Quick! Somebody Call a Doctor (Radiologist)! Diagnosing RUQ Pain in an ED Patient Gregory Chang, HMS III Gillian Lieberman, M.D. Harvard Medical School.

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 ChangGillian Lieberman, M.D.

November 2001

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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.


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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.


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Send in the Med Students


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After further questioning…

• PMH: dilated thoracic aortaPUD colonoscopy(polyp removal) 2 days

ago pyelonephritis• Meds: prilosec, percocet• Allergies: NKDA• FH: non-contributory• SH: former alcoholic (age 18-35)


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Differential Diagnoses

• Aortic dissection• Right-sided pneumonia• Acute cholecystitis• Acute pancreatitis• Chronic pancreatitis• Appendicitis• Acute hepatitis• PUD• Perforated viscus• Right kidney disease• Subhepatic abscess


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Initial Imaging Studies for LG

• Plain Films:- Chest PA and Lateral

- Abdomen Supine and Upright


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Results

widened mediastinum

PA Lateral


(images courtesy BIDMC)

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Results (cont.)

NormalAbdominal Plain Films

Erect Supine



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Next Imaging Studies for LG

• Plain Films

• Ultrasound

• CT with and w/o contrast


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Results

• slight gallbladder wall thickening

• 1 cm gallstone in gallbladder neck

• No pericholecystic fluid

• No gallbladder dilatation

• No sonographic Murphy’s

“cholelithiasis with slight wall thickening”


(image courtesy BIDMC)

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Results

Mild dilatation of thoracic aorta (4.3 x4.6 cm) Low attenuation mass (malignancy?)

CT w/ contrast CT w/ contrast



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What imaging study was performed next?

• Plain Films

• CT

• US

• MRI


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Results

T1 In Phase T1 Out of Phasewater water

fat fat



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

decreased signal intensity

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Results (cont.)

• Gallstone• No wall thickening• No pericholecystic

fluid

T1 w/Contrast, Fat Suppressed



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Significant Findings So Far...

• Gallstone

• Slight gallbladder wall thickening


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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.


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Results

• DISIDA Scan shows non-filling of the gallbladder, consistent w/cholecystitis.

• Activity is noted within the small bowel at 10 minutes.

QuickTime™ and aGIF decompressor

are needed to see this p icture.



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Results (cont.)

QuickTime™ and aGIF decompressor

are needed to see this p icture.

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



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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)

Let’s look at some more typical findings ...


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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


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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


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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


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• 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


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• 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)



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• 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.



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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


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Acknowledgments

• Dr. Chad Brecher, Dr. Bettina Siewert, Dr. Haldon Bryer, Dr. Joseph Makris, Dr. Daniel Saurborn

• Dr. Gillian Lieberman

• Pamela Lepkowski

• Kevin Reynolds


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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


Quick! Somebody Call a Doctor (Radiologist)! Diagnosing RUQ Pain in an ED Patient Gregory Chang, HMS III Gillian Lieberman, M.D. Harvard Medical School.

Documents

ed patient gregory chang

images courtesy bidmc

image courtesy bidmc

bidmc ed

results t1

lg plain films ultrasound

ct scan

slight wall