Ultrasound Case of the Week 11.5.13
47 year old female with a history of nephrolithiasis, peptic ulcers and GERD presented to the ED with complaints of epigastric pain upon waking a few hours prior. She characterized the pain as abrupt in onset, sharp, non-radiating 10/10 pain of the epigastrum and she took Mylanta at home with no relief.
Her initial vitals were Temp 36.2, Pulse 58, Resp rate 24, BP 177/90, sat 100%.
Review of systems was positive for +reddish tinted diarrhea and +TTP epig/RUQ. The patient denied nausea/vomiting, fevers/chills, CP, SOB, dizziness, weakness and dysuria.
Laboratory results did not reveal any abnormalities. CBC and BMP were WNL (WBC 9.0, HGB 13.0, PLT 258), total bilirubin 0.8, direct bilirubin 0.1, alk phos 77, AST 18 ALT 13, lipase 23. HCG was negative for pregnancy.
The patient’s pain had improved after ED management of 4mg Ondansetron, Mylanta and GI cocktail and she was tolerating PO. Upon reevaluation the patient reported feeling much better and was ready to be discharged home before a limited RUQ bedside ultrasound was performed in the ED which revealed an enlarged gallbladder with a large amount of echogenic stones and sludge, apparent gallbladder wall thickening, and pericholecystic fluid. The patient was then taken for a formal ultrasound performed using a curved 5-2MHz transducer which revealed
“Gallbladder is physiologically distended, with multiple stones and sludge, wall thickening, and pericholecystic fluid. The gallbladder wall measures about 3.9mm. Common duct measures 4mm the level of the porta hepatis. Sonographic Murphy's sign is positive. Small fluid is noted in the Morrison's pouch. Findings suggesting of cholelithiasis and gallbladder sludge calculus acute cholecystitis with pericholecystic fluid.”
Upon those results, the biliary fellow was contacted and suggested a formal surgery consult and the patient was taken for surgery later that day. The patient underwent a total robotic cholecystectomy and findings of surgery revealed “acute cholecystitis, thickened gallbladder, and perivesicular edema.” The patient tolerated procedure well and was discharged home.
