Lecture Notes
When a patient presents with a cc of ruq abdominal pain the first thing you will do. Like we do with all other chief complaints is create a list of critical differential diagnosis.
Critical Differential Diagnosis:
Symptomatic cholelithiasis
Acute cholecystitis
Choledocholithiasis
Gallstone pancreatitis
Cholangitis
Pancreatitis
(insert all ddx for abdominal pain including appendicitis)
Consider retroperitoneal structures (i.e. AAA or pancreatitis).
In this lecture we will focus on the biliary system.
When you look at the RUQ US the questions you want to ask yourself is if there is
Gallstones
Gallbladder Wall Thickness (Gallbladder anterior wall <3 mm)
Biliary Sludge
Pericholecystic fluid
CBD Dilation (nml: Common bile duct < 6 mm plus 1mm per decade after 60 yrs old)
Sonographic Murphy’s sign
Symptomatic Cholelithiasis
Ultrasound will reveal gallstones without any signs of inflammation and no dilation of the CBD.
Treatment: Pain management followed by outpatient surgical evaluation.
Acute Cholecystitis:
Ultrasound:
+Gallstones
+Gallbladder wall thickening
+Biliar Sludge
+Pericholecystic fluid
+Sonographic Murphys
Treatment:
Antibiotics: Cover gram negatives (i.e. Ceftriaxone) and Anaerobes (i.e. Flagyl)
Emergent surgical consult with admission
Choledocholithiasis
Ultrasound:
+Gallstones
+Dilated CBD
Labs:
Elevated LFTS
Treatment:
Needs ERCP. Consult whoever does that at your facility GI vs surgery
No need for abx unless pt is having fevers or other signs of infection
Summary: Dilated CBD + LFTs = Choledocholithiasis.
Gallstone Pancreatitis
Ultrasound:
+Gallstones
Labs:
Elevated Lipase
Treatment:
Needs ERCP. Consult whoever does that at your facility GI vs surgery
No need for abx unless pt is having fevers or other signs of infection
Cholangitis
Charcots Triad:
Fever
Jaundice
RUQ Pain
Reynold’s Pentad:
Charcots Triad + altered mental status + hypotension
Treatment:
Aggressive sepsis management with ivf and pressors
IV ABX
Consult
GI for emergent ERCP
Surgery for cholecystectomy
IR for possible percutaneous drain
DDXof.com Algorithm For Hepatobiliary Ultrasound
Full ddxof.com article and algorithm on Hepatobiliary Ultrasound can be found at https://ddxof.com/hepatobiliary-ultrasound/
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