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Revised Estimates of Diagnostic Test Sensitivity and Specificity in Suspected Biliary Tract Disease

Revised Estimates of Diagnostic Test Sensitivity and Specificity in Suspected Biliary Tract Disease Abstract Background: The purpose of this study was to estimate the sensitivity and specificity of diagnostic tests for gallstones and acute cholecystitis. Methods: All English-language articles published from 1966 through 1992 about tests used in the diagnosis of biliary tract disease were identified through MEDLINE. From 1614 titles, 666 abstracts were examined and 322 articles were read to identify 61 articles with information about sensitivity and specificity. Application of exclusion criteria based on clinical and methodologic criteria left 30 articles for analysis. Cluster-sampling methods were adapted to obtain combined estimates of sensitivities and specificities. Adjustments were made to estimates that were biased because the gold standard was applied preferentially to patients with positive test results. Results: Ultrasound has the best unadjusted sensitivity (0.97; 95% confidence interval, 0.95 to 0.99) and specificity (0.95; 95% confidence interval, 0.88 to 1.00) for evaluating patients with suspected gallstones. Adjusted values are 0.84 (0.76 to 0.92) and 0.99 (0.97 to 1.00), respectively. Adjusted and unadjusted results for oral cholecystogram were lower. Radionuclide scanning has the best sensitivity (0.97; 95% confidence interval, 0.96 to 0.98) and specificity (0.90; 95% confidence interval, 0.86 to 0.95) for evaluating patients with suspected acute cholecystitis; test performance is unaffected by delayed imaging. Unadjusted sensitivity and specificity of ultrasound in evaluating patients with suspected acute cholecystitis are 0.94 (0.92 to 0.96) and 0.78 (0.61 to 0.96); adjusted values are 0.88 (0.74 to 1.00) and 0.80 (0.62 to 0.98). Conclusions: Ultrasound is superior to oral cholecystogram for diagnosing cholelithiasis, and radionuclide scanning is the test of choice for acute cholecystitis. However, sensitivities and specificities are somewhat lower than commonly reported. We recommend estimates that are midway between the adjusted and unadjusted values.(Arch Intern Med. 1994;154:2573-2581) References 1. Friedman GD, Kannel WB, Dawber TR. The epidemiology of gallbladder disease: observations in the Framingham study . J Chronic Dis. 1966;19:292-293.Crossref 2. LaRusso NF. Gallstones and cholecystitis . In: Kelley WN, ed. Textbook of Internal Medicine . Philadelphia, Pa: JB Lippincott Co; 1992:537-542. 3. Gracie WA, Ransohoff DF. The natural history of silent gallstones: the innocent gallstone is not a myth . N Engl J Med. 1982;307:798-800.Crossref 4. McSherry CK, Ferstenberg H, Calhoun WF, Lahman E, Virshup M. The natural history of diagnosed gallstone disease in symptomatic and asymptomatic adults . Ann Surg. 1985;202:59-63.Crossref 5. Thistle JL, Cleary PA, Lachin JM, Tyor MP, Hersh T. The natural history of cholelithiasis . Ann Intern Med. 1984;101:171-175.Crossref 6. Friedman GD. Natural history of asymptomatic and symptomatic gallstones . Am J Surg. 1993;165:399-404.Crossref 7. National Institutes of Health Consensus Development Conference statement on gallstones and laparoscopic cholecystectomy . Am J Surg. 1993;165:390-396.Crossref 8. Nahrwold DL. Chronic cholecystitis and cholelithiasis . In: Sabiston DC Jr, ed. Textbook of Surgery . Philadelphia, Pa: WB Saunders Co; 1991:1057-1063. 9. Johnston DE, Kaplan MM. Pathogenesis and treatment of gallstones . N Engl J Med. 1993;328:412-421.Crossref 10. Marton KI, Doubiliet P. How to image the gallbladder in suspected cholecystitis . Ann Intern Med. 1988;109:722-729.Crossref 11. Berk RN, Ferruci JT Jr, Fordtran JS, Cooperburg PL, Weissmann MS. The radiological diagnosis of gallbladder disease . Radiology . 1981;141:49-56.Crossref 12. Cooperberg PL, Burhenne HJ. Real-time ultrasonography: diagnostic technique of choice in calculous gallbladder disease . N Engl J Med. 1980;302: 1277-1279.Crossref 13. Herlin P, Alinder G, Karp W, Holmin T. Contrast tomography of the gallbladder wall and ultrasonography in the diagnosis of acute cholecystitis . Br J Surg. 1984;71:850-853.Crossref 14. Barakos JA, Rails PW, Lapin SA, et al. Cholelithiasis: evaluation with CT . Radiology . 1987;162:415-418.Crossref 15. Havrilla TR, Reich NE, Haaga JR, Seidelmann FE, Cooperman AM, Alfidi RJ. Computed tomography of the gallbladder . AJR Am J Roentgenol. 1978;130: 1059-1067.Crossref 16. McCarthy S, Hricak H, Cohen M, et al. Cholecystitis: detection with MR imaging . Radiology . 1986;158:333-336.Crossref 17. Cotton PB. Preoperative diagnostic assessment of patients with biliary tract disease . In: Dudley H, ed. Rob & Smith's Operative Surgery . Stoneham, Mass: Butterworths; 1983:608-615. 18. Jones RS. Gallbladder and biliary tract. In: Hardy JD, ed. Hardy's Textbook of Surgery . Philadelphia, Pa: JB Lippincott; 1988:677-684. 19. Nahrwold DL. Acute cholecystitis . In: Sabiston DC Jr, ed. Textbook of Surgery . Philadelphia, Pa: WB Saunders Co; 1991:1050-1057. 20. Way LW, Sleisenger MH. Cholelithiasis: chronic and acute cholecystitis . In: Sleisenger MH, Fordtran JS. Gastrointestinal Disease: Pathophysiology, Diagnosis, Management . Philadelphia, Pa: WB Saunders Co; 1989:1691-1714. 21. May GR, Bender CE. The gallbladder. In: Putnam CE, Ravin CE, eds. Textbook of Diagnostic Imaging . Philadelphia, Pa: WB Saunders Co; 1988:1033-1053. 22. Sutton D. The biliary tract . In: A Textbook of Radiology and Imaging . New York, NY: Churchill Livingstone Inc; 1987:958-976. 23. Squire LF, Novelline RA. Fundamentals of Radiology . Cambridge, Mass: Harvard University Press; 1988:238-243. 24. Friedman LS, Needleman L. Hepatobiliary imaging . In: Wilson JD, Braunwald E, Isselbacher KJ, et al. Harrison's Principles of Internal Medicine . New York, NY: McGraw-Hill International Book Co; 1991:1303-1308. 25. Greenberger NJ, Isselbacher KJ. Diseases of the gallbladder and bile ducts . In: Wilson JD, Braunwald E, Isselbacher KJ, et al, eds. Harrison's Principles of Internal Medicine . New York, NY: McGraw-Hill International Book Co; 1991: 1358-1368. 26. Malet PF, Soloway RD. Diseases of the gallbladder and bile ducts . In: Wyngaarden JB Jr, Smith LH, Bennett JC, eds. Cecil Textbook of Medicine . Philadelphia, Pa: WB Saunders Co; 1992:804-815. 27. Cochran WG. Sampling Techniques . New York, NY: John Wiley & Sons Inc; 1977:64-69. 28. DerSimonian R, Laird N. Meta-analysis in clinical trials . Controlled Clin Trials . 1986;7:177-188.Crossref 29. Greenes RA, Begg CB. Assessment of diagnostic technologies . Invest Radiol . 1985;20:751-756.Crossref 30. Bennett MT, Sheldon MI, dos Remedios LV, Weber PM. Diagnosis of acute cholecystitis using hepatobiliary scan with technetium-99m PIPIDA . Am J Surg. 1981;142:338-343.Crossref 31. Freitas JE, Gulati RM. Rapid evaluation of acute abdominal pain by hepatobiliary scanning . JAMA . 1980;244:1585-1587.Crossref 32. Freitas JE, Coleman RE, Nagle CE, Bree RL, Krewer KD, Gross MD. Influence of scan and pathologic criteria on the specificity of cholescintigraphy: concise communication . J Nucl Med. 1983;24:876-879. 33. Freitas JE, Mirkes SH, Fink Bennett DM, Bree RL. Suspected acute cholecystitis . Clin Nucl Med. 1982;7:364-367.Crossref 34. Gilchrist NL, Boniface GR, Turner JG, Ovenden BM. Acute cholecystitis: a diagnostic approach using 99mTc diethyl IDA scintigraphy . Aust N Z J Surg. 1982; 52:461-465.Crossref 35. Mauro MA, McCartney WH, Melmed JR. Hepatobiliary scanning with 99mTc-PIPIDA in acute cholecystitis . Radiology . 1982;142:193-197.Crossref 36. Samuels BI, Freitas JE, Bree RL, Schwab RE, Heller ST. A comparison of radionuclide hepatobiliary imaging and real-time ultrasound for the detection of acute cholecystitis . Radiology . 1983;147:207-210.Crossref 37. Bednarz GM, Kalff V, Kelly MJ. Hepatobiliary scintigraphy: increasing the accuracy of the preoperative diagnosis of acute cholecystitis . Med J Aust. 1986; 145:316-318. 38. Boutkan H, Butzelaar RM, Davies G. The diagnosis of gallstones . Neth J Surg. 1984;36:124-126. 39. Brunkwall J, Borjesson B, Lindberg B. Cholescintiscan or infusion cholecystography in acute cholecystitis . Acta Chir Scand. 1985;151:139-142. 40. Colletti PM, Cirimelli KM, Radin DR, Chandrasoma P, Rails PW, Siegel ME. Radionuclide angiography in suspected acute cholecystitis: further observations . Clin Nucl Med. 1989;14:867-873.Crossref 41. Duch G, Nielsen A, Axelsson CK. The value of 99mTc-cholescintigraphy as compared with infusion cholecystography for diagnosing acute cholecystitis . Scand J Gastroenterol. 1981;16:993-997.Crossref 42. Edlund G, Kempi V. Cholescintigraphy versus infusion cholecystography in acute cholecystitis . Nuklearmedizin. 1990;29:51-53. 43. Gill PT, Dillon E, Leahy AL, Reeder A, Peel AL. Ultrasonography, HIDA scintigraphy or both in the diagnosis of acute cholecystitis? Br J Surg. 1985;72: 267-268.Crossref 44. Gupta SM, Owshalimpur D, Herrera NE. Radionuclide scanning for the rapid diagnosis of acute cholecystitis . Aust N Z J Med. 1982;12:265-268.Crossref 45. Jarvinen H, Standertskjold Nordenstam CG, Jappinen S, Lande S, Hastbacka J. Cholecystography, intravenous cholegraphy or ultrasonography in suspected acute cholecystitis: a controlled comparative study . Ann Chir Gynaecol. 1980;69:43-47. 46. Lantsberg L, Lantsberg S, Khodadadi J, Quastel MR. Diagnosis of acute cholecystitis by 99mTc-iminodiacetic acid cholescintigraphy . Isr J Med Sci. 1986; 22:445-447. 47. Mogensen NB, Madsen M, Stage P, et al. Ultrasonography versus roentgenography in suspected instances of cholecystolithiasis . Surg Gynecol Obstet. 1984;159:353-356. 48. Norrby S, Frank M, Sjodahl R. Intravenous cholecystography and ultrasonography in the diagnosis of acute cholecystitis: a prospective comparative study . Acta Chir Scand. 1985;151:255-259. 49. Ram MD, Mattingly SS, Kim EE, Coupal J, Griffen WO. Biliary scintiscanning in suspected acute cholecystitis . World J Surg. 1982;6:110-114.Crossref 50. Shuman WP, Mack LA, Rudd TG, Rogers JV, Gibbs P. Evaluation of acute right upper quadrant pain . Am J Radiol. 1982;139:61-64. 51. Soiva M, Suramo I, Taavitsainen M. Ultrasonography of the gallbladder in patients with a clinical suspicion of acute cholecystitis . Diagn Imag Clin Med. 1986;55:337-342. 52. Szilvasi I, Bohar L, Bor K, Kopcsanyi Z, Csakany G. Diagnostic value of Tc-99m-HIDA cholescintigraphy and ultrasonography in patients with suspected acute cholecystitis: a bayesian approach . Radiol Diagn. 1983;24:355-363. 53. Taavitsainen M, Jarvinen H, Tallroth K. Cholescintigraphy in the diagnosis of acute cholecystitis . Ann Clin Res. 1978;10:227-234. 54. Van Weelde BJ, Oudkerk M, Koch CW. Ultrasonography of acute cholecystitis: clinical and histological correlation . Diagn Imag Clin Med. 1986;55:190-195. 55. Weissmann HS, Frank MS, Bernstein LH, Freeman LM. Rapid and accurate diagnosis of acute cholecystitis with 99mTc-HIDA cholescintigraphy . Am J Radiol. 1979;132:523-528. 56. Weissmann HS, Sugarman LA, Freedman LM. Diagnosis of acute cholecystitis with 99mTc-IDA cholescintigraphy . Bull N Y Acad Med. 1981;57:741-746. 57. Worthen NJ, Uszler JM, Funamura JL. Cholecystitis: prospective evaluation of sonography and 99mTc-HIDA cholescintigraphy . Am J Radiol. 1981;137:973-978. 58. Health Care Financing Administration. Medicare Program: Revision of the Medicare Economic Index . Federal Register. 1992;57:228. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

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American Medical Association
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Copyright © 1994 American Medical Association. All Rights Reserved.
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0003-9926
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1538-3679
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10.1001/archinte.1994.00420220069008
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Abstract

Abstract Background: The purpose of this study was to estimate the sensitivity and specificity of diagnostic tests for gallstones and acute cholecystitis. Methods: All English-language articles published from 1966 through 1992 about tests used in the diagnosis of biliary tract disease were identified through MEDLINE. From 1614 titles, 666 abstracts were examined and 322 articles were read to identify 61 articles with information about sensitivity and specificity. Application of exclusion criteria based on clinical and methodologic criteria left 30 articles for analysis. Cluster-sampling methods were adapted to obtain combined estimates of sensitivities and specificities. Adjustments were made to estimates that were biased because the gold standard was applied preferentially to patients with positive test results. Results: Ultrasound has the best unadjusted sensitivity (0.97; 95% confidence interval, 0.95 to 0.99) and specificity (0.95; 95% confidence interval, 0.88 to 1.00) for evaluating patients with suspected gallstones. Adjusted values are 0.84 (0.76 to 0.92) and 0.99 (0.97 to 1.00), respectively. Adjusted and unadjusted results for oral cholecystogram were lower. Radionuclide scanning has the best sensitivity (0.97; 95% confidence interval, 0.96 to 0.98) and specificity (0.90; 95% confidence interval, 0.86 to 0.95) for evaluating patients with suspected acute cholecystitis; test performance is unaffected by delayed imaging. Unadjusted sensitivity and specificity of ultrasound in evaluating patients with suspected acute cholecystitis are 0.94 (0.92 to 0.96) and 0.78 (0.61 to 0.96); adjusted values are 0.88 (0.74 to 1.00) and 0.80 (0.62 to 0.98). Conclusions: Ultrasound is superior to oral cholecystogram for diagnosing cholelithiasis, and radionuclide scanning is the test of choice for acute cholecystitis. However, sensitivities and specificities are somewhat lower than commonly reported. We recommend estimates that are midway between the adjusted and unadjusted values.(Arch Intern Med. 1994;154:2573-2581) References 1. Friedman GD, Kannel WB, Dawber TR. The epidemiology of gallbladder disease: observations in the Framingham study . J Chronic Dis. 1966;19:292-293.Crossref 2. LaRusso NF. Gallstones and cholecystitis . In: Kelley WN, ed. Textbook of Internal Medicine . Philadelphia, Pa: JB Lippincott Co; 1992:537-542. 3. Gracie WA, Ransohoff DF. The natural history of silent gallstones: the innocent gallstone is not a myth . N Engl J Med. 1982;307:798-800.Crossref 4. McSherry CK, Ferstenberg H, Calhoun WF, Lahman E, Virshup M. The natural history of diagnosed gallstone disease in symptomatic and asymptomatic adults . Ann Surg. 1985;202:59-63.Crossref 5. Thistle JL, Cleary PA, Lachin JM, Tyor MP, Hersh T. The natural history of cholelithiasis . Ann Intern Med. 1984;101:171-175.Crossref 6. Friedman GD. Natural history of asymptomatic and symptomatic gallstones . Am J Surg. 1993;165:399-404.Crossref 7. National Institutes of Health Consensus Development Conference statement on gallstones and laparoscopic cholecystectomy . Am J Surg. 1993;165:390-396.Crossref 8. Nahrwold DL. Chronic cholecystitis and cholelithiasis . In: Sabiston DC Jr, ed. Textbook of Surgery . Philadelphia, Pa: WB Saunders Co; 1991:1057-1063. 9. Johnston DE, Kaplan MM. Pathogenesis and treatment of gallstones . N Engl J Med. 1993;328:412-421.Crossref 10. Marton KI, Doubiliet P. How to image the gallbladder in suspected cholecystitis . Ann Intern Med. 1988;109:722-729.Crossref 11. Berk RN, Ferruci JT Jr, Fordtran JS, Cooperburg PL, Weissmann MS. The radiological diagnosis of gallbladder disease . Radiology . 1981;141:49-56.Crossref 12. Cooperberg PL, Burhenne HJ. Real-time ultrasonography: diagnostic technique of choice in calculous gallbladder disease . N Engl J Med. 1980;302: 1277-1279.Crossref 13. Herlin P, Alinder G, Karp W, Holmin T. Contrast tomography of the gallbladder wall and ultrasonography in the diagnosis of acute cholecystitis . Br J Surg. 1984;71:850-853.Crossref 14. Barakos JA, Rails PW, Lapin SA, et al. Cholelithiasis: evaluation with CT . Radiology . 1987;162:415-418.Crossref 15. Havrilla TR, Reich NE, Haaga JR, Seidelmann FE, Cooperman AM, Alfidi RJ. Computed tomography of the gallbladder . AJR Am J Roentgenol. 1978;130: 1059-1067.Crossref 16. McCarthy S, Hricak H, Cohen M, et al. Cholecystitis: detection with MR imaging . Radiology . 1986;158:333-336.Crossref 17. Cotton PB. Preoperative diagnostic assessment of patients with biliary tract disease . In: Dudley H, ed. Rob & Smith's Operative Surgery . Stoneham, Mass: Butterworths; 1983:608-615. 18. Jones RS. Gallbladder and biliary tract. In: Hardy JD, ed. Hardy's Textbook of Surgery . Philadelphia, Pa: JB Lippincott; 1988:677-684. 19. Nahrwold DL. Acute cholecystitis . In: Sabiston DC Jr, ed. Textbook of Surgery . Philadelphia, Pa: WB Saunders Co; 1991:1050-1057. 20. Way LW, Sleisenger MH. Cholelithiasis: chronic and acute cholecystitis . In: Sleisenger MH, Fordtran JS. Gastrointestinal Disease: Pathophysiology, Diagnosis, Management . Philadelphia, Pa: WB Saunders Co; 1989:1691-1714. 21. May GR, Bender CE. The gallbladder. In: Putnam CE, Ravin CE, eds. Textbook of Diagnostic Imaging . Philadelphia, Pa: WB Saunders Co; 1988:1033-1053. 22. Sutton D. The biliary tract . In: A Textbook of Radiology and Imaging . New York, NY: Churchill Livingstone Inc; 1987:958-976. 23. Squire LF, Novelline RA. Fundamentals of Radiology . Cambridge, Mass: Harvard University Press; 1988:238-243. 24. Friedman LS, Needleman L. Hepatobiliary imaging . In: Wilson JD, Braunwald E, Isselbacher KJ, et al. Harrison's Principles of Internal Medicine . New York, NY: McGraw-Hill International Book Co; 1991:1303-1308. 25. Greenberger NJ, Isselbacher KJ. Diseases of the gallbladder and bile ducts . In: Wilson JD, Braunwald E, Isselbacher KJ, et al, eds. Harrison's Principles of Internal Medicine . New York, NY: McGraw-Hill International Book Co; 1991: 1358-1368. 26. Malet PF, Soloway RD. Diseases of the gallbladder and bile ducts . In: Wyngaarden JB Jr, Smith LH, Bennett JC, eds. Cecil Textbook of Medicine . Philadelphia, Pa: WB Saunders Co; 1992:804-815. 27. Cochran WG. Sampling Techniques . New York, NY: John Wiley & Sons Inc; 1977:64-69. 28. DerSimonian R, Laird N. Meta-analysis in clinical trials . Controlled Clin Trials . 1986;7:177-188.Crossref 29. Greenes RA, Begg CB. Assessment of diagnostic technologies . Invest Radiol . 1985;20:751-756.Crossref 30. Bennett MT, Sheldon MI, dos Remedios LV, Weber PM. Diagnosis of acute cholecystitis using hepatobiliary scan with technetium-99m PIPIDA . Am J Surg. 1981;142:338-343.Crossref 31. Freitas JE, Gulati RM. Rapid evaluation of acute abdominal pain by hepatobiliary scanning . JAMA . 1980;244:1585-1587.Crossref 32. Freitas JE, Coleman RE, Nagle CE, Bree RL, Krewer KD, Gross MD. Influence of scan and pathologic criteria on the specificity of cholescintigraphy: concise communication . J Nucl Med. 1983;24:876-879. 33. Freitas JE, Mirkes SH, Fink Bennett DM, Bree RL. Suspected acute cholecystitis . Clin Nucl Med. 1982;7:364-367.Crossref 34. Gilchrist NL, Boniface GR, Turner JG, Ovenden BM. Acute cholecystitis: a diagnostic approach using 99mTc diethyl IDA scintigraphy . Aust N Z J Surg. 1982; 52:461-465.Crossref 35. Mauro MA, McCartney WH, Melmed JR. Hepatobiliary scanning with 99mTc-PIPIDA in acute cholecystitis . Radiology . 1982;142:193-197.Crossref 36. Samuels BI, Freitas JE, Bree RL, Schwab RE, Heller ST. A comparison of radionuclide hepatobiliary imaging and real-time ultrasound for the detection of acute cholecystitis . Radiology . 1983;147:207-210.Crossref 37. Bednarz GM, Kalff V, Kelly MJ. Hepatobiliary scintigraphy: increasing the accuracy of the preoperative diagnosis of acute cholecystitis . Med J Aust. 1986; 145:316-318. 38. Boutkan H, Butzelaar RM, Davies G. The diagnosis of gallstones . Neth J Surg. 1984;36:124-126. 39. Brunkwall J, Borjesson B, Lindberg B. Cholescintiscan or infusion cholecystography in acute cholecystitis . Acta Chir Scand. 1985;151:139-142. 40. Colletti PM, Cirimelli KM, Radin DR, Chandrasoma P, Rails PW, Siegel ME. Radionuclide angiography in suspected acute cholecystitis: further observations . Clin Nucl Med. 1989;14:867-873.Crossref 41. Duch G, Nielsen A, Axelsson CK. The value of 99mTc-cholescintigraphy as compared with infusion cholecystography for diagnosing acute cholecystitis . Scand J Gastroenterol. 1981;16:993-997.Crossref 42. Edlund G, Kempi V. Cholescintigraphy versus infusion cholecystography in acute cholecystitis . Nuklearmedizin. 1990;29:51-53. 43. Gill PT, Dillon E, Leahy AL, Reeder A, Peel AL. Ultrasonography, HIDA scintigraphy or both in the diagnosis of acute cholecystitis? Br J Surg. 1985;72: 267-268.Crossref 44. Gupta SM, Owshalimpur D, Herrera NE. Radionuclide scanning for the rapid diagnosis of acute cholecystitis . Aust N Z J Med. 1982;12:265-268.Crossref 45. Jarvinen H, Standertskjold Nordenstam CG, Jappinen S, Lande S, Hastbacka J. Cholecystography, intravenous cholegraphy or ultrasonography in suspected acute cholecystitis: a controlled comparative study . Ann Chir Gynaecol. 1980;69:43-47. 46. Lantsberg L, Lantsberg S, Khodadadi J, Quastel MR. Diagnosis of acute cholecystitis by 99mTc-iminodiacetic acid cholescintigraphy . Isr J Med Sci. 1986; 22:445-447. 47. Mogensen NB, Madsen M, Stage P, et al. Ultrasonography versus roentgenography in suspected instances of cholecystolithiasis . Surg Gynecol Obstet. 1984;159:353-356. 48. Norrby S, Frank M, Sjodahl R. Intravenous cholecystography and ultrasonography in the diagnosis of acute cholecystitis: a prospective comparative study . Acta Chir Scand. 1985;151:255-259. 49. Ram MD, Mattingly SS, Kim EE, Coupal J, Griffen WO. Biliary scintiscanning in suspected acute cholecystitis . World J Surg. 1982;6:110-114.Crossref 50. Shuman WP, Mack LA, Rudd TG, Rogers JV, Gibbs P. Evaluation of acute right upper quadrant pain . Am J Radiol. 1982;139:61-64. 51. Soiva M, Suramo I, Taavitsainen M. Ultrasonography of the gallbladder in patients with a clinical suspicion of acute cholecystitis . Diagn Imag Clin Med. 1986;55:337-342. 52. Szilvasi I, Bohar L, Bor K, Kopcsanyi Z, Csakany G. Diagnostic value of Tc-99m-HIDA cholescintigraphy and ultrasonography in patients with suspected acute cholecystitis: a bayesian approach . Radiol Diagn. 1983;24:355-363. 53. Taavitsainen M, Jarvinen H, Tallroth K. Cholescintigraphy in the diagnosis of acute cholecystitis . Ann Clin Res. 1978;10:227-234. 54. Van Weelde BJ, Oudkerk M, Koch CW. Ultrasonography of acute cholecystitis: clinical and histological correlation . Diagn Imag Clin Med. 1986;55:190-195. 55. Weissmann HS, Frank MS, Bernstein LH, Freeman LM. Rapid and accurate diagnosis of acute cholecystitis with 99mTc-HIDA cholescintigraphy . Am J Radiol. 1979;132:523-528. 56. Weissmann HS, Sugarman LA, Freedman LM. Diagnosis of acute cholecystitis with 99mTc-IDA cholescintigraphy . Bull N Y Acad Med. 1981;57:741-746. 57. Worthen NJ, Uszler JM, Funamura JL. Cholecystitis: prospective evaluation of sonography and 99mTc-HIDA cholescintigraphy . Am J Radiol. 1981;137:973-978. 58. Health Care Financing Administration. Medicare Program: Revision of the Medicare Economic Index . Federal Register. 1992;57:228.

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Nov 28, 1994

References