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Ultrasound

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  • ???Better at End of talk regarding Pitfalls????
  • Nl layering on L, clumped on R
  • Transcript

    • 1. Hepatobiliary Ultrasound Introduction to Emergency Ultrasound
    • 2. Goals
      • Why ultrasound?
      • Anatomy
      • Technique
      • Cholelithiasis
      • Cholecysitis
      • Pearls and Pitfalls
    • 3. Why ultrasound?
      • Hepatobiliary imaging modalities:
        • Ultrasound
        • CT
        • HIDA
        • MRI
        • ERCP
      • Benefits of Ultrasound
        • Performed at bedside
        • Fast information within 5-10 minutes
        • No radiation, No contrast, Low cost
        • Sensitivity 94% with specificity 78%
              • -Shea Arch Int Med 1994
    • 4. Why ultrasound?
      • Evaluation for:
        • Cholelithiasis
        • Cholecystitis
        • Choledocholithiasis
        • Jaundice
    • 5.
      • 1242 patients over 3 years receiving RUQ US
        • 753 from EPs
        • 489 from radiology
      • Average decrease in LOS 22 minutes if received EP US
      • After hours LOS decreased by 1:13 in EP US group
      Academic Emergency Medicine 1999
    • 6. RUQ Anatomy
      • Gallbladder:
      • Posterior to Liver
      • (acoustic window)
      • Right of the Portal Vein
      • Anterior to Duodenum
      • (Beware of Fake-outs)
    • 7. GB Variable Location
      • Scan entire RUQ
        • Midline to Mid-axillary line
      • Always Right of Falciform Ligament
      • Usually Right of Portal Vein
    • 8. GB US Anatomy
      • Gallbladder
        • 7-8 cm long
        • 2-3 cm diameter
          • Max normal <4 cm
      • GB wall
        • <2mm (97% cases)
        • Three layers
          • Outer – reflective
          • Muscular – anechoic
          • Inner – reflective
        • Measure -transverse view
    • 9. GB US anatomy - vascular
      • Distinguishing Hepatic Veins from Portal Veins
      • Hepatic Veins
        • -Thin Walled
        • -Converge into IVC
      • Portal Veins
      • -Echogenic Walls
      • -Branch from Portal Vein
    • 10. Technique
      • Liver is sonographic window
      • NPO (yeah, right)
      • Probe - curvilinear 2-5 MHz
      • Patient positioning
        • Supine
          • Subcostal
          • Deep inspiration and hold
            • Diaphragm pushes liver and gallbladder down
        • Left lateral decubitus
          • Allows GB drop down
        • Intercostal oblique
          • Liver window thru ribs
    • 11. Technique
      • Scan
        • Orientation marker toward head in midline
        • Scan laterally under R costal margin
        • Expect to see gallbladder around midclavicular line
        • Rotate probe to transform image of GB into long axis view
        • Confirm that it is GB by it's &quot;pointing&quot; to R portal vein along main lobar fissure
    • 12. Technique Main Lobar Fissure between gallbladder and right portal vein
    • 13. Technique
      • Two perpendicular views, fanning through gallbladder
        • Longitudinal
        • Transverse
          • 90 o counterclock to longitudinal, fundus to neck
      • Real time scanning
        • Through the entire organ
    • 14. Technique
      • Measurements
        • GB wall thickness
          • anteriorly
        • GB diameter
        • Common bile duct
      4
    • 15. Anatomy Consideration
      • Note gallbladder’s proximity to duodenum
        • Frequent error of novice
    • 16. Anatomy Consideration
      • Normal Folds
        • Crisp folds are normal
        • Hartman's pouch
          • folded neck
        • Apical fold 3%
          • “ Phrygian cap”
        • Septations in neck
          • “ valves of Heister”
    • 17. GB – Imaging Pitfalls
      • Misidentifying duodenum for GB
      • Unusual anatomic location
      • Contracted after eating
        • Smaller thereby harder to find
        • Contracted GB has thicker walls
          • Walls still <4mm
      • Missing the gallbladder neck
      • Bowel gas interfering with imaging
    • 18. Porta Hepatis
      • Portal Triad
      • Hepatic Artery
      • Common Bile Duct
      • Portal Vein
    • 19. CBD US Anatomy
      • <4mm (98% cases)
        • Inner wall to inner wall
            • Bachar JUM 2005
      • Can increase by 1mm/10 yrs age.
      • >10 mm =
        • Likely obstruction
    • 20. Landmark methods for finding CBD
      • Portal Vein - Extrahepatic
        • Runs longitudinally
        • Towards pt’s right shoulder
        • 11 O’clock
        • Rotate to 8 O’clock
    • 21. Porta Hepatis
      • Mickey Mouse Sign
      • Right Ear – Common Bile Duct
      • Left Ear – Hepatic Artery
      • Face – Portal Vein
    • 22. Landmark methods for finding CBD
      • Find “Confluence”
        • Splenic vein joins the SMV to become Portal Vein
        • Probe located in Epigastric - TRV
    • 23. Porta Hepatis - Pitfalls
      • Misidentification of right portal vein as the Common Portal Vein
      • Porta Hepatis off axis
      • Inability to use liver window
          • Left lateral decubitus
          • Have patient take deep breath and hold
            • Brings down liver to use as window
          • Intercostal view
            • Intercostal views take practice and patience
    • 24. Cholelithiasis
    • 25. U/S Gallstone Findings
      • Strongly Echogenic
      • Posterior Acoustic Shadowing
        • “ Clean” shadowing
      • Mobile
        • Move with change in patient position
    • 26.
      • Convenience sample of 109 ED patients undergoing RUQ ultrasound by radiology had EP RUQ US performed
      • 49/51 patients had their gallstones detected on EP RUQ US (96% [87-99])
      • 51/58 pts without gallstones correctly identified by EP RUQ US (88% [77-95])
      Journal of Emergency Medicine 2001
    • 27. Cholelithiasis
    • 28. Cholelithiasis
    • 29. Cholelithiasis
    • 30. Cholelithiasis
    • 31. Cholelithiasis
    • 32. Cholelithiasis - WES sign
    • 33. Sludge
      • Sludge is precursor of stones
        • significance depends clinically
        • including other US findings
            • Ohara 1990, Lee 1988
      • Bizarre echogenic “lava-lamp” shapes
        • Change with movement => flows
      • Can resemble tumor
      • “ pseudosludge” artifact
        • beam width /side lobe artifacts
          • do not layer out with gravity
          • extend beyond walls of GB
          • inconsistent between views
    • 34. Various Stages of Sludge Normal layering Clumpped 29559978 RUQ sludge filled GB29559978_2.2.2005.18.37.5_5.avi
    • 35. Sludge versus Stones
      • Sludge
      • Continuum
      • Crystallized Bile Salts
      • Allow passage of ultrasound waves
      • No shadowing seen
      • Stones
      • End of the continuum
      • Density prevents passage of ultrasound
      • “ Clean” shadowing
    • 36. Cholecystitis
    • 37. Cholecystitis
      • Signs and symptoms
        • RUQ abdominal pain
        • Murphy’s sign
        • Fever/ Chills
        • Leukocytosis
        • Jaundice (choledocolithiasis)
      Later finding
    • 38. Pathophysiology
      • Obstruction
      • Aseptic Inflammation
      • Wall Edema
      • Infection
    • 39. Cholecystitis: US Findings
      • Gallstones
      • Sonographic Murphy’s
      • GB wall edema
        • Especially Focal
      • GB wall thickening
      • Increased Transverse
        • GB diameter
      • Pericholecystic fluid
    • 40. Sonographic Murphy’s sign
      • Find gallbladder and press on it.
      • Sensitivity 60 – 95%
      • Specificity 90 – 95%.
        • Ralls 1985, Ralls 1982, Simeone 1988
      • 92% PPV SonoMurphy+stones
      • Morphine does not interfere with exam
            • -Nelson JEM v28, 2005
    • 41.
      • Sonographic Murphy's by EP
        • Sensitivity = 75%
        • Specificity = 55%
        • Positive predictive value = 17%
        • Negative predictive value = 95%
      Journal of Emergency Medicine 2001
    • 42. Wall Thickness
      • Normal Abnormal
      • Usual thickness – 2mm (4mm upper limit normal)
      • In the clinical setting of acute cholecystitis about 90 - 100% specific, 50 - 70% sensitive
              • Finberg 1979, Birnholz 1981
      • Thickened walls can be due to medical disease ie anasarca
    • 43. Wall thickness
      • Note the edema separating the walls
    • 44. Other causes of thickened walls
      • 55 consecutive patients w/ thick walls
        • one third due to biliary disease
        • out of 28 with medical etiologies:
          • 19 due to hypoproteinemic states
          • 9 due to CHF, 6 due to liver disease, 4 due to CRF
          • 3 due to pancreatitis
            • Coh an 1987
      • Also associated w/ AIDS and ascites
    • 45. Increased Transverse Diameter
      • > 4-5 cm diameter
        • Sens 84.4%
            • Weedle 1986
      • Dependent on degree of inflammatory process
    • 46. Pericholecystic Fluid
      • Seeping inflammatory fluid
        • Gallbladder
        • Liver
      • Consider Perforation
    • 47. Choledocolithiasis
      • View Portal Triad
        • Common bile duct
          • Avg size 4 mm
          • Incr 1mm/ 10 yrs
          • Up to 10 mm post cholecystectomy
          • >10 mm -> Obstruction
    • 48. Choledocolithiasis
      • Allow 1 mm for each decade to max 8.5mm
              • -Bachar JUM 22, 2003
      • CBD increased after cholecystectomy, with age and weight
              • Wu 1984
      • In acute obstruction
        • extrahepatic ducts dilate in > 24 hours
        • intrahepatic ducts 1 to 2 days later
    • 49. Intrahepatic Cholestasis -Too many tubes -best seen in transverse L liver
    • 50. Liver Masses
      • Check echodensity for homogeneity
        • Heterogeneous - consider masses vs edema
    • 51. Liver Masses
    • 52. Pitfalls – Bowel Gas
      • Proximity to colon
        • Hepatic flexure
        • Gas artifact
          • Impossible to state stones.
    • 53. And so remember
      • Real time dynamic scanning
      • Gallbladder
        • 4mm (GB wall)
        • 4cm (GB diameter)
      • CBD
        • Usually <4mm
        • <10 mm max in elderly patient
      • Gallstones always make clean shadows
      • Sludge resembles “lava lamp” layering
      • Check the neck for hidden stones
    • 54. Tips for improving view
      • Supine view with patient holding deep breath to move liver down
      • Intercostal oblique at anterior axillary line
      • Still can't find the gallbladder?
          • Transverse view of upper pole R kidney, then look medial for GB
          • Coronal view of Morison's pouch, then fan 20 degrees anteriorly for GB
    • 55. Pitfalls
      • Bowel gas obscuring the gallbladder
      • Failure to thoroughly scan the neck of the gallbladder
      • Mistaking the duodenum for the GB

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