Specialist Radiographic Imaging - Case Study Example

Specialist Radiographic Imaging Introduction One of the major steps towards the achievement of a quality healthcare is the extent to which medical professionals can guarantee the accuracy of disease investigations they undertake. In this case study, the 68 year old male patient will be diagnosed with cholecystitis. This diagnosis is selected due to available symptoms and known history of patient, including jaundice, right upper quadrant pain, and liver function problems. According to Khan, Jalil and Khan (2007), radiographic imagining is ideal in the diagnosis and investigation of disease of this nature as it offers supporting evidence for outlining management strategies and treatment of disease. Imaging strategy will be formulated by reviewing various imaging modalities. The epidemiology of cholecystitis, as well as treatment and follow-up plans shall also be outlines and critical discussed. Epidemiology Gallstones are known to be major cause of cholecystitis, which has major indication of imbalances in substances in the bile lead to hard particles developing in the gallbladder. Some of these substances include cholesterol and bile salts (Fink-Bennett et al., 2001). Once this condition happens, gallstones is said to have been developed. Gallstones cause cholecystitis because they block the cystic duct forcing the bile to build up and result in an inflammation (Barie and Fischer, 1995). Tumours are also causative factors for cholecystitis; as tumours that develop closer to the liver can hamper bile from draining out of the gallbladder as expected, leading to cholecystitis (Syrjälä et al., 2007). Jaundice is also another important factor in the cause of cholecystitis. Jaundice is said to occur when high blood bilirubin levels lead to yellowish pigmentation of various organs such as the skin, conjunctival membranes, and other mucous membranes (Yamashita et al., 2012). The yellow tinge occurs as a result of rising bilirubin levels (Jalil and Khan, 2007). The bilirubin is an orange-yellow pigment, which is considered a waste product when there is a normal breakdown of red blood cells (Yamashita et al., 2012). As far as jaundice is concerned, it may manifest in a number of ways, with each having its own causes and symptoms. (Appendix A). Cholecystitis can be defined as the inflammation of the gallbladder. As part of its function, the gallbladder is known to hold bile which is released into the small intestine. Disease related conditions such as blockage of the tubes leading out of the gallbladder can cause cholecystitis, which in return leads to the bile building up to cause inflammation (Barakos et al., 1987). The prevalence rate of cholecystitis in the UK over a one year period is approximately 16,884 cases, where two-thirds of all cases are reported in females (BMJ Group, 2015). According to the Bingener et al. (2014), there are 1 to 4% adult patients in the UK developing symptoms of cholecystitis each year. Among the number, 56% present biliary colic while 36% have presentations of acute cholecystitis. Those reporting with hepatobiliary tumours and acalculous causes have been less than 6-10% (de Groen et al., 2009). Further statistics are presented in appendix B. Even though the symptoms of cholecystitis are very similar to other conditions such as those relating to the gallbladder and biliary tract disease, it is possible to confirm diagnosis of the patient with cholecystitis, because of the combined symptoms of severe pain in the upper right abdomen, nausea, and history of pain in right upper quadrant. A number of studies have been conducted to look at the prevalence of cholecystitis. See appendix C. Differential diagnosis Tumours occur as one of the major areas to look at in terms of differential diagnosis. Even though gallbladder tumours are found to be one of the major similarities to cholecystitis, VanderMeer et al. (2015) noted that improvements in imaging techniques and increased utilisation of studies makes their recognition frequent. Tumours can however not be neglected as up to 5% of patients who go through US evaluation are said to have abdominal pain resulting from gallbladder polyp (VanderMeer et al., 2015). Under US, the size of the polyp has been said to be the major predictor of malignant transformation instead of cholecystitis. One other differential diagnosis that is worth consideration is acalculous cholecystitis. This is considered a cause of 5-10% of acute cholecystitis with differentiating signs including gallstones in some patients (de Groen et al., 2009). Major differentiating test or diagnosis can be determined with imaging studies which show distended acalculous gallbladder with thickened walls (>3-4 mm) with or without pericholecystic fluid (Shojamanesh et al., 2015). In terms of acute cholangitis, the major differentiating signs for this condition include fevers and chills, jaundice, and abdominal pain. The rate at which patient with cholangitis may develop all three symptoms is between 50% and 70% (ePocrates, 2015). Differentiating test has been noted to include MRI findings which show intraductal purulent material with low signal intensity on heavily T2-weighted images (ePocrates, 2015) Acute calculous cholecystitis is the condition the patient was diagnosed with. With this condition patients are found exhibiting biliary colic which causes pain being characteristically episodic, severe, and located in the right upper quadrant (Strasberg, 2008). An imaging differentiating diagnostic outcome is the concomitant presence of thickening of the gallbladder wall found 5 mm or greater (Strasberg, 2008). There could also be pericholecystic fluid, or direct tenderness when the probe is pushed against the gallbladder (Strasberg, 2008). Diagnosis Ultrasound scan (US) is used in the diagnosis of cholecystitis as highly reliable in diagnosing different forms of the disease including acute cholecystitis, complications of acute cholecystitis, and chronic cholecystitis (Keus et al., 2006). In several parts of the world including U.K, confirmation by US is part of the diagnostic standards for acute cholecystitis (Hirota et al., 2007). US can be helpful in detecting impacted stone in cystic duct, thickening of gallbladder wall (>3 mm), distention of gallbladder lumen (> 4cm), pericholecystic fluid collections, and hyperaemic gallbladder wall on colour Doppler in supportive test (Rumack, et al., 2005). The advantage with the use of US is that it gives quantitative indications of extent of disease based on measurements such as the thickness of the gallbladder wall. There is however a disadvantage as its level of imaging accuracy when compared to Hepatobiliary iminodiacetic acid (HIDA) scan has been said to be compromising (Dolan et al., 2009). Most studies on diagnosis of cholecystitis will be credited for high level of sensitivity and specificity of findings. For example Bingener et al. (2005) found that US is 90-95% sensitive for cholecystitis and 78-80% specificity, while minimal training can even guarantee accurate outcomes. The major limitation of this study however had to do with the demographic variables of participants, which was confined to a very small locality, making the issue of generalisation of outcomes very challenging. There are other sensitivity and specificity outcomes for different conditions including acute claculous cholecystitis, acalculous cholecystitis, and hepatic malignancy criteria as summarised in the table below. Table 1: Sensitivity and specificity of US under conditions Condition Sensitivity Specificity Acute calculous cholecystitis 98% 88% Acalculous cholecystitis 90% 94% hepatic malignancy 94% 100% Source: Jahromi et al. (2005); Hammoud et al. (2014) Refer to differential diagnosis for how to rule out unexpected results of calculous cholecystitis and acalculous cholecystitis and tumours. There are no other studies disputing these findings except that the NHS recommends a fast of at least 8 hours waiting time as gallstones are best visible when in a distended bile-filled gallbladder (Agrawal et al., 2009). Clinical Guidelines published by the National Institute for Health and Care Excellence (NICE) shows specific considerations that ought to be made for initial investigation for suspected cholecystitis. The guidelines are however subjective to patient’s response to the disease. For example there are patients for whom it is recommended that they receive treatments that help to prevent symptoms and complications if they have asymptomatic gallbladder stones (Hosseini, Mousavinasab and Rahmanpour, 2009). For other patients, it is recommended that they be made to adopt a “watch and wait” approach so that active treatment will begin only after stones begin to cause symptoms (NICE, 2015). The basis of this recommendation is on the differences in patient symptom behaviour as found in such studies as Gurusamy et al. (2013). As part of NICE’s Recommendation 4, it is necessary to refer people for further investigations if conditions other than gallstone disease are suspected after scans (NICE, 2015). This is one major reason that further radiographic examinations are carried out even when diagnosis is found in US but suspecting other conditions. In terms of computed tomography (CT) scan, Contini et al. (2004) reports 95% sensitivity and specificity of CT scan, which means it has a slightly higher level of reliance as against US since it could be less than 95% but not below 90%. Contini et al. (2004) however failed report on the use of random sampling technique, which affected claim of internal validity for the study. That is, evidence of absence of bias in the study could not be guaranteed. Wong et al (2012) noted that in the case of calculous cholecystitis, CT is not likely to provide more information than other imaging techniques such as ultrasonography. To this end, sensitivity ranging from 12-55% may be experienced. This outcome, together with what has been indicated under differential diagnosis is the most significant ways of ruling out calculous cholecystitis. For pancreatitis, its differentiating signs include bleeding into the gland, serious tissue damage, and cyst formation. CT results would show peripancreatic fluid extending anteriorly from the pancreatic head (Romero-Urquhat et al., 2013) A major advantage with the use of CT scans as against other forms of diagnostic scans including endoscopic retrograde cholangiopancreatography (ERCP) is the fact that the former is non-invasive, guaranteeing higher levels of safety for patients of different demographic characteristics (David et al., 2008). One disadvantage with CT scan however has to do with the fact that it has no therapeutic potential, meaning that they can best be trusted when stones are not likely to be present (Sitzmann et al., 2010). This is indeed a very significant limitation given the high level of probability that stones will be likely in the patient who has reported the nature of symptoms including the history of pain in the right upper quadrant. When used, there are a number of outcomes and indications that may suggest to the radiographer that cholecystitis may be present. One such major indication is the thickening of the gallbladder wall in a range > 4mm. Other detections that CT scan can reveal which are all helpful and suggestive of cholecystitis include pericholecystic fluid, subserosal edema, presence of intramural gas, and sloughed mucosa (Khan et al., 2009). A study carried out by Kim et al. (2009) noted that one major advantage for the use of CT scans is that even when diagnosis is uncertain at the initial investigations; it has the potential of viewing surrounding structures around the gallbladder, leading to further investigations being performed. This finding and the sensitivity and specificity which has been said to be up to 95% has not been disputed in any subsequent study. Based on this, Shojaiefard et al. (2009) suggested that CT scans offer one of the most comprehensive and evidence based approaches to diagnosing for cholecystitis. Donovan (1999) however said that using CT and magnetic resonance imaging (MRI) are sure to offer the same outcomes, including relatively same levels of sensitivity. This makes most practitioners substitute the use of CT for MRI as the second stage of diagnosis for cholecystitis. Research by Singer et al. (2006) found that using Cholescintigraphy or hepatobiliary scintigraphy (HBS) scan may either produce normal findings or abnormal findings; with the sensitivities and specificities of the normal finding on HIDA scan is 90 to 100% with the abnormal findings showing 85 to 95% sensitivities and specificities. On the whole, the range of sensitivities and specificities is higher when compared to US and CT, especially for normal findings. The sensitivity of calculous cholecystitis under HIDA has been said to be in the range of 85-90%, which is lower than hepatic malignancy with specificity of 95-100% as depicted in table 1 (Hammoud, 2014). Under a normal cholescintigraphy, it is common to find the gallbladder, common bile duct, and small bowel being filled within 30 to 45 minutes. This is the major approach by which radiographers use for the state of health of patients to diagnose cholecystitis. One important advantage that makes cholescintingraphy or HIDA preferable is the fact that when used in scanning and the gallbladder is not visible, intravenous contrast administration can be performed to improve the accuracy of results (McEvoy and Suchy, 1996). In order to do this in a typical HBS, there must be an increase in the resistance to flow through the spincter of Oddi so as to lead to the filling of the gallbladder of a patent cystic duct (Forbes et al., 1996). In relation to this, the overall accuracy with using nuclear scan has been found to be 95%, which means that when applied on the patient, there are very high chances of attaining correct diagnosis of cholecystitis. Particularly, there are control mechanisms that may be applied to ensure that the accuracy level is further improved or enhanced. One of this is the addition of contrast medium to help reduce the false-positive scan that may accompany the outcome in patients, especially those who are critically ill and cannot move (Bloom et al., 2014). There are however disadvantages with the use of HIDA. For example Cullen et al. (2000) debated the study of Singer et al. stating that there are major weaknesses with the use of cholescintigraphy, including high chances that outcome of images may be abnormal rather than normal. In the light of this disadvantage, Kalim et al, 2001) recommends the use of HIDA as the first modality for patients who are suspected with acute cholecystitis. More to the above, magnetic retrograde cholangiopancreatograpgy (MRCP) is a type of medical imaging technique which employs the use of MRI to visualise the biliary and pancreatic ducts through the use of non-invasive methods (Huang et al., 2009). For most radiographers therefore, the choice and preference for MRCP in diagnosing cholecystitis is in the fact that it is specially linked to the biliary and pancreatic ducts. This is because when used for this specialised purpose, it is possible to make detections as to whether or not gallstones are logged in any of the ducts around the gallbladder (Lee et al, 2009). Meanwhile, it has already been noted that such lodging of gallstones could be a situation leading to the inflammation of the gallbladder and thus resulting in cholecystitis. MRCP is advantageous for the fact that it is less invasive when compared to other techniques such as endoscopic retrograde cholangiopancreatography (ERCP) (AHRQ. 2015). In a study by Towfigh et al. (2001), the non-invasive nature of MRCP was maintained but when compared to some invasive techniques such as nuclear scan, the sensitivities and specificity of the former is low as it ranges from 90% to 95%. This according to Wong et al. (2012) is not the case with diagnosing calculous cholecystitis which could have low sensitivity of 57% and specificity of 86%. However; absence of explanation of study’s reliability was a limitation of this study. The major advantage with MRCP therefore has to do with the fact that it guarantees a clear sensitivity and specificity difference for ruling out other differential diagnosis’s. It has also been indicated that a major disadvantage with the use of MRCP is the fact that it is common that several categories of patients may fall in its intermediate-risk and low risk patient classifications (Gruber et al., 1996). For those regarded as low-risk patients, MRCP is not recommended because direct procession to intervention is regarded as being more preferred. Some of the intermediate-risk patients are those who have indications of previous history of cholangitis or pancreatitis. These limitations nevertheless, high-risk patients have been found to benefit tremendously from MRCP (Yates and Baron, 1999). High-risk patients on the other hand refer to those whose cholangitis and pancreatitis can be said to be recent (Liolios, Oropello and Benjamin, 1999). However, patients with jaundice such as the one presented in the case are also considered high-risk patients, for whom MRCP is known to come with a lot of benefits. With these points made, the selection of MRCP and its possible outcomes can be said to be dependent on the category of patient in question. Percutaneous transhepatic cholangiography (PTC) is an imaging procedure that employs the use of percutaneous binary interventions for the diagnosis and treatment of biliary stone disease (Chiu, Chen and Mo, 2004). These diseases can actually be diagnosed with PTC whether or not choledochoscopy is performed. Like the use of MRCP, PTC is mostly preferred for cholecystitis because it is specific to biliary stone disease, of which cholecystitis is related. In a study by Moscati (1996), it was noted that PTC is very advantageous as it may be used in cases where other forms of scans including ERCP fails or cannot be performed due to restrictions on patient compatibility. The reason this is said is that in some cases with ERCP and even MRCP, there are chances that the duct may not be cleared of the blockage. This is the time where PTC is considered very useful as the PTC is known to be performed directly of the bile ducts (Nidimusili et al., 2013). Because the bile ducts are tubes which carry bile from the liver to the gallbladder and small intestine, it is very easy for diagnosis with PTC to determine the cause of bile duct blockage. Kim et al. (2009) however argued that there are a number of risks that PTC could carry, making it less desirable in some patients. For example there are chances that patients may show allergy to the contrast medium used in performing the scan (Sahai et al., 1999). In a study by Rosen et al. (2001), the sensitivity, specificity and accuracy of PTC was at 95%. This rating nevertheless, there have been other studies that have outlined more risks associated with PTC. Roe (2006) indicated that damage to nearby organs and excessive blood loss are likely situations. Stephen and Berger (2001) also stated that sepsis and inflammation of the bile ducts are likely risks that come with PTC. Rubens (2004) however argued most of the premise in these studies by stating that the possibility of risk is highly minimal to negligible. After a successful imaging procedure with PTC, results are normal or abnormal; abnormal results include patient has enlarged ducts (Siddiqui et al., 2008). The enlargement of the duct is what gives indication to the effect that the ducts have been blocked and thus require further intervention for clearance; as blockage is a possible cause of scarring or stone, which in turn cause cholecystitis (Shah and Wolfe, 2004). Based on possible risks, NICE has guidelines for diagnosing cholecystitis, where it recommends that there should be specific threshold known as procedure threshold or overall threshold associated with complication-specific thresholds (NICE, 2015). The evidence of this is based previous studies in the paper, which have given indications to complications. Some of the complications are said to include bile peritonitis, haemobilia, and gallbladder perforation. Treatment For the patient in the case, the cholecystitis can be said to have been caused by bile duct blockage which had been developed due to protracted health indications which have failed to seek the needed attention. Examples of these are the pain in the right upper quadrant and jaundice. Dasari et al. (2013) noted that pain in the right upper quadrant is a situation that could lead to differential diagnosis for any of acute cholecystitis, chronic cholecystitis and/or choledocholithiasis. The management and treatment of the patient will be focused on the use surgical approach. Based on the outcome of symptoms, radiographic imaging procedures may also be employed as part of the treatment. In such an instance, ERCP will be recommended; advantage for selecting ERCP is due to the fact that it offers the benefit of combining endoscopy and fluoroscopy for the treatment of the cholecystitis (Kiewiet et al., 2012). By extension, the ERCP will be used for therapeutic purposes even though it could also be used for diagnostic purposes (Hunt and Chu, 2000). As a radiographic technique, ERCP will allow visualisation of the anatomy whilst giving additional therapeutic support for the removal of the stones from the common bile duct as patient has been said to be having bile duct blockage as the cause of cholecystitis. The visualisation also comes with sensitivity as high as 90-95% and specificity of up to 100% (Alder et al., 2005). The size of the sample used in this study was another limitation because generalisation of findings was a major hindrance as a sample size of 120 makes it difficult to generalised outcomes of the study. Finally, follow up will be planned to look at possibilities of perforation or gangrene of the gallbladder. Such follow up will be necessitated due to the limitation or disadvantage with the use of ERCP which is invasive in nature and thus comes with some levels of perforation risks (Farrell et al., 2005). It is not surprising therefore that Alder et al. (2005) suggested that unless there are therapeutic intents, MRCP and endoscopic US rather be used. Andriulli et al. (2007) also recommended the use of PTC but only in cases where ERCP proves unsuccessful. The disadvantage with using PTC is that it is also invasive and so does not serve as a better alternative to ERCP for minimising effects or risks associated with invasion. Furthermore, PTC may not be preferred as its sensitivity in some studies has been found to be as low as 75% with 85% specificity (Farrell et al., 2005). This study’s major limitation was that whereas the researchers admitted that there were other diagnostic methods to use as biliary sphincterotomy and endoscopic papillary balloon dilation, the methods used were not compared to these to compare levels of efficacy. The advantage with PTC however has to be the fact that it is conducive as a therapeutic technique. It also has the advantage of clearing an obstructed biliary system until such permanent solutions as surgery is introduced. Follow up Follow up will only be necessary if symptoms continue to occur; in which the patient will go through the process of diagnosis again. Depending on the prevailing outcomes of the symptoms that may resurface however, there may be decision to modify the choice of diagnosis and treatment used in the previous case. It will be noted that the surgical approach to treatment which emphasises on the use of ERCP has been prescribed as the most preferred form of treatment for the patient’s situation. This is because of the advantage it has by combining both endoscopy and fluoroscopy for the treatment. Once the follow-up shows that the combined method has left patient with side effects then only a single approach such as PTC which is typically therapeutically will be recommended. Conclusion Overall, it has been found that the formulation of imaging strategy for the diagnosis and management of the cholecystitis may be approached in several different ways. Most of these ways are however dominated with the use of imaging modalities. The need for looking into as many imaging modalities as possible is in the fact that each type seeks to come with its own advantages, weaknesses, and approaches. There are certain disease scenarios that some forms of imaging modalities may be found to be more suitable than others. Using the outcome of the various imaging modalities, the patient will be diagnosed and managed on the use of Cholescintigraphy. There are three major factors that inform the selection of this modality. First, the fact that its sensitivities and specificity can be up to 100% means high level of reliance with outcomes. Second, this method is ideal and makes provisions for critical patient health situations such as times that the patient may not be mobile. Finally, this method is preferred because of the guaranteed assurance that there are ways in which the radiographer can manually and technically induce the accuracy of imaging such as through the introduction of intravenous contrast. References References Agrawal, S., Battula, N., Barraclough, L., Durkin, D., & Cheruvu, C. V. N. (2009). 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Appendix A Table 2: Summary of Jaundice types, causes and symptoms Type of jaundice Cause Symptoms Pre-hapatic jaundice Malaria Sickle cell anemia Hereditary spherocytosis Increased level of bilirubin in the blood Intra-hepatic jaundice Alcohol liver disease Leptospirosis Glandular fever Drug misuse Liver cancer Viral hepatitis infections Disrupted ability of liver to process bilirubin Post-hepatic jaundice Gallstones Pancreatic cancer Gallbladder cancer Pancreatitis last over a year Damaged bile duct system Inflamed or obstructed bile duct system Adapted from WebMD (2015) Appendix B Table 2: Summary of statistics on cholecystitis Finding Statistics Adults who develop cholecystitis with gallstones or biliary sludge 95% (Patient.co.uk, 2015) Average annual emergency admissions with gallbladder 12,300 people (Patient.co.uk, 2015) Risk factors Increasing age Family history Sudden loss of weight Crohn’s disease Obesity Female gender Hyperlipidaemia Occurrence of CBD stones 3-14% of patients undertaking cholecystectomy (Yeh, Chen and Jan, 2002) Appendix C Table 3: Summary of studies on cholecystitis Study Aim Findings Critique Sanders G and Kingsnorth A.N (2008) To find the prevalence rate of gallstones and its indication in cholecystitis and other liver diseases 95% of adults with gallstones develop cholecystitis Several generalised claims made with impact of gallstones on cholecystitis, affecting study’s sensitivity negatively David et al. (2008) To find how acute gallbladder diseases are managed in England Most cases are reported late, leading to complications The sample size was small, affecting generalisation of findings Khan, Jalil and Khan (2007) To find the impact of oral contraception on developing cholecystitis Oral contraception is a risk factor in getting gallstones, later leading to cholecystitis Researchers could relate the use of oral contraception to other known risk factors to draw a correlation Khan et al. (2009) To find the prevalence of gallstone in South East England There has been a steadily increasing trend with the prevalence of gallstone, influencing higher rates of cholecystitis Study was limited to Necropsy, affecting generalisation of findings Read More