Biliary Ultrasonography Kathleen OBrien - - PDF document

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Biliary Ultrasonography Kathleen OBrien - - PDF document

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3/22/2016 Biliary Ultrasonography Kathleen OBrien https://www.google.com/search?sa=G&hl=en&q=public+disclosure&tbm=isch&tbs=simg:CAQSigEahwELEKjU2AQaAAwLELCMpwgaYgpgCAMSKPIB_1QnzA7AI

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Biliary Ultrasonography

Kathleen O’Brien MD 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_1QnzA7AI 9gObEoAK8wH1A5gGzT2sPb4_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:

  • 4

 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:

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http://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?”

  • 7

 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:

  • 8

Evaluate for:

Cholelithiasis Acute cholecystitis Obvious 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

  • f 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 Pancreas Gallbladder

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
  • r 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

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Gallbladder Portal vein CBD

head feet posterior anterior

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19 QuickTime™ and a Animation 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

  • nto the body
  • Septate GB:

thin septa inside gallbladder

The highly elusive Commo Common Bil Bile Duc 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

  • 24

‘Exclamation point’ sign

Find the Gallbladder in the longest axis, follow the main lobar fissure from the neck

  • f the gallbladder to

the porta hepatis. CBD forms the point

  • f 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

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  • 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?

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http://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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1) Are there any stones?

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Posterior acoustic enhancement

1) Are there any stones?

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1) Are there any stones?

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1) Are there any stones?

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1) Are there any stones?

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1) Are there any stones?

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WES sign

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Shadow Echo Wall

Gallbladder filled completely with stone

1) Are there any stones?

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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/

#2) Is there pericholecystic fluid?

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#2) Is there pericholecystic fluid?

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3) Is there GB wall thickening?

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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? 3) Is there GB wall thickening? 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

  • f the clinical presentation.

Questions? Kathleen.OBrien@kp.org, katieoinaz@gmail.com

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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Exclamation point sign

57 QuickTime™ and a Animation decompressor are needed to see this picture.

Portal vein

CBD Hepatic artery

Inferior vena cava

Gallbladder