Cholecystitis : Full house

Images Victoria Bond Text Genevieve Carbonatto

A 42 year old lady presents to the Emergency Department with RUQ pain. She has had episodes of cholelithiasis in the past. She is mildly tender in her RUQ. A point of care ultrasound is performed along with the history and examination.

This is her ultrasound

Note the GB is full of sludge. There is an obstructing stone in the neck of the GB. The wall of the GB is thickened (>0.3cm)

The CBD is dilated (> than o.6cm)

An obstructing mass is seen in the CBD. It is rounded and looks very much like tumified sludge or possibly a calculus. It is accompanied by a faint acoustic shadow.

Discussion

  • Approximately 90 – 95% of acute cholecystitis are related to gallstones. 5 – 10% of cholecystitis being acalculous
  • The hallmarks of acute cholecystitis includes the presence of stones, especially if obstructing the neck of the gallbladder, the presence of sludge, GB wall thickening of > 3mm, pericholicystic fluid and a sonographic +ve Murphy’s test.
  • Choledocholithiasis associated with cholecystitis is found in 10% of patients (5)
  • A +ve sonographic Murphy’s sign combined with the presence of stones has been associated with a positive predictive value of 92%, and if combined with gallbladder wall thickening 95% for the diagnosis of cholecystitis
  • A +ve Murphy’s sign in the elderly is not always present.  In one  retrospective  study (4)  the diagnostic accuracy for acute cholecystitis was 80% dropping to 34% when the sign was negative. Caution should be exercised therefore before a diagnosis of cholecystitis is excluded on the basis of a negative Murphy’s sign in elderly patients presenting with abdominal pain.

 

References

  1. Emerg (Tehran). 2018;6(1):e11. Epub 2018 Jan 20.Emergency Department Bedside Ultrasonography for Diagnosis of Acute Cholecystitis; a Diagnostic Accuracy Study.
    Shekarchi B1, Hejripour Rafsanjani SZ2, Shekar Riz Fomani N2,3, Chahardoli M3
  2. Can J Surg. 2014 Jun; 57(3): 162–168 Does ultrasonography accurately diagnose acute cholecystitis? Improving diagnostic accuracy based on a review at a regional hospital Hamish Hwang, MD,*† Ian Marsh, BSc, MD,* and Jason Doyle, MD*†
  3. Radiology. 1985 Jun;155(3):767-71.Real-time sonography in suspected acute cholecystitis. Prospective evaluation of primary and secondary signs.Ralls PW, Colletti PM, Lapin SA, Chandrasoma P, Boswell WD Jr, Ngo C, Radin DR, Halls JM
  4. J R Coll Surg Edinb. 1996 Apr;41(2):88-9. Murphy’s sign, acute cholecystitis and elderly people. Adedeji OA1, McAdam WA
  5. Arch Surg. 1979 Aug;114(8):887-8.Choledocholithiasis associated with acute cholecystitis.Pitluk HC, Beal JM

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