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Unusual RUQ Scan in a Patient with Altered Mental Status

8/26/2014

The IOW this week comes from Drs. Woods and Ander who identified a markedly abnormal gallbladder on point-of-care ultrasound. Their patient was a 68  year-old female who was undergoing a work-up for undifferentiated altered mental status.  The patient denied complaints, but per family was not acting normal.  Vitals signs were significant for fever and tachycardia. Her initial exam, cxr, & urinalysis did not suggest a source of potential infection.  Her labs however showed elevated Alkaline phosphatase, AST and ALT. Which prompted them to perform a RUQ US.  The image below was obtained.  

Image 1

altered1

Note the presence of  a thickened gallbladder wall and pericholecystic fluid which suggest a diagnosis of cholecystitis.  There is also a large nonshadowing mass in the center of the gallbladder.   A polypoid mass within the gall bladder may represent adenocarcinoma, a benign adenoma, polyp, focal adenomyomatosis, metastases, or tumefactive sludge. Tumefactive sludge occurs when sludge fills the gallbladder and take on a solid form that mimics a tumor. Below is a short axis image of the gallbladder. 

Image 2

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Following the scan the patient received IV antibiotic directed at billiary source of infection. Further imaging showed common bile duct stones in addition to the abnormal findings above.  She underwent ERCP and cholecystectomy, and is currently doing well awaiting pathology results on the gallbladder mass.   

For a nice overview of the basics of performing the RUQ scan see http://www.sonoguide.com/biliary.html

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

Happy scanning!


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Sierra Beck MD 
Assistant Professor
Department of Emergency Medicine
Emory University