Post on 14-Dec-2015
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.
Gregory ChangGillian Lieberman, M.D.
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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.
Gregory ChangGillian Lieberman, M.D.
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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)
Gregory ChangGillian Lieberman, M.D.
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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
Gregory ChangGillian Lieberman, M.D.
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Initial Imaging Studies for LG
• Plain Films:- Chest PA and Lateral
- Abdomen Supine and Upright
Gregory ChangGillian Lieberman, M.D.
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Results
widened mediastinum
PA Lateral
Gregory ChangGillian Lieberman, M.D.
(images courtesy BIDMC)
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Results (cont.)
NormalAbdominal Plain Films
Erect Supine
Gregory ChangGillian Lieberman, M.D.
(images courtesy BIDMC)
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Next Imaging Studies for LG
• Plain Films
• Ultrasound
• CT with and w/o contrast
Gregory ChangGillian Lieberman, M.D.
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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”
Gregory ChangGillian Lieberman, M.D.
(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
Gregory ChangGillian Lieberman, M.D.
(images courtesy BIDMC)
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What imaging study was performed next?
• Plain Films
• CT
• US
• MRI
Gregory ChangGillian Lieberman, M.D.
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Results
T1 In Phase T1 Out of Phasewater water
fat fat
Gregory ChangGillian Lieberman, M.D.
(images courtesy BIDMC)
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
Gregory ChangGillian Lieberman, M.D.
(image courtesy BIDMC)
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Significant Findings So Far...
• Gallstone
• Slight gallbladder wall thickening
Gregory ChangGillian Lieberman, M.D.
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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.
Gregory ChangGillian Lieberman, M.D.
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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.
Gregory ChangGillian Lieberman, M.D.
(images courtesy BIDMC)
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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.
Gregory ChangGillian Lieberman, M.D.
(images courtesy BIDMC)
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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
Gregory ChangGillian Lieberman, M.D.
(Not LG’s gallbladder)
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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
Gregory ChangGillian Lieberman, M.D.
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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
Gregory ChangGillian Lieberman, M.D.
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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
Gregory ChangGillian Lieberman, M.D.
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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
Gregory ChangGillian Lieberman, M.D.
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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)
Gregory ChangGillian Lieberman, M.D.
(images courtesy BIDMC)
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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.
Gregory ChangGillian Lieberman, M.D.
(image courtesy BIDMC)
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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
Gregory ChangGillian Lieberman, M.D.
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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
Gregory ChangGillian Lieberman, M.D.
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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
Gregory ChangGillian Lieberman, M.D.