A 40-year-old male presented to the ED with 4 days of right upper quadrant pain. The pain came on acutely 4 days ago while eating and had been constant since then. He endorsed nausea, but denied vomiting, diarrhea, and fever. He had never had pain like this before.

 

VS: BP 138/74, P 58, T 36.7 °C (98.1 °F), RR 20, SpO2 100%

 

Physical exam revealed an abdomen that was soft and non-distended. There was mild tenderness in the RUQ. Murphy’s sign was absent.

 

The ED team taking care of him decided to do a point-of-care RUQ ultrasound and obtained laboratory tests. The BSUS can be seen below:

 

 

You can see that the GB is not filled with anechoic fluid like normal. The GB appears to be hyperechoic compared to the liver. Also, please note the edge artifact seen on the lateral edges of the GB.

 

Here is a measurement of the GB wall:

Screen Shot 2015-04-05 at 5.48.14 PM

It was 2.2 mm, which is normal. A normal GB wall is less than or equal to 3 mm.

 

Here is a measurement of the common bile duct:

Screen Shot 2015-04-05 at 5.47.01 PM

It measures 9.7 mm, which is enlarged. A normal CBD should be less than or equal to 6-7 mm.

 

WBC count was 3.4. Lipase and LFTs were normal.

 

What do you make of all these results?

 

We thought that the GB was sludge-filled because either a stone or stenosis was blocking the outflow of bile. There was no evidence of GB wall thickening, pericholecystic fluid, or a positive sonographic Murphy’s sign. Given the lack of these things, it was felt that the patient did not have cholecystitis currently, but it was believed that if his GB were not taken out, he would inevitably develop cholecystitis.

 

He was admitted to surgery and underwent an uneventful cholecystectomy. The surgeons noted a stone lodged in the neck of the gallbladder. Given the CBD dilation, an intraoperative cholangiogram was also performed. There was no stone or stenosis present.

 

Bottom Line: 

  1. A normal GB wall is less than or equal to 3 mm.
  2. A normal CBD is less than or equal to 6-7 mm.
  3. Bedside RUQ ultrasound can rapidly aid in the diagnosis of a vast array of hepatobiliary pathology.
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