Photo of the Month for April 2010
Right Upper Quadrant Abdominal Pain
Submitted By: Dr. Schippel, Dr. Hickman, and Dr. Wu
A 40 year old female presents to the ED with right upper quadrant pain for the past few days. It is associated with nausea, vomiting, fevers, chills, and decreased appetite.
Her vital signs are significant for a fever to 38 degrees Celcius, a HR of 112 bpm, and a blood pressure of 112/76 mmHg.
A focused, bedside RUQ ultrasound was performed and a representative image is included above.
What abnormalities do you see?
The patient’s focused RUQ ultrasound demonstrates:
1) Gallbladder wall thickening
2) Pericholecystic fluid
3) Gallstones in the neck of the gallbladder with acoustic shadowing
Remember that ultrasonography is the most common test used in the ED for the diagnosis of biliary colic and acute cholecystitis. It is 90-95% sensitive for cholecystitis and 82-90% specific.
You should suspect cholecystitis if your patient has:
1) Gallbladder wall thickening (>3 mm): False-positive wall thickening found in hypoalbuminemia, ascites, congestive heart failure, carcinoma, or a contracted GB.
2) Gallbladder distention (diameter > 4 cm, length >10 cm): Pericholecystic fluid from perforation or exudate may be seen as a hypoechoic or anechoic region seen along the anterior surface of the gallbladder within the hepatic parenchyma
3) Air in the gallbladder wall (indicating gangrenous cholecystitis)
4) Sonographic Murphy sign (86-92% sensitive, 35% specific), pain when the probe is pushed directly on the gallbladder (not related to breathing like the Clinical Murphy’s sign).
5) Pericholecystic fluid
