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Emergency Ultrasound Course
Huntington Beach, CA November 2-4, 2018
Hepatobiliary Ultrasound
Nick Gastelum, MD UCSF Fresno - Department of Emergency Medicine
Overview
• Indications for hepatobiliary ultrasound
• Gallbladder anatomy
• Ultrasound technique
• Evaluation of gallbladder
• Evaluation of common bile duct
Clinical Utility
• >700,000 ED visits/year with diagnosis of gallbladder or bile duct pathology
• Variety of imaging to evaluate hepatobiliary disease
• Ultrasound, HIDA, CT, MRCP
• Ultrasound most sensitive for gallstones, 94%
• Ultrasound as sensitive as HIDA for cholecystitis
Indications
• Evaluation of RUQ abdominal pain, epigastric pain, jaundice, abnormal LFTs, sepsis
• symptomatic cholelithiasis, acute cholecystitis, choledocholithiasis, ascending cholangitis
Symptomatic Cholelithiasis
• Symptoms: RUQ abdominal pain
• Pain associated with temporary blockage of bile flow
• Treatment: diet modification, elective cholecystectomy
Acute Cholecystitis
• Symptoms: RUQ abdominal pain, nausea and vomiting, fever
• Gallbladder inflammation which leads to bacterial infection
• 95% due to gallstones
• Treatment: antibiotics and cholecystectomy
Choledocholithiasis
• Symptoms: RUQ abd pain, jaundice, elevated alk phos, elevated direct bilirubin
• Gallstones in common bile duct
• Treatment: ERCP (endoscopic retrograde cholangiopancreatography) and cholecystectomy
Ascending Cholangitis
• Symptoms: RUQ abdominal pain, fever, jaundice, altered mental status, shock
• Partial/complete bile duct obstruction which leads to bacterial infection of the bile duct
• Can be caused by choledocholithiasis, malignancy
• Treatment: antibiotics, ERCP, cholecystectomy
Focused Questions• Is there a sonographic Murphy’s sign?
• Are gallstones present?
• Is a gallstone stuck in the neck?
• Is there anterior gallbladder wall thickening?
• Is pericholecystic fluid present?
• Is there dilation of the common bile duct?
Anatomy
Anatomy
Technique
Transducers
Gallbladder
Longitudinal View
Longitudinal View
Transverse View
Transverse View
Intercostal View
Fanning
GB Wall Thickness• Transverse view
• Anterior wall
• Outer edge to outer edge
• > 3 mm abnormal
• cholecystitis
• ascites, CHF, nephrotic syndrome, renal failure
GB Wall Thickness
Pathology
Contracted Gallbladder
Contracted Gallbladder
Sludge
Cholangiocarcinoma
Gallstones
Gallstones
Polyps
Acute Cholecystitis
Acute Cholecystitis
Pericholecystic Fluid
Pericholecystic Fluid
Wall/Echo/Shadow (WES)
Duodenum
Duodenum
Sonographic Murphy’s Sign
• Reproducible point tenderness directly over the gallbladder with transducer pressure
• 87% specific for cholecystitis
• Gallstones + Murphy’s sign
• 92% PPV for cholecystitis
Common Bile Duct
Longitudinal View
Exclamation Point
Mickey Mouse
Transverse CBD
Transverse CBD
Longitudinal CBD
CBD Diameter
• Longitudinal view
• Inner edge to inner Edge
• < 6 mm normal
• Can add 1 mm per decade over age of 60
• <10 mm if s/p cholecystectomy
Normal CBD
Dilated CBD
Choledocholithiasis
Question
• Does measuring the CBD identify complicated biliary pathology that would be missed by labs and other ultrasound findings?
Methods
• Prospective, Observational
• N = 158
• # of patients with complicated biliary pathology and isolated CBD dilation without:
• abnormal labs, pericholecystic fluid, thickened GB wall, sonographic Murphy’s sign
Results
• 0 patients with complicated biliary pathology had CBD dilation without other signs:
• abnormal labs, pericholecystic fluid, thickened GB wall, sonographic Murphy’s
• CBD dilation for complicated biliary pathology
• Sensitivity: 23.7%
Take Home Points
• Normal gallbladder anterior wall < 3 mm
• Normal CBD diameter < 6 mm
• Can add 1 mm for every decade over 60
• CBD diameter can be up to 10 mm s/p cholecystectomy
Take Home Points
• Have patient take a deep breath
• Left lateral decubitus
• Intercostal view with phased array probe
• Track down to portal triad via main lobar fissure
References1. Ma, O.J., Mateer, J.R. (2014) Emergency Ultrasound, 3rd Edition. New
York, NY: McGraw-Hill.
2. Soni N.J., Arntfield R. (2015) Point-of-Care Ultrasound. Philadelphia, PA: Elsevier Saunders.
3. Fox, J.C. (2011) Atlas of Emergency Ultrasound. New York, NY: Cambridge University Press.
4. Lahham, S. (2017) Utility of common bile duct measurement in ED point of care ultrasound: A prospective study. American Journal of Emergency Medicine, 36, 962-966.
5. Summers, S.M. (2010) A Prospective Evaluation of Emergency Department Bedside Ultrasonography for the Detection of Acute Cholecystitis. Annals of Emergency Medicine, 56(2), 114-122.
Emergency Ultrasound Course
Huntington Beach, CA November 2-4, 2018