Sonography of Right Upper Quadrant Emergencies - SD

Sonography of Right Upper Quadrant Emergencies

Hello, my name is Hut
and I'm assistant professor in the Department
of Radiology at University of Rochester.
I will be talking on sonography
of right upper quadrant emergencies.
This talk has been prepared jointly by myself and Dr.
Rem Dore, and I'll be presenting this talk
sonography of right upper quadrant emergencies.

Every time we talk about right upper quadrants, the first thing
that comes to your mind is gallbladder.
And that is why most of the entities
that I'm gonna be talking about in this talk today is gonna
be related to the gallbladder.
Some of the other, rarer
and uncommon entities will include that of the liver
and other organs in the right upper
quadrant, including the kidney.

Acute Cholecystitis

This is the first case of a 25-year-old female who presented
with acute onset right upper quadrant pain.
The three sonographic pictures presented here
demonstrate a very classical picture of
what we call acute cholecystitis.
It demonstrates a distended gallbladder, some gallstones
and gall sludge, a very thickened gallbladder wall,
some pericholecystic fluid.
And what we are not able to demonstrate here,
but is extremely important in making the diagnosis
of acute cholecystitis is that of sonographic Murphy's sign.
Sonographic Murphy's sign is defined as the presence
of maximal tenderness elicited by direct pressure
of the transducer over a sonographically localized gallbladder.

Now, Murphy sign can be demonstrated by physical exam also,
but ultrasound helps you to identify the position
of the gallbladder and helps us
to elicit the tenderness right over the gallbladder
and thus specify the etiology
to the gallbladder itself.
The reported prevalence
of Sonographic Murphy sign is more than 95% in patients
with acute cholecystitis,
and that is why it makes it the most specific sign in making
the diagnosis of acute cholecystitis.

However, the problem that we most often incur is
that most of these patients who come from the ED
to the radiology suite are already medicated.
And so the sign is not extremely useful
because they do not have any tenderness.
So we have to rely on the other sonographic signs
to make the diagnosis of acute cholecystitis.

The physiology behind Sonographic Murphy sign is
that the gallbladder distension
and the inflammation, it stimulates the visceral pain
nerves, the muscular and serosal layers the gallbladder,
while the autonomic nervous system, thus creating
the tenderness right over the gallbladder.

In today's world,
CAT scan plays an important role in any patient
who walks into the ED with the abdominal pain.
And most of these cases
who do not have a primary diagnosis of a gallbladder disease
may get a CAT scan first before an ultrasound.
These two CT pictures actually demonstrate a very
classical picture of what is called an acute cholecystitis.
You see a very enhancing thickened gallbladder wall.
You see some gallstones and a pericholecystic fluid
and gallbladder wall edema, which are very classical
of acute cholecystitis.

So the patients usually present
with fever pain, elevated white count.
The ultrasound criteria, as I already talked about,
includes some very specific signs
and some other useful signs,
and a combination of all these signs helps us
to make the diagnosis.
Sonographic Murphy sign being the most specific
is demonstrated by eliciting maximum tenderness over the
sonographically localized gallbladder.
Other findings include sludge, impacted stone in the neck of the
gallbladder or the cystic duct.
There should be a gallbladder wall thickening greater
than three millimeter.
However, you have to demonstrate
that the gallbladder is optimally distended,
so the gallbladder, which is less than two centimeter wide,
may have thick walls just because of suboptimal distension
and may represent a non-fasting state.
So the gallbladder wall thickness will not
hold true in such cases.
Nuclear scan, including the high dose scan,
should be reserved only for equivocal cases on ultrasound.

Emphysematous Cholecystitis

Moving on to the second case.
This is a 54-year-old female with right upper quadrant pain
and this is a single ultrasound picture
of the right upper quadrant, which demonstrates,
contracted gallbladder with some echogenic area within the
gallbladder lumen and
some posterior reverberation artifact
and some posterior acoustic shadowing.

Now this is a difficult diagnosis to make just on the basis
of ultrasound because what you're not able
to determine here is whether
that echogenic focus is calcium or whether it is air.
So CT becomes a friend here
and is, as you can see, in the CT picture
of the right upper quadrant, demonstrates,
partially distended gallbladder with a huge gallstone
and some air in the gallbladder wall
and gallbladder lumen as demonstrated here.
So you can correlate the ultrasound picture
with the given ct
and as that the echogenic focus,
which was seen in the gallbladder lumen, was probably the air
and the posterior reverberation artifact was coming from the air
and not from the calcium represented by the stone.
So the diagnosis here is that of an emphysematous cholecystitis.

Yet another example, a better example of
ultrasound images of emphysematous cholecystitis,
which demonstrates a very inflamed gallbladder.
Once again, this is a transverse image
and the sagittal image demonstrates a distended gallbladder,
some dependent echogenic foci
with posterior acoustic shadowing,
which represent gallstones
and some non-dependent echogenic foci.
More anteriorly in the non-dependent position
that demonstrated here and here in the sagittal image
with some posterior reverberation artifact,
which suggests presence of air.

Yet another example of emphysematous cholecystitis,
A distended inflamed appearing gallbladder
with some dependent echogenic foci representing gallstones
and non-dependent echogenic foci, which rise
and demonstrate air emphysematous.

Emphysematous cholecystitis is a rare entity.
It's about 1% of the all cases of acute cholecystitis.
The main risk factors are that of elderly males
with diabetes mellitus.
There is vascular compromise of the gallbladder wall,
which leads to infection by the gas forming organisms,
mainly the Clostridium and e coli.
The ultrasound findings, as I already showed in my cases,
consist of curvilinear echogenic areas in the gallbladder
wall with reverberation artifact.
The obscuration of the gallbladder
by the high level echoes should also raise a suspicion
for presence of air within the gallbladder.
The differential diagnosis includes porcelain gallbladder,
which is calcification in the gallbladder wall.
However, the posterior acoustic shadowing will be more
discreet and more sharp compared
to the reverberation artifact.
And CT, of course, is most sensitive
and helps us to make the diagnosis
with ease compared to the ultrasound.

Gangrenous Cholecystitis

Moving on to the next case.
This is a 54-year-old male who presented
with elevated liver function tests.
What we are seeing in these two images of the gallbladder is this avascular area within the gallbladder lumen,
which some people may call sludge.
But the interesting thing to note here is
that the gallbladder wall is not very well defined
and the sludge happens to layer more dependently,
which is not happening in this case.
And this actually was transmural hemorrhagic necrosis
involving the gallbladder wall.
These are the two CT image
and the nuclear medicine image, which just demonstrates
findings of an inflamed gallbladder
and is non-specific in further making the diagnosis,
which was gangrenous cholecystitis in this case
and was proven surgically.

Gangrenous cholecystitis demonstrates transmural necrosis,
which produces the inflammation
of the adjacent parietal peritoneum producing generalized
right upper quadrant pain.
Ultrasound demonstrates, again, findings suggestive
of inflamed gallbladder,
but without sonographic Murphy sign.
This gangrenous status has a very high mortality rate of up
to 22% and a complication rate of 16 to 25%,
which needs early diagnosis and therefore surgery.
According to Figan AAL in his paper,
the only statistically significant predictors
of gangrenous change in the gallbladder in the setting
of acute cholecystitis were a history of diabetes mellitus
and a white count greater than 15,000 according
to TFL El LA specific sign supporting the diagnosis
of gangrenous cholecystitis is that of gallbladder wall striation
or the presence of alternating hypo echoic
and hyperechoic linear areas,
which can be seen in about 40% of patients.

This is a classical picture of a HIDA scan in a case
of gangrenous cholecystitis in a different patient,
which is called the rim sign, which is seen here
with increased uptake in the liver parenchyma adjacent
to the gallbladder without any activity in the gallbladder.

Acalculous Cholecystitis

Moving on to the next case
and in the series of cholecystitis, this is a 55-year-old female with right upper quadrant pain.
This is a single sonographic picture of the gallbladder,
which again everyone would agree is that
of an inflamed gallbladder, very thick wall,
gallbladder wall, and some pericholecystic fluid as well.
However, what is lacking here is the presence of gallstones
and therefore the diagnosis here is that
of an acalculous cholecystitis.
This is also an extremely rare condition accounting
for only five to 10% of cases of acute cholecystitis.
There are several etiological
or predisposing risk factors, which include trauma,
mechanical ventilation, hyperalimentation, et cetera.
The patient is usually very sick
and an outpatient walking into the radiology suite
with right upper quadrant pain usually does not have
acalculous cholecystitis.
The patient has to be usually sick
with all these predisposing risk factors
that I just talked about.
The cause usually is related to functional obstruction
of the cystic duct by viscous bile.

Xanthogranulomatous Cholecystitis

Moving on to the next case, it's a 56-year-old female
with again presenting with right upper quadrant pain
and fever, and I have shown some sequential ultrasound
images from August and then October.
The first image is that from August of 2008,
which demonstrates a distended gallbladder
with multiple gallstones.
It, the gallbladder looked pretty unremarkable
otherwise without any evidence of inflammation.
However, the two sonographic images taken
after two months demonstrate a very ugly looking gallbladder
with ill-defined gallbladder wall
and a very echogenic mass like sludge like presence within
the gallbladder lumen.

Here are the CT
and MRI images from the same patient,
which demonstrate a distended gallbladder
with a very irregular inflamed gallbladder wall
and some nodularities.
As you can see here, the MRI findings correlate
with the CT findings and the ultrasound findings.
This was confirmed on surgery
and pathology as xanthogranulomatous cholecystitis.

This is a very difficult diagnosis to make on radiology
and it's usually a pathological diagnosis.
It's an uncommon variant of chronic cholecystitis
and extremely rare incidence of about less than 1%.
It is characterized by the presence of granulation
or nodules, the streaks in the gallbladder wall,
which are caused by lipid laden macrophages similar
to xanthoma pal nephritis.
The radiologic findings, as I said, are very nonspecific.
They consist of wall thickening presence of gallstones
and the radiological diagnosis is usually very difficult.
Presence of cystic duct obstruction is seen
in almost all the cases.
The most characteristic radiologic findings in this disease
are that of hypoechoic nodules
and bands as we saw in retrospect on the ct.

AIDS Cholangiopathy

Just to show a comparative image of another entity,
which also can demonstrate very thickened gallbladder wall
and appear similar to an inflamed gallbladder.
As you can see here in these two images of the gallbladder
demonstrate a markedly thickened gallbladder wall
with some pericholecystic fluid.
However, the patient was totally asymptomatic
and was being scanned to look at her kidneys.
And on further delving into the history, we found
that the patient did have history of AIDS
and a diagnosis of AIDS cholangiopathy was
therefore forwarded.

Other Types of Cholecystitis

To complete the series
of cholecystitis.
There are three other conditions which needs
to be mentioned here, although I do not have any
images to support it.
Suppurative cholecystitis also called gallbladder
empyema is a complication
of acute cholecystitis which results when purulent material
or pus fills and distends the gallbladder lumen.
The symptoms are pretty non-specific again
and include fever, chills, rigor
and right upper quadrant pain.

Hemorrhagic cholecystitis, as a name suggests, is suggested by hemorrhage within the gallbladder,
again in the presence of an inflamed gallbladder.
Patients present with acute onset of biliary colic,
jaundice, melena.

And Mirizzi syndrome is an interesting condition in which there is an impacted gallstone in the
gallbladder neck or the cystic duct, which
therefore causes biliary tree obstruction by edema and
therefore cholestasis.

Here are two ultrasound images,
which demonstrate a stone within the gallbladder neck,
which was non-mobile and was impacted.
However, the gallbladder right now here does not appear very
inflamed, but such impacted gallstones can also give rise
to right upper quadrant pain
and may potentially give rise to Mirizzi syndrome.

Gallbladder Perforation

Moving on to the next case.
This is an 85-year-old male who presented
with weak right abdominal pain
and came to ultrasound
for evaluation of the gallbladder.
So the three ultrasound images demonstrate the gallbladder
with another fluid collection adjacent
to the gallbladder fundus.
And if you look closely in the, on the third image,
there appears to be a communication
with this fluid collection with the gallbladder lumen
with no evidence of flow here.
So what is it? Is it a pericholecystic fluid, is it sinus tract
or is it just ascites?
What really helps us is this cine clip,
which can demonstrate the communication of the fluid pocket
with the gallbladder lumen.
So as you can see, there is a communication
between this fluid pocket
and the gallbladder lumen
with some sludge within the gallbladder lumen,
hence suggesting a diagnosis of gallbladder perforation.
This further stresses the importance of doing a cine loop
and demonstrating where that fluid pocket is arising from.

Gallbladder perforation usually results in the formation of abscesses around the gallbladder.
As you can see in this case, this is the part of the liver,
a lot of fluid as a result of the perforation
and a very heterogeneous fluid collection near the
gallbladder suggestive of an abscess.

Here is yet another case with a sonographic image
of an inflamed gallbladder,
very thickened gallbladder wall sludge within the
gallbladder surrounding fluid
and the CT images clinch the diagnosis, which shows
a break in the gallbladder wall suggestive
of gallbladder perforation.

So the gall perforated gallbladder usually results
in presence of cholecystitis,
most commonly emphysematous or gangrenous cholecystitis.
It may be a result of trauma or also iatrogenic.
Clinical presentation is usually very unique in such
patients because the patients get a temporary relief
of acute abdominal pain when the gallbladder perforates, which if
therefore left untreated leads to peritonitis.
Hence, it's very important for the clinicians
to identify the series of symptoms with right acute onset,
right upper quadrant pain with temporary relief
and the supportive ultrasound findings.

The site of rupture most commonly is the fundus
or the neck in case of an impacted stone
and cholecystectomy is almost always performed to salvage.

There are three types of gallbladder perforation.
Type one perforation refers to free spillage
of gallbladder intraluminal contents into the
peritoneal cavity.
Type two perforation is a more subacute process which is
contained by an adjacent abscess.
Type three perforation is a chronic process
with the formation of a cholecystoenteric fistula.

The ultrasound findings and the CT findings,
I just talked about the ultrasound findings,
is the most specific findings of that of a disruption
of the gallbladder wall, along
with a complex echogenic pericholecystic fluid collection in
presence of an inflamed gallbladder.
The CT findings are also pretty much the same
as seen in ultrasound with presence
of a gallbladder perforation
or a break in the gallbladder wall continuity,
pericholecystic fluid collection, gallbladder collapse,
and high attenuation intraluminal density
secondary to hemorrhage.

These two images are just to demonstrate a comparison
with the what gallbladder perforation is
most often mistaken with.
And that is the Phrygian cap.
This is just a cartoon picture of the Phrygian
cap, the from where the term originates
and this is the normal variant of the gallbladder
or the Phrygian cap where the fundus folds on itself like the cap as seen in the scattered picture.

Here is another example
of a gallbladder perforation in presence
of acute cholecystitis.
As you can tell with the thickened gallbladder,
gallbladder sludge and gallstones.
However, this is an atypical site
of gallbladder rupture not in the gallbladder fundus which
appears intact in this image.
And the rupture appears
to be somewhere in the body posteriorly
with a very contained leak.

Yet another example of gallbladder perforation,
which was initially not suspected an ultrasound,
probably because of a difficult scan,
but the findings are somewhat suggestive in retrospect when
you look at the gallbladder
with an irregular gallbladder wall.
Lot of sludge within the gallbladder lumen
and some fluid pockets around the gallbladder.
A CT was therefore performed
and demonstrated an inflamed gallbladder
with an obstructing stone in the gallbladder neck
and a huge loculated fluid collection
or an abscess which had resulted from
gallbladder perforation.

This is again the movie of the same case
that I just showed you, which demonstrates better the
fluid collection surrounding the gallbladder
and the inflamed gallbladder
with irregular gallbladder wall and sludge within the lumen.

Another example of gallbladder perforation.
The first image demonstrates a very inflamed gallbladder,
irregular gallbladder wall gallstones sludge
and this fluid collection was actually within the left
hepatic lobe and had was
therefore diagnosed as a liver abscess as a result
of ruptured gallbladder, which was again,
better demonstrated on a ct as you can see here.
So this is this large fluid collection within the left
hepatic lobe, which corresponds
to the second ultrasound image here
And here is the inflamed gallbladder with some gallstones,
gallbladder wall thickening and discontinuity
or a break in the gallbladder wall
and continuity with the large liver abscess.

Liver Abscess

Moving on to the next case.
This is a 45-year-old male
with right upper quadrant pain and fever
and these are two images from the right upper quadrant.
Two images
of the liver which demonstrate a very heterogeneous
appearance of the liver and multiple echogenic foci
with reverberation artifact.
Another image from the same patient which demonstrates the
hypoechoic fluid collection, very irregular shaggy walls
and echogenic foci and reverberation artifact.
This finding itself on ultrasound should raise suspicion
for presence of air within the liver
and hence the presence of liver abscess.
CT always is very sensitive in making this diagnosis
as was in this case,
which demonstrates a fluid collection in the right hepatic
lobe with multiple foci of air.
And this was diagnostic of a liver abscess.

Another example of liver abscess on ultrasound images,
which demonstrates a lot of echogenic
foci within the liver.
Almost occupying the entire right hepatic lobe
with a lot of reverberation artifact
that's making the diagnosis easy of a liver abscess.

So liver abscesses are usually pyogenic abscesses,
which are usually polymicrobial.
They account for 80%
of hepatic abscess cases in the United States.
Amebic abscesses are relatively rare, caused
by Entamoeba histolytica, accounting for about 10% of cases.
Fungal abscesses are also another 10% mainly
caused by candida.
Other rare causes of liver abscesses are that of hydatid
and cysicercosis.

Choledocholithiasis

Another cause of right upper quadrant pain also related
to the biliary tract is a bile duct stone,
as you can see here very clearly in the sonographic picture,
which demonstrates an enlarged or dilated common bile duct
and an echogenic focus within the distal common bile duct
with a posterior acoustic shadowing
suggesting the presence of stone.
You can partially see the gallbladder over here as well
and it demonstrates a very normal appearance without
evidence of any gallbladder wall thickening or gallstones.
The CT picture also demonstrates very clearly the presence
of stone within the common bile duct, as you can see here.
So the diagnosis here was choledocholithiasis,
which is also another common cause
of right upper quadrant pain.

Another example of choledocholithiasis
as you can see on this ultrasound picture,
which demonstrates a dilated common bile duct
with multiple echogenic areas within the bile duct
with sludge, which represents sludge and gallstones.
This finding was confirmed on ERCP
where you can see a dilated common bile duct
and multiple filling defects which represent gallstones
as seen on ultrasound.
Patient also underwent a CT which demonstrates a very
inflamed gallbladder, some gallstones,
and there were some common bile duct stones,
which are not very well seen on these two images.

Biliary Necrosis

Moving on to the next case, this is a 54-year-old male,
who was post liver transplant,
and the ultrasound picture of the left lobe
of the liver demonstrates a fluid collection within
the left hepatic lobe.
However, it was unclear based on this image and
therefore the CT was performed,
which demonstrates multiple dilated tubular fluid filled
areas within the liver, mainly in the left hepatic lobe.
Again here the diagnosis would be easy if you look at the cine loop image
of the left hepatic lobe,
which demonstrates this fluid collection,
but this is not just one fluid collection.
These are actually tubular fluid-filled ducts,
Which actually represent the bile ducts within the liver,
as was better seen on ct.
The diagnosis therefore was that of a biliary necrosis.
Patient also had hepatic artery thrombosis,
which further corroborated to the diagnosis.

So biliary necrosis represents destruction
of the bile ducts with formation of biliary lakes
or bilomas and almost
always has concomitant arterial thrombosis.

Other Causes of Right Upper Quadrant Pain

Just some rare causes.
Non-biliary
and non-hepatic causes of right upper quadrant pain include,
that of perforated duodenal ulcers
and some renal causes.

Here's one such example which in retrospect was diagnosed on ultrasound.
However, the CT helped us in actually making the diagnosis.
So if you look at these two ultrasound images
of the right upper quadrant, which demonstrate the liver, you
would notice that there is an extra amount
of air which you more than
that you would normally see in a patient.
However, when the patient underwent ct, this suspicion was confirmed as there were extra luminal foci
of air in the right upper quadrant, as you can see here,
and the patient was taken to surgery
and was confirmed to have a perforated duodenal ulcer.

Renal Abscess or Pyelonephritis

Another right upper quadrant pain cause is that
of a renal abscess or pyelonephritis.
Pyelonephritis usually can be a difficult diagnosis in
ultrasound, however, when it forms a renal abscess,
it's usually better seen on ultrasound
as you can see here in this ultrasound image, seen
as a focal hypoechoic area within the renal parenchyma
with increased peripheral vascularity.

Budd-Chiari Syndrome

And the last case for the day is that
of a 45-year-old female who presented
with abdominal pain increasing bilirubin levels
and the first image here itself will clinch the diagnosis.
As you can see the IVC
and an echogenic material within the IVC,
which actually represents thrombus.
The other pictures demonstrate the right hepatic
and the middle hepatic vein.
Although the left hepatic vein was not seen, also seen as
an area of aliasing
or a mosaic artifact, which corresponds to the presence
of thrombus within the IVC.
The diagnosis, therefore was forwarded of
Budd-Chiari syndrome,
which actually is hepatic vein outflow obstruction,
which can originate anywhere within the hepatic
venous systems or even the right atrium.
It results in increased hepatic sinusoidal pressure,
portal hypertension and hepatic congestion.
It results in progressive centrilobular necrosis,
nodular regenerative hyperplasia and cirrhosis
and end hepatic failure.
The patients usually present with abdominal pain,
hepatomegaly, and ascites,
and need in emergent TIPS to relieve the pressure.

Sonographic Evaluation Technique

Just to finish the talk, I would like to reiterate the gallbladder,
the sonographic evaluation technique as given by the AIUM,
which requires fasting for eight hours
before the examination.
For adequate distention
of a normally functioning gallbladder, a long axis
and transverse views must always be
obtained in the supine position.
Also if necessary, a left lateral decubitus, erect
and prone position, particularly when gall stones
or sludge is observed.
If the patient presents with pain tenderness,
transducer compression
or the sonographic Murphy sign must also be elicited.

Thank you.