RUQ Abdominal Pain

HPI: 70 y/o F with no significant PMH who presented with several days of RUQ abdominal pain. Patient endorses fevers and chills, denies nausea, vomiting, diarrhea.

Brief Exam: RUQ abdominal tenderness on deep palpation. Murphy's sign negative.

Bedside Ultrasound of the Right Upper Quadrant:

LONGITUDINAL:

TRANSVERSE:

Diagnosis: Cholecystitis

Management: General surgery was notified and came to evaluate the patient. She was started on IV fluids, antibiotics, made NPO, and cholecystectomy was scheduled for the next morning.

How to perform a Gallbladder US:

-Use the curvilinear probe

-Patient should be supine. Place a large amount of gel on the patient's right upper quadrant.

-Start by placing the probe in a longitudinal plane (indicator towards the patient's head) under the right costal margin along the midclavicular line.

-Sweep through the RUQ to find the gallbladder, which will be an anechoic elongated structure.

-To help identify the gallbladder, look for a strongly reflective, hyperechoic thick fibrous band known as the main lobar fissure which connects the main portal vein to the gallbladder.

-Once the gallbladder is identified, use sweeping strokes in both the longitudinal and transverse plane to evaluate the entire gallbladder. Look for gallstones, pericholecystic fluid, determination of gallbladder wall thickness, and perform the sonographic "Murphy's Sign".

-To measure the gallbladder wall, choose an area on the anterior wall peripendicular to the imaging plane as this is the closest to the probe and therefore the most accurate. A measurement greater than 3mm is considered abnormal.

Brief Review and Ultrasound Education:

Abdominal pain is a common complaint in the Emergency Department. If the pain is in the patient's RUQ, the ultrasound can be used to identify pathology in the gallbladder. The gallbladder should be scanned for gallstones, determination of wall thickness, pericholecystic fluid, and the sonographic "Murphy's Sign".

Gallstones are bright, hyperechoic areas within the gallbladder. They are highly reflective and as a result produce posterior acoustic shadowing. They tend to rest in the most dependent portion of the gallbladder. Having the patient turn on the side or change positions will often change the location of the gallstone, allowing you to visualize it within different anatomical planes. Pericholecystic fluid appears as an anechoic outline adjacent to the gallbladder wall.

Findings consistent with acute cholecystitis include wall thickening >3mm as discussed above, pericholecystic fluid, and presence of a sonographic "Murphy's sign". Note that the presence of gallstones themselves does not mean the patient has cholecystitis but rather cholelithiasis. At least one of these other findings is required to make the diagnosis of cholecystitis.

Additional Resources:

Sonoguide. Ultrasound Guide for Emergency Medicine Physicians. https://www.acep.org/sonoguide/biliary.html

Emergency Ultrasound Podcast. J. Christian Fox https://itunes.apple.com/us/podcast/emergency-ultrasound/id429668403?mt=2

Brianna Miner MD