Slide 1

Anthony E. Hanbidge

Acute Upper

Quadrant Pain

(Case-based approach)

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Slide 2 Abdominal/Pelvic Pain

•Most common presenting symptom

•Approximately 7% all ED visits

•Acute RUQ >>>> Acute LUQ

•Hepatobiliary disease – common &

important

•Determining cause - clinical challenge

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Slide 3 RUQ Pain

•Diagnosis based on clinical & labs:

inaccurate

•Imaging critical to management

•Ultrasound should always be initial

imaging test

•Accurate, safe, inexpensive, available,

portable

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Slide 4 Learning Objectives

1) Discuss the value of US in assessing

the patient with acute RUQ pain

2) Identify the imaging features of acute

cholecystitis and its complications

3) Describe other conditions that can

cause acute pain in RUQ when GB

normal

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Slide 5 “Rule out Acute Cholecystitis”

•Acute cholecystitis and complications

•Choledocholithiasis and ascending

cholangitis

•Recurrent pyogenic cholangiohepatitis

•Liver abscess

•Rupture/hemorrhage of liver masses

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Slide 6 Acute Cholecystitis - Ultrasound

•Accuracy 88%

•Similar to scintigraphy

BUT

•Will show complications, alternate

diagnoses

•Scintigraphy more time consuming

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Slide 7 Acute Cholecystitis

•90% to 95% have cholelithiasis

•Calculus obstruction neck or cystic duct

•Variable degrees infection and necrosis

•RUQ pain, tenderness and guarding

•Spectrum: Mild to dramatic

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Slide 8

Each of the following four patients

presented with pain and tenderness

in the right upper quadrant. Which of

the following ultrasound appearances

is most typical of acute cholecystitis?

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Slide 9

4)3)

2)1)

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Slide 10 Acute Cholecystitis: US findings

•Most sensitive: sonographic Murphy’s

sign in presence stones

PPV 92%, 497 patients

(Ralls et al, Radiology 1985;155:767-771)

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Slide 11 Acute Cholecystitis: US findings

•Gallbladder distension

•Diffuse wall thickening

•Pericholecystic fluid

Secondary findings: Not sensitive nor

specific

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Slide 12 Acute Cholecystitis: US findings

•GALLBLADDER DISTENSION

Be reluctant to diagnose acute

uncomplicated cholecystitis if GB not

tensely distended

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Slide 13

4)3)

2)1)

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Slide 14

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Slide 15 Pitfalls/Mimics

Courtesy of Dr. S. WilsonAcute Hepatitis

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Slide 16 Pitfalls/Mimics

Not tensely distendedPerforated Duodenal Ulcer

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Slide 17 Pitfalls/Mimics

Cirrhosis

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Slide 18 Pitfalls/Mimics

Acute Diverticulitis with Perforation

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Slide 19 Acute Cholecystitis: US findings

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Slide 20

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Slide 21

www.laparoscopy.com

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Slide 24

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Slide 25 Gangrenous Cholecystitis

•2% to 38% of acute cholecystitis

•Asymmetric thickening GB wall

•Intraluminal membranes

•-ve sonographic Murphy’s sign: 66%

•Symptoms and signs may shift from

RUQ

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Slide 27

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Slide 28

Acute cholecystitis; 1) Yes

2) No

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Slide 29

Gallbladder Perforation

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Slide 30 Gallbladder Perforation

•5% to 10% of acute cholecystitis

•19% to 24% mortality

•Acute - generalized peritonitis

•Subacute - pericholecystic abscess

•Chronic - internal biliary fistula

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Slide 31

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Slide 32

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Slide 33

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Slide 34 An 84-year-old man presents to the

emergency department in septic shock.

An abdominal ultrasound is performed.

What is the most likely diagnosis?

1) Perforated duodenal ulcer

2) Gallstone ileus

3) Emphysematous cholecystitis

4) Porcelain gallbladder

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Slide 35

1) Perforated duodenal ulcer 2) Gallstone ileus

3) Emphysematous cholecystitis 4) Porcelain gallbladder

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Slide 36 Emphysematous Cholecystitis

•Rare

•Gas forming bacteria

•Cholelithiasis often absent

•38% patients diabetic - M:F 7:3

•Gangrene/perforation x 5

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Slide 37

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Slide 38

W E S

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Slide 39

?

1) Porcelain

2) Emphysematous

3) Stones

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Slide 40

Courtesy of Dr. K. Khalili

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Slide 41

Gallstone Ileus

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Slide 43

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Slide 44

Bouveret’s

Syndrome

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Slide 45 Choledocholithiasis

•Ultrasound 70% sensitivity (Laing et al, AJR 1984;143:949-952)

•Dilated ducts improves detection

•Advances: Harmonic imaging

•Distal CBD: erect RPO

•Proximal/mid: supine/LPO

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Slide 46

2.56 cm

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Slide 47

1) Stone 2) Tumor 3) Can’t tell

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Slide 48

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Slide 49

1) Doppler 2) CT 3) MR/MRCP

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Slide 50 Ascending Cholangitis

•Pain, fever, leucocytosis, elevated LFTs

•Ultrasound hallmark: bile duct wall

thickening

•CBD obstruction (stones)

•Intervention

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Slide 51 Septic Shock

PV

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Slide 52 Septic Shock

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Slide 53 A 34-year-old woman presents to the

emergency department with acute right

upper quadrant pain and fever. Abdominal

ultrasound demonstrates a liver mass.

What is the most likely diagnosis?

1) Liver abscess

2) Hepatic adenoma

3) Hepatocellular carcinoma

4) Cavernous hemangioma

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Slide 54

1) Liver abscess 2) Hepatic adenoma

3) Hepatocellular carcinoma 4) Cavernous hemangioma

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Slide 55 Liver Abscess

•Pyogenic or Amebic: Pain, fever,

malaise

•No underlying cause in 50%, anaerobes

•Biliary tract, gut, bone, heart

•Percutaneous image guided drainage

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Slide 56

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Slide 57

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Slide 58 Masses that Rupture and Bleed

•Adenoma, hepatocellular carcinoma,

others

•Patient profile:

- premenopausal woman on BCP

- known cirrhotic, hepatitis B, C

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Slide 59 Hepatic Adenoma

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Slide 60 Hepatic Adenoma

Courtesy of Dr. M. Asch

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Slide 61 Hepatocellular Carcinoma

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Slide 62

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Slide 63 Hemangioma

Courtesy of Dr. M. Asch

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Slide 64 Summary

•Be reluctant to diagnose simple acute

cholecystitis if GB not tensely distended

•Look for stone in GB neck and cystic

duct

•Remember possibility underlying GB

cancer

•Air vs. Calcium: Character of shadowing

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Slide 65 Summary

•Straight to ERCP if CBD stone on US

•Include unenhanced CT for CBD stone

•Doppler cystic masses

•Early abscess ? solid on US - do CT

•Ruptured mass: adenoma/HCC - Patient

profile

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Slide 66

Thank you

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