Evolution of secondary findings in acute cholecystitis: A temporal analysis from POCUS to subsequent imaging

Sonographic signs of cholecystitis tend to progress from the primary findings of cholelithiasis and a positive sonographic Murphy’s sign to the secondary findings of gallbladder wall changes, namely wall thickening and pericholecystic oedema. The presence of these secondary signs increases the specificity for diagnosing cholecystitis and surgeons often rely on them to guide admission and treatment decisions.

How quickly these changes develop has not really been established… until now.

These authors from the USA performed a dual site retrospective cohort study with good methodology. They included adult patients who underwent POCUS in the ED and later had a formal radiology ultrasound after admission.

The gold standard for diagnosing cholecystitis was primarily positive histology following cholecystectomy.

A total of 352 patients were included, with a 50% prevalence of cholecystitis.

Among the 252 patients without initial gallbladder wall changes on ED POCUS, around 20% developed wall changes on subsequent imaging, with a median time of 4 hours. Gallstones and a positive sonographic Murphy’s sign predicted the later development of wall changes.

The authors conclude that the evolution of cholecystitis is a dynamic process. This makes intuitive sense, as inflammatory conditions evolve over time, so there are no major surprises here.

There was another important finding. Acute cholecystitis can occur without gallbladder wall changes. In this study, most patients with cholecystitis did not have wall changes in the ED and never developed them prior to cholecystectomy. Importantly, these patients had positive histology following surgery, so this was unlikely to represent false positive diagnoses.

Interestingly, there was no mention of stones impacted in the gallbladder neck. This is the most common cause of cholecystitis. In my experience, it is also a fairly specific finding that strongly suggests developing cholecystitis.

So what is the take home message?

Yes, cholecystitis is a dynamic process. It takes time, with a median of 4 hours in this study, for gallbladder wall changes to appear on ultrasound if they are going to develop at all. This raises the possibility of repeat imaging in early presenters or in patients observed in a short stay unit when there is reasonable clinical suspicion for cholecystitis. 

Covering:

D. Ivanov, D. Cannata, K. A. Chin et al. Evolution of Secondary Findings in Acute Cholecystitis: A Temporal Analysis from Point of Care to Subsequent Imaging. J Emerg Med 2025;78:266-274. [link to article]

Duration of resuscitation interruption using point-of-care ultrasound versus traditional manual pulse check: A systematic review and meta-analysis

We know manual pulse checks during CPR are unreliable and often slow. “Do you feel a pulse…? I’m not sure… is that my pulse?”

So, is a POCUS pulse check faster and more accurate? Hmmm…

But first: what is a POCUS pulse check?

No, it’s not just looking at the heart during a rhythm check. It means using a linear probe to assess the carotid artery for compressibility and pulsatility, or using pulse-wave Doppler at the femoral artery to assess flow velocity.

So, is this actually better than our old-school manual checks?

The authors reviewed seven studies involving 496 participants. Overall, ultrasound was associated with a shorter pulse-check duration—by about 1.39 seconds.

Yes, that is not exactly a clinically earth-shattering difference.

(For what it’s worth, I’m a little skeptical of the overall data. Pulse checks in both groups were remarkably quick—around 3 to 10 seconds. This is quite different from earlier studies reporting much longer interruptions.)

But the more interesting difference is accuracy. Who cares how fast it is if it gets the answer wrong?

Three studies reported accuracy data. Manual pulse checks had a pooled sensitivity of 62% and specificity of 91%. POCUS pulse checks performed much better, at 99% and 96%, respectively.

Thoughts? Should we abandon manual pulse checks?

To be fair, major guideline groups (ILCOR, ACC/AHA, etc.) have recognised this problem and have been moving away from manual pulse checks for years. For lay rescuers, they now recommend looking for signs of life instead. Even so, health professionals are still checking pulses.

The authors do add some caution: the overall certainty of evidence is low. They also highlight the need for standard protocols, operator training, and high-quality prospective studies before practice changes too much.

For what it’s worth, I usually have a quick peek at the heart during rhythm and pulse checks. If it’s not moving, there's no point hunting for a pulse. (If you want to see this in action, check out Vijay’s paper in Emergency Medicine Australasia.)

Oh, and a strong word of caution: do not waste time checking for a pulse when a shockable rhythm is present!

If you want the best paper using a femoral artery catheter as the gold standard, look at Cohen’s study below. They used femoral pulse-wave Doppler to calculate peak systolic velocity and correlated it with blood pressure. It sounds complicated, but it's not. To me, this looks like the most promising technique.

What’s the takeaway?

POCUS pulse checks may catch on. Keep your eyes peeled and your finger on the pulse… or maybe not.

Covering:

Neto ES, Scapin M, Lazaro-Paulina F, et al. Duration of resuscitation interruption using point-of-care ultrasound versus traditional manual pulse check: A systematic review and meta-analysis. Amer J Emerg Med. 2025;98:145-152. [Link to article]

Cohen AL, Li T, Becker LB, et al. Femoral artery Doppler ultrasound is more accurate than manual palpation for pulse detection in cardiac arrest. Resuscitation. 2022;173:156-65. [Link to article]