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The Speed of Sound: Where a Casino Buffet and the ED Intersect

Hissett, Jennifer MD

Emergency Medicine News: May 2013 - Volume 35 - Issue 5 - p 15
doi: 10.1097/01.EEM.0000430478.54786.53
The Speed of Sound

Dr. Hissett is a first-year resident in emergency medicine at Louisiana State University at New Orleans, where Dr. Christine Butts, who served as the medical editor of this column, is the director of the division of emergency ultrasound and a clinical assistant professor of emergency medicine.

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A 54-year-old woman presents to the emergency department with four days of fever, abdominal pain, nausea, and vomiting. She reports that all of this started after eating pork at a casino buffet.

She is not jaundiced on exam, but has severe pain to palpation of the entire abdomen, worst in the right upper quadrant with a positive Murphy's sign. Her blood pressure is 96/52 mm Hg, pulse is 110 bpm, and her temperature is 100.4°F. Fluid resuscitation is started, and a bedside ultrasound is performed.

Abdominal pain is a common presenting complaint in the ED, and biliary disease is frequently suspected in these patients. Ultrasound has become the first-line imaging modality to evaluate the gallbladder in the ED, but many departments do not have ultrasound available 24 hours a day. It may be a dilemma in choosing an imaging modality if the gallbladder is only one of several possible etiologies for a patient's complaint. A focused right upper quadrant ultrasound at the bedside can help the emergency physician quickly narrow his differential and guide treatment.

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Several different approaches can be taken to optimize bedside visualization. Put the patient in the supine or left lateral decubitus position, and apply a low-frequency transducer (2-5 MHz) to the midclavicular line of the right upper quadrant at the inferior costal margin. Some rotation of the transducer may be required to visualize the gallbladder in its long axis. Having the patient take a deep breath can move the structures inferiorly and avoid rib shadowing. Alternatively, placing the transducer on the right flank and angling the transducer toward the anterior abdominal wall may reveal the gallbladder by using the liver as a window.

The gallbladder should be identifiable between the right and left main lobes of the liver as an anechoic (black) sack with a hyperechoic (white) wall. (Image 1.) A normal gallbladder wall should measure less than 3-4 mm. Ideally, the measurement should be taken in the short axis view at the anterior wall. (Image 2.) Ultrasound can detect gallstones as small as 2 mm; they will appear as hyperechoic masses, and most will cast anechoic shadows. Gallstones may occasionally be difficult to appreciate, and having the patient turn onto his left side may cause the stones to roll into view. Pericholecystic fluid is found in more advanced disease, and can be a harbinger of impending perforation.

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