Impendi的紅旗ng Gallbladder Rupture

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超聲波和微妙的實驗室調查結果可能會使您承認患者的痛苦疼痛。

It’s another hectic day in paradise when your resident asks if she can present a case to you. The patient is a 49-year-old female who presents to the ED for abdominal pain. The patient states that three days ago she had an episode of epigastric pain that came on suddenly, was bad for about an hour, and then gradually resolved over about three hours. Today it recurred, but is more severe, 9 out of 10, and radiates to the right upper quadrant. It has been present for over 10 hours and is getting no better. She states that she vomited once and has chills but doesn’t think she has had a fever. She took ibuprofen about an hour ago for the pain, noting that it hasn’t really helped. She denies any other complaints.

For her physical exam, your resident notes “stable” vital signs although the vitals have only been taken once. Pulse is 97, blood pressure is 93/61, respirations are 22, and temperature is 98.9. She is described to you as obese with right-upper-quadrant tenderness and a positive Murphy’s sign, but not other positive findings.


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The PA in triage ordered labs about an hour and a half ago, and they are already resulted and show the following: WBC 5.7, hemoglobin 12.3, chemistry and LFTs all within normal limits. Your resident brings you the following images that she saved with her own bedside sonogram. She tells you her plan, “This looks like simple gallstones with no real red flags. Can we send her home with hydrocodone and arrange for a formal ultrasound and surgical consult as an outpatient?”

Q: Do you sign off on your resident’s management plan? What do the images show?


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不要在這個計劃上簽字!在我們到達圖像之前,這裏有多個紅旗。首先,疼痛的持續時間:持續超過六小時的推定膽道疼痛是膽囊炎,直到依據否則,所以在此表明正式的成像(參見更多臨床珍珠和陷阱的EM 1分鍾谘詢膽囊炎)。第二個紅旗是生命體征:97的脈衝在100歲以下,但在高端的高端和93/61的血壓可能在49歲的肥胖女性中,93/61的血壓可能在9/10的49歲的肥胖女性中可能不正常疼痛,22的呼吸也不是98.9的溫度,在布洛芬可能代表發燒後的每小時,特別是在患有寒冷的患者中。

The third red flag is the physical exam: a positive Murphy’s sign is an exam finding that has been described in cholecystitis, not biliary colic.

更多的:


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The labs are reassuring, but did you notice that the differential was not reported? This patient actually had 22 bands. Always wait for the results of the differential if one was ordered. A normal white count is usually reassuring, but in the setting of possible infection the differential includes severe sepsis. It is important to be aware that no single lab value is better than 50% sensitive for cholecystitis, and not infrequently all the labs will be normal.

圖像顯示膽囊的兩個跨腹部視圖。首先顯示了一個大型膽結石,後陰影可能影響膽囊頸部。在圖像的右側,靠近膽囊眼底,還有陰影但沒有石頭的證據。這可能是由於膽囊破裂的空氣收集(見下麵標記的超聲)。上麵的第二個圖像側重於該區域,並顯示了具有遮蔽的非描述區域,該區域可能是自由空氣的,與來自膽囊炎的穿孔膽囊相一致。

A confirmatory CT scan (shown below) was requested by the surgical consult. Note the pericholecystic fluid but also the fluid collection medial to the posterior liver and lateral to the right kidney, as well as free air anterior and medial to the gallbladder.

The patient received IV ampicillin/sulbactam and was taken emergently to the operating room. Fortunately, she did well and followed up in the post-operative surgical clinic rather than in the septic-shock or ascending cholangitis clinic.


珍珠和陷阱:Gallbladder & RUQ Ultrasound

  1. Know Your Limits:超聲可能有助於澄清通過徹底曆史和體檢引發的結果。正確使用時,它可以大大提高診斷準確性和幫助指導患者管理,特別是對於不穩定患者的時間關鍵診斷和治療。它還可以減少CT掃描的使用,從而最小化輻射曝光。但是,您需要考慮您的技能水平並了解您的局限性。當不確定時,命令正式的學習。如果您的部門擁有ED專用超聲機,它應考慮實施ED管理和放射學批準的質量改進計劃。
  2. Finding the Gallbladder:Lying the patient on their left side and starting by locating the inferior liver edge can help.
  3. The Sonographic Murphy’s Sign:To check for a sonographic Murphy’s sign, which is a sign of cholecystitis, place the ultrasound probe at the maximal point of tenderness in the right upper quadrant. If the probe is placing direct pressure on the gallbladder fundus, you have a positive sonographic Murphy’s sign. False negatives may occasionally occur if the patient has received opiates prior to examination.
  4. The Gallbladder Wall:膽囊炎的一個跡象是一個加厚的膽囊牆。正常的膽囊壁可以高達3mm厚。膽囊炎可能導致膽囊壁增厚的最常見條件包括肝炎,低惡蛋白血症,腫瘤,增生性膽囊增生症,腺瘤菌症和CHF。在沒有腹水的情況下,存在終生液體,也支持急性膽囊炎的診斷。如果存在臨床不確定性,則可以進行核膽掃描(HIDA或DESIDA掃描)。
  5. The Common Bile Duct:擴張的常見膽管是急性膽囊炎的另一個跡象。正常的膽總管內徑應小於4mm,但可能更高,高達10mm,後膽囊切除術。此外,老年患者的直徑可能更高,每年壽命達1毫米。
  6. The Gallbladder Contents:尋找擴張的膽囊,石頭的證據,以及汙泥。膽結石應該是移動的,除非它們受到膽囊頸部受到影響,並應施放聲學陰影。如果所有石頭都在留在仍然有症狀的患者中,請考慮他們可能是紅鯡魚,而不是患者疼痛的真正原因。請記住,大約15%的成年人具有無症狀的膽結石。如果沒有膽囊炎的超聲波跡象,但膽結石受到膽囊頸部的影響(非機動性),對早期膽囊炎可疑,並考慮入場,額外的成像或至少下一天的後續行動。當疼痛持續超過六個小時時,總是考慮早期的膽囊炎,即使超聲波是正常的,除了存在一塊石頭。簡單的膽結石攻擊通常應該持續幾個小時。如果您出於某種原因決定將其與Apiates一起發送回家,請務必向患者解釋這一點。攻擊持續時間比可能更嚴重的東西。
  7. 陷阱:Don’t miss a single obstructing gallstone hidden in the gallbladder neck. It can sometimes be hard to see. Also, do not get faked out by an incidental “red herring” gallstone. As previously mentioned, many people have gallstones for years with no symptoms, so if everything does not fit clinically, look further for something else causing the abdominal, flank, or rib pain. Some examples include aortic aneurysm, Fitz-Hugh-Curtis syndrome, high appendicitis, PE, kidney stone, and pneumonia. Finally, don’t miss an AAA, even if it is also incidental, because you did not look for it. Ultrasound techs look. The aorta is not that far away, and should be checked routinely in anyone over the age of 50 who is having an abdominal ultrasound for another reason. Screening saves lives!

ABOUT THE AUTHOR

EMERGENCY ULTRASOUND SECTION EDITOR Dr. Pregerson manages a free online EM Ultrasound Image Library. He is the author of the Emergency Medicine 1-Minute Consult Pocketbook and the A to Z Pocket Emergency Pharmacopoeia & Antibiotic Guide (available atEMresource.org) and the Tarascon Emergency Department Quick Reference Guide (tarascon.com.).

12 Comments

  1. 琳達補助金

    多年來,我有右上象限痛苦。
    過去的一年是壞的,但在我吃的時候並不總是,它可以從消費率開始,或者運動。
    I am beside myself, I had a cat scan in 9/22/17 also a ultra sound, A MRI in 8/2018 one show the gallbladder minimal dilated. pain almost like a spasm goes from 3- to a 10. then leaves and comes back.
    我也有一個膽囊空的研究,他們說沒事......任何建議?生無可戀

  2. Trevor Wuoti.

    我的疼痛基本上低於乳腺骨骼不同水平的疼痛,而不與進食無關。不同水平的疼痛延伸到右側和左側的左側,左側的左側,最後在我的右側右側的右側。我有12個月的這種痛苦,得到了我的症狀不支持的IBS治療。

    The gall bladder was removed and initially had stones in the bile ducts that were not able to be removed but seemingly cleared them selves based on the outcome of the follow up blood test.

    No more chronic and repeated pain.. Seems that the US an CT can’t see the issue but after I receive pathology results this week I am going to request a re-read of the CT so that the doctors learn and can hopefully pinpoint the issue for other patients.

  3. 琥珀亨利

    我現在有三個月的HA Gallbladder Stones。我隻發現了兩個月前,因為我每天都有一個月的慢性腹瀉。那天有5-8集。我的腹部非常緊張,我的肝髒酶被淘汰。
    So they did an ultrasound, and saw the stones and sludge. They admitted me and gave me fluids overnight, then discharged me, telling me I should find a surgeon.

    我終於找到一個,一直到the ER again since then, because of servere pain in my upper right flank that made me cry, but they just keep saying it’s just stones, and I should look into having the organ removed.

    我每天都在吃痛苦,寒冷和腹瀉。I feel a stabbing pain under my ribs that runs down my right flank burning, and even got so disoriented, I almost fell and fainted several times at the doctor’s.. I’m scared, and my appointment isn’t for 11 days to even get examined for surgery. I also have a MRSA skin infection that my doctor’s refuse to treat for over a year. I don’t know what to do.
    有小費嗎?我的膽囊可以泄漏嗎?

    • Am I reading this right? Your doctor won’t treat your MRSA? You need a new doctor. They work for you, not the other way round!

    • 嗨琥珀,你必須閱讀“肝髒和膽囊奇跡奇跡清潔”,andreas moritz /標題為自己說話,並且啟示錄會讓你覺得我確定,就像它對我一樣。開始閱讀2019年底的書籍;並開始我的旅程2020年1月 - 我非常建議為自己讀這本書,而不是依賴第二次手下載。互聯網上有許多“itemonies”;當然我已經聽了,但是一個人會在這本書中找到確切的信息。我可以整天聊聊這個......

    • Peppermint, tumeric, ginger hot teas.. per serving add two apple cider vinegar tabs. I added lemon and organic Honey..

  4. What effect on digestion system would you expect from gallbladder during attack, if any?
    Not a doctor, but have been told that I do have stones, that were picked up on unrelated MRI of spine.
    我的右側柔軟地觸摸肋骨下方。

  5. 我已經慢性腹瀉大約7個月了。有些日子我得到2-3次等10次。我進入了我的gi博士,但是當這個整個Covid的事情開始和非緊急程序被取消時。有一天,我開始在我的胸口痛苦地回來。當我有大約2個小時的時候,我去了ed,因為我有冠狀動脈疾病的曆史,它害怕我。他們跑了各種各樣的測試,並進行了壓力測試,一切都很好。痛苦繼續。我的gi對我的胃部沒有發現沒有發現。除了可能的腎髒問題外,我有一個膽囊超聲,沒有發現的結果。GI決定試試硝酸甘油,看看它是否是食管痙攣,但這也不是工作。 I feel tired all the time and still have pain. Family history of gallbladder disease. I don’t know what I should do. I’m in pain while writing this.

  6. Sylviane Bloss

    I’m veryyy discouraged at the medical care in emergency rooms I’m 69 and finally went to ER for after five days constant on and off upper right side,, had no fever, blood pressure 135/83,, no chills just horrible pain and nausea,, doctor never examined me, just ordered labs and ultrasound, comes back in room an hour later says allll is well,what the heck!! I asked him to please do catscan because I have brain tumor and was told several years ago I have a growth also on my liver, I explain to the doctor that my stools had turned yellow within a week that is not normal so I thought it was my gallbladder he insisted that it was not the gallbladder never said anything else they did the CAT scan and within 15 minutes they came in my room and told me I was fine,, they had the clipboard ready to zoom me out of the hospital room like I said I’m 69-year-old female with brain tumor and I have another tumor in my left long as well they treated me and shoved me out!! My son drove me home and I am still at home suffering not knowing what to do

  7. Good god thank goodness i dont live where you all do our nhs is absolutely fantastic my heart goes out to all of you i pray you all find someone to ease your pain soon xx

  8. I’m a 29 year old female. Was diagnosed with gallstones a year ago because I had really bad pain in upper right side of abdomen so I went to urgent care and they sent me to do sonograms. So I did and they found 2 gallstones. For a few months after that I didn’t have any pain related to gallbladder so I thought surgery may not be necessary since I didn’t feel pain anymore. Now fast forward to a month ago. I been having on and off pain almost everyday. Feels like trapped gas. Sometimes it’s sharp sometimes it just a discomfort. some days it’s for a while but days like today I been having the pain all day on and off. It’s a pain I feel higher above my right breast and sometimes near my right armpit. I’m scared and don’t know if I should go to ER or just to see if it pain goes away. I don’t have fever or chills or vomiting. My stools have started to change color but I’m also on medication for H. Pylori so I don’t know if it could be that. I’m sick and tired of feeling this pain everyday and im afraid that my gallbladder will burst. What do you think I should do ?

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