The Elusive Diagnosis of Acute Cholecystitis in the Elderly
Abstract & Commentary
Source: Parker LJ, et al. Emergency department evaluation of geriatric patients with acute cholecystitis. Acad Emerg Med 1997;4:51-55.
In this retrospective chart review of 168 elderly patients (ages ³ 65 years) with operative diagnoses of acute cholecystitis, Parker et al sought to evaluate the frequency of clinical and ancillary test abnormalities at the time of ED presentation. A secondary purpose was to determine whether presentations varied among three subsets of patients: young-old (ages 65-74 years), middle-old (ages 75-84 years), and old-old (ages ³ 85 years). The following data points were evaluated: abdominal pain and its radiation, nausea, emesis, fever, chills, visible jaundice, leukocyte counts, aspartate aminotransferase, direct and total bilirubin, alkaline phosphatase, amylase, and imaging studies (abdominal ultrasound, CT scan, or both).
Of the 168 patients, only 110 (65%) had right upper quadrant pain; 31 (18%) had mid-epigastric pain, and eight (5%) had no pain. Ninety-four patients (56%) were afebrile and 69 (41%) had normal leukocyte counts. Of the 149 patients sent to ultrasound, 135 (91%) had evidence of acute cholecystitis, whereas only 22 of 38 patients (58%) had positive CT scans. Except for visible jaundice, which was more common in the old-old group, there was no difference in clinical presentation between the three subgroups analyzed.
COMMENT BY FREDERIC KAUFFMAN, MD
The retrospective nature of this study presents several obvious limitations. Some patients with acute cholecystitis could have been discharged from the ED, only to be diagnosed elsewhere; data from such patients would not have been included in this study. The extent and accuracy of chart documentation is always suspect in retrospective reviews, though the authors state that all data points (except the results of imaging studies) were noted and complete for all patients. This is remarkable in that the degree and extent of patient evaluation was done solely at the discretion of the evaluating physicians; no protocol for the workup of elderly patients with abdominal complaints was in effect.
Despite these limitations, this study does drive home the crucial point that elderly patients with abdominal complaints can harbor serious disease even in the absence of "classic" clinical findings. This study demonstrates that the lack of fever, elevated leukocyte count, or liver function abnormalities does not rule out a diagnosis of acute cholecystitis in the elderly population. In fact, 5% of the patients with surgically proven disease had no complaint of abdominal pain and a full 13% had no laboratory test abnormalities. What is the take-home message? Beware the elderly patient with abdominal complaints of any type; diagnosis can be particularly elusive.