Kelly Dougherty, PGY - 1

Article Title: A Case of Expedited Diagnosis By Point of Care Ultrasound in the Emergency Department

Author: David Reens, MD and Beata Podgorski, AGACNP-S

Study: Case report w/ N=1, observational/retrospective

Question: Proof of concept - can US be used to detect hemorrhagic cholecystitis?

Point of care ultrasound is key in the diagnostic pathway for acute cholecystitis. However, it’s use in complications of acute cholecystitis is less known. This case report presents an instance of point of care ultrasound in a patient with a complication (hemorrhage cholecystitis) from acute cholecystitis.

Case: 76 year old (pmhx HTN, HLD, DM, afib on warfarin, CAD) presents with abdominal pain radiating to his back, with associated nausea, and vomiting. He was tachycardic, febrile, hypotensive, and his exam was positive for abdominal tenderness.

His labs demonstrated a white cell count of 26K, T bili 1.8, AST 332, ALT 178, lipase 7761, INR 4.3.

Findings: RUQ ultrasound demonstrated an edematous gallbladder wall (0.72 cm), focal pericholecystic fluid, and a hyperechoic, non-shadowing globular structure inside the gallbladder. CT scan demonstrated hemorrhage cholecystitis with a perforated gallbladder.

Editorial: This paper and the attached images demonstrate a scenario where a sick patient (elderly, comorbidities) presented with severe sepsis and abdominal tenderness. The RUQ ultrasound demonstrated a hyperechoic gallbladder mass as well as findings diagnostic of acute cholecystitis (edematous wall, pericholecystic fluid). CT ultimately provided the diagnosis. Given that there are multiple complications of acute cholecystitis with high morbidity/mortality, including some which do not image well with ultrasound (emphysematous cholecystitis), the role of ultrasound in parsing out complications is limited. As a “proof of concept” paper, this case demonstrates that blood can be visualized within the gallbladder. Here, it was a hyper-echoic globular structure that would not be easily discernible from a mass. The case did not discuss any changes in management that resulted from the POCUS, including selection of broad-spectrum antibiotics.