(Last Updated On: October 20, 2015)

Hello all. We are very fortunate at UIC | EM to have access to 5 different fellowships – 5 different sets of fellows, 5 different sets of fellowship educators. One of the goals of this blog is to bring the learning from these areas together for everyone to enjoy.

With that in mind, welcome to the first in our series of Ultrasound Educational Posts.


Here is your patient:

58 year old male, h/o partial gastrectomy and partial SBO, presented to the ED with c/o periumbilical abdominal pain for 4 days. He is unable to eat solids. As mentioned he has had a partial SBO in the past, and he is feeling the same today. He denies fever/chill, nausea/vomiting, back pain or urinary symptoms. Bowel movements are not too unchanged, and he is passing gas.

On physical examination, he was found to be in moderate distress. Right Upper Quadrant discomfort was noted on exam, with no guarding or rebound tenderness.

For this reason, a CT was done….wait, no, a bedside RUQ US was performed to evaluate for Cholecystitis.


Screen Shot 2015-10-20 at 12.01.12 PMPerforming the RUQ US:

The good people at EMCurious have done a fantastic job of explaining this procedure. I am linking to their blog, in true FOAMed fashion:

EMCurious – The RUQ US


What are you looking for?

After reading the tremendous review above, what are the key findings you are looking for

1. Stones!

a. Cholelithiasis is responsible for 90-95 of cases of acute cholecytisis

2. A Sonographic Murphy’s Sign:

a. Tenderness is maximal when pressing the probe on the visualized gallbladder1

b. When combined with cholelithiasis, is sensitive for acute cholecystitis (~75-85%), with a PPV of ~90-92%2&3

3. Gallbladder Wall Thickening:

a. Both 3mm and 4mm is quoted as being abnormal in the literature. We commonly teach less than 3mm as normal4

4. Pericholecystic Fluid:

a. Not as helpful when present without the other findings.


Your Images:

You bring your US to the patient, and obtain the following:

 

The following are select images with labels on important structures (click to enlarge):

unnamed unnamed1 unnamed3

Findings:

1. Echogenic foci within the gall-bladder with prominent posterior acoustic shadowing consistent with gall-stones, with a positive Sonographic Murphy’s Sign

2. Anterior gall-bladder wall is measured to be 7.1 mm (normal wall thickness is < 3mm)

3. A small amount of pericholecystic fluid

4. Common bile duct is measured as 6.1 mm (normal < 7mm)


Case Conclusion:

You astutely call this Acute Cholecystitis, involve your General Surgery colleagues, and the patient undergoes a cholecystectomy, and ultimately does well.


References:

1. Bree RL. 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. Link To Paper

2. Ralls PW, et al. Real-time sonography in suspected acute cholecystitis. Prospective evaluation of primary and secondary signs. Radiology.1985;155(3):767-71. Link To Paper

3. Kendall JL, Shimp RJ. Performance and interpretation of focused right upper quadrant ultrasound by emergency physicians. J Emerg Med.2001;21(1):7-13. Link To Paper

4. Smith JA. In Clinical Ultrasound, 3rd Ed., Allan PL, Baxter GM, Weston MJ, eds. 2011. Elsevier Limited