Ultrasound of Acute Right Upper Quadrant Pain - HD

Introduction

Thank you, Sheila.

Thank you, the society for having me.

And I'm glad to see you all this morning for topics which
sort of seem like this is US ultrasound
and what more could we possibly say?

But it is my pleasure today to speak
to you about the gallbladder,

and this is the outline of what I'm going to talk about,
a bit on whether this is or is not cholecystitis,
and then some pitfalls.

We think the gallbladder is easy,
but it isn't always.

And I will share some of that.

Then we'll talk a little bit about other organs in the area
that can cause a problem, a little about the right kidney,
and then some interesting miscellaneous topics
that you might come across in the right upper
quadrant causing pain.

Totally unrelated to the gallbladder.

Diagnosis of Acute Cholecystitis

Not a lot exists new in the literature,
certainly in our literature I should say,
about the diagnosis of acute cholecystitis.

And if you look at the appropriateness criteria from the ACR,
certainly ultrasound is the top imaging modality
for this diagnosis.

But in fairly large analyses, if you look, ultrasound
for acute cholecystitis does not
come in at a hundred percent.

It certainly doesn't come in at 90%.

It's actually a little bit lower.

Nuclear scanning clearly is higher,
but gives you limited other information.

And that's what puts ultrasound certainly in terms
of no ionizing radiation
and ease of ability
to order this study high on the list.

But remember that number
and let's see if we can improve our diagnoses
and make that higher in our own practices.

Findings for Confidence in Diagnosis

Acute cholecystitis has a whole lot of findings,
and the more findings you have,
the more confident you'll be about the diagnosis
of acute cholecystitis
because gallstones alone certainly do not make
that diagnosis.

Insights from Beth Israel Paper

A very nice paper was published from the people at
the Beth Israel some years ago.

I suspect it grew out of a quality assurance project,
but it was very telling
about some
of the problems that we encounter in this diagnosis.

And they were looking at both ultrasound and CT.

But as far as ultrasound went,
when they looked at their misdiagnoses
of acute cholecystitis,
there were both overcall and under calls.

And the overcall often had to do with other causes
of gallbladder wall thickening.

The under calls had to do with very subtle findings.

These were some of their conclusions.

And I point out this one here, the Murphy sign,
that's sort of like the B wick of life in my emergency room.

People calling me, is there a Murphy sign?

Is there a Murphy sign?

And sometimes with all of the medications that are given
to patients, it's very difficult to tell.

It's very dependent on who does it.

I'm not sure I trust anybody else except myself
and some of my colleagues to do it.

And I'm sure my residents get annoyed at me when I say,
walk over to the emergency room and figure it out
and come back and tell me.

Subtle Findings of Acute Cholecystitis

You can have subtle
or moderate findings of acute cholecystitis.

Here's a case in which the gallbladder has
that fat tensile shape.

There are very tiny little calculi with a
shadowing all clump together.

And the wall thickening here is very subtle
but best appreciated at high frequency imaging.

And that's something that I would ask you to perhaps add in
to your imaging if you do not do that,
especially when you're considering the diagnosis.

And there are subtle findings.

Also, make sure you look all at the whole gallbladder wall
because there may be areas that are thicker
and other areas in which you cannot appreciate it
and someone measures where it's normal
and you shouldn't necessarily assume.

Of course, you can have a much more uncomfortable looking
gallbladder than this patient who's much sicker
and has much more wall thickening.

And this one wouldn't be a problem for most people.

Complications of Cholecystitis

The next thing to think about are the complications
of cholecystitis.

Things that go beyond just simple obstructed gallbladder.

And that's when there is vascular compromising can lead
to gangrene and gas in the gallbladder
or in the gallbladder wall.

Sometimes it could be so severe.

This is a CT in which the gas in the lumen
and the wall completely obscures the gallbladder.

This was a patient who came into an outpatient,
one
of our outpatient clinics.

She had been having some gallbladder,
some right upper quadrant pain was an older woman,
happened to be a diabetic.

And the person who
did the impression said cholelithiasis
and she was sent home.

But if you look a little bit more closely, in addition
to the gallstones,
there is some sludge in the gallbladder,
which is not a common thing in outpatients.

I tell you, when people come into the emergency room
who are otherwise healthy
or come to outpatient centers,
sludge is a very important finding to note.

There are these thick pieces of something
stretching across the gallbladder,
and if you look really carefully at the wall,
it's probably not quite intact in some places.

This was a case of gangrenous cholecystitis.

The patient came back one week later to the emergency room
and had a frankly perforated gallbladder.

Acalculous Cholecystitis

Acalculous cholecystitis comes up in conversation more in
inpatients than the emergency room.

But every now and then, it is more common in patients
who are sick overall.

And this is a difficult diagnosis,
a really difficult one to make.

Just seeing gallbladder wall thickening, there are
so many systemic reasons for that,
that it may not be truly related to the gallbladder.

And sometimes you just have to poke it.

This was a patient who had a lot
of stuff in the gallbladder, a thickened wall.

The CT wasn't really very helpful showing
significant inflammation.

But nonetheless, this was infected material
and the patient had a cholecystotomy done.

Chronic Cholecystitis

Another patient comes into the emergency room
and sometimes has some pain intermittently, not
that much at the time, but came in anyway.

And the gallbladder looks like this in sagital and transverse.

This is not a distended gallbladder,
it is not a tensile gallbladder.

It is clearly abnormal.

There are stones and there's wall thickening.

And this is more a representative of chronic cholecystitis
and unlikely needs an admission at that time.

Typically the issue here is
that the gallbladder is not that distended.

Pitfalls in Gallbladder Imaging

Now let's turn
to some pitfalls in imaging of the gallbladder.

And I collect these.

If you are honest and work day in
and day out, you will come across these kinds of problems.

These fall into the technical anatomic and the interpretive.

Everybody gets their due here.

Some of these things are well known.

Technical Pitfalls

Here's a patient who's scanned at five two megahertz
and there are things in the gallbladder
and there really are no shadows.

You increase the frequency and take off the compound imaging
and the shadows are more apparent.

How about this one? A distended gallbladder
and an outpatient sludge.

Maybe some tiny little calculi.

Is there any wall thickening here?

This was another one that we went up in frequency
and we're able to see the gallbladder wall thickening,
which I think is not very apparent.

At the lower frequency is this sludge.

We turned on the harmonics
and cleaned up the gallbladder.

And I presume most of you know that that helps as well.

How about color, right?

You think stones,
you think in the kidneys, turn on the color.

Look with twinkles sometimes it often is very helpful.

Is it helpful in the gallbladder?

There are lots of twinkling things in the gallbladder.

Sometimes they're stones, more often than not,
they're not stones.

Here's lots of twinkling in this gallbladder,
but you'll notice most of it has to do
with all this sludgy stuff
and not terribly much with the calculi.

It turns out that though the majority
of cholesterol stones probably twinkle pigment stones
generally do not.

And if you put all that together, it's not all that helpful.

Since we do very well in gray scale,
what really twinkles is adenomyosis
and that's not gonna cause anybody
an obstructed gallbladder.

Now let's look at some problem technical,
other technical issues.

Here's the image presented to us.

It's a transverse view, right?

Kidney, liver, the patient is supine
and this is labeled, that's how it came out,
labeled gallbladder fossa.

And the tech thought,
is this a so-called wall echo shadow,
wall echo shadow.

We went in and we moved the patient around
and all of a sudden we could see the
gallbladder a lot better.

But when we moved the patient back,
we couldn't see it very well.

What's going on here?

This patient had gas in the gallbladder.

This is a CT, so it's supine, but with the level of gas
and fluid in the gallbladder, sometimes yes, sometimes no.

We saw it.

This was not a wall echo shadow,
this was much more significant.

This was emphysematous cholecystitis.

This one was interpreted as adenomyosis,
tiny little echogenic foci in the wall
and some little ring down artifact.

Afterwards we turned the patient and lo
and behold they moved.

Little crystals in the Rokitansky-Aschoff sinuses don't
move, but gas moves.

Those were little bubbles
that had bumped up against the top of the gallbladder.

Normal Variants and Interpretive Pitfalls

There are variety of normal variants
that might cause you problems.

This is not fluid near the gallbladder. It's a vessel.

These are not sloughed membranes.

These are just folds in the gallbladder.

We had this case a few months ago.

We cover other sites at night from afar.

Sometimes those images are read
preliminarily by other people.

And we see them in the morning for final reads.

And this one came up.

This was a 3-year-old woman came into the emergency room
with a lot of pain in the right upper quadrant.

These were the images presented.

I think we'd all agree it's a pretty
distended gallbladder.

The wall is a little bit thick in places
and maybe it's a little bright around here.

And probably there was a little bit of low level sludge,
but there were no calculi.

And the Murphy sign by the tech was reported
as, I don't know, I'm not sure.

We encouraged the sonographers
and in our protocol have a variety
of cine clips that they take.

We looked at the cine clip and here was the cine clip.

And I'm looking and looking, I don't see any
stones on that cine clip.

And that was the gallbladder cine clip.

You can see a little bit of fluid here.

This was pretty suspicious.

What was the preliminary read that was sitting there?

It said acalculous cholecystitis.

That doesn't make a lot of sense.

This is not a sick patient who came.

Why would this patient have a acalculous cholecystitis?

Part of the protocol is the liver and the bile ducts
and there were other cine clips in there.

I keep going through the other cine clips
and I come across this one labeled sagittal liver.

If you look really carefully, right over there,
you see it, there's the stone, one stone in the neck.

Those to me are the most fearsome ultrasounds that are done
by people in the evening or night who are not experienced.

Because if that one thing is down in the neck
and the angle is such that you can't see the neck
of the gallbladder, that's it.

You miss the one stone.

As I say to my residents,
I'd rather see your images that show me this.

The patients I worry about the most are the ones
that look like a fat gallbladder
with no stones, that you missed it.

Beware of the one stone in that area.

This was an offsite.

Our offsite sonographers in some
offices do not have a radiologist on site.

Others do.

If there's nobody there, they have to call
before the patient leaves.

And the call came in
that the person there just couldn't find the gallbladder.

The patient says they didn't have a cholecystectomy
and she says, I don't know, I don't see the gallbladder.

This was a little bit suspicious there.

And it was the cine clip that saved us
because if you look, you can better appreciate
that there's a gallbladder in there.

It's so filled with thick echogenic sludge.

That's even hard to see the stones
that are shadowing, but that's what it was.

Sometimes the sludge can be so thick, so bright
that it just becomes the same density as the liver
and it's hard to see.

Okay, other problems. Here we go.

This one's labeled gallbladder sag, gallbladder transverse.

Is that the gallbladder?

It's a little odd that it didn't really change a whole
lot in shape between the two images.

There is fluid, there's something
a little bit bright in there.

Go back in, work at it a little bit more.

And lo and behold, we found the gallbladder.

This is a gallbladder that's so filled with stones
and shadowing that you don't see much bile in there.

It is a wall echo shadow.

And that's the problem when the gallbladder is
so abnormal in appearance
that it's not appreciated initially by the person imaging,
they'll pick out something else.

What did they pick out here to label gallbladder?

That was the duodenum.

The opposite can happen.

Also, this thing here was so weird.

And somebody put color on
and it just looked so crazy
that they labeled it stomach said
patient ate three hours ago.

That was the debris in the stomach.

When in reality, if you look again at the cine clip,
that's the gallbladder with stones down there.

There happened to be a cyst in the liver nearby.

The gallbladder that isn't the gallbladder, the duodenum
that isn't, you can see the problems that go on
and then you ultimately can get to this point.

This person comes into the emergency room with fever
and right upper quadrant pain.

That's a pretty good looking thing.

That could be a gallbladder.

It's got lots of sludgy stuff and maybe some things and
maybe the wall is interrupted.

This looks like a very sick, ugly gallbladder except
for the fact that the patient had had a
recent cholecystectomy.

This was an abscess in the gallbladder fossa,
certainly important to know, but you would look pretty silly
if you said it was the gallbladder.

And equally as much this one with right upper quadrant pain,
there's a little fluid collection
with something that's shadowing.

This was what the gallbladder looked like three months
earlier before it was taken out.

And every now and then a stone gets dropped in the
gallbladder fossa
and a little fluid can accumulate around it.

And both ultrasound
and CT, it can almost simulate a gallbladder.

How about even, is that a stone?

Did we get that one right?

There are other things
that I've shown you already in the gallbladder in terms
of adenomyosis polyps can give you a problem as well.

Let's look at some of those.

These are classic findings of adenomyosis
and I'm sure you would not miss those.

How about these? This gallbladder was interpreted as having
adenomyosis little bright things anteriorly with little kind
of ring downs after them.

And everybody thought, that
was the interpretation of this study.

And nobody said
otherwise until a few days later the patient had a CT
and they happened to be in acute renal insufficiency
and had gotten contrast previously.

And there was like curious excretion into the gallbladder
and that allowed us to see that there were actually calculi
and those calculi had gas in them
and they were floating in the gallbladder.

That was not adenomyosis.

Differentiating Stones, Polyps, and Other Features

Now you get a choice Patient A patient B
two different gallbladders.

This gallbladder has some bright stuff with shadowing.

It looks like stones up here at the fundus.

And this patient has bright things
with some shadowing up at the fundus.

Which of these patients is at risk for acute cholecystitis?

Patient A, those are truly calculi up in the fundus
and they could fall out.

They could fall out and get into the neck.

The other patient, if you look at the high res, all
of this stuff was up in the fundus of the gallbladder
with funny little shadows.

And this one isn't going
to cause the patient acute cholecystitis
because this is focal adenomyomatosis,
which often occurs in the fundus.

And all those little crystally things are stuck up there
and they're not, unless the patient develops stones,
otherwise they're not going to cause the patient any pain.

Polyps usually we're pretty good at figuring out
that they're polyps, they're not in the dependent portion
and there's no shadowing.

But the more polyps that you get,
the more problematic it would be.

Look at this person to try
and figure out, is one single one of those a stone?

I think in these cases you'd just be humble.

You say I think of most of those,
if not all are polyps,
but I don't know, I couldn't definitely rule out
that one of them was a stone.

This one's a problem sometimes.

Here's patient A and patient B.

And I'll tell you that we saw one
of these patients in an earlier slide,
they both had some pain, neither of them had any calculi.

They both have a lot of echogenic
material in the gallbladder.

What's the issue here?

The thing that you really need to do is use color
because patient A had color flow in the debris,
in the material, in the gallbladder lumen.

Patient B had no
flow anywhere in this material.

And here's the spectral doppler that confirms this.

Don't just turn on the color and get one twink of color.

You need to make sure that there is actually flow.

This patient has gallbladder carcinoma
and this patient had sludge.

This was the patient with that.

We poked the on the previous slide.

And this was a case we had within the last
six months in our practice.

This one was read out as sludge,
big tumor effect of sludge balls.

And the patient went to the OR for acute cholecystitis because there were also stones
and they unhappily found the carcinoma.

Tumor effect of sludge, big sludge balls can be a problem
and can cause patients
to have pain if there are no calculi.

The big issue here is to try
and distinguish it from malignancy.

And if you can't be honest that you can't,
but remember that both those two things
can look like each other.

Other Causes of Gallbladder Wall Thickening

Now, going to other causes of gallbladder wall thickening,
which I've already mentioned in part there are many processes,
systemic processes, things in the neighborhood
of the gallbladder that can cause
gallbladder wall thickening.

And in fact in my experience,
the thickest gallbladder walls are not the ones
that typically have acute cholecystitis from
a calculus in the neck.

Beware.

And those some
of those patients will have stones.

Stones are very common.

You don't want to over call acute
cholecystitis in those cases.

Here's an example. This patient has acute hepatitis.

There are a bunch of little lymph nodes in the porta
hepatis, a very dark looking liver.

And this is the hugely thickened gallbladder wall.

Mind you, the gallbladder is actually small
and we have found in some of our patients
with really severe acute hepatitis
and present with fulminant hepatic failure that
the wall can be very thick
and there's not much bile being made
'cause the liver is so sick.

The lumen will actually be small.

Here's another case.

This patient is in right-sided heart failure.

You can see the heart and the
distended veins in the liver
and the very thick gallbladder wall.

There's nothing to do
with intrinsic gallbladder disease.

One of the things that can help you is to remember
that people with acute cholecystitis have lots
of flow in their gallbladder wall
unless it's become gangrenous.

As opposed to people
who have gallbladder wall thickening for other causes.

Other Right Upper Quadrant Issues

Turning now towards the end about other issues in the right
upper quadrant that you need to think about.

There are a variety of other GI issues that you need
to actually look for and will find from time to time.

Bile Ducts and Related Findings

Here's a patient who did have acute calculus cholecystitis.

We had already established that.

And when we went looking in the liver,
there were no dilated ducts.

The extra hepatic duct along its way was just at sort
of the upper limit of normal 0.63,
but there were calculi in the duct.

Remember that normal
extra hepatic bile duct can certainly still have calculi
and you would absolutely want to know about
that if you were able to make that diagnosis.

In addition to the acute cholecystitis, this is a case
as I mentioned earlier, in which sludge tumor effect
of thick sludge can cause problems.

And this is clearly a big tensile gallbladder filled with all kinds of debris
and there are dilated ducts in the liver
and the debris is in the duct.

The same thing. This toothpaste stuff is going out
and causing trouble everywhere.

Pancreas and Liver Abscess

The next patient we looked at had a normal gallbladder
and was having pain more in the epigastric region.

And if there's not too much bowel gas, you might be able
to get a good look at the pancreas.

In this case, we have an enlarged,
swollen heterogeneous pancreas in a case of acute pancreatitis.

This is a not very common cause
of right upper quadrant pain, but every now
and then we'll come across, here's the liver
and within the liver is a very large well circumscribed
collection containing all kinds of debris and bright echoes
and there is a little bit of shadowing.

And this patient had a hepatic abscess with gas.

Kidney-Related Issues

Don't forget the kidney.

It's hard.

I believe that,
it's very hard in the emergency room
to tell the difference sometimes
where the pain is coming from.

Is it really in the flank or is it the gallbladder?

And that goes for CT as well.

And no matter how good the person is, sometimes they'll
think it's a stone and get a stone search study
and it's the gallbladder or vice versa.

Take a look if you're in the neighborhood, you don't have
to do an excruciatingly painful, delicate study looking
for a small renal cell carcinoma.

We're looking for major diagnoses.

This patient came for right upper quadrant pain.

This is one we actually missed.

The gallbladder was fine
and duly noted were calculi in the kidney
and that's all that came out of it.

If you have calculi
in the kidney and the patient has pain, think and
look a little bit more.

And if you do look, you'll notice there's a little bit
of perinephric fluid and the stones were kind of shadowing
and that I think caused us to miss the fact
that there was a little bit of dilatation
of the collecting system as well.

And that was not appreciated
and not commented on and nobody did.

And the people in the emergency room were concerned.

And not surprisingly they got a CT
and that's what the kidney looked like.

I suspect we could have figured out the whole thing
by ultrasound had we worked at it a good bit.

This 36-year-old woman came in
with right upper quadrant pain and flank pain and fever
and leukocytosis.

This is a sagittal view of the right kidney
and that's a cine clip going from superior to inferior.

And I think you can very nicely see a pretty nice normal
looking lower pole of the kidney
with nice cortico medullary differentiation
and an enlarged swollen heterogeneous upper pole
of the kidney with poor differentiation and
appreciate that on the clip here again, upper pole,
lower pole and we look with color,
poor qualitatively poor color in the upper pole,
much better color in the lower pole.

This is classic acute pyelonephritis
and that is not an infrequent finding
that we have in patients as an alternative cause
for right upper quadrant pain.

This patient came for gallbladder study
for right upper quadrant pain,
had a perfectly normal gallbladder,
had a funny looking cystic thing in the kidney
with some echoes in it
and that one turned out to be a renal abscess.

People don't think about abscess
and they go off on is this a complex cystic mass
tumor, et cetera.

This was a really interesting case.

This patient presented most.

The thing that they were complaining about the most was
right upper quadrant pain,
very significant right upper quadrant pain.

We did the ultrasound of the gallbladder
and it was stone cold normal.

I remember one of the GI fellows coming
and say, this is impossible, this patient has severe pain,
there's gotta be something wrong.

And we had of course looked at the kidney, a few images,
but we went back again and
did turn on color, not to do a fancy Doppler exam,
but lo and behold there really wasn't any color there.

We checked the other side just to make sure
that one had pretty good color.

The kidney looked fine in terms of size.

It turned out this is the MRI.

The patient, they didn't do an MRI.

I can't remember exactly why it came to doing an MRI.

The patient was a hypercoagulable patient,
had had a big pulmonary embolism, mind you
and had infarcted the right kidney
and it was an acute infarction
so the kidney hadn't shrunken in size at all.

And several I've had this happen a few times,
once a different patient had a dissection a,
a type B dissection and
the thing that brought them in was the pain
of the infarcted right kidney.

You don't need to do a fancy doppler examination,
but just qualitatively make sure there actually
is flow in that kidney.

Miscellaneous Diagnoses in the Right Upper Quadrant

And the last thing I wanna turn to are few diagnoses as sort
of fun things
that you might see in the right upper quadrant
that you might not think about at all.

This was a study done by a resident at night
and I'm reading it out in the morning
and he said, the gallbladder was fine,
the patient had pain.

I didn't think the bile duct was abnormal.

And I looked at the images
and I said, did you have difficulty doing this study?

And he said, I didn't wanna say I was a little
embarrassed, but yeah, it was really hard.

I had a hard time seeing the gallbladder.

And we're looking at the, what strikes you
as a little bit odd here, why did
I even think he had trouble?

If you look here, there's all this sort
of fuzzy shadowing where the edge of the liver is.

And here was another image he had,
he had a bunch of random images.

This was, he was trying to find the gallbladder and
there were all these weird ring downs, et cetera.

This is odd and this is gas
and it's true, some patients might have a bowel loop up
there in the right upper quadrant,
but this to me didn't look like a bowel loop.

It looked like extra luminal air.

And this was his image, another image that he took.

And I looked, I don't think I would've thought about it had
I not seen the free air.

But then I looked at the duodenum
and the wall looked a little bit thick.

I said, this is likely free air.

And I would worry about the duodenum
anyway if I hadn't seen that.

And we got the CT, the
patient was still in the emergency room
and this was a perforated ulcer.

Here's another case in which there's this odd air,
also very linear.

It's not in bowel, there's no bowel signature anywhere
and it's near the liver
and this is what the liver looked like.

Is this a mass in the liver?

Is this just a heterogeneous liver?

When you do the clip
and you look, you see that there's something actually focal
here and stuff is shimmering and moving in it.

This patient had a bowel perforation elsewhere
and had a subcapsular liver abscess and had free air.

We may not know the whole thing, but
could lead somebody in the right direction.

Chest and Pelvic Considerations

And lastly, remember that,
and if you read surgery texts about right upper quadrant
pain, things that go on in the lower portion
of the chest can often give people right upper quadrant pain
and bring them in and obviously vice versa.

Sometimes we can be helpful there.

If you have a person who has a chest radiograph
and there's all this white here in the lower half
of the chest, you really don't know without other
imaging or other views.

How much of this is fluid, how much
of this is lung, et cetera.

Here are three different examples of what that could be.

This patient has a pleural effusion
and atelectasis this patient.

This is liver. There is no fluid.

This is not a mirror image artifact.

This is what consolidated lung looks like
with air bronchograms.

It looks just as solid as the liver.

And a third patient has this collection in the pleural space
and this is an empyema.

Lastly, and this will lead into other
lectures in this series.

You can think of the right upper quadrant
and the right lower quadrant is sort
of a continuous corridor of possible things that come to us
with pain and certainly PID in the pelvis
and salpingitis can present primarily
with the pain in the right upper quadrant from PID.

We will hear more I'm sure about this, but
think about things that might go on in the pelvis
as the cause of the pain in the right upper quadrant
and actually vice versa.

Conclusion

Thank you very much for your attention.

I hope I gave you something to think about.