How Do You Know if Your Gallbladder Ruptured?
Ultrasound and subtle lab findings may convince yous to acknowledge that patient with RUQ pain.
I t'southward another hectic day in paradise when your resident asks if she can present a instance to you. The patient is a 49-year-old female person who presents to the ED for abdominal pain. The patient states that 3 days ago she had an episode of epigastric pain that came on suddenly, was bad for most an 60 minutes, and then gradually resolved over nigh three hours. Today it recurred, only is more astringent, 9 out of 10, and radiates to the right upper quadrant. It has been present for over 10 hours and is getting no better. She states that she vomited once and has chills but doesn't think she has had a fever. She took ibuprofen about an hour agone for the pain, noting that information technology hasn't actually helped. She denies any other complaints.
For her physical exam, your resident notes "stable" vital signs although the vitals have only been taken one time. Pulse is 97, blood pressure is 93/61, respirations are 22, and temperature is 98.9. She is described to yous as obese with correct-upper-quadrant tenderness and a positive Murphy'southward sign, but not other positive findings.
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The PA in triage ordered labs near an hour and a half ago, and they are already resulted and testify the post-obit: WBC 5.7, hemoglobin 12.3, chemistry and LFTs all inside normal limits. Your resident brings you lot the post-obit images that she saved with her own bedside sonogram. She tells you her program, "This looks like unproblematic gallstones with no existent ruby-red flags. Can we send her home with hydrocodone and adjust for a formal ultrasound and surgical consult as an outpatient?"
Q: Do you sign off on your resident's management plan? What do the images prove?
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Do not sign off on this programme! Earlier we get to the images, there are indeed multiple red flags here. First, the duration of the pain: pain of a presumed biliary origin that lasts more than six hours is cholecystitis until proven otherwise, and so formal imaging is indicated here (encounter the EM i-minute consult on cholecystitis below for more clinical pearls and pitfalls). The second red flag is the vital signs: a pulse of 97 is nether 100, just is a petty on the high side and a claret pressure of 93/61 is probably non normal in a 49-year-old obese female with ix/ten pain, neither are respirations of 22, and a temperature of 98.9 an hour or ii after ibuprofen could represent a fever, peculiarly in a patient with chills.
The third cherry-red flag is the physical exam: a positive Murphy's sign is an exam finding that has been described in cholecystitis, non biliary colic.
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The labs are reassuring, but did you find that the differential was not reported? This patient actually had 22 bands. E'er look for the results of the differential if one was ordered. A normal white count is unremarkably reassuring, but in the setting of possible infection the differential includes severe sepsis. It is important to exist aware that no unmarried lab value is improve than fifty% sensitive for cholecystitis, and not infrequently all the labs will be normal.
The images show ii transabdominal views of the gallbladder. The first shows a large gallstone with posterior shadowing that is perhaps impacted in the gallbladder neck. To the right side of the prototype, about the gallbladder fundus, there is likewise shadowing just no evidence of stones. This could be due to an air collection from gallbladder rupture (see labeled ultrasound beneath). The 2d image above focuses on this surface area and shows a non-descript area with shadowing that is probably gratis air, consistent with a perforated gallbladder from cholecystitis.
A confirmatory CT scan (shown below) was requested by the surgical consult. Note the pericholecystic fluid just likewise the fluid collection medial to the posterior liver and lateral to the correct kidney, as well every bit gratis air anterior and medial to the gallbladder.
The patient received Iv ampicillin/sulbactam and was taken emergently to the operating room. Fortunately, she did well and followed up in the mail service-operative surgical clinic rather than in the septic-daze or ascending cholangitis dispensary.
Pearls and Pitfalls: Gallbladder & RUQ Ultrasound
- Know Your Limits: Ultrasound may help clarify findings elicited by a thorough history and physical exam. When used correctly, it can greatly improve diagnostic accuracy and help guide patient management, specially for fourth dimension-disquisitional diagnoses and treatment of unstable patients. It can also decrease the employ of CT scan and thereby minimize radiation exposure. However, you need to consider your skill level and know your limitations. When unsure, club a formal written report. If your section has an ED dedicated ultrasound automobile, it should consider implementing a quality improvement program that is approved by both ED administration and radiology.
- Finding the Gallbladder: Lying the patient on their left side and starting past locating the inferior liver edge can help.
- The Sonographic Murphy's Sign: To check for a sonographic Irish potato'south sign, which is a sign of cholecystitis, identify the ultrasound probe at the maximal point of tenderness in the right upper quadrant. If the probe is placing direct pressure level on the gallbladder fundus, you lot have a positive sonographic Murphy'due south sign. Simulated negatives may occasionally occur if the patient has received opiates prior to examination.
- The Gallbladder Wall: One sign of cholecystitis is a thickened gall-bladder wall. The normal gallbladder wall can be up to 3mm thick. The most common conditions other than cholecystitis that may cause thickening of the gallbladder wall include hepatitis, hypoalbuminemia, tumor, hyperplastic cholecystosis, adenomyomatosis, and CHF. In the absence of ascites, the presence of pericholecystic fluid, as well supports the diagnosis of astute cholecystitis. If there is clinical incertitude, a nuclear biliary scan (HIDA or DESIDA browse) may exist performed.
- The Common Bile Duct: A dilated common bile duct is another sign of astute cholecystitis. The normal mutual bile duct inner bore should exist less than 4mm, but may be higher, up to 10mm, post-cholecystectomy. In addition, the diameter may be higher in older patients, up to 1mm per decade of life.
- The Gallbladder Contents: Look for a dilated gallbladder, bear witness of stones, and for sludge. Gallstones should be mobile, unless they are impacted in the gallbladder neck, and should cast an acoustic shadow. If all stones are mobile in a patient who remains symptomatic, consider that they may be a red herring and non the true crusade of the patient's hurting. Recall that approximately 15% of adults have asymptomatic gallstones. If there are no sonographic signs of cholecystitis, but a gallstone is impacted (not-mobile) in the gallbladder neck, exist suspicious for early cholecystitis and consider admission, additional imaging, or at least next-twenty-four hour period follow-upwards. Always as well consider early on cholecystitis when pain lasts for more than than six hours, even when the ultrasound is normal except for the presence of a stone. Uncomplicated gallstone attacks usually should only last a few hours. Make sure to explain this to patients if you for some reason decide to ship them habitation with opiates. Attacks lasting longer than that may be something more than serious.
- Pitfalls: Don't miss a single obstructing gallstone hidden in the gallbladder neck. It can sometimes exist difficult to see. Also, practice non get faked out by an incidental "red herring" gallstone. Every bit previously mentioned, many people have gallstones for years with no symptoms, then if everything does not fit clinically, expect further for something else causing the abdominal, flank, or rib pain. Some examples include aortic aneurysm, Fitz-Hugh-Curtis syndrome, loftier appendicitis, PE, kidney stone, and pneumonia. Finally, don't miss an AAA, even if it is also incidental, because yous did not expect for it. Ultrasound techs look. The aorta is not that far away, and should be checked routinely in anyone over the age of 50 who is having an abdominal ultrasound for another reason. Screening saves lives!
Source: https://epmonthly.com/article/red-flags-impending-gallbladder-rupture/
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