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Gregory Chang Gillian Lieberman, M.D. November 2001. Quick! Somebody Call a Doctor (Radiologist)! Diagnosing RUQ Pain in an ED Patient. Gregory Chang, HMS III Gillian Lieberman, M.D. Harvard Medical School Beth Israel Deaconess Medical Center Boston, MA. Gregory Chang

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quick somebody call a doctor radiologist diagnosing ruq pain in an ed patient

Gregory Chang

Gillian Lieberman, M.D.

November 2001

Quick! Somebody Call a Doctor (Radiologist)! Diagnosing RUQ Pain in an ED Patient

Gregory Chang, HMS III

Gillian Lieberman, M.D.

Harvard Medical School

Beth Israel Deaconess Medical Center

Boston, MA

objectives

Gregory Chang

Gillian Lieberman, M.D.

Objectives
  • Review the radiologic work-up and findings of an ED patient with RUQ/epigastric pain.
  • Discuss the different imaging modalities available for diagnosing this patient’s disease.
  • Review some typical radiologic findings of this patient’s disease.
let s meet our patient

Gregory Chang

Gillian Lieberman, M.D.

Let’s Meet Our Patient
  • LG, a former alcoholic, is a 48 yo man who presents to the BIDMC ED complaining of severe RUQ and epigastric pain that is radiating to his back. He has had this pain for the last several hours. No n/v/d.
after further questioning

Gregory Chang

Gillian Lieberman, M.D.

After further questioning…
  • PMH: dilated thoracic aorta PUD colonoscopy(polyp removal) 2 days ago pyelonephritis
  • Meds: prilosec, percocet
  • Allergies: NKDA
  • FH: non-contributory
  • SH: former alcoholic (age 18-35)
differential diagnoses

Gregory Chang

Gillian Lieberman, M.D.

Differential Diagnoses
  • Aortic dissection
  • Right-sided pneumonia
  • Acute cholecystitis
  • Acute pancreatitis
  • Chronic pancreatitis
  • Appendicitis
  • Acute hepatitis
  • PUD
  • Perforated viscus
  • Right kidney disease
  • Subhepatic abscess
initial imaging studies for lg

Gregory Chang

Gillian Lieberman, M.D.

Initial Imaging Studies for LG
  • Plain Films: - Chest PA and Lateral - Abdomen Supine and Upright
results

Gregory Chang

Gillian Lieberman, M.D.

Results

PA

Lateral

widenedmediastinum

(images courtesy BIDMC)

results cont

Gregory Chang

Gillian Lieberman, M.D.

Results (cont.)

Erect

Supine

Normal

Abdominal

Plain Films

(images courtesy BIDMC)

next imaging studies for lg

Gregory Chang

Gillian Lieberman, M.D.

Next Imaging Studies for LG
  • Plain Films
  • Ultrasound
  • CT with and w/o contrast
results1

Gregory Chang

Gillian Lieberman, M.D.

Results
  • slight gallbladder wall thickening
  • 1 cm gallstone in gallbladder neck
  • No pericholecystic fluid
  • No gallbladder dilatation
  • No sonographic Murphy’s

(image courtesy BIDMC)

“cholelithiasis with slight wall thickening”

results2

Gregory Chang

Gillian Lieberman, M.D.

Results

CT w/ contrast

CT w/ contrast

Mild dilatation of thoracic aorta

(4.3 x4.6 cm)

Low attenuation mass (malignancy?)

(images courtesy BIDMC)

what imaging study was performed next

Gregory Chang

Gillian Lieberman, M.D.

What imaging study was performed next?
  • Plain Films
  • CT
  • US
  • MRI
results3

Gregory Chang

Gillian Lieberman, M.D.

Results

The area called into question on the CT scan represents focal fat.

T1 In Phase

T1 Out of Phase

water

water

fat

fat

decreased signal intensity

(images courtesy BIDMC)

results cont1

Gregory Chang

Gillian Lieberman, M.D.

Results (cont.)

T1 w/Contrast, Fat Suppressed

  • Gallstone
  • No wall thickening
  • No pericholecystic fluid

(image courtesy BIDMC)

significant findings so far

Gregory Chang

Gillian Lieberman, M.D.

Significant Findings So Far...
  • Gallstone
  • Slight gallbladder wall thickening
what imaging study was performed next1

Gregory Chang

Gillian Lieberman, M.D.

What imaging study was performed next?
  • Plain Films
  • CT and Ultrasound
  • MRI
  • DISIDA Scan - peripheral injection of 99Tc- labeled di-isopropyl iminodiacetic acid, which is taken up by hepatocytes, then excreted in the bile duct system. Images are taken once per minute. Look for non-filling of the gallbladder.
results4

Gregory Chang

Gillian Lieberman, M.D.

Results
  • DISIDA Scan shows non-filling of the gallbladder, consistent w/cholecystitis.
  • Activity is noted within the small bowel at 10 minutes.

(images courtesy BIDMC)

results cont2

Gregory Chang

Gillian Lieberman, M.D.

Results (cont.)
  • Post-morphine images show non-filling of the gallbladder, consistent w/cholecystitis.

(images courtesy BIDMC)

to the or

Gregory Chang

Gillian Lieberman, M.D.

To the OR
  • LG had a lap cholecystectomy
  • Pathology revealed a diagnosis of chronic cholecystitis.
  • LG has not had episodes of RUQ pain since.

http://erl.pathology.iupui.edu/C604query.cfm?Table=Hepatobiliary

(Not LG’s gallbladder)

more typical radiologic findings of cholecystitis

Gregory Chang

Gillian Lieberman, M.D.

More Typical Radiologic Findings of Cholecystitis
  • Plain Films: only 15% of gallstones are visible on plain films.

http://www.med.umich.edu/lrc/coursepages/M1

/anatomy/html/radiology/abdomen/gallstones_1.html

more typical radiologic findings of cholecystitis1

Gregory Chang

Gillian Lieberman, M.D.

More Typical Radiologic Findings of Cholecystitis
  • Plain Films also allow you to detect:
    • gallbladder wall calcification
    • “milk of calcium”: biliary sludge formed from precipitated calcium carbonate crystals (or calcium bilirubinate)

calcified gallbladder wall

http://www.uhrad.com/ctarc/ct186.htm

more typical radiologic findings cont

Gregory Chang

Gillian Lieberman, M.D.

More Typical Radiologic Findings (cont.)
  • Ultrasound: Test of choice if suspicious of cholecystitis.
  • Look for:

- sonographic Murphy’s

- gallstones

- gb wall thickening (> 4-5 mm)

- pericholecystic fluid (hypoechoic halo)

- dilatation of gb

http://www.ibiblio.org/jksmith/UNC-Radiology-Webserver/

Ultrasound/us4.html

more typical radiologic findings cont1

Gregory Chang

Gillian Lieberman, M.D.

More Typical Radiologic Findings (cont.)
  • CT- Not the modality of choice, but very useful. You can detect:

- pericholecystic fluid

- gb wall thickening

- gallstones

- complications

- emphysema

- gangrene

- perforation

- liver abscess

Gas within gallbladder wall

http://www.vh.org/Providers/TeachingFiles/RCW2/121296/

121296.html

more typical radiologic findings cont2

Gregory Chang

Gillian Lieberman, M.D.

More Typical Radiologic Findings (cont.)
  • HIDA/DISIDA Scan – useful when the diagnosis is unclear after US
  • Sensitivity and specificity of 95% for detecting cholecystitis.
  • Look for:
    • non-filling of gallbladder
    • rim sign (pericholecystic hepatic activity)

(images courtesy BIDMC)

more typical radiologic findings cont3

Gregory Chang

Gillian Lieberman, M.D.

More Typical Radiologic Findings (cont.)
  • MRCP:

- can be used to visualize intrahepatic/extrahepatic bile ducts, and pancreatic ducts

- heavily T2-weighted MRI (no contrast needed)

• Excellent for detecting duct obstruction and can be used to detect cholecystitis:

- Sensitivity 100% for detection of stones in cystic duct (US 14%)

- Sensitivity 69% for detection of gb wall thickening (US 96%).

Park et al. Radiology 1998;209:781.

(image courtesy BIDMC)

summary

Gregory Chang

Gillian Lieberman, M.D.

Summary
  • Reviewed an example of diagnostic imaging for RUQ pain
  • Reviewed the different imaging modalities that are available for diagnosing cholecystitis
  • Reviewed the typical radiologic findings for cholecystitis
acknowledgments

Gregory Chang

Gillian Lieberman, M.D.

Acknowledgments
  • Dr. Chad Brecher, Dr. Bettina Siewert, Dr. Haldon Bryer, Dr. Joseph Makris, Dr. Daniel Saurborn
  • Dr. Gillian Lieberman
  • Pamela Lepkowski
  • Kevin Reynolds
references

Gregory Chang

Gillian Lieberman, M.D.

References
  • Gore RM, Levine MS, Laufer I, eds. Textbook of Gastrointestinal Radiology. W.B. Saunders and Company. Philadelphia; 1994.
  • Harris JH and Harris WH, eds. The Radiology of Emergency Medicine. Lippincott Williams & Wilkins. Philadelphia; 2000.
  • Katz DS, Math KR, Groskin SA, eds. Radiology Secrets. Hanley & Belfus, Inc. Philadelphia; 1998.
  • Park MS et al. Acute cholecystitis: Comparison of MR Cholangiography and US. Radiology. 1998; 209:781.
  • Barish MA et al. Current Concepts: Magnetic Resonance Cholangiopancreatography. New England Journal of Medicine. 1999; 341(4): 258-264.
  • http://www.uptodateonline.com (“Clinical Features and Diagnosis of Acute Cholecystitis”)
  • http://erl.pathology.iupui.edu/
  • http://www.med.umich.edu/lrc/coursepages/M1/anatomy/html/radiology
  • http://www.uhrad.com/ctarc
  • http://www.ibiblio.org/jksmith/UNC-Radiology-Webserver/Ultrasound
  • http://www.vh.org/Providers/TeachingFiles
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