Biliary Ultrasonography KOBrien_RUQlecture.pdfCurrent imaging options for AC: •6 HIDA: -highest diagnostic accuracy in older studies ... When GB is filled multiple stones or one

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Biliary Ultrasonography Kathleen O’BrienMD MPH RDMS

Kaiser Permanente South Sacramento

NONE

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https://www.google.com/search?sa=G&hl=en&q=public+disclosure&tbm=isch&tbs=simg:CAQSigEahwELEKjU2AQaAAwLELCMpwgaYgpgCAMSKPIB_1QnzA7AI9gObEoAK8wH1A5gGzT2sPb4_1rT3RPas9oj3TPdA9gj0aMKH8NOYEFXq-bLiqT1dZVwE0H7ZToFj_1o1v8lT5SxLIe14QK-_1Ecx3m3snDE4-4zCSADDAsQjq7-CBoKCggIARIEz6gJwAw&ved=0ahUKEwim9uWFrMPLAhUQ0GMKHazFD5IQwg4IGigA&biw=1347&bih=592

Objectives:

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•Discuss clinical indications and questions answered by RUQUS

•Review of pertinent RUQ anatomy

•Share techniques & scanning tips

•Literature to support use of RUQUS

Scope of the problem:

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Abdominal pain accounts for 5-10% of ED visits in US

1/3 of our abdominal pain patients in ED have GB etiologies for their pain

20M Americans have gallstones; ½ M undergo cholecystectomy each year 2’ stones

*Abdominal pain in the ED: stability and change over 20 years. Powers RD, Guertler AT.Am J Emerg Med. 1995;13(3):301.

SEE MORE PATIENTS!DISPO THEM FASTER!SPEND LESS MONEY!

BUT DON’T COMPROMISE QUALITY OF CARE.

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One solution:

•5http://personalbestpersonaltraining.com/5‐nutrition‐aha‐moments/

https://yazrooney.wordpress.com/2012/11/24/the-aha-moments-that-heal/

http://www.uk-ireland.bcftechnology.com/blog/2013/september/introduction-to-small-animal-veterinary-probes

Current imaging options for AC:

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HIDA:

-highest diagnostic accuracy in older studies

- sensitivity 96%, specificity 90%

Ultrasound:

-sensitivity 88-90%, specificity 80-88%

-NPV 95-98%

CT:

-helpful for detecting complications

- sensitivity 73-99%, specificity 42-74%

MRI:

-similar to u/s test characteristics

- MRCP helpful if choledocholithiasis suspected

http://emedicine.medscape.com/article/171886‐overview

“But isn’t that why we have radiologists?”

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ED performed RUQ ultrasound shown to be as sensitive and specific for radiology performed RUQ ultrasound for acute cholecystitis!

ED physicians often not formally trained in RUQ u/s and test characteristics still acceptable

Advantage: increased efficiency, decreased time to diagnosis and disposition

Purpose of RUQUS:

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Evaluate for:

CholelithiasisAcute cholecystitisObvious liver/biliary pathology

Indications:

• RUQ pain

• Flank/shoulder/ epigastric pain

• Ascites

• Hepatomegaly

• Jaundice

• Pancreatitis

• Sepsis

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Anatomy Gallbladder is located at the inferior surface of the liver; consists of the fundus, the body and the neck

The neck of the gallbladder drains into the cystic duct which joins the hepatic duct to form the common bile duct (CBD)

The portal triad consists of the hepatic artery , common bile duct (CBD) and the portal vein

The CBD and the hepatic artery lie anterior to the portal vein

Anatomy

Hepatic duct

Cystic duct

Liver

Pancreatic duct

Duodenum Common bile duct

PancreasGallbladder

Techniques 101: Probe selection

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Use 2.5-5 MHz low frequency abdominal probe.

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www.befunky.com

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Techniques 101: SUBcostal approach

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The probe is placed below the rib cage, lateral to epigastrium

Good for avoiding Rib shadows

Reliable Sono Murphy’s

Probe marker to head/R Shoulder

hold probe at shallow angle

Techniques 101: INTERcostal approach

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Probe placed in the right anterior axillary line over the lower rib spaces, marker facing to right shoulder/head

Slow sweep across the ribs

Use the liver as an acoustic window

Anchor your hand for stability

Aka “X minus 7”

Techniques 101: Positioning in Left Lateral Decubitus

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• Can place probe subcostal or intercostal

• GB should move anteriorly

• Use the liver as acoustic window

• Slow sweep along costal margin

Techniques 101:

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-Always scan the entire

gallbladder in two planes:

Longitudinal Transverse

-Slowly fan through entire gallbladder in these two planes

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What should you see: GB long

head feet

posterior

anterior

supine

Left lateral decubitus •18

Gallbladder

Portal vein

CBDhead feet

posterior

anterior

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QuickTime™ and aAnimation decompressor

are needed to see this picture.

Normal Gallbladder in long axis

head feet

posterior

anterior What should you see: GB short

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supine

Left lateral decubitus

right

posterior

anterior

left

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Normal Gallbladder in short axis

right left

posterior

anterior Normal variants of the Gallbladder

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Pharyngian cap:

The fundus is folded

onto the body

Septate GB:

thin septa inside gallbladder

The highly elusive Common Bile Duct...

‐CBD lies anterior to portal vein and next to hepatic artery

-Color Doppler can help identify vascular structures

‐Normal <7mm.

-CBD dilates with increasing age and after cholecystectomy!

-PEARL: measure CBD from inner wall to inner wall

CBD

Hepatic artery

Portal vein

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‘Exclamation point’ sign

Find the Gallbladder in the longest axis,

follow the main lobar fissure from the neck of the gallbladder to

the porta hepatis.

CBD forms the point of the exclamation

mark, anterior to the portal vein.

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CBD

Again, CBD anterior to portal vein and hepatic artery. CBD does not show flow; helps to identify the CBD.

Portal vein

Hepatic artery

Inferior vena cava

CBD

Mickey Mouse sign

•26•http://www.em.emory.edu/ultrasound/ImageWeek/Abdominal/mickey_mouse.html

Great news… perhaps finding the CBD doesn’t really matter?!

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What am I looking for exactly?

•28http://www.siasat.pk/forum/showthread.php?325970‐Question‐Mark

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Look for Acute cholecystitis by asking:

1) Are there gallstones present?

AND

2) Is there pericholecystic fluid present?

3) Is there GB wall thickening?

4) Is there a sonographic murphy’s sign?

5) +/- Is the CBD dilated?

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Acute cholecystitis:

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1) Are there any stones?

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When looking for stones, keep in mind…Stones: hyperechoic, cast a shadow. Stones are often mobile;

scan patients in different positions. ALWAYS convince yourself there is no stone in GB neck.

Wall-echo-complex (WES):

When GB is filled multiple stones or one giant stone you just see wall, then bright reflex and then shadow.

Sludge: biliary sand/microlithiasis: Echoes within depending part of GB without shadowing (resettles in dependent parts > scan patients in different positions)

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Posterior acoustic

enhancement


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WES sign

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Shadow

EchoWall

Gallbladder filled completely with stone


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Patient supine, stones in the neck

Pat. rolled to left lateral decubitus, stones in body

Stones vs polyps or tumors: -stones are mobile and can be moved by changing the position of the patient, not adhered to wall.

-Polyps do not shadow.

1) Is there a stone?

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Life just got easier…

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Brief mention: CBD stones

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CBD

Dilated intrahepatic

ducts

Stone in CBD

Shadow cast by stone

CBD stones: round echogenic lesion with posterior shadowing. Most stones are impacted in the distal duct at the papilla.

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#2) Is there pericholecystic fluid?

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•http://www.hindawi.com/journals/criid/2014/171496/fig1/


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PEARL: Measure anterior wall because resolution is better.

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RUQUS and GB wall thickening:

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-NONSPECIFIC finding!

-DDx include:

CHF

Renal failure

Hypoalbuminemia

Hepatitis

Cirrhosis

Pancreatitis

Carcinoma….

•http://www.ultrasoundcases.info/case‐list.aspx?cat=151

4) Is there a Sono Murphys sign?

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maximal abdominal tenderness from pressure of the ultrasound probe over the visualised gallbladder

SMS is a sign of local inflammation around the gallbladder along with right upper quadrant pain, tenderness or mass

•http://www.alifeatrisk.com/2012/04/does‐murphys‐sign‐and‐sonographic.html

5) Is the CBD dilated?

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<=6mm is normal

Add 1 mm as normal dilatation for every decade above 60 years old

CBD dilated in pts s/p cholecystecomy

Measure INNER wall to inner wall

https://www.pinterest.com/pin/53128470580861359/

FYI: Cholangitis

Fever, RUQ pain, Jaundice.

~85% of cases associated with CBD stones.

On ultrasound: •Dilation of biliary tree•Choledocholithiasis and possibly sludge•Bile duct wall thickening•Hepatic abscess

Shadow cast by stone

Stone in CBD

CBD with thickened wall

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Again, ask yourself:

1) Are there gallstones present?

AND

2) Is there pericholecystic fluid present?


4) Is there a sonographic murphy’s sign?

5) +/- Is the CBD dilated?

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Take home points:

Always scan through the GB in both longitudinal and transverse planes.

Scan through GB neck to ensure no obstructing stone

Use color Doppler to help distinguish nonvascular from vascular structures.

Be aware of normal variants (folds).

Measure the anterior wall of the gallbladder.

Normal GB wall <4mm

Normal CBD <7mm

Position for success: left lateral decubitus

Can’t see the GB? Ask pt to take a deep breath in

Stones are mobile and shadow; polyps do not.

Ultrasound findings must ALWAYS be interpreted in the context of the clinical presentation.

Questions?

[email protected], [email protected]

Thank you!

Further reading

Hepatobiliary disease: a comparative evaluation by ultrasound and computed tomography, Raskin MM. Gastrointest Radiol. 1978 Aug 31;3(3):267-71

Role of ultrasonography for acute cholecystic conditions in the emergency room. Golea et al. Med Ultrason 2010 Dec;12 (4):271-9

Performance and interpretation of focused right upper quadrant ultrasound by emergency physicians Kendall et al. J Emerg Med 2001

A prospective evaluation of emergency department bedside ultrasonography for the detection of acute cholecystitis, Shane et al.

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•57Exclamation point sign57

QuickTime™ and aAnimation decompressor

are needed to see this picture.Portal vein

CBD

Hepatic artery

Inferior vena cava

Gallbladder

Documents

Biliary Ultrasonography KOBrien_RUQlecture.pdfCurrent imaging options for AC: •6 HIDA: -highest diagnostic accuracy in older studies ... When GB is filled multiple stones or one