Quick! Somebody Call a Doctor (Radiologist)! Diagnosing RUQ Pain in an ED Patient

1. Gregory Chang Gillian Lieberman, M.D. November 2001 Quick! Somebody Call a Doctor (Radiologist)! Diagnosing RUQ Pain in an ED Patient Gregory Chang, HMS III Gillian Lieberman, M.D. Harvard Medical School Beth Israel Deaconess Medical Center Boston, MA

2. Gregory Chang Gillian Lieberman, M.D. Objectives • Review the radiologic work-up and findings of an ED patient with RUQ/epigastric pain. • Discuss the different imaging modalities available for diagnosing this patient’s disease. • Review some typical radiologic findings of this patient’s disease.

3. Gregory Chang Gillian Lieberman, M.D. Let’s Meet Our Patient • LG, a former alcoholic, is a 48 yo man who presents to the BIDMC ED complaining of severe RUQ and epigastric pain that is radiating to his back. He has had this pain for the last several hours. No n/v/d.

4. Gregory Chang Gillian Lieberman, M.D. Send in the Med Students

5. Gregory Chang Gillian Lieberman, M.D. After further questioning… • PMH: dilated thoracic aorta PUD colonoscopy(polyp removal) 2 days ago pyelonephritis • Meds: prilosec, percocet • Allergies: NKDA • FH: non-contributory • SH: former alcoholic (age 18-35)

6. Gregory Chang Gillian Lieberman, M.D. Differential Diagnoses • Aortic dissection • Right-sided pneumonia • Acute cholecystitis • Acute pancreatitis • Chronic pancreatitis • Appendicitis • Acute hepatitis • PUD • Perforated viscus • Right kidney disease • Subhepatic abscess

7. Gregory Chang Gillian Lieberman, M.D. Initial Imaging Studies for LG • Plain Films: - Chest PA and Lateral - Abdomen Supine and Upright

8. Gregory Chang Gillian Lieberman, M.D. Results PA Lateral widenedmediastinum (images courtesy BIDMC)

9. Gregory Chang Gillian Lieberman, M.D. Results (cont.) Erect Supine Normal Abdominal Plain Films (images courtesy BIDMC)

10. Gregory Chang Gillian Lieberman, M.D. Next Imaging Studies for LG • Plain Films • Ultrasound • CT with and w/o contrast

11. Gregory Chang Gillian Lieberman, M.D. Results • slight gallbladder wall thickening • 1 cm gallstone in gallbladder neck • No pericholecystic fluid • No gallbladder dilatation • No sonographic Murphy’s (image courtesy BIDMC) “cholelithiasis with slight wall thickening”

12. Gregory Chang Gillian Lieberman, M.D. Results CT w/ contrast CT w/ contrast Mild dilatation of thoracic aorta (4.3 x4.6 cm) Low attenuation mass (malignancy?) (images courtesy BIDMC)

13. Gregory Chang Gillian Lieberman, M.D. What imaging study was performed next? • Plain Films • CT • US • MRI

14. Gregory Chang Gillian Lieberman, M.D. Results The area called into question on the CT scan represents focal fat. T1 In Phase T1 Out of Phase water water fat fat decreased signal intensity (images courtesy BIDMC)

15. Gregory Chang Gillian Lieberman, M.D. Results (cont.) T1 w/Contrast, Fat Suppressed • Gallstone • No wall thickening • No pericholecystic fluid (image courtesy BIDMC)

16. Gregory Chang Gillian Lieberman, M.D. Significant Findings So Far... • Gallstone • Slight gallbladder wall thickening

17. Gregory Chang Gillian Lieberman, M.D. What imaging study was performed next? • Plain Films • CT and Ultrasound • MRI • DISIDA Scan - peripheral injection of 99Tc- labeled di-isopropyl iminodiacetic acid, which is taken up by hepatocytes, then excreted in the bile duct system. Images are taken once per minute. Look for non-filling of the gallbladder.

18. Gregory Chang Gillian Lieberman, M.D. Results • DISIDA Scan shows non-filling of the gallbladder, consistent w/cholecystitis. • Activity is noted within the small bowel at 10 minutes. (images courtesy BIDMC)

19. Gregory Chang Gillian Lieberman, M.D. Results (cont.) • Post-morphine images show non-filling of the gallbladder, consistent w/cholecystitis. (images courtesy BIDMC)

20. Gregory Chang Gillian Lieberman, M.D. To the OR • LG had a lap cholecystectomy • Pathology revealed a diagnosis of chronic cholecystitis. • LG has not had episodes of RUQ pain since. http://erl.pathology.iupui.edu/C604query.cfm?Table=Hepatobiliary (Not LG’s gallbladder)

21. Gregory Chang Gillian Lieberman, M.D. Let’s look at some more typical findings ...

22. Gregory Chang Gillian Lieberman, M.D. More Typical Radiologic Findings of Cholecystitis • Plain Films: only 15% of gallstones are visible on plain films. http://www.med.umich.edu/lrc/coursepages/M1 /anatomy/html/radiology/abdomen/gallstones_1.html

23. Gregory Chang Gillian Lieberman, M.D. More Typical Radiologic Findings of Cholecystitis • Plain Films also allow you to detect: • gallbladder wall calcification • “milk of calcium”: biliary sludge formed from precipitated calcium carbonate crystals (or calcium bilirubinate) calcified gallbladder wall http://www.uhrad.com/ctarc/ct186.htm

24. Gregory Chang Gillian Lieberman, M.D. More Typical Radiologic Findings (cont.) • Ultrasound: Test of choice if suspicious of cholecystitis. • Look for: - sonographic Murphy’s - gallstones - gb wall thickening (> 4-5 mm) - pericholecystic fluid (hypoechoic halo) - dilatation of gb http://www.ibiblio.org/jksmith/UNC-Radiology-Webserver/ Ultrasound/us4.html

25. Gregory Chang Gillian Lieberman, M.D. More Typical Radiologic Findings (cont.) • CT- Not the modality of choice, but very useful. You can detect: - pericholecystic fluid - gb wall thickening - gallstones - complications - emphysema - gangrene - perforation - liver abscess Gas within gallbladder wall http://www.vh.org/Providers/TeachingFiles/RCW2/121296/ 121296.html

26. Gregory Chang Gillian Lieberman, M.D. More Typical Radiologic Findings (cont.) • HIDA/DISIDA Scan – useful when the diagnosis is unclear after US • Sensitivity and specificity of 95% for detecting cholecystitis. • Look for: • non-filling of gallbladder • rim sign (pericholecystic hepatic activity) (images courtesy BIDMC)

27. Gregory Chang Gillian Lieberman, M.D. More Typical Radiologic Findings (cont.) • MRCP: - can be used to visualize intrahepatic/extrahepatic bile ducts, and pancreatic ducts - heavily T2-weighted MRI (no contrast needed) • Excellent for detecting duct obstruction and can be used to detect cholecystitis: - Sensitivity 100% for detection of stones in cystic duct (US 14%) - Sensitivity 69% for detection of gb wall thickening (US 96%). Park et al. Radiology 1998;209:781. (image courtesy BIDMC)

28. Gregory Chang Gillian Lieberman, M.D. Summary • Reviewed an example of diagnostic imaging for RUQ pain • Reviewed the different imaging modalities that are available for diagnosing cholecystitis • Reviewed the typical radiologic findings for cholecystitis

29. Gregory Chang Gillian Lieberman, M.D. Acknowledgments • Dr. Chad Brecher, Dr. Bettina Siewert, Dr. Haldon Bryer, Dr. Joseph Makris, Dr. Daniel Saurborn • Dr. Gillian Lieberman • Pamela Lepkowski • Kevin Reynolds

30. Gregory Chang Gillian Lieberman, M.D. References • Gore RM, Levine MS, Laufer I, eds. Textbook of Gastrointestinal Radiology. W.B. Saunders and Company. Philadelphia; 1994. • Harris JH and Harris WH, eds. The Radiology of Emergency Medicine. Lippincott Williams & Wilkins. Philadelphia; 2000. • Katz DS, Math KR, Groskin SA, eds. Radiology Secrets. Hanley & Belfus, Inc. Philadelphia; 1998. • Park MS et al. Acute cholecystitis: Comparison of MR Cholangiography and US. Radiology. 1998; 209:781. • Barish MA et al. Current Concepts: Magnetic Resonance Cholangiopancreatography. New England Journal of Medicine. 1999; 341(4): 258-264. • http://www.uptodateonline.com (“Clinical Features and Diagnosis of Acute Cholecystitis”) • http://erl.pathology.iupui.edu/ • http://www.med.umich.edu/lrc/coursepages/M1/anatomy/html/radiology • http://www.uhrad.com/ctarc • http://www.ibiblio.org/jksmith/UNC-Radiology-Webserver/Ultrasound • http://www.vh.org/Providers/TeachingFiles