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Wall Echo Shadow

1/10/13 -  The IOW is comes to us from Drs. Stokes & Ander who captured a great right upper quadrant (RUQ) finding with bedside ultrasound. The patient presented with colicky RUQ pain with tenderness to palpation on exam. Focused bedside ultrasound evaluation of the RUQ revealed the following image (image 1). 

Image 1:  WES

WES

The image captures a stone filled gallbladder. Note the large stone with associated shadowing. The pattern of shadowing is consistent with the WES sign. Specifically, the wall-echo-shadow (WES) sign is composed of two curvilinear, echogenic lines with an intervening hypoechoic space. The near field line represents the gallbladder wall while the deeper line represents the surface of the gallstone. The hypoechoic layer between the lines represents biliary fluid. The finding is important as it signifies a gallbladder either distended with or collapsed around a gallstone(s). Do not mistake this for a loop of bowel. It is important to recognize the WES sign as it is suggestive of acute or chronic cholecystitis and therefore benefits from early surgical intervention.

Link for a case series illustrating how the WES correlates with surgical pathology. 

As for acquiring gallbladder images with RUQ scanning – there is no set convention. A common approach is to place the probe over the site of RUQ pain or more generically one can start in the right mid-clavicular line just below the costal margin. If still not visible with careful scanning, consider placing the patient in the left lateral decubitus position – this may help displace overlying bowel gas as well as swing the gallbladder anteriorly and permit better viewing. Thank you for your continued use of bedside US. 

John Lemos, MD, MPH
Clinical Instructor
Department of Emergency Medicine
Emory University