Algorithm of Ralls et al for Ultrasonography and Cholescintigraphy in a Patient with Suspected Acute Cholecystitis

Description

Ralls et al evaluated the use of imaging studies in patients suspected of having acute cholecystitis. They developed an algorithm for cost effective use of the these tests. The authors are from the University of Southern California in Los Angeles.

Patient inclusion: suspected of acute cholecystitis

Patient exclusion: chronic cholecystitis OR biliary obstruction OR incidental gallstones if not suspected of having acute cholecystitis

Parameters:

(1) gallstones

(2) sonographic Murphy sign

(3) gallbladder wall (thickened if >= 3 mm thick)

Gallstone	Sonographic Murphy Sign	Gallbladder Wall	Pattern
absent	absent	not thickened	1
absent	absent	thickened	2
absent	present	not thickened	3
absent	present	thickened	4
present	absent	not thickened	5
present	absent	thickened	6
present	present	not thickened	7
present	present	thickened	8

where:

• A positive sonographic Murphy sign overlaps with a positive clinical Murphy sign but may differ.

• Murphy's sign is positive if the person is unwilling to breath because of pain if the examiner's fingers are hooked under the right costal margin so as to touch the gallbladder as it descends during breathing.

• The sonographic Murphy sign is positive IF maximal tenderness over the location of the gallbladder on ultrasonography.

• Pattern 4 suggests acalculous cholecystitis or else cholesterolosis.

• Some gallbladder walls were contracted due to fibrosis.

Pattern	Predictive Value	Management
1	NPV 98%	observation; cholescintigraphy if clinical suspicion persistent
2	NPV 95%	cholescintigraphy
3	NPV 97%	cholescintigraphy
4		cholescintigraphy
5		cholescintigraphy
6	PPV 95% (PPV 99%)	cholecystectomy
7	PPV 92% (PPV 99%)	cholecystectomy
8	PPV 94% (PPV 99%)	cholecystectomy

where:

• The predictive value are those for all cases (Table 4).

• The value in parentheses for patterns 6, 7 and 8 are values for those conditions requiring cholecystectomy (Table 5).

• Cholescintigraphy = Technetium-99m

A patient with a positive cholescintigraphy underwent cholecystectomy if clinically confirmed.

A patient with negative cholescintigraphy was observed.

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Description

Specialty

ICD-10