springer-Verlag Berlin Heidelberg; 2007:481–491. Imaging and InterventionView ArticleGoogle Scholar
- Zeman RK: Cholelithiasis and cholecystitis. In Textbook of gastrointestinal radiology. Edited by: Gore RM, Levine MS, Laufer I. Philadelphia, PA, PA: Saunders; 1994:1636–1674.Google Scholar
- Bortoff GA, Chen MY, Ott DJ, Wolfman NT, Routh WD: Gallbladder stones: imaging and intervention. RadioGraphics 2000, 20: 751–766. 10.1148/radiographics.20.3.g00ma16751View ArticlePubMedGoogle Scholar
- Watanabe Y, Nagayama M, Okumura A, et al.: MR imaging of acute biliary disorders. RadioGraphics 2007, 27: 477–495. 10.1148/rg.272055148View ArticlePubMedGoogle Scholar
- Trowbridge RL, Rutkowski NK, Shojania KG: Does this patient have acute cholecystitis. JAMA 2009, 289: 80–86.Google Scholar
- Nino-Marcia M, Jeffrey RB Jr: Imaging the patient with right upper quadrant pain. Semin Roentgenol 2001, 36: 81–91. 10.1053/sroe.2001.22825View ArticleGoogle Scholar
- Schiller VL, Turner RR, Sarti DA: Color doppler imaging of the gallbladder wall in acute cholecystitis: sonographic-pathologic correlation. Abdom Imaging 1996, 21: 233–237. 10.1007/s002619900053View ArticlePubMedGoogle Scholar
- Paulson EK, Kliewer MA, Hertzberg BS, Paine SS, Carroll BA: Diagnosis of acute cholecystitis with color Doppler sonography: significance of arterial flow in thickened gallbladder wall. Am J Roentgenol 1994, 162: 1105–1108. 10.2214/ajr.162.5.8165991View ArticleGoogle Scholar
- Shea JA, Berlin JA, Escarce JJ, Clarke JR, Kinosian BP, Cabana MD, Tsai WW, et al.: Revised estimates of diagnostic test sensitivity and specificity in suspected biliary tract disease. Arch Intern Med 1994, 154(22):2573–2581. 10.1001/archinte.1994.00420220069008View ArticlePubMedGoogle Scholar
- Lorusso F, Fonio P, Scardapane A, Giganti M, Rubini G, Ferrante A, Stabile Ianora AA: Gatrointestinal imaging with multidetector CT and MRI. Recenti Prog Med 2012, 103(11):493–9.PubMedGoogle Scholar
- Reginelli A, Pezzullo MG, Scaglione M, Scialpi M, Brunese L, Grassi R: Gastrointestinal disorders in elderly patients. Radiol Clin North Am 2008, 46(4):755–71. 10.1016/j.rcl.2008.04.013View ArticlePubMedGoogle Scholar
- Laing FC, Federle MP, Jeffrey RB, Brown TW: Ultrasonic evaluation of patients with acute right upper quadrant pain. Radiology 1981, 140(2):449–455. 10.1148/radiology.140.2.7255722View ArticlePubMedGoogle Scholar
- Ralls PW, Colletti PM, Lapin SA, et al.: Real-time sonography in suspected acute cholecystitis: prospective evaluation of primary and secondary signs. Radiology 1985, 155: 767–771. 10.1148/radiology.155.3.3890007View ArticlePubMedGoogle Scholar
- Imhof M, Raunest J, Ohmann C, Röher HD: Acute acalculous cholecystitis complicating trauma: a prospective sonographic study. World J Surg 1992, 16(6):1160–1165. discussion 1166 10.1007/BF02067089View ArticlePubMedGoogle Scholar
- van Breda Vriesman AC, Engelbrecht MR, Smithuis RH, Puylaert JB: Diffuse gallbladder wall thickening: differential diagnosis. Am J Roentgenol 2007, 188: 495–501. 10.2214/AJR.05.1712View ArticleGoogle Scholar
- Grantcharov TP, Rasti Z, Rossen B, Kristiansen VB, Rosenberg J: Interobserver agreement in ultrasound examination of the biliary tract. Acta Radiol 2002, 43(1):77–79. 10.1080/028418502127347484View ArticlePubMedGoogle Scholar
- Kiewiet JJS, Leeuwenburgh MMN, Bipat S, Bossuyt PMM, Stoker J, Boermeester MA: A systematic review and meta-analysis of diagnostic performance of imaging in acute cholecystitis. Radiology 2012, 264(3):708–720. 10.1148/radiol.12111561View ArticlePubMedGoogle Scholar
- O’Connor OJ, Maher MM: Imaging of cholecystitis. Am J Roentgenol 2011, 196: W367-W374. 10.2214/AJR.10.4340View ArticleGoogle Scholar
- Van Epps K, Regan F: MR cholangiopancreatography using HASTE sequences. Clin Radiol 1999, 54(9):588–94. 10.1016/S0009-9260(99)90020-XView ArticlePubMedGoogle Scholar
- Reginelli A, Mandato Y, Solazzo A, Berritto D, Iacobellis F, Grassi R: Errors in the radiological evaluation of the alimentary tract: part II. Semin Ultrasound CT MR 2012, 33(4):308–17. 10.1053/j.sult.2012.01.016View ArticlePubMedGoogle Scholar
- Buonamico P, Suppressa P, Lenato GM, Pasculli G, D'Ovidio F, Memeo M, Scardapane A, Sabbà C: Liver involvement in a large cohort of patients with hereditary hemorrhagic telangiectasia: echo-color-Doppler vs multislice computed tomography study. J Hepatol 2008, 48(5):811–20. 10.1016/j.jhep.2007.12.022View ArticlePubMedGoogle Scholar
- Regan F, Schaefer DC, Smith DP, Petronis JD, Bohlman ME, Magnuson TH: The diagnostic utility of HASTE MRI in the evaluation of acute cholecystitis. Half-Fourier acquisition single-shot turbo SE. J Comput Assist Tomogr 1998, 22(4):638–42. 10.1097/00004728-199807000-00025View ArticlePubMedGoogle Scholar
- Sood B, Jain M, Khandelwal N, Singh P, Suri S: MRI of perforated gall bladder. Australas Radiol 2002, 46(4):438–40. 10.1046/j.1440-1673.2002.01011.xView ArticlePubMedGoogle Scholar
- Oh KY, Gilfeather M, Kennedy A, Glastonbury C, Green D, Brant W, Yoon HC: Limited abdominal MRI in the evaluation of acute right upper quadrant pain. Abdom Imaging 2003, 28(5):643–51. 10.1007/s00261-003-0037-7View ArticlePubMedGoogle Scholar
- Håkansson K, Leander P, Ekberg O, Håkansson HO: MR imaging in clinically suspected acute cholecystitis. A comparison with ultrasonography. Acta Radiol 2000, 41(4):322–8. 10.1080/028418500127345587View ArticlePubMedGoogle Scholar
- Park MS, Yu JS, Kim YH, Kim MJ, Kim JH, Lee S, Cho N, Kim DG, Kim KW: Acute cholecystitis: comparison of MR cholangiography and US. Radiology 1998, 209(3):781–5. 10.1148/radiology.209.3.9844674View ArticlePubMedGoogle Scholar
- deDombal FT: Introduction. In Diagnosis of acute abdominal pain. 2nd edition. Edited by: deDombal FT. New York: Churchill Livingston; 1991:1–10.Google Scholar
- Rumack CM, Wilson SR, Charboneau JW: Diagnostic ultrasound. 2nd edition. St Louis, MO: Mosby; 1998:175–200.Google Scholar
- Scardapane A, Pagliarulo V, Ianora AA, Pagliarulo A, Angelelli G: Contrast-enhanced multislice pneumo-CT-cystography in the evaluation of urinary bladder neoplasms. Eur J Radiol 2008, 66(2):246–52. 10.1016/j.ejrad.2007.06.005View ArticlePubMedGoogle Scholar
- Panico MR, Vallone G, Mollica C, Nicolai E, Di Cosmo N, Vajro P: Massive hydrops of the gallbladder mimicking a choledochal cyst. J Pediatr Surg 2011, 46(5):1015–8. 10.1016/j.jpedsurg.2011.02.051View ArticlePubMedGoogle Scholar
- Giannattasio A, Cirillo F, Liccardo D, Russo M, Vallone G, Iorio R: Diagnostic role of US for biliary atresia. Radiology 2008, 247(3):912. author reply 912–3 10.1148/radiol.2473071715View ArticlePubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.