A 40-year-old male presented to the ED with 4 days of right upper quadrant pain. The pain came on acutely 4 days ago while eating and had been constant since then. He endorsed nausea, but denied vomiting, diarrhea, and fever. He had never had pain like this before.
VS: BP 138/74, P 58, T 36.7 °C (98.1 °F), RR 20, SpO2 100%
Physical exam revealed an abdomen that was soft and non-distended. There was mild tenderness in the RUQ. Murphy’s sign was absent.
The ED team taking care of him decided to do a point-of-care RUQ ultrasound and obtained laboratory tests. The BSUS can be seen below:
You can see that the GB is not filled with anechoic fluid like normal. The GB appears to be hyperechoic compared to the liver. Also, please note the edge artifact seen on the lateral edges of the GB.
Here is a measurement of the GB wall:
It was 2.2 mm, which is normal. A normal GB wall is less than or equal to 3 mm.
Here is a measurement of the common bile duct:
It measures 9.7 mm, which is enlarged. A normal CBD should be less than or equal to 6-7 mm.
WBC count was 3.4. Lipase and LFTs were normal.
What do you make of all these results?
We thought that the GB was sludge-filled because either a stone or stenosis was blocking the outflow of bile. There was no evidence of GB wall thickening, pericholecystic fluid, or a positive sonographic Murphy’s sign. Given the lack of these things, it was felt that the patient did not have cholecystitis currently, but it was believed that if his GB were not taken out, he would inevitably develop cholecystitis.
He was admitted to surgery and underwent an uneventful cholecystectomy. The surgeons noted a stone lodged in the neck of the gallbladder. Given the CBD dilation, an intraoperative cholangiogram was also performed. There was no stone or stenosis present.
Bottom Line:
- A normal GB wall is less than or equal to 3 mm.
- A normal CBD is less than or equal to 6-7 mm.
- Bedside RUQ ultrasound can rapidly aid in the diagnosis of a vast array of hepatobiliary pathology.
Did the surgeons comment on what the GB looked like intraoperatively? Any word on why the GB looked like it did on US?
Jacob,
The gallbladder looked as it did because it was completely sludge filled. A stone was lodged in the neck of the GB presumably blocking all outflow, hence the build up of sludge. It is probably uncommon that we see this because it seems patients become symptomatic earlier in the process or the GB gets infected before it gets completely filled and in both cases the GB comes out usually. The pathology report was read as “chronic cholecystitis and cholelitiasis.” On the path report the GB was completely slugged filled and there was a focal area of wall thickening at the fundus.
Thanks!
Andie
Many lingering questions about this case.
1. Why the enlarged CBD without choledocholithiasis?
2. Intraoperatively was the gallbaldder filled with sludge that would explain the hyperechoic ultrasound?
Charles,
1. After a stone has passed through the CBD it often stays dilated indefinitely. It is possible that the patient had perviously passed a stone and her CBD stayed dilated after that.
2. The GB was completely filled with sludge and that is why it appears hyperechoic. A stone was lodged in the neck blocking all outflow probably causing the build up of the sludge.
Thanks!