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.
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?
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.
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.
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
- 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。
- Finding the Gallbladder:Lying the patient on their left side and starting by locating the inferior liver edge can help.
- 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.
- 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）。
- 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。
- 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。
- 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!