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Age: 46

Sex: Female

Indication: Right upper quadrant pain, elevated liver function tests

Sonographic Murphy sign: Negative

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Case #4


Findings

  • Edematous and thickened gallbladder wall
  • Gallbladder is nondistended with no gallstones identified
  • Liver is enlarged measuring 21.6 cm in craniocaudal span with possible mildly nodular surface contour
  • Diffusely increased echogenicity of the hepatic parenchyma, which markedly limits assessment of the intrahepatic portal and hepatic veins and intrahepatic bile ducts
  • Reversal of flow in the main portal vein
  • Normal appearance of the spleen, kidneys, and urinary bladder
  • Visualized portion of the pancreas appears normal
  • Visualized portions of the abdominal aorta are normal in caliber


Diagnosis

Hepatitis

Sample Report

Hepatomegaly with diffusely increased echogenicity of the hepatic parenchyma, suggestive of steatosis, which limits assessment of the intrahepatic veins and bile ducts. Reversal of flow in the main portal vein likely relates to intrinsic liver disease. Despite this, the spleen appears normal in size and no ascites is identified.

Edematous and thickened gallbladder wall without distension or gallstones, favored to relate to adjacent liver disease.

Query mildly nodular hepatic surface contour, concerning for cirrhotic change.


Discussion

  • Gallbladder wall thickening without distension or gallstones is unlikely to represent acute cholecystitis (except in rare cases of acalculous cholecystitis) and an alternate diagnosis should be considered
  • It is common for hepatitis (which was alcoholic in this case) to result in gallbladder wall edema, which can be confused for acute cholecystitis
  • Marked gallbladder wall thickening has been described as particularly characteristic for hepatitis A
  • In the naïve liver, hepatitis may result in decreased parenchymal attenuation, which increases the conspicuity of portal triads (the so-called “starry sky” appearance), but this finding is incredibly insensitive for hepatitis and is probably not even worth remembering
  • The ultrasound appearance of acute on chronic hepatitis is even more confusing, making the diagnosis difficult or impossible on ultrasound
  • Think of underlying chronic hepatitis when you see:
    • Enlarged liver (measuring > 15.5 cm craniocaudally in the midclavicular line), though this can be seen with acute hepatitis in an otherwise normal liver
    • Increased parenchymal echogenicity (hepatic echogenicity similar or greater than that of the right kidney, assuming the kidney is normal), which suggests hepatic steatosis, though the absence of this finding does not preclude steatosis
    • Nodular hepatic surface contour (best observed when imaging with a high-frequency linear probe) indicative of cirrhosis
    • Asymmetric enlargement of the left and caudate lobes, also a finding seen in cirrhosis
  • Fortunately, hepatitis is a clinical diagnosis and the value of ultrasound is to look for precipitating factors and complications
    • Make sure to assess the portal and hepatic veins as well as the IVC, as thrombosis may precipitate or result from hepatitis
    • Look for hepatic abscesses, which will typically appear as heterogeneous structures without internal Doppler flow
  • In patients with chronic liver disease, make sure to also look for liver lesions to raise concern for hepatocellular carcinoma



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