Acute cholecystitis - Does the clinical diagnosis correlate with the pathological diagnosis?

Background: Most of the literature dealing with the surgical management of acute cholecystitis bases patient selection on pathological diagnosis, either exclusively or using it as a major selection criteria or as a confirmation of diagnosis. The purpose of this study was to examine the correlation between preoperative clinical findings, intraoperative gross findings, and postoperative pathological findings. Methods: A retrospective review of 493 consecutive laparoscopic cholecystectomies performed by a single surgeon (RJF) in a single institution was done. Four different sets of criteria were used to define four groups of patients as having acute cholecystitis: (1) preoperative acute cholecystitis based on defined criteria (PA); (2) intraoperative gross findings of acute or subacute cholecystitis based on surgeon assessment of inflammation (IA); (3) initial pathological evaluation by a staff pathologist (IP); and (4) expert pathological (EP) review using strictly defined histological criteria. Results: Of 41 patients, 40 (97.6%) were classified as having acute cholecystitis by IA, 21 (51.2%) by IP, and 17 (41.5%) by EP. Of the 75 patients classified as having acute cholecystitis by IA, 40 (53.0%) were classified acute by PA, 34 (45.0%) by IP, and 17 (22.7%) by EP. Of the 72 IP patients, 34 (47.2%) were classified as acute by IA, 15 (20.8%) by EP, and 24 (33.3%) were PA. Of the 32 EP patients, 21 (65.6%) were classified as acute by IA, 14 (43.8%) by IP, and 18 (56.3%) were PA. Conclusion: The correlation between the pathological diagnosis and intraoperative findings is poor. Preoperative clinical findings of acute cholecystitis are highly reliable for predicting intraoperative gross findings. However, intraoperative findings of acute cholecystitis are commonly found in the absence of preoperative clinical signs. Recommendations for surgical therapy should be based on studies which use either operative findings or the preoperative clinical findings as the basis for patient selection.