A 63 year old male with a history of diabetes and hypertension presents with epigastric pain, vomiting, and fever. He is ill appearing with dry mucous membranes. His RUQ is tender to palpation. Emergency Bedside Ultrasound obtained the following images.

Discussion: Undifferentiated abdominal pain is a common emergency room presentation. One of the most common causes is gallbladder disease, which, in 2009 alone, was responsible for 700,000 emergency room visits. The prevalence of gallbladder pathology necessitates timely and accurate diagnosis, which can be achieved with proper use of point of care ultrasound. Multiple studies have demonstrated the emergency physician to be highly sensitive and specific in proper identification of cholelithiasis and cholecystitis.

Gallstones will typically appear as hyperechogenic structures with posterior acoustic shadowing, that may not be present if the stone is less than 2mm in diameter.

In the appropriate clinical setting, acute cholecystitis can generally be diagnosed with one or more of the following findings on ultrasound:

Pericholecystic fluid
Gallbladder wall thickening greater than 3mm
Presence of a sonographic Murphy’s sign

Pitfalls:

Mistakes the duodenum for the gallbladder.
Over-interpreting the significance of gallbladder wall thickening: Patients with ascites may have a thickened gallbladder wall without the presence of cholecystitis.
Failure to identify gallbladder: Have your patient change positions, and or use the patients respiratory variability in order to properly view gallbladder.

References:

Lanoix et al. Am J Emerg Med 2000;18:4145

Ma, O. J. (2014). Ma and Mateers emergency ultrasound. New York: McGraw-Hill Education Medical.