the diagnosis of acute acalcolous cholecystitis - a comparison of sonography scintigraphy and ct

7/29/2019 The Diagnosis of Acute Acalcolous Cholecystitis - A Comparison of Sonography Scintigraphy and CT

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1171

The D iagnos is o f A cu teA ca lcu lous C ho lecys tit is : ACom parison o f Sonog raphy ,S c in tig raphy , and C T

S tua rt E . M irv i&Ju lian R . V a in r igh t1

A va W . N e lson1Ge ra ld S . J oh ns to n1

Robe r t Shor r2A ure lio R od riguez3Nancy 0 . W h itley1

Rece ive d A pr il 21 . 1 98 6; a cce pted a fte r re vis ionJu ne 24 , 19 86 .

1 D epa rtm en t o f D ia gn os tic R ad io log y, U nive rs ityo f M ary la nd M ed ica l S ys tem /H osp ita l, 2 2 5 . G ree neS t.. B a ltim ore , MD 21 201 . A dd re ss re prin t re qu es tsto S . E . M irv is .

2 Depa rtm en t o f Su rge ry . U nive rs ity o f S ou themC a lifom ia , L os Ange les . C A 90032 .

3 Ma ry la nd in s titu te fo r Em erg en cy M ed ic a lS erv ice s System (M IE MS S), U nive rs ity o f M ary la ndM ed ica l S ys tem /H osp ita l, 22 5 . G reen e S t., B a lt i-mo re, MD 212 01.AJ R 147:1171 -1175, Dece mber 19860 36 1 -80 3X /86 /1 4 76 -11 71 Am erican R oen tg en R ay S oc ie ty

The c lin ic a l and labo ra to ry d iagnos is o f a cu te aca lcu lous cho le cyst it is is d ifficu lt, a ndth e re lia b ility o f va rio u s d iagnos tic im ag ing te chn iques has no t b een estab lis h ed . Theresu lts o f s eve ra l im ag ing p ro cedu res per fo rmed ove r a 6 -y ea r p er io d on 56 pa tie n tsw ith c lin ica lly suspec ted acu te aca lcu lous cho le cystitis w ere eva lu a ted re trospectiv e ly .Sonog raphy and C T w e re bo th h igh ly sens itive (92% and 100% , respec tiv e ly ) andspec ific (9 6% and 100% , re spect iv e ly ). H epatob ilia ry s c in tig raphy w as com p rom ised byfre q uen t fa lse -p os itive s ; th e res u lt w as a spec ific ity o f on ly 38% . Pe rcu taneous b ileasp ira tion w as in su ff ic ien tly s ens itiv e (3 3% ) fo r d iagnos is . Sonog raphy w as as sens it iv eas hepa tob ilia ry s c in t ig raphy and w as m o re spec ific in es tab lish ing th e d iagnos is .Because sonog raphy is re la tive ly inexpens ive and can be pe rfo rm ed a t th e beds id e , its hou ld be regard ed as a sat is fa c to ry sc reen ing p ro cedu re . How ever , C T is a gooda lte rn a tive in an eas ily t ranspor ted pa tie n t w hen o th e r in tra abdom ina l d ise ase is sus-pec ted .

Acu te aca lcu lous cho lecys titis is an uncomm on bu t po ten tia lly fa ta l c om p lic a tiono f p ro longed critica l illn ess [1 -4 ]. The cond ition m ost like ly re su lts from a g radua lin c rease in b ile v is cos ity , due to p ro longed s tas is , tha t leads to a func tiona lobs tru c tion o f the cys tic duc t [1 , 4 ]. C om p rom ised pe rfu s ion o f the m e tabo lica llyac tive ga llb ladde r m ucosa m ay a lso be con tribu to ry [3 ]. O the r fa c to rs such asp ro longed hype ra lim en ta tion , pro longed suc tion ing by nasogas tric tube , pos itivep ressu re ven tila to ry suppo rt, num e rous trans fus ions , use o f vasoac tiv e am ines ,and use o f m o rph ine ana lges ia a lso have been im p lica ted [1 , 4] .

U n fo rtuna te ly , bo th c lin ica l and labo ra to ry te s ts la ck sens itiv ity and spec ific ity fo ra rriv ing a t a p reope ra tive d iagnos is [1 -5 ]. B ecause pa tien ts w ith acu te aca lcu louscho lecys titis a re typ ica lly v ic tim s o f m u ltis ys tem traum a o r o the r seve re illn ess ,they rep resen t a popu la tion fo r w hom exp lo ra to ry lapa ro tom y shou ld be avo ided ,if a t a ll po ss ib le , a s a m ean s o f d iag nos ing th is co nd itio n . A ltho ugh hepa tob ilia rysc in tig raphy and sonog raphy have been va luab le in the d iagnos is o f acu te andch ron ic ca lcu lous cho lecys titis , the ir u se fu lness and tha t o f o the r te chn iques suchas C T and pe rcu taneous asp ira tion o f b ile have no t been es tab lished in thed iagnos is o f acu te aca lcu lous cho lecys titis [6 -17 ].

To assess the va lue o f im ag ing m e thods in the d iagnos is o f acu te aca lcu louscho le cys tit is , w e unde rto o k a 6 -ye a r re tro sp ec tive s tu d y o f p a tie n ts w ith c lin ica llysuspec ted acu te aca lcu lous cho lecys titis in w hom hepa tob ilia ry sc in tig raphy , so -nog raphy , CT , o r b ile asp ira tions w e re pe rfo rm ed .

M e thods and M ate r ia lsS ince 1 980 , 60 pa tie n ts h a ve been e va lu a te d b y d ia gnos tic im ag in g m e th ods fo r po ss ib le

a cu te a ca lcu lo u s cho lecy s tit is a fte r tra um a. C om p le te m ed ica l re co rd s and im ag in g s tu d yres u lts w e re ava ilab le in 56 . A ll p a tie n ts w ere adm itte d to the S ho ck T ra um a C en te r o f th eUn ive rs ity o f M ary lan d M ed ica l S y s tem /Ho sp ita l a fte r m a jo r traum a . T he re w ere 3 7 m en and


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1172 MIRVIS ET AL. AJR :1 47 , D ecem be r 19 86

1 9 w om en ; th e age range w as 1 4 to 83 yea rs , w ith a m ean o f 39 .M os t w e re in ju re d in m o to r veh ic le acc id en ts (3 9 ); the rem a ind e rw ere in vo lved in fa lls ( fou r) , c ru sh in ju rie s (th ree ), d iv ing acc iden ts( tw o ), ba ll is tic in ju ries (tw o ), o r o the r a cc ide n ts (10 ). Tw o pa tie n tsw ere adm itte d fo r h ype rb a ric o xygen th e rap y fo r s eve re anae ro b icso ft-t issu e in fec tion s . A ll s tu d ies w ere eva lu a te d re tro sp e c tive ly w ith -ou t k now le dg e o f re su lts o f o th e r d iag nos tic p ro ce dures o r fina lc lin ica l ou tcom e . N o pa rtic u la r im ag ing se qu en ce a lgo rithm was fo l-ow ed a s pa tien ts w e re ca re d fo r b y a va rie ty o f d iffe ren t c lin ic ian sduring th e pe rio d o f th e s tud y .

H e pa to bil ia ry S cin tig ra ph yH epa to b il ia ry sc in t ig ra ph y w as p erfo rm ed on 45 pa t ien ts in jec ted

in traven ous ly w ith 5 -10 mC i (18 5 -3 70 M Bq ) o f 99m -tech ne tium -tag ged para isop ro py la ce ta n ilido im in od ia ce tic ac id (P IP ID A, D ia g no s-tic Iso to pe s , B loom fie ld , N J ). S e ria l sc in tig ram s w ere ob ta in e d a t5 -m m in te rv als . S ta tic im age s we re rec o rd ed a t 2 h r a nd aga in a t 4 -6 h r if th e re w as no v is ua liza tion o f th e ga llb la dde r. S ta tic v iew s w ereob ta in ed from the an te rio r a n d r ig h t la te ra l p ro je c tio ns . Im ag in g w aspe rfo rm ed by us ing a 37- tu b e A nger g am m a cam era . S tu d ie s w erere v iew ed by tw o sta ff rad io log is ts and w e re ana lyzed fo r hepa ticup take and ex c re tion o f tra ce r in to th e b ilia ry sys tem , tim e to v is ua l-iza tio n o f a c tiv ity in the sm a ll bow e l, a nd tim e o f v isua liza tio n o f thega llb lad de r if th is oc cu red w ith in 6 h r. S tud ie s dem ons tra ting a c tiv ityin the sm a ll bowe l w itho u t v isu a liza t ion o f th e g a llb lad de r w ith in 6 hrwere cons ide red pos itiv e . V isua liz a tion o f the ga llb ladde r a fte r 1 h rwas cons id e re d to rep re sen t ch ro n ic c ho le cys titis . C ho lec ys tok in inw a s adm in is te re d to o n ly o ne pa tie n t w hen the ga llb la dde r had no tbeen v is ua lize d 3 h r a fte r in jec tio n o f trace r.

Sonog ra p h ySonogra ph ic exam ina tio n o f th e ga llb lad de r an d rig h t u pp er qu ad-

ran t w as pe rfo rm ed in 40 pa tien ts by us ing rea l-tim e and /o r a rticu la t-in g a rm tra nsdu ce rs . Im ag in g de v ic es u sed inc lu ded a To sh ib a Son -o lay e r L (M ode l SA L-2 0A ) (T o sh iba Am erica In c ., T u s tin , C A ), an A TLM K -100 P rec is io n se rie s (A d vanced Techno log y Labo ra to rie s , B e lle -v ue , W A ), a P icke r E chov iew S ys tem 80 -L (P ick e r In te rna tio na l In c .,N o rth fo rd , C T ), a nd a Ph illip s S ono D iagno s tic B (P h ill ip s U ltra so undInc ., S an ta Ana , C A ). A ll im ages w e re ob ta in ed w ith e ith e r a 3 - o r3 .5 -m Hz tra nsdu ce r. W hen ne ce ss ita ted b y the pa tie n ts c lin ica lcon d ition , p o r tab le s tu d ies w ere p e rfo rm ed by us ing re a l- tim e equ ip -m en t o n ly . Th e s tud ie s g ene ra lly w e re pe rfo rm ed w ith the pa tie n tssu p ine , a ltho ug h , w hen po ss ib le , pa tie n ts a ls o we re exam ine d in th er igh t decub itu s pos ition . E rec t im ages w e re se ldom obta ined due toth e genera l se ve r ity o f th e il ln es ses . S onog raph ic s tu d ie s w e rere v iew ed by tw o s ta ff ra d io log is ts , an d fin d ing s w ere d iv ide d in tom ajo r an d m in o r c rite ria a s fo llow s : M a jo r c r ite r ia in c lu de d a w a llth ick ne ss o f 4 m m o r g rea te r w hen th e g a llb la dde r w as d is te nd ed toa t le as t 5 cm in th e lo ng itu d ina l d im ens io n and th e re w as no ev id en ceo f as c ite s o r hypoa lbum inem ia (se rum p ro te in < 3 .2 m g /d l), th e p res -e n ce o f p e rich o le cys tic flu id o r su bse ro sa l e d em a, ca lcu li, in tram ura lg a s , a s lou ghed m ucosa l m em b ra ne , o r a c om p le te la ck o f re spon seto cho le cys tok in in . M in o r cr ite r ia in c lu de d th e p resence o f echo gen icb ile (s lu dg e ) , d is te ns ion g re a te r th an 8 cm in the long itud ina l o r 5 cmin the tra n sve rse d im en s io n , o r a p a rtia l res ponse (


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AJR :1 47 , D ecem be r 19 86 D IAGNOS IS OF ACUTE ACA LCU LOUS CHO LECYST IT IS 1173

th e ga llb lad de r b ecau se o f p o o r h epa tic fu nc tion and fa ilu reto secre te su ffic ien t tra ce r in to the b ilia ry s ys tem . A no the rpa tien t had obs tru c tion o f the p rox im a l hepa tic duc t and we rethus inde te rm inate find ings fo r the ga llb ladde r bu t a t su rge rywas shown to have bo th acu te and ch ron ic ca lcu lous cho le -cys titis . E ig h t pa tie n ts w ith abno rm a l fin d in gs had aca lcu lou s(s ix ) , o r ca lcu lous (tw o ) acu te cho lec ys titis e s tab lis hed pa th -o log ic a lly b y the p re sence o f a cu te in flamm atio n , ba c te r ia lin vas ion , o r necros is o f the ga llb ladde r w a ll. O ne pa tien t w ithacu te aca lcu lous cho lecys titis re ce ived cho lecys tok in in , bu tv is ua liz a tion o f the ga llb ladde r s til l d id no t occu r. H oweve r,the re we re 1 3 o the r pa tien ts w ith nonv isua liz a tion o f thega llb ladder in whom the c lin ica l cou rse (1 1 ), o r su rg ica l in -spe c tion a lon e (tw o) ind ic a te d a norm a l ga llb lad de r. C ons id -e rin g a ll c ase s in w h ic h the ga llb la dde r cou ld b e e va lu at ed ,1 3 ( 5 4% ) of 24 w e re fa lse -pos itive , y ie ld ing a spec ific ity o fon ly 38% in the pos ttraum a popu la tion . H epa tob ilia ry sc in tig -raphy was 95 % sens itive in the d iagnos is o f pos ttraum atica cu te c ho le cy st it is .

Sonog ra p h ySonog raph ic s tud ie s we re ava ilab le from 40 pa tien ts . In 26

the s tu d y was cons ide re d nega tiv e b y ou r e s tab lishe d c rite ria(see M ethods ). O f th is g roup tw o pa tien ts subsequen tly w e reshow n a t su rge ry to have e ithe r ch ron ic ca lcu lous cho lecys -tit is o r bo th acu te and ch ro n ic ca lcu lo u s cho le cys tit is . In th efirs t p a tie n t so nog raphy re vea led on ly m in im a l w a ll th ic ke n ingand echogen ic b ile w ithou t v isua liza tion of ca lcu li. In thesecond the ga llb ladde r w as m odera te ly d is tended w ith m in i-m al echogen ic b ile b u t no de fin ite c a lcu li. B o th s tud ie s w e repe rfo rm ed ea rly in th is ser ie s w ith le ss p rec ise rea l- tim eequ ipm en t than is cu rren tly ava ilab le .

In 1 4 pa tien ts sonog raph ic find ings we re abno rm a l by ou rc rite ria . S e ven had pa tho lo g ica lly ve rified a cu te aca lcu lou scho lecys titis and five had acu te and chron ic ca lcu lous cho le -cys titis . O ne pa tien t had an equ ivoca l re su lt: ca lcu li and m ildw a ll th icken ing (5 mm ), bu t a pa rtia l re sponse to cho lecys to -k in in in je c tio n (lo n g itu d in a l d iam e te r d e c re ased from 7.4 to6 .8 cm ). T h is pa tien ts sym p tom s and e leva ted b ilirub in le ve lre so lved w ith conse rva tive trea tm en t. Th ree o the r pa tien tsin jec te d w ith ch o lecy s tok in in fa ile d to sh ow any ga llb la dde rcon tra c tion in 1 5 mm and a ll had acu te aca lcu lous cho lecys -tit is d iag nosed pa tho lo g ica lly . A s ing le p a tien t w ith a bnorm a lsonog raph ic find ings im p roved c lin ic a lly and thus w as cons id -e red fa lse -pos itive . O ve ra ll, s onography dem onstra ted a sen-s itiv ity o f 92% fo r acu te cho lecys titis w ith o r w ithou t ca lcu lip re sen t and a spec ific ity o f 96% (T ab le 1 ).CT

Resu lts o f C T w e re ava ilab le fo r 1 5 pa tien ts . In fiv e thes tudy w as pos itive by ou r c r ite r ia fo r acu te aca lcu lous cho le -cys titis , an d a ll five ca se s we re pa tho lo g ica lly co n firm ed . T enpa tien ts w ere con s id e red to b e nega tive fo r a cu te aca lcu lou scho lecys titis , and a ll 1 0 cases w e re con firm ed by c lin ica lcou rse (e igh t) o r su rg ica l pa tho logy (tw o ). Thus , in th is lim itedse rie s CT w as bo th 1 00% sens itive and 1 00% spec ific in thed iagnos is o f acu te aca lcu lous cho lecys titis (Tab le 1 ).

TABLE 1 : S onog raph ic and C T F ind ings in Pa tie n ts Eva lu a tedfo r A cu te C ho le cy stitis

F dn in gs Sonog raphy(N = 40 )CT

(N = 15 )M in or c rit er ia

D is ten s iona 17 5S ludge 16 6Pa rtia l resp onse to C C Kb 1 0

M a jo r c rit er iaCalculi 7 0No re spon se to CC K 4 0W all th icken ing 4 mm c 1 3 4P e ri ch ole cy st ic f lu id d 2 1Subserosa l e dem a (h a lo ) 5 5Pos itiv e (2 m ajo r o r 1 m ajor and2 m ino r c r ite ria ) 14 5

Nega t iv e 2 6 1 0T ru e p os itiv e 13 5T ru e nega tive 2 4 10Sens it iv i ty (% ) 92 100Spec ific i ty (% ) 9 6 1 00P os itiv e p re d ic tive va lue (% ) 9 2 1 00Nega tive p re d ic tiv e va lu e (% ) 9 2 100

a Long itud ina l d iam ete r > 8 cm or tra ns ve rse d iam ete r > 5 cm .a 3 .2 m g/d i.a In a bs en ce o f a sc ite s.

Pe rcu tan eou s A sp ira tio n o f B ileB ile w as asp ira ted pe rcu taneous ly in s ix cases and ob -

tam ed a t su rge ry in fou r o the rs . In tw o cases bac te r ia we reobta ined (C i t robac te r an d E sche rich ia co /i), and bo th pa tien tshad pa tho log ica lly ve rifie d acu te aca lcu lous cho lecys titis . Infou r pa tien ts the asp ira te w as s te r ile and con ta ined no leu -kocy te s ; th ese pa tie n ts had norm a l c lin ica l ( th re e ) o r su rg ica l(one ) resu lts . H oweve r, fou r o the r pa tien ts had s te rile b ilecu ltu res and no o rgan ism s on G ram s ta in s , a s we ll a s spec i-m ens w ithou t leukocy tes , bu t had acu te aca lcu lous cho lecys -titis pa tho log ica lly . Thus , a lthough b ile asp ira tion , e ithe r pe r-cu taneous ly o r a t su rge ry , w as 1 00% spec ific , the m e thodwas on ly 33% sens itive in d iagnos ing acu te ga llb ladde r in flam -mation.

Discuss ionThe con tr ibu tion o f im ag ing s tud ie s to the d iagnos is o f

acu te cho lecys titis in gene ra l is w e ll e s tab lished . O ve ra ll s en-s itiv ity and spec ific ity fo r hepa tob ilia ry s c in tig raphy in thed iagnos is o f acu te cho lec ys titis a re 95 -1 00% and 81 -100% ,respec tive ly , w he reas the sens itiv ity and spec ific ity o f sonog -raphy is repo rted as 67 -93% and 82 -1 00% , respec tive ly[8 , 12 -17 ]. These se rie s in gene ra l rep resen t a subs tan tia lm a jo rity o f cases o f acu te ca lcu lous cho lecys titis and re fle c tthe p reponde rance o f the ca lcu lous fo rm in the gene ra l pop -u la tion [7 ]. H ow eve r, the va lue o f d iagnos tic im ag ing in es tab -lish ing the d iagnos is o f acu te aca lcu lous cho lecys titis is fa rle ss firm ly e sta blis he d.

In 1983 W e is sm an e t a l. [1 1 ] desc ribed the ir e xpe riencew ith hepatob ilia ry sc in tig raphy and sonog raphy in 1 5 pa tien tsw ith acu te aca lcu lous cho lecys titis . T hey repo rted a 93 %spec ific ity and 93% accu racy for hepa tob ilia ry s c in tig raphy


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1174 MIRVIS ET AL. AJR:147 , Dec embe r 1986

bu t found sonog raphy to be fa r le ss re liab le , w ith num e rousfa lse -pos itive and fa lse -nega tive resu lts . In 1 984 Shum an eta l. [7 ] e va lua ted hepa tob ilia ry sc in tig raphy and sonog raphy in33 su rg ica lly p roven cases o f acu te o r ch ron ic aca lcu louscho lecys titis . They repo rted a sens itiv ity o f on ly 67% forsonog raphy and 68% fo r cho le sc in tig raphy in es tab lish ing thed iagnos is . They conc luded tha t the im ag ing d iagnos is o faca lcu lous cho lecys titis rem ains e lu s ive .

O u r resu lts a re a t va r iance w ith these p rev ious s tud ie s .A lthough w e have found hepa tob ilia ry sc in tig raphy to beh ig hly s en sitiv e ( 9 5% ) w ith on ly a s ing le fa lse -nega tive resu lt,m any fa lse -pos itive resu lt led to low spec ific ity ( 38%) . Th eh igh frequency o f fa ls e -pos itive resu lts is no t su rp ris ing be -cause p ro longed pa ren te ra l a lim en ta tion , p ro longed fas ting ,seve re nonb ilia ry in te rcu rren t illn ess , and hepa toce llu la r dys-func tion a re am ong the cond itions know n to p roduce fa lse -pos itiv e resu lts and a re a lso comm on ly found in v ic tim s o fm ajo r traum a [17 -21 ].

B y p roduc ing spasm o f the sph inc te r o f O dd i, m o rph inecan increase p ressu re in the b ilia ry sys tem and d ire c t flow ofb ile in to the cys tic duc t [1 0 ]. In an e ffo rt to dec rease fa lse -pos itiv e cho lesc in tig ram s , C hoy e t a l. [1 0 ] have suggestedthe use o f IV m o rph ine su lfa te ; how eve r, they cau tioned tha tm o rph ine su lfa te m ay p roduce fa lse -nega tive resu lts in caseso f aca lcu lous cho lecys titis b y ove rcom ing a func tiona l ob -s tru c tion in the cys tic duc t. W e d id no t assess the use fu lnesso f m o rph ine su lfa te in th is s tudy .

P rev ious s tud ie s have suggested tha t in je c tion o f cho lec ys -tok in in to p rom o te em p ty ing o f v iscous b ile from the ga llb lad -de r m igh t decrease fa lse -pos itive find ings on sc in tog ram s.D av is e t a l. [22 ] eva lua ted cho lecys tok in in in the d iagnos is o fch ron ic aca lcu lous cho lecys titis and found it o f little va lue ind is tingu ish ing sym p tom a tic pa tien ts from vo lun tee rs . P roud -foo t e t a l. [23 ] and P ic k lem an e t a l. [24 ], however, found theresponse to cho lecys tok in in use fu l in p red ic ting sym ptom aticim p rovem en t a fte r cho le cys tec tom y . E xpe rience w ith the useo f cho le c ys tok in in in the d iagnos is o f acu te aca lcu lous cho -le cys titis has been lim ite d . W e issm an e t a l. [ 25 ] s pe cif ic al lyre commended in je c tion o f cho le cys tok in in in cases o f poss ib leacu te aca lcu lous cho lecys titis . C hoy e t a l. [1 0 ] ra ised thec r it ic ism tha t in jec tion o f ch o le cys to k in in a fte r n on v is ua liza tiono f the ga llb ladde r w ill n ecess ita te re in je c tion o f the rad iopha r-m aceu tic a l and undu ly p ro long the tim e o f s tudy . A lthoughou r expe rience w ith cho le cys tok in in is lim ited , the th ree pa -tien ts w ith no sonog raph ica lly dem onstrab le response w e resubsequen tly p roven to have acu te aca lcu lous cho lecys titisand the s ing le pa tien t w ith a pa rtia l re sponse expe riencedc lin ic al r es olu tio n.

O ne pa tien t in ou r s tudy had acu te aca lcu lous cho lecys titisand no rm a l find ings on hepa tob ilia ry s c in tig raphy . S hum an e ta l. [7 ] repo rted frequen t fa lse -nega tive resu lts in the ir se r ie so f 33 pa tien ts , p roduc ing a low sens itiv ity o f 68 -76% . Theysugges ted , as d id W e issm an e t a I. [25 ], tha t pa tency o f thecys tic duc t can pe rs is t in acu te aca lcu lous cho lecys titis de -sp ite in flamm a tion o f the ga llb ladde r. The inc lu s ion o f n inecases o f ch ron ic aca lcu lous cho lecys titis in the Shum an study[7 ] m ay a lso have con tribu ted to the frequency o f fa ls e -n eg ativ e re su lts .

Sonog ra ph y w as u se fu l in e s tab lish ing the d iagnos is o facu te aca lcu lous cho lecys titis , w ith a sens itiv ity o f 92% anda spec ific ity o f 96% . A lthough d is tens ion o f the ga llb ladde rand echogen ic b ile we re frequen t abno rm a litie s shown in thepos ttraum a popu la tion , the de tec tion o f w a ll th ic ken ing , pe r i-cho lec ys tic flu id , and subse rosa l edem a we re m o re ind ica tiveo f acu te cho lec ys titis . In 1 1 pa tien ts w ith acu te cho lecys titise xam ined by sonog raphy , M a rcha l e t a l. [26 ] saw a sono lu -cen t ha lo a round the ga llb ladde r, w h ich w as show n pa tho log -ica lly to rep resen t subse rosa l edem a and ce llu la r in filtra tion .They be lie ved tha t th is s ign w as spec ific fo r acu te cho lecys-titis . F iv e o f ou r pa tien ts w ith th is find ing a lso had acu teaca lcu lous cho lecys titis ; the s ign was neve r obse rved in anypa tien t shown c lin ica lly o r su rg ic a lly to have a non in flam edga llb ladder. F ive o f 1 2 pa tien ts w ith pos ttraum a tic acu techo lec ys titis had ca lcu li a s show n by sonog raphy and p rovenpa tho log ica lly . T h is h igh pe rcen tage suggests tha t pa tien tsw ith ca lcu li o r ch ron ic cho le c ys titis m ay be a t in c reased riskfo r the deve lopm en t o f acu te in flamm a tion a fte r m a jo r traum ao r s im ila r p ro longed c ritica l illn ess .

C T w as used to eva lua te 1 5 pa tien ts w ith suspec ted acu teaca lcu lous cho lecys titis and w as 1 00% sens itive and spec ificin th is lim ite d se rie s . T he CT fe a tu res o f a cu te cho lec ys tit ishave been desc ribed p rev ious ly [27 -33 ]. T h icken ing o r nod -u la rity o f th e ga llb la d de r w a ll, g a lls to ne s , poo r defin ition o fthe ga llb ladde r/live r in te rfa ce , and pe richo le cys tic flu id w ithou tasc ite s have been reported m os t frequen tly [27 , 29 , 31 , 33].T he C T equ iva len t o f the sonog raph ic ha lo s ign w as p resen tin a ll fiv e pa tien ts w ith acute aca lcu lous cho lecys titis s tud iedby C T . T he rim o f subse rosa l edem a m ay m im ic pe richo le c ys-tic flu id , a s recen tly repo rted by G o lds te in e t a l. [34 ]. A lthoughsonog ra ph y and hepa to b ilia ry s c in tig rap h y ha ve ga ine d w id ea ccep ta n ce a s in it ia l sc ree n ing s tud ie s fo r p a tien ts w ith sym p -tom s sugges tive o f acu te cho lecys titis , the use o f CT as anin itia l d iagnos tic p rocedu re seem s qu ite reasonab le . In thetyp ica l case ou r pos ttraum a pa tien ts a re re fe rred fo r im ag ingeva lua tion if they have feve r and seps is o f unknow n sou rce .T hey comm on ly a lso have assoc ia ted liv e r enzym e abnor-m a litie s , o ften re la ted to o the r aspec ts o f the ir in ju ry . Theinves tiga tion o f the abdom en by C T fac ilita te s the sea rch fo roccu lt abscesses and the eva lua tion o f the b ilia ry s ys tem . Inm any ins tances sonog raph ic assessm en t o f the abdom en ish inde red by in te s tina l ile us o r ove r ly ing bandages .

R ecen tly , M cG ahan and W a lte r [5 ] repo rted the ir e xpe ri-ence w ith pe rcu taneous asp ira tion o f b ile in pa tien ts w ithsu spec te d acu te a ca lc u lou s cho lec ys tit is . T h ey em phas ize dits va lue in suspec ted cases because o f the po ten tia l fo r fa lse -pos itive find ings on cho lesc in tig ram s o r fa lse -nega tive find -ings on sonog ram s. T hey be lie ve tha t asp ira tion o f b ile p ro-v ides a m e thod o f exc lud ing the ga llb ladde r as a sou rce o fin fe c tion . H ow eve r, fou r o four pa tien ts in w hom b ile asp ira tionw as pe rfo rm ed had pa tho log ica lly ve rifie d acute aca lcu louscho lecys titis desp ite the absence o f bac te r ia o r leukocy tes inthe b ile spec im en . O ve ra ll the techn ique w as on ly 33% sen -s itive in de te rm in ing pa tien ts w ith acu te ga llb ladde r in flam -m a tion . In desc rib ing the pa tho logy o f acu te cho lec ys titis ,G lenn [4 ] no ted no s ign ifican t d iffe rence in ca lcu lous vs aca l-cu lous d isease . T he num be r o f leukocy tes found in the ga ll-


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A JR :14 7, D ecem be r 19 86 DIAGNOSIS OF ACUTE ACALCULOUS CHOLECYSTITIS 1175

b ladde r w a ll w as va riab le ; o c cas iona lly none we re found . O nthe bas is o f th is expe rience , we be lie ve tha t the absence o fle u koc y tes o r ba c te ria in the b ile s hou ld n o t e xc lud e thed iagnos is o f acu te ca lcu lous o r aca lcu lous cho lecys titis .

In summ ary , ou r experience w ith 56 pa tien ts w ith c lin ic a llysu spec te d a cu te aca lcu lo us cho le cys tit is has show n tha tsonog raphy has sens itiv ity equ iva len t to and spec ific ity su -peno r to cho le s c in tig raphy . CT w as accu ra te in eva lua tingthe ga llb ladde r fo r suspec ted acu te cho lec ys titis and shou ldbe rega rded as a reasonab le screen ing tes t, e spec ia lly w heno the r in traabdom ina l d iseases a re an tic ipa ted [4 ]. F ina lly ,pe rcu taneous asp ira tion o f b ile m ay be a va luab le m e thod fo rcon firm ing the d iagnos is o f acu te cho lecys titis , bu t a s te r ilespec im en w ithou t leukocy tes canno t be used re liab ly to ex -dude the d iagnos is .

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the diagnosis of acute acalcolous cholecystitis - a comparison of sonography scintigraphy and ct

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