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Age: 85

Sex: Male

Indication: Right upper quadrant pain

Sonographic Murphy sign: Positive

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Case #5


Findings

  • Multiple gallstones layering in the gallbladder
  • Gallbladder is distended with a thickened, hypoechoic wall
  • Small amount of pericholecystic fluid
  • Liver is mildly enlarged, measuring 18.1 cm in craniocaudal span
  • No biliary duct dilation
  • Normal appearance of the kidneys, spleen, and of the visualized portion of the pancreas


Diagnosis

Acute cholecystitis

Sample Report

Cholelithiasis with gallbladder distension, gallbladder wall thickening and edema, pericholecystic fluid, and positive sonographic Murphy sign, consistent with acute cholecystitis.


Discussion

  • The following ultrasound findings support a diagnosis of acute cholecystitis:
    • Gallstones, particularly a gallstone lodged in the gallbladder neck or cystic duct
    • Gallbladder distension
    • Gallbladder wall thickening
    • Pericholecystic inflammatory changes/fluid
    • Positive sonographic Murphy sign
  • Many radiologists shy away from confidently making the diagnosis of acute cholecystitis, which leads to additional (and often unnecessary) imaging and delayed intervention. Think about it: cholecystitis and appendicitis both typically result from obstruction and are usually managed laparoscopically, but radiologists make the diagnosis of appendicitis without hesitation on ultrasound or CT but often are more vague and suggest additional imaging confirmation (e.g. HIDA) when approaching cholecystitis
  • Here are some common pitfalls:
    •  About 5-10% of cases of acute cholecystitis are acalculous – think about this especially in patients with underlying severe systemic illness
    • While ultrasound is more sensitive than standard CT imaging for gallstones, ultrasound and CT are equally sensitive and specific for acute cholecystitis – take away: you do not need to confirm negative or positive CT findings with ultrasound in the acute setting
    • The sonographic Murphy sign does not have to be positive in acute cholecystitis – it is useful when supportive of other imaging findings, but does not preclude the diagnosis if discordant
    • The gallbladder physiologically distends when a patient is fasting
    • Adjacent liver disease may cause gallbladder wall thickening
    • Common bile duct obstruction may result in gallbladder distension and even wall thickening


Images

Multiple echogenic gallstones layering in the gallbladder (red arrows) with associated posterior acoustic shadowing (yellow arrows). Gallbladder wall thickening (red dotted line). Hypoechoic appearance of the gallbladder wall is indicative of edema.

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