UCONN Emergency Medicine Interest Group

Ultrasound Case #5

In RADIOLOGY on October 23, 2011 at 7:00 AM

Syndicated from the UCONN EM Residency website; credit to Dr. Russell and Dr. Kleinberg for cases and images.

Gallbladder wall

Common bile duct

CC: Abdominal pain – RUQ

HPI: 25 yo female with no PMH presents to the ED with nausea, vomiting and abdominal pain beginning the previous evening ½ hour after eating dinner.  Pain located in RUQ, 10/10 intermittent colicky pain.  Denies any fevers, chills, diarrhea, constipation, urinary symptoms or anorexia.

SH: Smokes 1.5 pack year history, denies other drugs or alcohol.

FH: DM2, HTN, Hyperlipidemia, Colon Cancer

PE: Afebrile, VSS
Abdomen is obese, soft, non-distended, tender in RUQ, + murphy’s sign, + bowel sounds

Labs: WBC’s14.9 with left shift.  H/H, Platelets and Chem7, AST, ALT, lipase and bilirubin within normal limits.  Alk Phos 141.

Bedside U/S: see above images.

How would you describe the ultrasonographic findings?

Stone visualized in Gallbladder neck.  No GB wall thickening, CBD thickening or pericholecyctic fluid appreciated. + sonographic Murphy’s sign.

Plan: Patient admitted to surgery for acute cholecystitis.  She was given IV Zosyn and had a laparoscopic cholecystectomy.

There are other potential presentations of acute gallbladder disease, as the next 2 cases will illustrate.

Case 5b

CC: Abdominal Pain – RUQ

HPI: 30 yo female with PMH asthma presents to the ED with RUQ abdominal pain beginning one day ago.  Associated nausea and vomiting, worse after eating. Denies fever, chills, shortness of breath or diarrhea.

SH: denies drug and alcohol use

FH: DM, HTN

PE: afebrile.  Vital signs stable.

Labs: WBC 8.9.  CBC, Chem7 and LFTs within normal limits.

Bedside U/S: see next 3 images below.

Pericholecystic fluid

Findings: Stone visualized in Gallbladder neck with posterior shadowing.  No GB wall thickening.  + pericholecyctic fluid. + sonographic Murphy’s sign (even after morphine administration)

Plan: Patient was given IV Unasyn, pain control and admitted to surgery for a laparoscopic cholecystectomy.

Case 5c

CC: Abdominal Pain – RUQ

HPI: 36 yo female with PMH DM, high cholesterol, gastritis and chronic pancreatitis presents to the ED with 6 months of RUQ abdominal pain.  Pain is described to be sharp, 10/10 and constant.  There is associated nausea and vomiting.  Denies fever or chills.

SH: Denies drug and alcohol use. 20 pack year smoking history.

FH: denies

PE: afebrile.  Vital signs stable.

Labs: WBC elevated at 16.  CBC, Chem7, LFTs and lipase within normal limits.

Bedside U/S: see next 2 images below and click here for video (gallbladder in long axis view showing wall edema; fluid is seen within the thickened wall).

Gallbladder wall thickening, measuring 0.48cm.

Dilated CBD, 0.81 cm inside wall to inside wall.

Findings: GB wall thickening seen in multiple views.  No evidence of stone in gallbladder.  No pericholecystic fluid. + sonographic Murphy’s sign.

Plan: Surgery was consulted based on ultrasound findings and elevated white blood cell count.  Patient was given IV antibiotics, pain control and admitted to surgery for a laparoscopic cholecystectomy.

Teaching Points

  • Measure gallbladder wall in short axis, closest to the probe, at the narrowest point.  GBW should be <4 mm

Thickened gallbladder wall:

  • False positive wall thickening may be seen in fluid overload states (CHF, renal and liver failure), ascites, HIV, hepatitis
  • Common bile duct should be assessed in the long axis.  Color flow Doppler can be used to differentiate CBD from the portal vein.

Dilated common bile duct, measuring 0.87 cm.

Click here for video of common bile duct with color flow doppler.  Notice the CBD does not light up.

  • Measure inside wall to inside wall at the largest diameter.  Abnormal is >4 mm in patients 40 and under.  Normal values increase by 1 mm each decade over 40.
  • Gallstones may be confused with bowel gas, gallbladder polyps (which are non-dependent, not mobile and do not cast shadows)
  • Scan through gallbladder in multiple plains – both long and short axis views.

References

  • Bree R.  Further observations on the usefulness of the sonographic Murphy sign in the evaluation of suspected acute cholecystitis. J Clin Ultrasound.1995;23(3):169-72.
  • Kendall J. Performance and interpretation of focused right upper quadrant ultrasound by emergency physicians. J Emerg Med.2001;21(1):7-13.
  • Singer A.  Correlation among clinical, laboratory, and hepatobiliary scanning findings in patients with suspected acute cholecystitis. Ann Emerg Med.1996;28(3):267-72.
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