Attempting to Bridge the Gap: Comparison of Clinical Characteristics, Ultrasound, and Final Surgical Pathology of Emergency Department vs Outpatient Clinic Patients Undergoing Cholecystectomy

Abstract

INTRODUCTION: After emergency department (ED) discharge for symptomatic cholelithiasis, many patients fail the outpatient clinic (OC) algorithm. Our previous study showed that clinical diagnosis is better at predicting cholecystitis than ultrasound (US) in ED patients. This study compares clinical presentation (CP), US, and final surgical pathology (FSP) in the ED and OC patients undergoing cholecystectomy. METHODS: This retrospective chart review compared ED and OC patients at a single institution with right upper quadrant pain (RUQ) and cholelithiasis who underwent cholecystectomy. CP including duration of pain and Murphy’s sign, laboratory values, US, and FSP were compared. RESULTS: A total of 607 patients underwent cholecystectomy: 299 OC and 308 ED. ED patients were younger, more likely to have RUQ pain >4 hours (90% vs 27.5%), positive Murphy’s sign, leukocytosis, and positive US (30% vs 5% (p < 0.0001)). Although, FSP revealed chronic cholecystitis in a majority of patients including 56% and 72% of ED and OC, respectively, ED patients were more likely to have acute cholecystitis (39.3% vs 4.7%) and less likely to have isolated cholelithiasis (4.6% vs 23% [p < 0.0001]). Among patients with an acute component, RUQ pain >4 hours was more frequently positive than US in both ED (p < 0.0001) and OC (p < 0.02; Table 1). Table 1. - Demographic and Clinical Characteristics Variable Inpatient308 (50.7) Outpatient299 (49.3) p Value Age, mean (+SD) 40.3 (14.5) 47.5(28.0) 0.0001 Pathology, n (%): acute and chronic cholecystitis 76 (24.7) 5 (1.7) <0.0001 Acute cholecystitis 45 (14.6) 10 (3.4) Chronic cholecystitis 173 (56.2) 216 (72.2) Cholelithiasis 14 (4.6) 68 (22.7) Pain history: pain duration ≥ 4 h 276 (90.2) 82 (27.7) <0.0001 Provider + Murphy’s sign 100 (33.3) 18 (6.1) <0.0001 Laboratory tests, n (%): white blood cells >11,000 148 (48.1) 22 (8.2) <0.0001 US findings positive 93 (30.2) 12 (5.0) <0.0001 CONCLUSION: CP and duration of pain is a better predictor than US for cholecystitis in both OC and ED populations. Although chronic cholecystitis on FSP is prevalent in both populations, ED presentation likely represents an acute exacerbation of chronic disease, despite negative US findings, and urgent inpatient cholecystectomy is recommended.