GALLBLADDER NONVISUALIZATION WITH PERICHOLECYSTIC RIM SIGN - MORPHINE-AUGMENTATION OPTIMIZES DIAGNOSIS OF ACUTE CHOLECYSTITIS

This study investigated the value of morphine-augmentation in patients who demonstrated gallbladder nonvisualization with a pericholecystic rim sign at 1 hr, a cholescintigraphic pattern considered highly predi ctive of acute cholecystitis. Methods: Retrospectively, 170 consecutiv e morphine-augmented cholescintigrams were analyzed for the presence o f a pericholecystic rim sign, marked or mild, associated with gallblad der nonvisualization at 1 hr (before morphine); those with a perichole cystic rim sign were further evaluated for persistent gallbladder nonv isualization versus gallbladder visualization after morphine. Scintigr aphic interpretations were correlated with surgical pathology or clini cal diagnosis. Results: Before morphine, 43/170 (25%) patients demonst rated gallbladder nonvisualization with a pericholecystic rim sign. Si nce only 31 had acute cholecystitis, a diagnosis based solely on that scintigraphic pattern would have resulted in 12 false-positives. After morphine, gallbladder visualization correctly excluded acute cholecys titis in seven; a single false-negative was encountered; five false-po sitives remained, Morphine-augmentation improved the positive predicti ve value from 72% (gallbladder nonvisualization with pericholecystic r im sign before morphine) to 86% (gallbladder nonvisualization after mo rphine). Of 24 patients with marked pericholecystic rim signs, 21 had acute cholecystitis. Of 31 with acute cholecystitis, however, 10 (32%) had a mild pericholecystic rim sign, Conclusion: Morphine-augmented c holescintigraphy optimizes the diagnosis of acute cholecystitis in pat ients with the suggestive, but not pathognomonic, cholescintigraphic p attern at 1 hr of gallbladder nonvisualization with a pericholecystic rim sign, regardless of its intensity.