Brief Report

Point-of-care ultrasound diagnosis of pediatric cholecystitis in the ED

James W. Tsung MD, MPH^a,b,?, Christopher C. Raio MD^c,

Daniela Ramirez-Schrempp MD^d, Michael Blaivas MD^e

^aDepartment of Emergency Medicine, Bellevue Hospital Center/NYU School of Medicine, New York, NY 10016, USA ^bDepartment of Pediatrics, Bellevue Hospital Center/NYU School of Medicine, New York, NY 10016, USA ^cDepartment of Emergency Medicine Northshore University Hospital, Manhasset, NY 11030, USA

^dDivision of Pediatric Emergency Medicine, Boston Medical Center, Boston, MA 02118, USA

^eDepartment of Emergency Medicine, Northside Hospital-Forsyth, Atlanta, GA 31029, USA

Received 9 August 2008; revised 4 November 2008; accepted 2 December 2008

Abstract

Objective: The diagnosis of cholecystitis or biliary tract disease in children and adolescents is an uncommon occurrence in the emergency department and other Acute care settings. Misdiagnosis and delays in diagnosing children with cholecystitis or biliary tract disease of up to months and years have been reported in the literature. We discuss the technique and potential utility of point-of-care ultrasound evaluation in a series of pediatric patients with suspected cholecystitis or biliary tract disease.

Methods: We present a nonconsecutive case series of pediatric and Adolescent patients with abdominal pain diagnosed with cholecystitis or biliary tract disease using point-of-care ultrasound. The published sonographic criteria is 3 mm or less for the upper limits of normal gallbladder wall thickness and is 3 mm or less for normal common bile duct diameter (measured from inner wall to inner wall) in children. Measurements above these limits were considered abnormal, in addition to the sonographic presence of gallstones, pericholecystic fluid, and a sonographic Murphy’s sign.

Results: Point-of care ultrasound screening detected 13 female pediatric patients with cholecystitis or biliary tract disease when the authors were on duty over a 5-year period. Diagnoses were confirmed by radiology imaging or at surgery and Surgical pathology.

Conclusions: Point-of-care ultrasound to detect pediatric cholecystitis or biliary tract disease may help avoid misdiagnosis or delays in diagnosis in children with abdominal pain.

(C) 2010

* Corresponding author. Bellevue Hospital Center/NYU School of Medicine, Emergency Care Institute, New York, NY 10016, USA. Tel.: +1 212 562 5070; fax: +1 212 562 3001.

E-mail address: [email protected] (J.W. Tsung).

Introduction

Although an uncommon occurrence in the emergency department (ED), the diagnosis of cholecystitis or biliary tract disease in children and adolescents has been reported to be increasing since the 1970s [1]. This may be due to several

0735-6757/$ – see front matter (C) 2010 doi:10.1016/j.ajem.2008.12.003

Ultrasound technique“>factors: rates of obesity have tripled in school-aged children aged 6 to 19 from 5% to 6.5% in the 1976-1980 National Health And Nutrition Examination Survey (NHANES) to 17.4% to 18.8% in the 2003-2004 NHANES [2]; more

available diagnostic capability with the introduction of ultrasound in the 1970s; and the more recent expanding use of point-of-care ultrasound by clinicians around the world.

Health care providers may not be aware of the features of pediatric cholecystitis and its atypical presentation because it is infrequently encountered in the pediatric population and primarily considered an adult disease entity. In fact, many may not include cholecystitis or biliary tract disease on a differential diagnosis list when evaluating a pediatric patient with abdominal pain. The medical literature consists of case series with patients younger than 20 years, making 1.2% [3] to 4.3% [4] of all patients with gallbladder or biliary tract disease. No recent prospective population-based data of pediatric cholecystitis or biliary tract disease are available. Reports of delays in diagnosing Younger children with cholecystitis or biliary tract disease of up to months and years are not infrequent in the medical literature [1,3-7]. In addition, misdiagnosis of cholecystitis in children can occur, with one series reporting up to 15% of pediatric cholecystitis patients with Typical symptoms having a preoperative diagnosis of acute appendicitis [5]. The age of presentation can range from as early as the neonatal period to adolescence where features of Gallbladder disease become similar to adult cholecystitis.

Data to support sonographic criteria for the diagnosis of cholecystitis or biliary tract disease in children are limited. The gallbladder wall thickness and common bile duct diameter measurements have been extrapolated from adult criteria and may pose a problem in certain cases. The purpose of this report is to present a series of pediatric and adolescent patients with cholecystitis or biliary tract disease diagnosed using point-of-care ultrasound. We discuss the technique and sonographic criteria for point-of-care ultrasound evaluation of children and adolescents with suspected cholecystitis or biliary tract disease.

Methods

We report the demographic, clinical, and sonographic indicators of 13 nonconsecutive pediatric patients with cholecystitis or biliary tract disease collected from 4 different EDs. These patients presented when the authors were on duty over a 5-year period and when clinical suspicion (upper abdominal pain) prompted the performance of a point-of- care ultrasound examination. We used the published sonographic criteria for the upper limits of 3 mm or less for normal for gallbladder wall thickness [8] in children up to 16 years old and 3 mm or less for normal common bile duct diameter [9] (measured from inner wall to inner wall) in children up to age 13 years old. Measurements above these

limits were considered abnormal, in addition to the sonographic presence of gallstones, pericholecystic fluid, and a sonographic Murphy sign. We defined obesity as N95th percentile of body mass index according to CDC guidelines [10]. This brief report in case series format was determined to be exempt from review by the authors’ institutional review boards.

Ultrasound technique

All patients were scanned with curvilinear or phased array transducers from 3.5 to 5 MHz in multiple transverse and longitudinal planes to evaluate the gallbladder, main lobar fissure, and portal triad in detail. When necessary, scanning in oblique planes or scans in the left lateral decubitis position were obtained.

Results

Point-of-care Ultrasound screening detected 13 female pediatric patients with cholecystitis or biliary tract disease when the authors were on duty from 2004 to 2008. Table 1 describes the demographic and clinical information of the

13 cases. All cases were confirmed by subsequent radiology department imaging (ultrasound, hepatobiliary iminodiAcetic acid [HIDA] scan, or magnetic resonance imaging) or at surgery.

Discussion

One of the primary difficulties in diagnosing cholecystitis or biliary tract disease in the pediatric population is the high threshold for suspecting the disease. Risk factors for cholecystitis or cholelithiasis in the pediatric population have been identified as menarche in females, obesity, a history of receiving total parental nutrition with and without ileal resection or dysfunction (eg, from necrotizing enter- ocolitis) in infants, biliary dyskinesia, and hemoglobinopa- thies such as Sickle cell disease and hereditary spherocytosis. These risk factors are reviewed in detail elsewhere [1,4,11]. On clinical presentation, none of the pediatric patients in our series had the classic constellation of fever, elevated leukocyte count, and an acute abdomen on physical examination. In contrast to adults studied with nongangre- nous acute cholecystitis, approximately 25% of adult patients lacked fever and elevated leukocyte count [12]. Thus, physical examination and laboratory testing can be of limited value in diagnosing pediatric biliary tract disease. Abdom- inal x-rays may only detect radiopaque pigmented gallstones in less than half of symptomatic children with hemolytic disorders [11]. Patients in our series were often referred by

Table 1 Demographic, clinical, and sonographic data of pediatric cholecystitis and biliary tract disease cases

primary care physicians with other diagnoses such as gastritis or for psychiatric evaluation, and in some cases, were returning after a prior ED visit. Thus, it is infrequent for physicians caring for pediatric patients to readily consider cholecystitis or biliary tract disease in the differential diagnosis of upper abdominal pain. Furthermore, this frequently led to considerable delays in diagnosis. Several patients in our series experienced delays in diagnosis ranging from greater than 60 days to 5 years.

Management of these pediatric patients can be compli- cated by their lack of symptoms or otherwise well appearance when symptoms are intermittent. Disagreement

with discharge disposition can arise when a child becomes completely asymptomatic during ED evaluation despite an abnormal point-of-care gallbladder ultrasound evaluation, as occurred in patient 1 (Fig. 1A). The patient was discharged home and returned to pediatric surgery clinic a week later with intermittent abdominal pain. She was sent for radiology department ultrasound that was read as equivocal with an anterior gallbladder wall thickness measurement of 2.8 mm. On further radiology imaging, the patient had a positive HIDA scan and was admitted for Intravenous antibiotics for a week and underwent elective cholecystectomy 2 weeks later. In addition, point-of-care ultrasound can be useful when

Fig. 1 A, Patient 1 with gallbladder wall thickness (GBWT) measuring 4.4 mm with gallstone in gallbladder. B, Patient 2 with choledochal cyst; image showing dilated common bile duct measuring 11.1 mm. Flow (in red) visualized in the hepatic artery (HA) and portal vein (PV). C, Patient 7 with pericholecystic fluid and gallstone in gallbladder neck. D, Patient 13, an 18-month-old ex-32 weeks’ gestation premature infant, had received total parental nutrition during neonatal course, with thickened anterior GBWT measuring 4.5 mm.

pathology other than cholecystitis or cholelithiasis may be detected: in patient 2, referred for midepigastric pain and a tentative diagnosis of gastritis by her pediatrician, point-of- care ultrasound examination demonstrated a normal gall- bladder but revealed a dilated common bile duct measuring

1.1 cm (Fig. 1B), and a type 4 choledochal cyst was confirmed on subsequent magnetic resonance imaging.

In the past, physicians considering these uncommon diagnoses in children would be required to obtain radiology department imaging services. However, in the last decade, emergency ultrasound has expanded greatly [13]. It is now more likely that emergency physicians will themselves perform a focused point-of-care ultrasound of the right upper quadrant. Previous research on emergency gallbladder ultrasound in adults has shown that emergency physicians accurately perform and interpret the examination [14]. In addition, point-of-care gallbladder ultrasound performance tends to decrease throughput time and allow for faster

disposition [15,16]. As emergency physicians in general and pediatric EDs increase point-of-care ultrasound utilization, they will be more likely to diagnose pediatric patients with cholecystitis or biliary tract disease. An increased awareness and a lower index of suspicion will be critical.

Limitations

This report is a limited nonconsecutive case series. Thus, we were unable to determine test performance characteristics for point-of-care gallbladder ultrasound to diagnose pediatric cholecystitis or make systematic observations regarding risk factors for cholecystitis or biliary tract disease in pediatric patients. Furthermore, no data exist that describe test performance characteristics of sonographic indicators such as the anterior gallbladder wall thickness measurement, common bile duct diameter, presence of pericholecystic fluid (Fig. 1C), or the sonographic Murphy’s sign in children. In

our limited experience, the anterior gallbladder wall cutoff measurement of 3 mm to define the limits of normal [8] was occasionally problematic. Patient 4, with an anterior gallbladder wall thickness measurement of 2.6 mm, was diagnosed with cholecystitis confirmed by positive HIDA scan. These measurements will need to be confirmed by prospective investigation.

History regarding duration of chronic abdominal pain was obtained from parental recall and in the child with symptoms for 5 years, it was possible that there were other causes for chronic abdominal pain other than gallbladder disease. Contrary to the published literature, it is also notable that the gender predilection in our series was entirely female. In our collective experience, we know of only one male child (12 years old) who presented clinically with biliary colic symptoms with gallstones diagnosed by point-of-care ultrasound but was not included in this case series because of lack of a definitive diagnosis. We would caution readers that the lack of male patients in our series compared to the literature [1,4,7] may reflect underdiagnosis of male children on our part or the very limited number of patients in this series. In addition, being in EDs of general hospitals (as opposed to Tertiary care children’s hospitals), we did not encounter any children with hemoglobinopathies in our series, which is another well-documented risk factor for gallstones and biliary tract disease.

Conclusions

Point-of-care ultrasound to detect pediatric cholecystitis or biliary tract disease may help avoid misdiagnosis or delays in diagnosis in children with abdominal pain, especially in the context of intermittent symptoms or multiple visits to health care providers. Further research is necessary to determine the accuracy of point-of-care ultrasound in the diagnosis of pediatric cholecystitis or biliary tract disease. Further prospective population-based investigation is war-

ranted to better describe the epidemiology of cholecystitis or biliary tract disease in the pediatric population.

References

1. Bailey PV, Connors RH, Tracy Jr TF, et al. Changing spectrum of cholelithiasis and cholecystitis in infants and children. Am J Surg 1989;158(6):585-8.
2. http://www.cdc.gov/nccdphp/dnpa/obesity/index.htm. [Accessed June 15, 2008].
3. Blalock A. A statistical study of eight hundred eighty-eight cases of biliary tract disease. Bull Johns Hopkins Hosp 1924;24:391.
4. Andrassy RJ, Treadwell TA, Ratner IA, et al. Gallbladder disease in children and adolescents. Am J Surg 1976;132(1):19-21.
5. Kirtley JA, Holcomb Jr GW. Surgical management of disease in the gallbladder and common duct in children and adolescents. Am J Surg 1966;111(1):39-46.
6. Fisher M, Rosenstein J, Schussheim A, et al. Gallbladder disease in children and adolescents. J Adolesc Health Care 1981;1(4):309-12.
7. Haff RC, Andrassy RJ, LeGrand DR, et al. Gallbladder disease in the young male. Am J Surg 1976;131(2):232-4.
8. McGahan JP, Phillips HE, Cox KL. Sonography of the normal pediatric gallbladder and biliary tract. Radiology 1982;144(4):873-5.
9. Hernanz-Schulman M, Ambrosino MM, Freeman PC, Quinn CB. Common bile duct in children: sonographic dimensions. Radiology 1995;195(1):193-5.
10. http://www.cdc.gov/nccdphp/dnpa/bmi/childrens_BMI/about_

childrens_BMI.htm. [Accessed June 15, 2008].

1. Rescorla FJ. Cholelithiasis, cholecystitis and common bile duct stones. Curr Op Pediatrics 1997;1(9):276-82.
2. Gruber PJ, Silverman RA, Gottefeld S, et al. Presence of fever and leukocytosis in acute cholecystitis. Ann Emerg Med 1996;28(3):273-7.
3. Ma OJ, Mateer JR, Blaivas M. Emergency ultrasound. 2nd ed. New York: McGraw Hill Publishing; 2008.
4. Kendall JL, Shimp RJ. Performance and interpretation of focused right upper quadrant ultrasound by emergency physicians. J Emerg Med 2001;21(1):7-13.
5. Bassler D, Snoey ER, Kim J. Goal-directed abdominal ultrasono- graphy: impact on real-time decision making in the emergency department. J Emerg Med 2003;24(4):375-8.
6. Blaivas M, Harwood RA, Lambert MJ. Decreasing length of stay with emergency ultrasound examination of the gallbladder. Acad Emerg Med 1999;6(10):1020-3.