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Emergency Ultrasound Course

Huntington Beach, CA November 2-4, 2018

Hepatobiliary Ultrasound

Nick Gastelum, MD UCSF Fresno - Department of Emergency Medicine

Overview

• Indications for hepatobiliary ultrasound

• Gallbladder anatomy

• Ultrasound technique

• Evaluation of gallbladder

• Evaluation of common bile duct

Clinical Utility

• >700,000 ED visits/year with diagnosis of gallbladder or bile duct pathology

• Variety of imaging to evaluate hepatobiliary disease

• Ultrasound, HIDA, CT, MRCP

• Ultrasound most sensitive for gallstones, 94%

• Ultrasound as sensitive as HIDA for cholecystitis

Indications

• Evaluation of RUQ abdominal pain, epigastric pain, jaundice, abnormal LFTs, sepsis

• symptomatic cholelithiasis, acute cholecystitis, choledocholithiasis, ascending cholangitis

Symptomatic Cholelithiasis

• Symptoms: RUQ abdominal pain

• Pain associated with temporary blockage of bile flow

• Treatment: diet modification, elective cholecystectomy

Acute Cholecystitis

• Symptoms: RUQ abdominal pain, nausea and vomiting, fever

• Gallbladder inflammation which leads to bacterial infection

• 95% due to gallstones

• Treatment: antibiotics and cholecystectomy

Choledocholithiasis

• Symptoms: RUQ abd pain, jaundice, elevated alk phos, elevated direct bilirubin

• Gallstones in common bile duct

• Treatment: ERCP (endoscopic retrograde cholangiopancreatography) and cholecystectomy

Ascending Cholangitis

• Symptoms: RUQ abdominal pain, fever, jaundice, altered mental status, shock

• Partial/complete bile duct obstruction which leads to bacterial infection of the bile duct

• Can be caused by choledocholithiasis, malignancy

• Treatment: antibiotics, ERCP, cholecystectomy

Focused Questions• Is there a sonographic Murphy’s sign?

• Are gallstones present?

• Is a gallstone stuck in the neck?

• Is there anterior gallbladder wall thickening?

• Is pericholecystic fluid present?

• Is there dilation of the common bile duct?

Anatomy

Anatomy

Technique

Transducers

Gallbladder

Longitudinal View

Longitudinal View

Transverse View

Transverse View

Intercostal View

Fanning

GB Wall Thickness• Transverse view

• Anterior wall

• Outer edge to outer edge

• > 3 mm abnormal

• cholecystitis

• ascites, CHF, nephrotic syndrome, renal failure

GB Wall Thickness

Pathology

Contracted Gallbladder

Contracted Gallbladder

Sludge

Cholangiocarcinoma

Gallstones

Gallstones

Polyps

Acute Cholecystitis

Acute Cholecystitis

Pericholecystic Fluid

Pericholecystic Fluid

Wall/Echo/Shadow (WES)

Duodenum

Duodenum

Sonographic Murphy’s Sign

• Reproducible point tenderness directly over the gallbladder with transducer pressure

• 87% specific for cholecystitis

• Gallstones + Murphy’s sign

• 92% PPV for cholecystitis

Common Bile Duct

Longitudinal View

Exclamation Point

Mickey Mouse

Transverse CBD

Transverse CBD

Longitudinal CBD

CBD Diameter

• Longitudinal view

• Inner edge to inner Edge

• < 6 mm normal

• Can add 1 mm per decade over age of 60

• <10 mm if s/p cholecystectomy

Normal CBD

Dilated CBD

Choledocholithiasis

Question

• Does measuring the CBD identify complicated biliary pathology that would be missed by labs and other ultrasound findings?

Methods

• Prospective, Observational

• N = 158

• # of patients with complicated biliary pathology and isolated CBD dilation without:

• abnormal labs, pericholecystic fluid, thickened GB wall, sonographic Murphy’s sign

Results

• 0 patients with complicated biliary pathology had CBD dilation without other signs:

• abnormal labs, pericholecystic fluid, thickened GB wall, sonographic Murphy’s

• CBD dilation for complicated biliary pathology

• Sensitivity: 23.7%

Take Home Points

• Normal gallbladder anterior wall < 3 mm

• Normal CBD diameter < 6 mm

• Can add 1 mm for every decade over 60

• CBD diameter can be up to 10 mm s/p cholecystectomy

Take Home Points

• Have patient take a deep breath

• Left lateral decubitus

• Intercostal view with phased array probe

• Track down to portal triad via main lobar fissure

References1. Ma, O.J., Mateer, J.R. (2014) Emergency Ultrasound, 3rd Edition. New

York, NY: McGraw-Hill.

2. Soni N.J., Arntfield R. (2015) Point-of-Care Ultrasound. Philadelphia, PA: Elsevier Saunders.

3. Fox, J.C. (2011) Atlas of Emergency Ultrasound. New York, NY: Cambridge University Press.

4. Lahham, S. (2017) Utility of common bile duct measurement in ED point of care ultrasound: A prospective study. American Journal of Emergency Medicine, 36, 962-966.

5. Summers, S.M. (2010) A Prospective Evaluation of Emergency Department Bedside Ultrasonography for the Detection of Acute Cholecystitis. Annals of Emergency Medicine, 56(2), 114-122.

Emergency Ultrasound Course

Huntington Beach, CA November 2-4, 2018