PMC4384720_01
Timeline of hospital events and severity of right upper quadrant pain. HD, hospital day; POCUS, point-of-care ultrasound; RUQ, right upper quadrant; US, ultrasound; GB, gallbladder; SMS, sonographic Murphy sign. The cross symbol represents the patient's pain level.
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Fig1
A formal RUQ ultrasound (Figure 1, Timeline = 'Formal RUQ US #1') was obtained that afternoon, 8 h after bedside assessment of the patient, and showed a few small stones within the gallbladder, a normal gallbladder wall, no pericholecystic fluid, no ductal dilatation (Figure 2), and a negative sonographic Murphy sign. A POCUS exam (Figure 1, Timeline = 'POCUS #2') was repeated by the internal medicine resident with an ultrasound mentor and showed bilateral diffuse pulmonary B-lines (interstitial pattern) consistent with new pulmonary edema.
Formal right upper quadrant ultrasound #1. (A) Long and (B) short axis views showing a few small stones within the gallbladder, with no gallbladder wall thickening or pericholecystic fluid.
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Fig2
A formal RUQ ultrasound (Figure 1, Timeline = 'Formal RUQ US #1') was obtained that afternoon, 8 h after bedside assessment of the patient, and showed a few small stones within the gallbladder, a normal gallbladder wall, no pericholecystic fluid, no ductal dilatation (Figure 2), and a negative sonographic Murphy sign. A POCUS exam (Figure 1, Timeline = 'POCUS #2') was repeated by the internal medicine resident with an ultrasound mentor and showed bilateral diffuse pulmonary B-lines (interstitial pattern) consistent with new pulmonary edema.
POCUS #2. (A) Long and (B) short axis views of the gallbladder showing abnormal gallbladder wall thickening to 0.78 cm with edematous narrowing of the gallbladder neck. (C) IVC measuring 2 cm with <10% inspiratory collapse and associated hepatic vein engorgement indicating volume overload. (D) Diffuse pulmonary B-lines consistent with interstitial edema.
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Fig3
Despite the unremarkable formal RUQ ultrasound 42 h prior, POCUS at the time of her recurrent RUQ pain revealed a markedly abnormal gallbladder with wall thickening to 8 mm, narrowing of the gallbladder neck due to edema, a small non-obstructing gallstone, a normal common bile duct, subserosal edema, and pericholecystic fluid (Figure 3).
Formal right upper quadrant ultrasound #2. (A) Formal ultrasound long axis and (B) short axis views confirming gallbladder wall thickening (0.58 cm, 6 h after bedside ultrasound and initiation of diuresis).
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Fig4
Timeline = 'Formal RUQ US #2') confirmed new marked echogenic gallbladder wall thickening (decreased to 6 mm with diuresis between POCUS and the formal study), pericholecystic fluid, and a normal common bile duct with no impacting cholelithiasis (Figure 4). The formal RUQ ultrasound impression was 'acute cholecystitis.' Cholecystectomy versus percutaneous cholecystostomy was recommended, pending the outcome of cholescintigraphy and the patient's overall medical stability.
POCUS #3. (A) Long axis and (B) short axis views showing improvement in gallbladder wall thickening after diuresis, with gallbladder wall thickness measuring 0.15 cm.
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Fig5
Timeline = 'POCUS #3') was again repeated and showed significant improvement, without gallbladder wall thickening or sonographic Murphy sign (Figure 5). The patient was discharged without RUQ pain after optimization of her volume status without plans for future cholecystectomy.