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Biliary Ultrasonography Kathleen OBrien - PDF document

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


  1. • 3/22/2016 Biliary Ultrasonography Kathleen O’Brien https://www.google.com/search?sa=G&hl=en&q=public+disclosure&tbm=isch&tbs=simg:CAQSigEahwELEKjU2AQaAAwLELCMpwgaYgpgCAMSKPIB_1QnzA7AI 9gObEoAK8wH1A5gGzT2sPb4_1rT3RPas9oj3TPdA9gj0aMKH8NOYEFXq-bLiqT1dZVwE0H7ZToFj_1o1v8lT5SxLIe14QK-_1Ecx3m3snDE4- MD MPH RDMS 4zCSADDAsQjq7-CBoKCggIARIEz6gJwAw&ved=0ahUKEwim9uWFrMPLAhUQ0GMKHazFD5IQwg4IGigA&biw=1347&bih=592 Kaiser Permanente South Sacramento NONE • 2 Scope of the problem: Objectives:  Abdominal pain accounts for 5-10% of ED visits in US • Discuss clinical indications and questions  1/3 of our abdominal pain patients in ED have GB etiologies answered by RUQUS for their pain  20M Americans have gallstones; ½ M undergo • Review of pertinent RUQ anatomy cholecystectomy each year 2’ stones SEE MORE PATIENTS! • Share techniques & scanning tips DISPO THEM FASTER! SPEND LESS MONEY! • Literature to support use of RUQUS BUT DON’T COMPROMISE QUALITY OF CARE. *Abdominal pain in the ED: stability and change over 20 years. Powers RD, Guertler AT.Am J Emerg Med. 1995;13(3):301. • 4 • 3 • 1

  2. • 3/22/2016 Current imaging options for AC: One solution: HIDA: -highest diagnostic accuracy in older studies - sensitivity 96%, specificity 90% Ultrasound: https://yazrooney.wordpress.com/2012/11/24/the-aha- moments-that-heal/ -sensitivity 88-90%, specificity 80-88% -NPV 95-98% CT: -helpful for detecting complications http://www.uk-ireland.bcftechnology.com/blog/2013/september/introduction-to-small- animal-veterinary-probes - sensitivity 73-99%, specificity 42-74% MRI: http://emedicine.medscape.com/article/171886 ‐ overview -similar to u/s test characteristics - MRCP helpful if choledocholithiasis suspected • 5 • 6 http://personalbestpersonaltraining.com/5 ‐ nutrition ‐ aha ‐ moments/ “But isn’t that why we have Purpose of RUQUS: radiologists?” Indications: Evaluate for:  ED performed RUQ ultrasound shown to be as sensitive and • RUQ pain  Cholelithiasis specific for radiology performed RUQ ultrasound for acute  Acute cholecystitis • Flank/shoulder/ epigastric cholecystitis!  Obvious liver/biliary pathology pain • Ascites  ED physicians often not formally trained in RUQ u/s and • Hepatomegaly test characteristics still acceptable • Jaundice • Pancreatitis • Sepsis  Advantage: increased efficiency, decreased time to diagnosis and disposition • 7 • 8 • 2

  3. • 3/22/2016 Anatomy Anatomy Liver  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) Hepatic duct Cystic duct  The portal triad consists of the hepatic artery , common bile duct (CBD) and the Gallbladder portal vein Pancreas  The CBD and the hepatic artery lie Common bile duct Duodenum anterior to the portal vein Pancreatic duct Techniques 101: Probe selection  Use 2.5-5 MHz low frequency abdominal probe. www.befunky.com • 11 • 12 • 3

  4. • 3/22/2016 Techniques 101: Techniques 101: INTERcostal approach SUBcostal approach  Probe placed in the right anterior axillary line over  The probe is placed the lower rib spaces, below the rib cage, marker facing to right lateral to epigastrium shoulder/head  Good for avoiding Rib  Slow sweep across the ribs shadows  Use the liver as an acoustic  Reliable Sono window Murphy ’ s  Anchor your hand for  Probe marker to head/R stability Shoulder  Aka “X minus 7”  hold probe at shallow angle • 13 • 14 Techniques 101: Techniques 101: Positioning in Left Lateral Decubitus • Can place probe subcostal or intercostal -Always scan the entire • GB should move gallbladder in two planes: anteriorly • Use the liver as acoustic  Longitudinal window  Transverse • Slow sweep along costal -Slowly fan through margin entire gallbladder in these two planes • 15 • 16 • 4

  5. • 3/22/2016 anterior What should you see: GB long Gallbladder Portal vein anterior feet head CBD feet supine head posterior posterior Left lateral decubitus • 18 What should you see: GB short anterior anterior feet head QuickTime™ and a Animation decompressor are needed to see this picture. supine right left posterior Normal Gallbladder in long axis posterior Left lateral decubitus • 19 • 20 19 • 5

  6. • 3/22/2016 Normal variants of the Gallbladder anterior  Pharyngian cap: The fundus is folded onto the body right left  Septate GB: thin septa inside gallbladder posterior Normal Gallbladder in short axis • 22 The highly elusive Commo Common Bil Bile Duc Duct... ‘Exclamation point’ sign ‐ CBD lies anterior to portal vein and next Find the Gallbladder to hepatic artery in the longest axis, -Color Doppler can help identify vascular follow the main lobar structures fissure from the neck of the gallbladder to the porta hepatis. ‐ Normal <7mm. CBD CBD forms the point -CBD dilates with increasing age and of the exclamation after cholecystectomy! mark, anterior to the portal vein . - PEARL: measure CBD from inner wall to inner wall Hepatic Portal vein artery • 24 • 6

  7. • 3/22/2016 Mickey Mouse sign CBD CBD Portal Hepatic artery vein Inferior vena cava Again, CBD anterior to portal vein and hepatic artery. CBD does not show flow; helps to identify the CBD. • 26 • http://www.em.emory.edu/ultrasound/ImageWeek/Abdominal/mickey_mouse.html • 25 25 Great news… perhaps finding the CBD What am I looking for exactly? doesn’t really matter?! http://www.siasat.pk/forum/showthread.php?325970 ‐ Question ‐ Mark • 27 • 28 • 7

  8. • 3/22/2016 Look for Acute cholecystitis by Acute cholecystitis: 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? • 30 • 29 When looking for stones, keep in mind… 1) Are there any stones? 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) • 31 • 8

  9. • 3/22/2016 1) Are there any stones? 1) Are there any stones? Posterior acoustic enhancement • 33 • 34 1) Are there any stones? 1) Are there any stones? • 35 • 36 • 9

  10. • 3/22/2016 1) Are there any stones? 1) Are there any stones? • 37 • 38 WES sign 1) Are there any stones? Wall Echo Shadow • 40 • 39 Gallbladder filled completely with stone • 10

  11. • 3/22/2016 1) Is there a stone? Patient supine, stones in the neck 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. Pat. rolled to left lateral decubitus, stones in body • 42 • 41 Brief mention: CBD stones Life just got easier… Dilated intrahepatic ducts CBD 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. • 43 • 44 • 11

  12. • 3/22/2016 #2) Is there pericholecystic fluid? #2) Is there pericholecystic fluid? • http://www.hindawi.com/journals/criid/2014/171496/fig1/ • 45 • 46 #2) Is there pericholecystic fluid? 3) Is there GB wall thickening? PEARL: Measure anterior wall because resolution is better. • 47 • 48 • 12

  13. • 3/22/2016 RUQUS and GB wall thickening: 4) Is there a Sono Murphys sign? -NONSPECIFIC finding!  maximal abdominal tenderness from pressure of the ultrasound probe over the visualised gallbladder -DDx include:  SMS is a sign of local inflammation around the gallbladder CHF along with right upper quadrant pain, tenderness or mass Renal failure Hypoalbuminemia Hepatitis Cirrhosis Pancreatitis Carcinoma…. • http://www.ultrasoundcases.info/case ‐ list.aspx?cat=151 • 49 • 50 • http://www.alifeatrisk.com/2012/04/does ‐ murphys ‐ sign ‐ and ‐ sonographic.html FYI: Cholangitis 5) Is the CBD dilated? Fever, RUQ pain, Jaundice.  <=6mm is normal  Add 1 mm as normal ~85% of cases dilatation for every decade associated with CBD CBD with thickened wall stones. above 60 years old  CBD dilated in pts s/p On ultrasound: cholecystecomy • Dilation of biliary tree Stone in • Choledocholithiasis CBD  Measure INNER wall to and possibly sludge inner wall • Bile duct wall Shadow thickening cast by stone • Hepatic abscess https://www.pinterest.com/pin/53128470580861359/ • 51 • 13

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