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<br /> Ultrasound<br /> Focused ultrasound for cholelithiasis<br /> and acute cholecystitis<br /> Philips tutorial<br /> Arun Nagdev, MD<br /> Department of Emergency Medicine<br /> Alameda County Medical Center<br /> Highland General Hospital, Oakland, CA<br /> Contents<br /> Focused ultrasound for cholelithiasis<br /> and acute cholecystitis<br /> 1 Introduction 3<br /> 2 Clinical case 4<br /> 3 Identification of acute cholecystitis 5<br /> 4 Ultrasound techniques 10<br /> 5 Clinical pearls 34<br /> 6 Common ultrasound findings 36<br /> 7 Image and video gallery 42<br /> 8 Case resolution 52<br /> 9 Summary 53<br /> 10 References 54<br /> Additional r<a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 1" href="http://viewer.zmags.com/publication/2be5b268?page=1"> Ultrasound Focused ultrasound for cholelithiasis</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 2" href="http://viewer.zmags.com/publication/2be5b268?page=2"> Contents Focused ultrasound for cholelithiasis a</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 3" href="http://viewer.zmags.com/publication/2be5b268?page=3"> 1 Introduction Healthcare providers worldwide</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 4" href="http://viewer.zmags.com/publication/2be5b268?page=4"> 2 Clinical case A 45-year-old female presents</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 5" href="http://viewer.zmags.com/publication/2be5b268?page=5"> 3 Identification of acute cholecystitis The p</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 6" href="http://viewer.zmags.com/publication/2be5b268?page=6"> [Figures 1a and 1b] Ultrasound image demonstratin</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 7" href="http://viewer.zmags.com/publication/2be5b268?page=7"> Clinicians should be aware of patient risk factor</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 8" href="http://viewer.zmags.com/publication/2be5b268?page=8"> Pericholecystic fluid due to gallbladder inflamma</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 9" href="http://viewer.zmags.com/publication/2be5b268?page=9"> Sonographic Murphy’s sign (SMS) is defined as max</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 10" href="http://viewer.zmags.com/publication/2be5b268?page=10"> 4 Ultrasound techniques Usually, a low-frequen</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 11" href="http://viewer.zmags.com/publication/2be5b268?page=11"> [Figure 3] Anatomical illustration demonstrating </a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 12" href="http://viewer.zmags.com/publication/2be5b268?page=12"> Due to the common presence of bowel gas in the no</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 13" href="http://viewer.zmags.com/publication/2be5b268?page=13"> [Figure 4] Start at Morrison’s Pouch and fan the </a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 14" href="http://viewer.zmags.com/publication/2be5b268?page=14"> [Video 1 ] Video demonstrat</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 15" href="http://viewer.zmags.com/publication/2be5b268?page=15"> • The gallbladder will appear as a large anechoi</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 16" href="http://viewer.zmags.com/publication/2be5b268?page=16"> [Figure 5] Place the patient in LLD position (all</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 17" href="http://viewer.zmags.com/publication/2be5b268?page=17"> [Video 2 ] Video demonstrat</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 18" href="http://viewer.zmags.com/publication/2be5b268?page=18"> Imaging the gallbladder • Once the gallbladder i</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 19" href="http://viewer.zmags.com/publication/2be5b268?page=19"> [Figure 6a] Image of a sagittal view of the entir</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 20" href="http://viewer.zmags.com/publication/2be5b268?page=20"> [Video 3 ] Scan of a sa</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 21" href="http://viewer.zmags.com/publication/2be5b268?page=21"> [Video 4 ] Scan of a tr</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 22" href="http://viewer.zmags.com/publication/2be5b268?page=22"> • Measure the anterior wall of the gallbladder. W</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 23" href="http://viewer.zmags.com/publication/2be5b268?page=23"> [Figure 7b] Measurement of the anterior wall of t</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 24" href="http://viewer.zmags.com/publication/2be5b268?page=24"> Imaging the neck of the gallbladder • If possi</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 25" href="http://viewer.zmags.com/publication/2be5b268?page=25"> [Figure 8a] Image demonstrating the classic “excl</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 26" href="http://viewer.zmags.com/publication/2be5b268?page=26"> [Video 5 ] Video demons</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 27" href="http://viewer.zmags.com/publication/2be5b268?page=27"> [Video 6 ] Video of the</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 28" href="http://viewer.zmags.com/publication/2be5b268?page=28"> • Because the CBD is often difficult to locate an</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 29" href="http://viewer.zmags.com/publication/2be5b268?page=29"> Measure the CBD from the interior margin of the a</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 30" href="http://viewer.zmags.com/publication/2be5b268?page=30"> [Figure 8e] Image of a dilated CBD measuring 11.7</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 31" href="http://viewer.zmags.com/publication/2be5b268?page=31"> Why the gallbladder may not be identified The gal</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 32" href="http://viewer.zmags.com/publication/2be5b268?page=32"> If the gallbladder is completely filled with gall</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 33" href="http://viewer.zmags.com/publication/2be5b268?page=33"> [Figure 9] Image demonstrating the WES sign in a </a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 34" href="http://viewer.zmags.com/publication/2be5b268?page=34"> 5 Clinical pearls • The LLD position is optim</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 35" href="http://viewer.zmags.com/publication/2be5b268?page=35"> • When small gallstones are located in the neck o</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 36" href="http://viewer.zmags.com/publication/2be5b268?page=36"> 6 Common ultrasound findings Gallstones in the </a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 37" href="http://viewer.zmags.com/publication/2be5b268?page=37"> Gallstones in the neck of the gallbladder [Figure</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 38" href="http://viewer.zmags.com/publication/2be5b268?page=38"> False-positive bowel wall shadow [Figures 11a and</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 39" href="http://viewer.zmags.com/publication/2be5b268?page=39"> [Figures 11a and 11b] Two images demonstrating fa</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 40" href="http://viewer.zmags.com/publication/2be5b268?page=40"> Wall Echo Shadow (WES) sign [Figure 12] • Another</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 41" href="http://viewer.zmags.com/publication/2be5b268?page=41"> False-positive polyps • A false-positive finding </a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 42" href="http://viewer.zmags.com/publication/2be5b268?page=42"> 7 Image and video gallery 1 Gallstones with </a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 43" href="http://viewer.zmags.com/publication/2be5b268?page=43"> 3 Sagittal view of gallbladder with a l</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 44" href="http://viewer.zmags.com/publication/2be5b268?page=44"> 5 Sagittal view of gallbladder with m</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 45" href="http://viewer.zmags.com/publication/2be5b268?page=45"> 7 This image demonstrates a distended </a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 46" href="http://viewer.zmags.com/publication/2be5b268?page=46"> [Video 7 ] Sagittal ima</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 47" href="http://viewer.zmags.com/publication/2be5b268?page=47"> [Video 8 ] Sagittal swe</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 48" href="http://viewer.zmags.com/publication/2be5b268?page=48"> [Video 9 ] Transverse s</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 49" href="http://viewer.zmags.com/publication/2be5b268?page=49"> [Video 10 ] Sagittal sw</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 50" href="http://viewer.zmags.com/publication/2be5b268?page=50"> [Video 11 ] Sagittal sw</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 51" href="http://viewer.zmags.com/publication/2be5b268?page=51"> [Video 12 ] Sagittal sw</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 52" href="http://viewer.zmags.com/publication/2be5b268?page=52"> 8 Case resolution The initial bedside ultr</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 53" href="http://viewer.zmags.com/publication/2be5b268?page=53"> 9 Summary Assessment of abdominal pain can</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 54" href="http://viewer.zmags.com/publication/2be5b268?page=54"> 10 References 1. Bennett GL, Balthazar</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 55" href="http://viewer.zmags.com/publication/2be5b268?page=55"> Additional resources Additional resources re</a> <a title="Focused ultrasound for cholelithiasis_acute cholecystitis_tutorial page 56" href="http://viewer.zmags.com/publication/2be5b268?page=56"> This paper reflects the opinion of the author, no</a>