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Ultrasound

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

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