Bedside RUQ Ultrasound. Replace Formal ULS? Why Bedside ULS RUQ? RUQ Ultrasound. Bedside ULS is Limited, Goal-Directed
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1 Bedside RUQ Ultrasound RUQ Ultrasound Why do it How to do it Elizabeth Kwan UCSF Emergency Ultrasound Fellow Why Bedside ULS RUQ? Dx or Rule Out Acute Cholecystitis Cholelithiasis, Choledocolithiasis Earlier Dx, shorter stay 30-60min Quick: Most <10min 1/4 EDs: no after hr ULS Replace Formal ULS? Bedside ULS is Limited, Goal-Directed Low Lying Fruit Clearly POS: start consult, Rx Clearly NEG: alternate Dx? Available 24/7 1
2 Bedside ULS: Gallstones 86-96% SENS 78-97% SPEC Bedside ULS: Acute Cholecystitis Sono Murphy s and Gallstones: 91% SENS Schlager 1996 Kendall and Shimp 2001 Rosen 2001 Why lower specificity? 70% PPV 90% NPV Rosen Focused Questions, Stepwise Approach 1. Gall Bladder? 2. Gallstones? 3. Acute Cholecystitis? 4. Dilated CBD? 1. Gall Bladder? 2. Gallstones? 3. Acute Cholecystitis? 4. Dilated CBD? 2
3 Finding the GB RUQ Anatomy Highly variable anatomy Obstacles: Air (bowel) Small GB (post prandial) No GB (post cholecystectomy) Abdominal or Cardiac probe Probe Selection Intercostal MCL 7th/8th IS Probe Position (2-5 MHz frequency) Flank FAST view, fan anterior 3
4 Intercostal MCL 7th/8th IS Flank Ant from FAST Subcostal Sono Murphy s Subxiphoid Then fan R Probe Position 4 Points Scanning GB 1. Position: Roll L side, deep breath 2. Probe Placement 3. Planes: Longitudinal/Transverse Slowly scan edge to edge Rotate 90 degrees and repeat 4. Examine GB neck carefully Normal Gallbladder Anterior GB shapes Right Posterior 4
5 Normal Gallbladder Normal Gallbladder Gallstones 95-99% Cholecystitis: +Gallstones 1. Gall Bladder? 2. Gallstones? 3. Acute Cholecystitis? 4. Dilated CBD? No gallstones + good view + not ill appearing, no ERCP = NOT Cholecystitis 5
6 4 Characteristics Gallstones 1. Hyperechoic 2. In GB Lumen 3. Dependent 4. Cast Shadows Fake Outs Edge artifact Fake Outs Air in bowel With shadow 6
7 Fake Outs Gallstones GB Polyps Not dependent No shadowing Gallstones Gallstones QuickTime and a decompressor are needed to see this picture. 7
8 Gallstones Where s the GB? QuickTime and a decompressor are needed to see this picture. Where s the GB? 1. Gall Bladder? 2. Gallstones? 3. Acute Cholecystitis? 4. Dilated CBD? 8
9 4 Signs Cholecystitis 1. Sono Murphy s 2. Big GB > 5 cm diam 3. Thick Wall >4mm Sonographic Murphy s Max TTP probe pressed directly over GB Sono Murphy s + Gallstones = 92% PPV Cholecystitis Rosen Pericholecystic Fluid Measure Wall Thickness ZOOM Near field wall Perpendicular <4mm thick Wall Thickening Cholecystitis Represents inflammation, hemorrhage, pus May not be circumferential Heterogeneous echogenicity Other common causes: Postprandial, Ascites, CHF, Renal Disease Often uniform, bland appearance 9
10 Wall Thickening Cholecystitis Wall Thickening Cholecystitis Thick wall Wall Thickening Cholecystitis Pericholecystic Fluid Fluid Thickened wall Wall GB 10
11 Pericholecystic Fluid Acute Cholecystitis Fluid 1. Sono Murphy s 2. Big GB > 5 x 10 cm Easily missed! 3. Thick Wall >4mm 4. Pericholecystic Fluid Scan carefully in 2 planes Why look for CBD? 1. Gall Bladder? 2. Gallstones? 3. Acute Cholecystitis? 4. Dilated CBD? Dilated CBD suggests Choledocolithiasis In Cholecystitis: ERCP before Cholecystectomy 11
12 4 Steps Scanning CBD CBD 1. Find Portal Triad 2. Find CBD Trans: Mickey Mouse Longitudinal: CBD is parallel and anterior PV 3. Color Doppler may help 4. Measure CBD CBD Mickey Mouse Sign CBD Double Barrel Likely Choledocolithiasis/Obstruction 12
13 Finding CBD Measuring CBD ZOOM outside wall to inside wall Normal CBD <5mm age 50 Additional 1mm per decade over age Gallbladder? 2. Gallstones? RUQ Summary 3. Acute Cholecystitis? Sono Murphy s? GB >5cm? Wall >4mm? PCF? RUQ Summary Low lying fruit! Dx, Rule Out Gallstones, Cholecystitis Decreases time to Dx, Rx, time in ED Exam is usually less than 10min 4. Dilated CBD? 13
14 References Blaivas M, et al: Decreasing length of stay with emergency ultrasound examination of the gallbladder. Acad Emerg Med 1999; 6(10): Quiz Cosby KS, Kendall JL Practical Guide to Emergency Ultrasound. Philadelphia, Lippincott Williams & Wilkins. Kendall JL, et al: Performance and interpretation of focused right upper quadrant ultrasound by emergency physicians. J Emerg Med 2001; 21(1) 7-13 Moore CL, et al: Ultrasonography in Community Emergency Departments in the United States: Access to Ultrasonography Performed by Consultants and Status of Emergency Physician-Performed Ultrasonography. Ann Emerg Med. 2006; 47: Rosen CL, et al. Ultrasonography by Emergency Physicians in patients with suspected cholecystitis. Am J Emerg Med 2001; 19(1):32-6 Schlager D, et al: A prospective study of ultrasonography in the ED by emergency physicians. Am J Emerg Med 1994; 12(2): Shah K, Wolfe R: Hepatobiliary Ultrasound. Emerg Med Clin N Am 2004; 22: Quiz Quiz 14
15 Quiz Quiz 15
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