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Fever and RUQ pain 5 years after cholecystectomy?

5/31/2014

The IOW this week comes from Drs. Dustin Hill and Katie Dean. Their patient is 42 year old male, who presented to the ER with fever, tachycardia, and  RUQ abdominal pain. He had a history  of cholecysttitis 5 years previously and had undergone cholecystectomy.  Bedside ultrasound below was obtained. It can be challenging to get oriented when imaging patients after cholecystectomy. To begin, scan through the liver and  try to identify the portal triad. Remember the portal triad contains the portal vein, hepatic artery, and common bile duct and will typically  looks like “Mickey Mouse” in short axis orientation. Color flow imaging may help you to identify which structure are vascular.  In the image below we see the portal triad in a long axis orientation. The CBD will run superior and parallel to the portal vein in this orientation.  The hepatic artery will be sandwiched between the CBD and portal vein in a short axis orientation.  After a cholecystectomy a normal CBD will measure 1cm or less. In this image the CBD is markedly dilated with sludge.  On continued scanning a 1.6cm obstructing stone is seen in the CBD (image 2).   LFT revealed obstructive pattern and elevated bilirubin.  Diagnosis of cholangitis was made, the patient was started on antibiotics, and admitted for ERCP.  Following admission sphincterotomy was performed with expression of pus,  stone was extracted, and patient recovered well. 

Image 1

cholangitis1

Image 2

chlolangitis2

Please check out our website collection of this and prior IOWs at: http://www.em.emory.edu/ultrasound/ImageWeek/index.html

Happy Scanning!

Sierra Beck MD, RDMS
Assistant Professor
Ultrasound Fellowship Director
Department of Emergency Medicine 
Emory University SOM