Radiology Imaging Adds Time and Diagnostic Uncertainty when Point of Care Ultrasound Demonstrates Cholecystitis

Abstract

Abstract Background: Point of care ultrasound (POCUS) is specific for acute cholecystitis (AC), but surgeons request radiology imaging (RI) prior to admitting patients with POCUS-diagnosed AC. Objectives: We sought to determine the test characteristics of POCUS for AC when performed and billed by credentialed emergency physicians (EPs), the accuracy rate of RI when performed after POCUS, and the time added when RI is requested after POCUS demonstrates AC. Methods: We performed a dual-site retrospective cohort study of admitted adult ED patients who had received biliary POCUS from November 1, 2020 to April 30, 2022. Patients with previously diagnosed AC, liver failure, ascites, hepatobiliary cancer, or cholecystectomy were excluded. Descriptive statistics and 95% confidence intervals for point estimates were calculated. Medians were compared using a Wilcoxon signed-rank test. Test characteristics of POCUS for AC were calculated using inpatient intervention for AC as the reference standard. Results: Of 473 screened patients, 143 were included for analysis: 80 (56%) had AC according to our reference standard. POCUS was positive for AC in 46 patients: 44 true positives and two false positives, yielding a positive likelihood ratio of 17.3 (95%CI 4.4-69.0) for AC. The accuracy rate of RI after positive POCUS for AC was 39.0%. Median time from ED arrival to POCUS and ED arrival to RI were 115 (IQR 64, 207) and 313.5 (IQR 224, 541) minutes, respectively; p < 0.01. Conclusion: RI after positive POCUS performed by credentialed EPs takes additional time and may increase diagnostic uncertainty.