Gallbladder with Biliary Sludge
Gallbladder with Biliary Sludge
Stones in Gallbladder Neck
Stones in Gallbladder Neck
Choledocholithiasis - Dilated Common Bile Duct with Stone
Choledocholithiasis - Dilated Common Bile Duct with Stone
Dilated Common Bile Duct
Dilated Common Bile Duct
Normal Common Bile Duct (Labeled)
Normal Common Bile Duct (Labeled)
Gallbladder with Biliary Sludge
Gallbladder with Biliary SludgeThe image above is from a patient presenting to the emergency department with recurrent abdominal pain. The image demonstrates a large amount of biliary sludge within a normal sized gallbladder. Biliary colic from intermittent obstruction was suspected. While the gallbladder wall is noted to be mildly thick here, cholecystitis was ruled out based on other clinical factors.Marco Garrone, MDTorino, Italy
Stones in Gallbladder Neck
Stones in Gallbladder NeckThis patient without cholecystitis clearly demonstrates cholelithiasis. A 2002 study demonstrated that ER doctors can diagnose gallstones with a sensitivity of 88% and specificity 96% with POCUS. Gallstones can be identified by hypoechoic "shadowing" behind hyperechoic stones. If there isn't shadowing, hyperechoic structures could represent polyps or sludge. In this image the stones are resting mainly in the neck of the gallbladder. Reference:Kendall JL, Shimp RJ. Performance and interpretation of focused right upper quadrant ultrasound by emergency physicians. J Emerg. Med. 2001; 21(1):7-13Image: Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al.
Choledocholithiasis - Dilated Common Bile Duct with Stone
Choledocholithiasis - Dilated Common Bile Duct with Stone A normal Common bile duct should be < 4 mm plus 1mm per decade after 40 years of age. A stone can clearly be seen in the area of color flow doppler. The bile duct is obviously dilated here (although  not measured). When searching for the CBD, it can be useful to turn color flow doppler on to ensure you're visualizing a biliary structure and not vessels. This technique was employed here.POCUS is highly sensitive for acute cholecystitis but as many people already know, it can be hard to find the CBD, which is reflected in the lower sensitivity and specificity for this indication in many studies. Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. (Dr. Dop Ahilan)
Dilated Common Bile Duct
Dilated Common Bile DuctThis patient with a dilated common bile duct and obstructive pattern LFTs is highly suggestive of Choledocholithiasis or other biliary obstruction. no stone is visualized on this study.A normal Common bile duct should be < 4 mm plus 1mm per decade after 40 years of age. Here it is 9.78 mm. POCUS is highly sensitive for acute cholecystitis but as many people already know, it can be hard to find the CBD, which is reflected in the lower sensitivity and specificity for this indication in many studies. Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. (Dr. Ken Lee)
Normal Common Bile Duct (Labeled)
Normal Common Bile Duct (Labeled)A normal Common bile duct should be < 4 mm plus 1mm per decade after 40 years of age. It should be measured from inner wall to inner wall. You should attempt to find the portal triad: the CBD, the portal vein, and the hepatic artery. You may need color flow to find all three. Here the CBD and portal vein and labeled (no labeled hepatic artery.To get better images, especially if you're dealing with a lot of rib shadow, it can be helpful to have your patient take a deep breath and/or roll onto their left side. Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al.
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