The impact of a rapid imaging protocol in acute cholecystitis-prospective cohort study

INTRODUCTION: In this study we assess the impact of a “rapid imaging protocol” (RIP) on outcomes in patients with suspected acute cholecystitis (AC). METHODS: From January 2017 to January 2018, a prospective cohort study was implemented using a RIP with hepatoscintigraphy (HIDA) or CT scan (first available, goal within 4 h) in patients (n = 52) presenting with highly suspected AC and a clinical feature score of ≥1. For the latter, the following presenting features were scored as follows: 1 point for WBC count ≥10,000 (10(9)/L), 1.5 points for glucose ≥140 (mg/dl), and/or 1 point for age ≥50 yrs. The historical control was all patients admitted with suspected AC in a 1.5-year period (n = 117) under our previous “delayed imaging protocol” (DIP), which used US ± HIDA (post-admission) in select patients. Primary end points included: compare outcome and quality measures between the groups, evaluate diagnostic imaging performance for AC, and evaluate our proposed clinical feature score in the setting of AC. RESULTS: Histopathologic features consistent with AC was more frequent in patients in the RIP (64% vs 39%, p = 0.008). The pooled positive predictive value of HIDA and CT scan for AC were 85% vs 94%, respectively. The RIP was associated with a significant reduction in time to surgery, length of stay, and conversions to open (p < 0.001, respectively). A clinical feature score of 3.5 predicted the likelihood of AC in 95% of the cases (x(2) for linear trend = 42, p < 0.001). CONCLUSION: A protocol centered around rapid identification, defined clinical criteria (i.e. clinical feature score), and confirmation with non-user dependent imaging modalities has resulted in favorable outcomes. CT may be the study of choice when the likelihood of AC is high because it is superior at identifying severity.