Cholescintigraphy in the critically III

doi:10.1016/S0002-9610(88)80030-8

The American Journal of Surgery

Volume 155, Issue 6, June 1988, Pages 727-729

https://doi.org/10.1016/S0002-9610(88)80030-8 Get rights and content

Summary

Critical review of cholescintigraphy in critically ill patients suggests the examination will not conclusively prove or disprove the diagnosis of acute cholecystitis. Of 17 scans performed in critically ill patients with clinical evidence of acute cholecystitis, 7 were true-negative, 1 was false-negative, 6 were false-positive, and 3 were nondiagnostic. Cholestasis and hepatocyte dysfunction, common in the critically ill, result in abnormal clearance of hepatobiliary radionuclide imaging agents, decreasing the usefulness of cholescintigraphy in this patient population. diagnosing acute cholecystitis in a critically ill patient remains difficult.

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Cited by (15)

Acute acalculous cholecystitis and cardiovascular disease, which came first? After two hundred years still the classic chicken and eggs debate: A review of literature
2022, Annals of Medicine and Surgery
Citation Excerpt :
Due to the possibility to allow a rapid diagnosis, the safety and absence of radiation ultrasonography- US represents the most useful diagnostic tool in the Emergency Department. Nevertheless, the sensitivity and the specificity of US varies from 30% to 100% [19,34,41,42,67–73]. This large divergence comes, probably from the different criteria for sonographic diagnosis used in the mostly retrospective studies.
The existence of a close association between disease of the biliary tract and disease of the heart is known from the mists of time.
Acute acalculous cholecystitis (AAC) can be defined as an acute necro inflammatory disease of the gallbladder in the absence of cholelithiasis.
AAC is a challenging diagnosis. The atypical clinical onset associated to a paucity and similarity of symptoms and to laboratory data mimicking cardiovascular disease (CVD) often results in under and misdiagnosed cases. Moreover, AAC has commonly a fulminant course compared to calculous cholecystitis and it is often associated with gangrene, perforation and empyema as well as considerable morbidity and mortality (up 50%). Early diagnosis is crucial to a prompt treatment in order to avoid complications and to increase survivability.
Even today, although scientific evidence dating two hundred years has shown a close association between AAC and CVD, due to the lack of RCT, there is still a lot of confusion regarding the relationship and consequently the clinical management AAC and CVD.
In addition, emergency physicians are not always familiar with transient ECG changes with AAC.
The aim of this review was to provide evidence regarding epidemiology, pathophysiology, clinical presentation and treatment of the complex association between AAC and CVD.
Our main findings indicate that AAC should be suspected after each general disease leading to hypoperfusion such as cardiovascular diseases or cerebrovascular diseases or major heart or aortic surgery. ECG changes in absence of significant laboratory data for IMA (Acute myocardial infarction) could be related to a misdiagnosed AAC.
US – Ultrasonography-plays a key role in the early diagnosis and also in the follow up of AAC.
Cholecystostomy and cholecystectomy as unique or sequential represent the two prevailing treatment options for AAC.
Acute Acalculous Cholecystitis: A Review
2010, Clinical Gastroenterology and Hepatology
Citation Excerpt :
It is evident that despite many attempts to elucidate the pathogenesis of AAC, it still is not completely defined. The diagnosis of AAC is difficult because no clinical findings (review of symptoms, physical examination, laboratory tests) establish it.2,3,7,8,11,16,20 There are many confounding factors.
Although recognized for more than 150 years, acute acalculous cholecystitis (AAC) remains an elusive diagnosis. This is likely because of the complex clinical setting in which this entity develops, the lack of large prospective controlled trials that evaluate various diagnostic modalities, and thus dependence on a small data base for clinical decision making. AAC most often occurs in critically ill patients, especially related to trauma, surgery, shock, burns, sepsis, total parenteral nutrition, and/or prolonged fasting. Clinically, AAC is difficult to diagnose because the findings of right upper-quadrant pain, fever, leukocytosis, and abnormal liver tests are not specific. AAC is associated with a high mortality, but early diagnosis and intervention can change this. Early diagnosis is the crux of debate surrounding AAC, and it usually rests with imaging modalities. There are no specific criteria to diagnose AAC. Therefore, this review discusses the imaging methods most likely to arrive at an early and accurate diagnosis despite the complexities of the radiologic modalities. A pragmatic approach is vital. A timely diagnosis will depend on a high index of suspicion in the appropriate patient, and the combined results of clinical findings (admittedly nonspecific), plus properly interpreted imaging. Sonogram (often sequential) and hepatic iminodiacetic acid scans are the most reliable modalities for diagnosis. It is generally agreed that cholecystectomy is the definitive therapy for AAC. However, at times a diagnostic/therapeutic drainage via interventional radiology/surgery may be necessary and life-saving, and may be the only treatment needed.
Acute Cholecystitis, Biliary Obstruction, and Biliary Leakage
2003, Seminars in Nuclear Medicine
Citation Excerpt :
However, all patients in that study also had hepatocellular disease. Severe intercurrent illness (eg, massive trauma, sepsis, life-threatening postoperative complications, acute respiratory diseases has been associated with false-positive cholescintigraphy.27,33,36 One report found a 30% false-positive rate.33
The use of cholescintigraphy to diagnose acute cholecystitis, biliary obstruction, and biliary leakage dates back to the late 1970s. Today, despite the many advances in imaging instrumentation, radiopharmaceuticals, and methodology over these years, cholescintigraphy still plays an important role in confirming or excluding these diagnoses in acutely ill patients. Acute calculous and acalculous cholecystitis, gallbladder perforation, biliary obstruction, and biliary leakage often present as acute abdominal pain, and must be differentiated from other surgical and nonsurgical etiologies with similar symptoms and presentation. Understanding the pathophysiology of acute hepatobiliary diseases is vital for deciding on the most advantageous imaging work-up and for interpretation of the studies. To optimize the value of cholescintigraphy, up-to-date methology, proper use of appropriate pharmacologic interventions, and recognition of characteristic image findings are critical.
Results of cholescintigraphy in a VA hospital
1992, Journal of Surgical Research
In a review of 200 hepatobiliary imaging studies done in a VA hospital over a 5-year period, a sensitivity of 96% and a specificity of 88% were obtained. In a subgroup of 40 patients with alcoholic liver disease, the specificity dropped to 60% although the sensitivity remained high (100%). These data indicated that in patients with alcoholic liver disease a positive DISIDA scan is not diagnostic of acute cholecystitis and cannot be interpreted as an indication for cholecystectomy. Possible modifications of imaging techniques, including delayed imaging and morphine-augmented cholescintigraphy, may prove to increase the specificity of cholescintigraphy in these patients. A prospective study using these modifications would help in determining the current role of cholescintigraphy in the diagnosis of acute cholecystitis in patients with alcoholic liver disease.
1990, The American Journal of Surgery
Use of cholescintigraphy with morphine in critically ill patients with suspected cholecystitis
1989, Surgery

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¹: From the Departments of Surgery and Radiology, The Ohio State University College of Medicine, 410 West Tenth Avenue, Columbus, Ohio.

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Cholescintigraphy in the critically III

Summary

Semin Nucl Med

Types of cholecystitis: the management of acute and chronic calculus cholecystitis

Gastrointestinal complications after cardiopulmonary bypass

Surgery

Hepatic dysfunction during hyperalimentation

Arch Surg

Liver function values in adults receiving total parenteral nutrition

JAMA

Functional and histopathologic changes in the liver during sepsis

Surg Gynecol Obstet