History, Physical Examination, Laboratory Testing, and Emergency Department Ultrasonography for the Diagnosis of Acute Cholecystitis

Background Acute cholecystitis ( AC ) is a common differential for patients presenting to the emergency department ( ED ) with abdominal pain. The diagnostic accuracy of history, physical examination, and bedside laboratory tests for AC have not been quantitatively described. Objectives We performed a systematic review to determine the utility of history and physical examination (H&P), laboratory studies, and ultrasonography ( US ) in diagnosing AC in the ED . Methods We searched medical literature from January 1965 to March 2016 in PubMed, Embase, and SCOPUS using a strategy derived from the following formulation of our clinical question: patients— ED patients suspected of AC ; interventions— H&P, laboratory studies, and US findings commonly used to diagnose AC ; comparator— surgical pathology or definitive diagnostic radiologic study confirming AC ; and outcome— the operating characteristics of the investigations in diagnosing AC were calculated. Sensitivity, specificity, and likelihood ratios ( LR s) were calculated using Meta‐DiSc with a random‐effects model (95% CI ). Study quality and risks for bias were assessed using the Quality Assessment Tool for Diagnostic Accuracy Studies. Results Separate PubMed, Embase, and SCOPUS searches retrieved studies for H&P ( n =  734), laboratory findings ( n =  74), and US ( n =  492). Three H&P studies met inclusion/exclusion criteria with AC prevalence of 7%–64%. Fever had sensitivity ranging from 31% to 62% and specificity from 37% to 74%; positive LR [ LR +] was 0.71–1.24, and negative LR [ LR –] was 0.76–1.49. Jaundice sensitivity ranged from 11% to 14%, and specificity from 86% to 99%; LR + was 0.80–13.81, and LR – was 0.87–1.03. Murphy's sign sensitivity was 62% (range = 53%–71%), and specificity was 96% (range = 95%‐97%); LR + was 15.64 (range = 11.48–21.31), and LR – was 0.40 (range = 0.32–0.50). Right upper quadrant pain had sensitivity ranging from 56% to 93% and specificity of 0% to 96%; LR + ranged from 0.92 to 14.02, and LR – from 0.46 to 7.86. One laboratory study met criteria with a 26% prevalence of AC . Elevated bilirubin had a sensitivity of 40% (range = 12%–74%) and specificity of 93% (range = 77%–99%); LR + was 5.80 (range = 1.25–26.99), and LR – was 0.64 (range = 0.39–1.08). Five US studies with a prevalence of AC of between 10% and 46%. US sensitivity was 86% (range = 78%–94%) and specificity was 71% (range = 66%–76%); LR + was 3.23 (range = 1.74–6.00), and LR – was 0.18 (range = 0.10–0.33). Conclusion Variable disease prevalence, coupled with limited sample sizes, increases the risk of selection bias. Individually, none of these investigations reliably rule out AC . Development of a clinical decision rule to include evaluation of H&P, laboratory data, and US are more likely to achieve a correct diagnosis of AC .