Case 5 - Sack of stones?
Author: Nish Cherian Reviewer: Nick Mani
A 50-year old female presents with 1 day of epigastric pain and nausea. The patient appears uncomfortable but vitals signs are stable. She has epigastric and RUQ tenderness on examination. Blood results are pending.
POCUS reveals the following:
Clip 1. Gallbladder long axis
Clip 2. Gallbladder long axis (from RUQ)
Image 1. Gallbladder wall thickness
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“X minus 7” position = from the xiphisternum, laterally 7cm to the patient’s right.
The best window might be between the ribs at times (the phased-array transducer may be helpful)
Alternatively, the gallbladder may be visualised from the RUQ window (similar to FAST but fanning anteriorly)
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A large gallstone impacted at the neck of the gallbladder
There is mild wall thickness and no pericholecystic fluid.
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Wall thickness may be overestimated due to post-cystic acoustic shadowing (particularly if gain/TGC not optimised.
Therefore, the anterior wall thickness is usually measured.
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Left lateral decubitus positioning
Asking the patient to breathe in deep (usually displaces the gallbladder inferiorly)
A fasted patient (not usually an option for us in acute care!)
Case resolution
A classic case of biliary colic with an impacted stone in the neck of the gallbladder. The neck of the gallbladder can sometimes follow a tortuous path, so take care when evaluating this area as there could be stones hiding! Wall thickness is slightly increased here, though there are no other sonographic features of cholecystitis (such as pericholecystic fluid and sonographic Murphy’s sign).
In this case, the patient didn’t have a fever, raised inflammatory markers or other clinical features to suggest cholecystitis (yet!). However, if such features were present, it may be sufficient to make a clinical diagnosis of acute cholecystitis. Impacted neck stones are high risk for causing acute cholecystitis, which may well develop over subsequent days.
