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Harrisburg, PA 17120


Phone: 717-346-0469
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Risk of Unnecessary Gall Bladder Surgery
PA PSRS Patient Saf Advis 2004 Dec;1(4):3-4. 
 

PA-PSRS has received three reports of attempted cholecystectomy in patients who had previously had their gall bladders removed. In each case, the patient was misdiagnosed with cholelithiasis following symptomotology consistent with this diagnosis as well as an ultrasound read as positive for gallstones. All three patients’ previous cholecystectomies did not become known until their surgeries were performed.

These cases share several characteristics that suggest potential risk factors for this type of problem:

  • All three patients were of advanced age, with the youngest being over age 80.
  • All three patients were poor historians and could not inform their clinicians definitively that they had previously undergone cholecystectomy. In one report, the patient suffered from Alzheimers-related dementia, and the other two reports indicate that family members were involved in providing the patient history.
  • In each case, either the patient or a family member expressed uncertainty about a prior cholecystectomy.
  • All three reports cite an ultrasonogram that was read as positive for cholelithiasis.
  • In one case, the patient had a history of unrelated prior abdominal surgery that could have explained a visible surgical scar without necessarily alerting the surgeon to a likely prior cholecystectomy.

An extensive search of the clinical literature failed to identify any published reports of attempted cholecystectomy in patients with prior gall bladder removal. However, the literature contains a number of case reports of misdiagnosed cholelithiasis or cholecystitis and attempted cholecystectomy in patients with a rare congenital anomaly in which the gall bladder fails to develop (known as agenesis).1-5

While these cases are fundamentally different from those reported to PA-PSRS, they document the potential for false-positive results not only from ultrasound but also from cholescintigraphy. A small, contracted gall bladder—which often accompanies gallstones—can be difficult to visualize on ultrasound.6-7 Similarly, complete inability to visualize the gall bladder in cholescintigraphy usually indicates acute cholecystitis, often secondary to gallstones.8-9

In followup, the Patient Safety Officer (PSO) from one facility informed us that in retrospect, their clinicians may have mistaken a loop of bowel for the gall bladder, while another facility’s PSO believes the hyperechoic surgical clips from the patient’s previous surgery were mistakenly interpreted as gallstones. A possible contributing factor to the misdiagnosis was that the radiologist was not informed of the uncertainty about the presence or prior surgical removal of the gall bladder.

In one case, the patient had recently had a chest CT performed for a comorbid condition, which showed surgical clips in the upper right quadrant. A history of prior gall bladder removal noted on a consultant’s report as part of a comprehensive workup was not reconciled with the clinical diagnosis.

We contacted the PSO from each facility, and they could not confirm in any of the three cases whether the ultrasound technician or the radiologist were aware of any uncertainty about prior cholecystectomies. We cannot know, of course, whether these patients’ sonograms might have been interpreted differently had this information been available.

Suggestions that may help to avoid similar problems in the future include:

  • Understanding the risk factors outlined above.
  • Pursuing uncertainty about possible prior removal of a potentially diseased organ.
  • Ensuring that radiologists and technicians are apprised of any uncertainty about prior organ removal.

PA-PSRS has also received two additional reports of patients with prior gall bladder removal whose imaging studies were read as positive for cholelithiasis. However, these patients helped to avert unnecessary surgery by speaking up and correcting the misdiagnosis. The patients in these cases were markedly younger than those in the cases described above and were not poor historians.

Notes

  1. Praseedom RK, Mohammed R. Two cases of gall bladder agenesis and review of the literature. Hepatogastroenterology. 1998 Jul-Aug;45(22):954-5.
  2. Vijay KT, Kocher HH, Koti RS, et al. Agenesis of the gall bladder—a diagnostic dilemma. J Postgrad Med. 1996 Jul-Sep;42(3):80-2.
  3. Watemberg S, Rahmani H, Avrahami R, et al. Agenesis of the gall bladder found at laparoscopy for cholecystectomy: an unpleasant surprise. Am J Gastroenterol. 1995 Jun;90(6):1020-1.
  4. Singh B, Moodley J, Haffejee AA, et al. Laparoscopic diagnosis of gallbladder agenesis. Surg Laparosc Endosc. 1997 Apr;7(2):129-32.
  5. Chopra PJ, Hussein SS. Isolated agenesis of the gallbladder. Saudi Med J. 2003 Apr;24(4):409-10.
  6. Chung JB, Yim DS, Chon CY, et al. Analysis of cases of nonvisualized gallbladder by ultrasonography. Korean J Intern Med. 1987 Jan;2(1):84-9.
  7. Serour F, Klin B, Strauss S, et al. False-positive ultrasonography in agenesis of the gallbladder: a pitfall in the laparoscopic cholecystectomy approach. Surg Laparosc Endosc. 1993 Apr;3(2):144-6.
  8. Giuliano V, Dadparvar S, Savit R, et al. Contracted gallbladder: a cause of false-positive hepatobiliary scan in patients with cystic fibrosis. Eur J Nucl Med. 1996 May;23(5):595-7.
  9. Arose B, Shreeve WW, Baim RS, et al. Phantom gallbladder. A variant of the rim sign. Clin Nucl Med. 1987 Jun;12(6):457-60.
 
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PSA LOGO The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s Web site at www.patientsafetyauthority.org .      
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