Diagnostic errors in acute cholecystitis: a scoping review
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Taku Harada
,
Taiju Miyagami
,
Yukinori Harada
and
Taro Shimizu
Abstract
Introduction
Diagnostic errors in acute cholecystitis significantly impact patient safety. Misdiagnosis, including both false negatives and false positives, is common due to the complex nature of abdominal pain and the overlapping symptoms of various conditions. This scoping review examines the definition, prevalence, and contributing factors of diagnostic errors in acute cholecystitis, emphasizing the need for improved diagnostic processes.
Content
Employing the PRISMA-ScR framework, this review examined definitions and factors contributing to diagnostic errors in cholecystitis. It highlights the variability in diagnostic criteria, with many studies relying on clinical judgment rather than standardized guidelines such as the Tokyo Guidelines. False negative diagnoses are often due to hypoalbuminemia, inconspicuous imaging findings, and the clinical setting, whereas false positives often result from misinterpreted imaging findings and failure to differentiate from other conditions.
Summary
This review found that approximately 30 % of acute cholecystitis cases may be missed (false negative), and 20–36 % of cases initially diagnosed can be incorrect (false positive). Adherence to standardized guidelines and improved recognition of atypical presentations could reduce diagnostic errors.
Outlook
Future research should aim for large-scale studies with clear diagnostic criteria and detailed clinical data to enhance diagnostic accuracy and patient safety.
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Research ethics: Not applicable.
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Informed consent: Not applicable.
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Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission. T.H. and T.M. conducted the literature search and data extraction. Y.H. contributed to study design and interpretation. T.S. supervised the study and provided critical revisions.
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Use of Large Language Models, AI and Machine Learning Tools: None declared.
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Conflict of interest: The authors state no conflict of interest.
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Research funding: This work was supported by MEXT/JSPS KAKENHI (grant number 25K13478).
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Data availability: Not applicable.
References
1. Balogh, EP, Miller, BT, Ball, JR, editors. Improving diagnosis in health care. Washington, DC: National Academies Press; 2015.10.17226/21794Search in Google Scholar PubMed
2. Newman-Toker, DE, Peterson, SM, Badihian, S, Hassoon, A, Nassery, N, Parizadeh, D, et al.. Diagnostic errors in the emergency department: a systematic review [internet]. Rockville (Maryland): Agency for Healthcare Research and Quality (US), Report No.: 22(23)-EHC043.Search in Google Scholar
3. Hooker, EA, Mallow, PJ, Oglesby, MM. Characteristics and trends of emergency department visits in the United States (2010–2014). J Emerg Med 2019;56:344–51.10.1016/j.jemermed.2018.12.025Search in Google Scholar PubMed
4. Halsey-Nichols, M, McCoin, N. Abdominal pain in the emergency department: missed diagnoses. Emerg Med Clin North Am 2021;39:703–17.10.1016/j.emc.2021.07.005Search in Google Scholar PubMed
5. Medford-Davis, L, Park, E, Shlamovitz, G, Suliburk, J, Meyer, AN, Singh, H. Diagnostic errors related to acute abdominal pain in the emergency department. Emerg Med J 2016;33:253–9.10.1136/emermed-2015-204754Search in Google Scholar PubMed
6. Chen, KC, Arad, A, Chen, KC, Storrar, J, Christy, AG. The clinical value of pathology tests and imaging study in the diagnosis of acute appendicitis. Postgrad Med J 2016;92:611–9.10.1136/postgradmedj-2015-133865Search in Google Scholar PubMed
7. Mahajan, P, Basu, T, Pai, CW, Singh, H, Petersen, N, Bellolio, MF, et al.. Factors associated with potentially missed diagnosis of appendicitis in the emergency department. JAMA Network Open 2020;3:e200612.10.1001/jamanetworkopen.2020.0612Search in Google Scholar PubMed PubMed Central
8. Harada, T, Harada, Y, Hiroshige, J, Shimizu, T. Factors associated with delayed diagnosis of appendicitis in adults: a single-center, retrospective, observational study. PLoS One 2022;17:e0276454.10.1371/journal.pone.0276454Search in Google Scholar PubMed PubMed Central
9. Ikeda, H, Ohta, R, Sano, C. Risk factors for delayed diagnosis of acute cholecystitis among rural older patients: a retrospective cohort study. Medicina (Kaunas) 2022;58:1392.10.3390/medicina58101392Search in Google Scholar PubMed PubMed Central
10. Halasz, NA. Counterfeit cholecystitis, a common diagnostic dilemma. Am J Surg 1975;130:189–93.10.1016/0002-9610(75)90369-4Search in Google Scholar PubMed
11. Yokoe, M, Takada, T, Strasberg, SM, Solomkin, JS, Mayumi, T, Gomi, H, et al.. TG13 diagnostic criteria and severity grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci 2013;20:35–46.10.1007/s00534-012-0568-9Search in Google Scholar PubMed
12. Yokoe, M, Hata, J, Takada, T, Strasberg, SM, Asbun, HJ, Wakabayashi, G, et al.. Tokyo guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci 2018;25:41–54.10.1002/jhbp.515Search in Google Scholar PubMed
13. Yokoe, M, Takada, T, Strasberg, SM, Solomkin, JS, Mayumi, T, Gomi, H, et al.. New diagnostic criteria and severity assessment of acute cholecystitis in revised Tokyo guidelines. J Hepatobiliary Pancreat Sci 2012;19:578–85.10.1007/s00534-012-0548-0Search in Google Scholar PubMed PubMed Central
14. Perry, JJ, Sivilotti, MLA, Emond, M, Hohl, CM, Khan, M, Lesiuk, H, et al.. Prospective implementation of the Ottawa subarachnoid hemorrhage rule and 6-hour computed tomography rule. Stroke 2020;51:424–30.10.1161/STROKEAHA.119.026969Search in Google Scholar PubMed
15. Dhatt, S, Sabhaney, V, Bray, H, Skarsgard, ED. Improving the diagnostic accuracy of appendicitis using a multidisciplinary pathway. J Pediatr Surg 2020;55:889–92.10.1016/j.jpedsurg.2020.01.040Search in Google Scholar PubMed
16. Schiff, GD, Volodarskaya, M, Ruan, E, Lim, A, Wright, A, Singh, H, et al.. Characteristics of disease-specific and generic diagnostic pitfalls: a qualitative study. JAMA Network Open 2022;5:e2144531.10.1001/jamanetworkopen.2021.44531Search in Google Scholar PubMed PubMed Central
17. Harada, Y, Watari, T, Nagano, H, Suzuki, T, Kunitomo, K, Miyagami, T, et al.. Diagnostic errors in uncommon conditions: a systematic review of case reports of diagnostic errors. Diagnosis 2023;10:329–36.10.1515/dx-2023-0030Search in Google Scholar PubMed
18. Harada, Y, Otaka, Y, Katsukura, S, Shimizu, T. Prevalence of atypical presentations among outpatients and associations with diagnostic error. Diagnosis 2024;11:40–8.10.1515/dx-2023-0060Search in Google Scholar PubMed
19. Tricco, AC, Lillie, E, Zarin, W, O’Brien, KK, Colquhoun, H, Levac, D, et al.. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med 2018;169:467–73.10.7326/M18-0850Search in Google Scholar PubMed
20. Brook, OR, Kane, RA, Tyagi, G, Siewert, B, Kruskal, JB. Lessons learned from quality assurance: errors in the diagnosis of acute cholecystitis on ultrasound and CT. Am J Roentgenol 2011;196:597–604.10.2214/AJR.10.5170Search in Google Scholar PubMed
21. Liberman, AL, Prabhakaran, S. Stroke chameleons and stroke mimics in the emergency department. Curr Neurol Neurosci Rep 2017;17:15.10.1007/s11910-017-0727-0Search in Google Scholar PubMed
22. Gallaher, JR, Charles, A. Acute cholecystitis: a review. JAMA 2022;327:965–75.10.1001/jama.2022.2350Search in Google Scholar PubMed
23. Polo, M, Duclos, A, Polazzi, S, Payet, C, Lifante, JC, Cotte, E, et al.. Acute cholecystitis-optimal timing for early cholecystectomy: a French nationwide study. J Gastrointest Surg 2015;19:2003–10.10.1007/s11605-015-2909-xSearch in Google Scholar PubMed
24. Yoo, MC, Yoo, SD, Chon, J, Han, YR, Lee, SA. Acute cholecystitis as a rare and overlooked complication in stroke patients: a retrospective monocentric study. Medicine 2019;98:e14492.10.1097/MD.0000000000014492Search in Google Scholar PubMed PubMed Central
25. Kelly-Schuette, KA, Chapman, AJ, Messer, LE, Kuk, CC, Lypka, MM, Krech, LA, et al.. Hotter than it looks: a retrospective review of patients with cholecystitis and with negative imaging. J Surg Res 2022;273:93–9.10.1016/j.jss.2021.12.003Search in Google Scholar PubMed
26. Powers, RD, Guertler, AT. Abdominal pain in the ED: stability and change over 20 years. Am J Emerg Med 1995;13:301–3.10.1016/0735-6757(95)90204-XSearch in Google Scholar PubMed
27. Eskelinen, M, Lipponen, P. Usefulness of history-taking in non-specific abdominal pain: a prospective study of 1333 patients with acute abdominal pain in Finland. Vivo 2012;26:335–9.Search in Google Scholar
28. Silpapojakul, K, Mitarnun, W, Ovartlarnporn, B, Chamroonkul, N, Khow-Ean, U. Liver involvement in murine typhus. QJM 1996;89:623–9.10.1093/qjmed/89.8.623Search in Google Scholar PubMed
29. Mohanty, B, Sunder, A, Pathak, S. Clinicolaboratory profile of expanded dengue syndrome – our experience in a teaching hospital. J Fam Med Prim Care 2019;8:1022–7.10.4103/jfmpc.jfmpc_12_19Search in Google Scholar PubMed PubMed Central
30. Eagle, KA, Quertermous, T, Kritzer, GA, Newell, JB, Dinsmore, R, Feldman, L, et al.. Spectrum of conditions initially suggesting acute aortic dissection but with negative aortograms. Am J Cardiol 1986;57:322–6.10.1016/0002-9149(86)90912-4Search in Google Scholar PubMed
31. Li, Y, Li, L, Mu, HS, Fan, SL, He, FG, Wang, ZY. Aortic dissection and sudden unexpected deaths: a retrospective study of 31 forensic autopsy cases. J Forensic Sci 2015;60:1206–11.10.1111/1556-4029.12768Search in Google Scholar PubMed
32. Schofield, PF, Hulton, NR, Baildam, AD. Is it acute cholecystitis? Ann R Coll Surg Engl 1986;68:14–6.Search in Google Scholar
33. Matsui, Y, Hirooka, S, Kotsuka, M, Yamaki, S, Kosaka, H, Yamamoto, T, et al.. Prognosis in patients with gallbladder edema misdiagnosed as cholecystitis. J Soc Laparoendosc Surg 2019;23:e2019.00022.10.4293/JSLS.2019.00022Search in Google Scholar PubMed PubMed Central
34. Ansaloni, L, Pisano, M, Coccolini, F, Peitzmann, AB, Fingerhut, A, Catena, F, et al.. 2016 WSES guidelines on acute calculous cholecystitis. World J Emerg Surg 2016;11:25.10.1186/s13017-016-0082-5Search in Google Scholar PubMed PubMed Central
35. Padda, MS, Singh, S, Tang, SJ, Rockey, DC. Liver test patterns in patients with acute calculous cholecystitis and/or choledocholithiasis. Aliment Pharmacol Ther 2009;29:1011–8.10.1111/j.1365-2036.2009.03956.xSearch in Google Scholar PubMed
36. Zgheib, H, Wakil, C, Shayya, S, Mailhac, A, Al-Taki, M, El Sayed, M, et al.. Utility of liver function tests in acute cholecystitis. Ann Hepatobiliary Pancreat Surg 2019;23:219–27.10.14701/ahbps.2019.23.3.219Search in Google Scholar PubMed PubMed Central
37. Huffman, JL, Schenker, S. Acute acalculous cholecystitis: a review. Clin Gastroenterol Hepatol 2010;8:15–22.10.1016/j.cgh.2009.08.034Search in Google Scholar PubMed
38. Fu, Y, Pang, L, Dai, W, Wu, S, Kong, J. Advances in the study of acute acalculous cholecystitis: a comprehensive review. Dig Dis 2022;40:468–78.10.1159/000520025Search in Google Scholar PubMed
39. Shaish, H, Ream, J, Huang, C, Troost, J, Gaur, S, Chung, R, et al.. Diagnostic accuracy of unenhanced computed tomography for evaluation of acute abdominal pain in the emergency department. JAMA Surg 2023;158:e231112.10.1001/jamasurg.2023.1112Search in Google Scholar PubMed PubMed Central
40. Kushiro, S, Miyagami, T, Kanai, Y, Yang, KS, Naito, T. Delayed diagnosis of portal vein thrombosis due to premature closure of cholecystitis. Am J Med 2021;134:e543–5.10.1016/j.amjmed.2021.05.015Search in Google Scholar PubMed
41. Hattori, S, Yokota, H, Takada, T, Horikoshi, T, Takishima, H, Mikami, W, et al.. Impact of clinical information on CT diagnosis by radiologist and subsequent clinical management by physician in acute abdominal pain. Eur Radiol 2021;31:5454–63.10.1007/s00330-021-07700-8Search in Google Scholar PubMed
42. Ely, JW, Graber, ML, Croskerry, P. Checklists to reduce diagnostic errors. Acad Med 2011;86:307–13.10.1097/ACM.0b013e31820824cdSearch in Google Scholar PubMed
43. Yale, SC, Cohen, SS, Kliegman, RM, Bordini, BJ. A pause in pediatrics: implementation of a pediatric diagnostic time-out. Diagnosis 2022;9:348–51.10.1515/dx-2022-0010Search in Google Scholar PubMed
44. Kasick, RT, Melvin, JE, Perera, ST, Perry, MF, Black, JD, Bode, RS, et al.. A diagnostic time-out to improve differential diagnosis in pediatric abdominal pain. Diagnosis 2021;8:209–17.10.1515/dx-2019-0054Search in Google Scholar PubMed
45. Kunitomo, K, Harada, T, Watari, T. Cognitive biases encountered by physicians in the emergency room. BMC Emerg Med 2022;22:148.10.1186/s12873-022-00708-3Search in Google Scholar PubMed PubMed Central
46. Dave, N, Bui, S, Morgan, C, Hickey, S, Paul, CL. Interventions targeted at reducing diagnostic error: systematic review. BMJ Qual Saf 2022;31:297–307.10.1136/bmjqs-2020-012704Search in Google Scholar PubMed
47. Shimizu, T, Graber, ML. An equation for excellence in clinical reasoning. Diagnosis 2022;10:61–3.10.1515/dx-2022-0060Search in Google Scholar PubMed
48. Shimizu, T. System 2 diagnostic process for the next generation of physicians: “inside” and “outside” brain-the interplay between human and machine. Diagnostics 2022;12:356.10.3390/diagnostics12020356Search in Google Scholar PubMed PubMed Central
Supplementary Material
This article contains supplementary material (https://doi.org/10.1515/dx-2025-0061).
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