Ultrasound of the Week #013 – Under The Helipad

Case:

A 55 year old male with PMH of newly diagnosed heart failure secondary to alcohol and amphetamine abuse attended with severe RUQ pain. He was not compliant with his heart failure medications.
On examination he was tachycardic at 100bpm, was requiring 2 litres of oxygen and his BP was 87/50.

Bedside echo showed significant biventricular failure.

POCUS of the abdominal RUQ showed the following:

Question: Can you identify the structures present? What abnormalities are present?

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This is the gallbladder. The wall is surrounded by a hypoechoic dark stripe – this is pericholecystic oedema. The image here shows the wall measured at 0.5cm (5mm), with the upper limit of normal being 3mm. Below the gallbladder you can see a grossly dilated IVC, and to the left of this the portal triad.

Case Progression:
The patient was initially treated for Cholecystitis and heart failure with Co-amox and Furosemide.

However inflammatory markers were completely normal so he was diagnosed with cholecystalgia secondary to severe heart failure which improved with diuresis.

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The gallbladder is an organ very suited to ultrasound assessment, as it is fluid filled and surrounded by conducting tissues such as the liver. Indeed, Ultrasound is the imaging modality of choice for most gallbladder pathology and is very accurate and diagnosing cholecystitis and gallstones.

The gallbladder is best visualised with the curvilinear probe, from the subcostal window and from the RUQ, using the liver as an acoustic window. Assess the GB wall thickness, signs of sludge/gallstones and for a ‘Sonographic Murphy’s Sign’ (pain on pressure applied over the GB with the US probe).

Normal GB:
-anterior wall in short axis <0.3cm in a fasted patient
-no pericholecystic fluid
-no sonographic Murphy’s sign
-a normal CBD diameter (<0.7cm)

Gallstones can be accurately identified by their highly echogenic (bright white) appearance, with an acoustic shadow behind them (as they do not conduct ultrasound) – similar to the appearances of bone. This is nicely seen here.

‘Acalculous’ Cholecystitis is rare (~5% cholecystitis cases) and has a myriad of contributing factors including gallbladder hypokinesis and hypoperfusion, and can occur due to critical illness, nutritional failure (TPN, starvation) and hypoperfusion (heart failure, vascular diseases).

Gallbladder Ultrasound is a quick and easy way to assess for GB pathology, and can aid a quick diagnosis and avoidance of unnecessary CT scanning with associated radiation.

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References/Resources:

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