• 3/22/2016 Biliary Ultrasonography Kathleen O’Brien https://www.google.com/search?sa=G&hl=en&q=public+disclosure&tbm=isch&tbs=simg:CAQSigEahwELEKjU2AQaAAwLELCMpwgaYgpgCAMSKPIB_1QnzA7AI 9gObEoAK8wH1A5gGzT2sPb4_1rT3RPas9oj3TPdA9gj0aMKH8NOYEFXq-bLiqT1dZVwE0H7ZToFj_1o1v8lT5SxLIe14QK-_1Ecx3m3snDE4- MD MPH RDMS 4zCSADDAsQjq7-CBoKCggIARIEz6gJwAw&ved=0ahUKEwim9uWFrMPLAhUQ0GMKHazFD5IQwg4IGigA&biw=1347&bih=592 Kaiser Permanente South Sacramento NONE • 2 Scope of the problem: Objectives: Abdominal pain accounts for 5-10% of ED visits in US • Discuss clinical indications and questions 1/3 of our abdominal pain patients in ED have GB etiologies answered by RUQUS for their pain 20M Americans have gallstones; ½ M undergo • Review of pertinent RUQ anatomy cholecystectomy each year 2’ stones SEE MORE PATIENTS! • Share techniques & scanning tips DISPO THEM FASTER! SPEND LESS MONEY! • Literature to support use of RUQUS BUT DON’T COMPROMISE QUALITY OF CARE. *Abdominal pain in the ED: stability and change over 20 years. Powers RD, Guertler AT.Am J Emerg Med. 1995;13(3):301. • 4 • 3 • 1
• 3/22/2016 Current imaging options for AC: One solution: HIDA: -highest diagnostic accuracy in older studies - sensitivity 96%, specificity 90% Ultrasound: https://yazrooney.wordpress.com/2012/11/24/the-aha- moments-that-heal/ -sensitivity 88-90%, specificity 80-88% -NPV 95-98% CT: -helpful for detecting complications http://www.uk-ireland.bcftechnology.com/blog/2013/september/introduction-to-small- animal-veterinary-probes - sensitivity 73-99%, specificity 42-74% MRI: http://emedicine.medscape.com/article/171886 ‐ overview -similar to u/s test characteristics - MRCP helpful if choledocholithiasis suspected • 5 • 6 http://personalbestpersonaltraining.com/5 ‐ nutrition ‐ aha ‐ moments/ “But isn’t that why we have Purpose of RUQUS: radiologists?” Indications: Evaluate for: ED performed RUQ ultrasound shown to be as sensitive and • RUQ pain Cholelithiasis specific for radiology performed RUQ ultrasound for acute Acute cholecystitis • Flank/shoulder/ epigastric cholecystitis! Obvious liver/biliary pathology pain • Ascites ED physicians often not formally trained in RUQ u/s and • Hepatomegaly test characteristics still acceptable • Jaundice • Pancreatitis • Sepsis Advantage: increased efficiency, decreased time to diagnosis and disposition • 7 • 8 • 2
• 3/22/2016 Anatomy Anatomy Liver Gallbladder is located at the inferior surface of the liver; consists of the fundus, the body and the neck The neck of the gallbladder drains into the cystic duct which joins the hepatic duct to form the common bile duct (CBD) Hepatic duct Cystic duct The portal triad consists of the hepatic artery , common bile duct (CBD) and the Gallbladder portal vein Pancreas The CBD and the hepatic artery lie Common bile duct Duodenum anterior to the portal vein Pancreatic duct Techniques 101: Probe selection Use 2.5-5 MHz low frequency abdominal probe. www.befunky.com • 11 • 12 • 3
• 3/22/2016 Techniques 101: Techniques 101: INTERcostal approach SUBcostal approach Probe placed in the right anterior axillary line over The probe is placed the lower rib spaces, below the rib cage, marker facing to right lateral to epigastrium shoulder/head Good for avoiding Rib Slow sweep across the ribs shadows Use the liver as an acoustic Reliable Sono window Murphy ’ s Anchor your hand for Probe marker to head/R stability Shoulder Aka “X minus 7” hold probe at shallow angle • 13 • 14 Techniques 101: Techniques 101: Positioning in Left Lateral Decubitus • Can place probe subcostal or intercostal -Always scan the entire • GB should move gallbladder in two planes: anteriorly • Use the liver as acoustic Longitudinal window Transverse • Slow sweep along costal -Slowly fan through margin entire gallbladder in these two planes • 15 • 16 • 4
• 3/22/2016 anterior What should you see: GB long Gallbladder Portal vein anterior feet head CBD feet supine head posterior posterior Left lateral decubitus • 18 What should you see: GB short anterior anterior feet head QuickTime™ and a Animation decompressor are needed to see this picture. supine right left posterior Normal Gallbladder in long axis posterior Left lateral decubitus • 19 • 20 19 • 5
• 3/22/2016 Normal variants of the Gallbladder anterior Pharyngian cap: The fundus is folded onto the body right left Septate GB: thin septa inside gallbladder posterior Normal Gallbladder in short axis • 22 The highly elusive Commo Common Bil Bile Duc Duct... ‘Exclamation point’ sign ‐ CBD lies anterior to portal vein and next Find the Gallbladder to hepatic artery in the longest axis, -Color Doppler can help identify vascular follow the main lobar structures fissure from the neck of the gallbladder to the porta hepatis. ‐ Normal <7mm. CBD CBD forms the point -CBD dilates with increasing age and of the exclamation after cholecystectomy! mark, anterior to the portal vein . - PEARL: measure CBD from inner wall to inner wall Hepatic Portal vein artery • 24 • 6
• 3/22/2016 Mickey Mouse sign CBD CBD Portal Hepatic artery vein Inferior vena cava Again, CBD anterior to portal vein and hepatic artery. CBD does not show flow; helps to identify the CBD. • 26 • http://www.em.emory.edu/ultrasound/ImageWeek/Abdominal/mickey_mouse.html • 25 25 Great news… perhaps finding the CBD What am I looking for exactly? doesn’t really matter?! http://www.siasat.pk/forum/showthread.php?325970 ‐ Question ‐ Mark • 27 • 28 • 7
• 3/22/2016 Look for Acute cholecystitis by Acute cholecystitis: asking: 1) Are there gallstones present? AND 2) Is there pericholecystic fluid present? 3) Is there GB wall thickening? 4) Is there a sonographic murphy’s sign? 5) +/- Is the CBD dilated? • 30 • 29 When looking for stones, keep in mind… 1) Are there any stones? Stones : hyperechoic, cast a shadow. Stones are often mobile; scan patients in different positions. ALWAYS convince yourself there is no stone in GB neck. Wall-echo-complex (WES) : When GB is filled multiple stones or one giant stone you just see wall, then bright reflex and then shadow. Sludge: biliary sand/microlithiasis: Echoes within depending part of GB without shadowing (resettles in dependent parts > scan patients in different positions) • 31 • 8
• 3/22/2016 1) Are there any stones? 1) Are there any stones? Posterior acoustic enhancement • 33 • 34 1) Are there any stones? 1) Are there any stones? • 35 • 36 • 9
• 3/22/2016 1) Are there any stones? 1) Are there any stones? • 37 • 38 WES sign 1) Are there any stones? Wall Echo Shadow • 40 • 39 Gallbladder filled completely with stone • 10
• 3/22/2016 1) Is there a stone? Patient supine, stones in the neck Stones vs polyps or tumors: -stones are mobile and can be moved by changing the position of the patient, not adhered to wall . - Polyps do not shadow. Pat. rolled to left lateral decubitus, stones in body • 42 • 41 Brief mention: CBD stones Life just got easier… Dilated intrahepatic ducts CBD Stone in CBD Shadow cast by stone CBD stones: round echogenic lesion with posterior shadowing. Most stones are impacted in the distal duct at the papilla. • 43 • 44 • 11
• 3/22/2016 #2) Is there pericholecystic fluid? #2) Is there pericholecystic fluid? • http://www.hindawi.com/journals/criid/2014/171496/fig1/ • 45 • 46 #2) Is there pericholecystic fluid? 3) Is there GB wall thickening? PEARL: Measure anterior wall because resolution is better. • 47 • 48 • 12
• 3/22/2016 RUQUS and GB wall thickening: 4) Is there a Sono Murphys sign? -NONSPECIFIC finding! maximal abdominal tenderness from pressure of the ultrasound probe over the visualised gallbladder -DDx include: SMS is a sign of local inflammation around the gallbladder CHF along with right upper quadrant pain, tenderness or mass Renal failure Hypoalbuminemia Hepatitis Cirrhosis Pancreatitis Carcinoma…. • http://www.ultrasoundcases.info/case ‐ list.aspx?cat=151 • 49 • 50 • http://www.alifeatrisk.com/2012/04/does ‐ murphys ‐ sign ‐ and ‐ sonographic.html FYI: Cholangitis 5) Is the CBD dilated? Fever, RUQ pain, Jaundice. <=6mm is normal Add 1 mm as normal ~85% of cases dilatation for every decade associated with CBD CBD with thickened wall stones. above 60 years old CBD dilated in pts s/p On ultrasound: cholecystecomy • Dilation of biliary tree Stone in • Choledocholithiasis CBD Measure INNER wall to and possibly sludge inner wall • Bile duct wall Shadow thickening cast by stone • Hepatic abscess https://www.pinterest.com/pin/53128470580861359/ • 51 • 13
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