Case 01

65 y/o F presents with postprandial substernal chest pain “like someone standing on her chest,” with mild SOB.  Review of systems unremarkable.  Physical exam grossly within normal limits, cardiac RRR, lungs CTAB, abdominal exam no tenderness or guarding.  EKG within normal limits.  Vitals: Temp 100.4, BP and HR within normal limits.  Laboratory work with WBC 7.57; cardiac enzymes negative x 1 set; LFTs: total bilirubin 2.5, alkaline phosphatase 140, AST 827, ALT 474, direct bilirubin 1.07. 

1.  What are the 5 signs of cholecystitis on Ultrasound?

2.  What views/structures do you need to visualize for a complete RUQ EM ultrasound? 

3.  Which of the two images below is the correct measurement?  What is a normal measurement for the anterior gall bladder wall?

A:

B:

4.  What does the image below depict?  What is the more sensitive measurement?

5.  What structure are we trying locate in the image below?  What ultrasound technique are we using to find this structure?

Most of the residents knew the answers but did not have time to post so here is the answer:

Acute cholecystitis p/w abdominal pain typically in the RUQ often associated with nausea and vomiting.  There is often a history of ingesting fatty foods before onset of pain.  On physical exam the pt is often febrile as well as tachycardic and has tenderness in RUQ or epigastric region.  Lab finds may include leukocytosis elevated LFTs including bilirubin, alk phos, AST, ALT. 

1.  U/S findings of acute cholecystitis include gallbladder wall thickening of 0.3cm and above, + gallstones, pericholecystic fluid, gallbladder size greater than 5 x 10cm in diameter (hydrops) and sonographic Murphy’s sign.

2.  You have to scan the gallbladder in the transverse and longitudinal plane. You have to visulaize down to the neck of the gallbladder, visualize and measure the cbd (visualize portal triad), measure the gallbladder wall and measure the gallbladder if it appears dilated.

3.  Choice B is the correct measurement for the wall and there is edema within the thickened wall.

4. Image depicts gallbladder hydrops and it is a meaurement greater than 10cm by 5cm, the 5 cm being more sensitive.

5.  The structure being located is the cbd and we are using color doppler to determine where the cbd is.