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Emergency Ultrasound

Cases That Count: Right upper quadrant (RUQ) pain: An unusual presentation for an unusual finding

By John T. Moeller MD, Seth Lotterman MD and Meghan Kelly Herbst, MD, FACEP

Questions

  1. What is the diagnosis demonstrated in the clip?
  2. What is the epidemiology of this disease in healthy young individuals?
  3. What other conditions can result in gallbladder wall thickening or pericholecystic fluid?


CLIP FROM THE CASE (YouTube Video)

Case Presentation

A 27-year-old healthy female on Depo-Provera presented to the ED with constant, sharp, non-radiating right upper quadrant (RUQ) pain for three days. The pain was unchanged with food intake, and was associated with nausea and one episode of non-bloody, non-bilious emesis on the day prior to presentation. She also reported pleuritic right lower chest pain, lightheadedness, and chills. On further review of systems, she denied sore throat, shortness of breath, cough, rash, urinary changes, diarrhea, and bloody stools. Social history was unremarkable.

On exam, she was afebrile (36.8C), with blood pressure 149/88, heart rate 51, respiratory rate 18, and oxygen saturation 100%. She appeared uncomfortable. Her head, neck, heart, and lung exams were unremarkable. Her abdomen was soft, non-distended, with RUQ tenderness and a positive Murphy’s sign. There was no guarding or rebound tenderness. The remainder of her physical exam was unremarkable.

A point-of-care ultrasound (POCUS) demonstrated gallbladder wall thickening, pericholecystic fluid, and a sonographic Murphy’s sign without evidence of gallstones. Liver function tests, complete blood count, and basic metabolic panel were all within normal limits. Urine pregnancy was negative. Urinalysis was negative for infection. A formal hepatobiliary ultrasound confirmed the POCUS findings consistent with acalculous cholecystitis, with the common bile duct diameter measured at 0.4 cm. Surgery was consulted.

Given her pleuritic pain, light-headedness and her increased risk of thrombosis in the setting of Depo-Provera injections, a high sensitivity d-dimer was sent and returned elevated at 5276 ng/mL (the cutoff for exclusion of venous thromboembolism is < 230 ng/ml). Of note, the patient had a negative d-dimer of < 150 ng/mL at an unrelated ED visit 3 months prior. On account of the unusual presentation of acalculous cholecystitis in an otherwise healthy woman, surgery recommended a computed tomography (CT) scan of the abdomen and pelvis to rule out intra-abdominal inflammatory changes, fluid collections, or other pathology. A CT angiogram of the chest was added to exclude pulmonary embolism. All imaging was negative for acute intra-pulmonary and intra-abdominal pathology other than the abnormal gallbladder findings. The patient was taken to surgery, with a postoperative diagnosis of acalculous cholecystitis.

Days after discharge, the patient was readmitted for a new-onset tonic-clonic seizure and was diagnosed with posterior reversible encephalopathy syndrome (PRES), nephritis and malignant hypertension. After extensive work up for systemic disease, including autoimmune serology, HIV, EBV, hepatitis, vasculitis, and malignancy, she has undergone outpatient workup and treatment for suspected systemic lupus erythematosus (SLE) after positive ANA and DS DNA antibody results.

Role of RUQ POCUS in the Emergency Department

 Abdominal pain is the most common presenting complaint to emergency departments, accounting for nearly 10 million emergency visits alone in 2013, or 7.7% of all visits.1 Of the estimated 700,000 cholecystectomies performed annually in the United States, > 90% are for acute calculous cholecystitis, and 95% of patients with acute cholecystitis will have associated gallstones.2 POCUS of the RUQ has become a safe, cost-effective imaging modality of choice for guiding the differentiation of medical and surgical causes of RUQ pain.

Signs of acute cholecystitis on POCUS include: cholelithiasis, a sonographic Murphy’s sign (the presence of maximal tenderness elicited over a sonographically localized gallbladder), gallbladder wall thickening, and pericholecystic fluid.3-5 Gallbladder wall thickening is defined as wall thickness > 0.3-0.5cm.3,4,6,7 The combination of gallstones and a sonographic Murphy’s sign is both specific and sensitive for acute cholecystitis, with a positive predictive value (PPV) of 92%. The addition of gallbladder wall thickening increases the PPV to 95%.3 Studies have demonstrated that emergency physicians diagnose acute cholecystitis with POCUS with similar sensitivity and specificity to formal radiology studies at 87% and 82%, respectively, for emergency physicians as compared to 83% and 86%, respectively, for radiology-performed studies.4

Answers to Questions

  1. The clip demonstrates acute acalculous cholecystitis (AAC). Thickening of the gallbladder wall without evidence of stones is the single most reliable ultrasound finding for AAC.8 To satisfy the diagnosis of AAC by ultrasound requires the inclusion of two major criteria (gallbladder wall thickening > 3 mm, striated gallbladder, sonographic murphy’s sign, pericholecystic fluid, mucosal sloughing, or intramural gas) or one major plus two minor criteria (gallbladder distention > 5 cm in transverse diameter, echogenic bile or sludge).9
  2. Gallbladder stasis and ischemia can lead to AAC. Elderly, critically ill, and post-operative patients are classically thought to be at risk. However, many inflammatory and infectious processes can lead to AAC, including diabetes mellitus, end-stage renal disease, cancer, acquired immune deficiency syndrome, abdominal vasculitis, and congestive heart failure. AAC occurs in 2-15% of all cases of acute cholecystitis in the general population.10 Among children, AAC represents up to 50-70% of cases of acute cholecystitis, with dehydration, viral infection, and upper respiratory infections representing the most common precipitants of the disease.11 Exceedingly rare, a de novo presentation of AAC in an otherwise healthy individual should prompt further investigation of underlying causes. In a retrospective review of 8411 hospitalized patients with SLE from 2001 to 2015, 13 patients (0.15%) were found to have acute acalculous cholecystitis.12 Four of the thirteen patients presented with AAC as the initial manifestation of SLE.12
  3. Hepatitis, pancreatitis, severe pyelonephritis, liver dysfunction, heart and renal failure, or sepsis can all lead to gallbladder wall thickening and pericholecystic fluid.

 


 

References:

  1. National Center for Health Statistics. National hospital ambulatory medical survey: 2013 emergency care summary tables. https://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2013_ed_web_tables.pdf. Accessed June 14, 2016.
  2. Marx JA, Hockberger RS, Walls RM, “Rosen's Emergency Medicine Concepts and Clinical Practice” 8th Edition, 2014.
  3. Strasberg SM. Clinical practice. Acute calculous cholecystitis. New Engl J Med. 2008; 358: 2804-11.
  4. Summers SM, Scruggs W, Menchine MD, et al. A prospective evaluation of emergency department bedside ultrasonography for the detection of acute cholecystitis. Ann Emerg Med. 2010; 56(2): 114-22.
  5. Bree RL. Further observations on the usefulness of the sonographic Murphy sign in the evaluation of suspected acute cholecystitis. J Clin Ultrasound. 1995; 23(3): 169-72.
  6. Pinto A, Reginelli A, Cagini L, et al. Accuracy of ultrasonography in the diagnosis of acute calculous cholecystitis: review of the literature. Crit Ultrasound J. 2013; 5(Suppl 1):S11.
  7. Runner GJ, Corwin Mt, Siewert B, et al. Gallbladder wall thickening. AJR Am J Roentgenol. 2014; 202: W1–W12
  8. O’Connor OJ, Maher MM. Imaging of cholecystitis. AJR Am J Roentgenol. 2011; 196: W367-W374.
  9. Huffman JL, Schwenker S. Acute acalculous cholecystitis: a review. Clin Gastroenterol Hepatol. 2010; 8: 15-22.
  10. Treinen C, Lomelin D, Krause C, et al. Acute acalculous cholecystitis in the critically ill: risk factors and surgical strategies. Langenbecks Arch Surg. 2015; 400: 421-427.
  11. Imamoglu M, Sarrhan H, Sari A, et al. Acute acalculous cholecystitis in children: diagnosis and treatment. J Pediatr Surg. 2002; 37:36-7.
  12.  Yang H, Bian S, Zhang F, et al. Acute acalculous cholecystitis in patients with systemic lupus erythematosus: A unique form of disease flare. Lupus. 2017;0:1-5.

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