vanPOCUS: Biliary Ultrasound

A Vancouver POCUS module on scanning the gallbladder for stones and cholecystitis by Neil Long

Summary of Biliary Ultrasound:

• Indications include: Right upper quadrant pain, epigastric pain, abnormal LFTs and Sepsis NYD
• Classic physical exam findings and laboratory results have poor sensitivity and specificity.
• Ultrasound is the gold standard for cholecystitis. POCUS exams are nearly as sensitive and specific as those done in the radiology department.
• Select Curvilinear or phased array probe.
• Place the probe vertical (probe marker to the head) 7cm across from the xiphisternum. You can also lie the patient on the side or take a deep breath in. Alternatively you can place the probe in the same position for your RUQ FAST scan and slide the probe more anterior to the chest wall.
• Ideal image is the ‘exclamation mark’. Seeing the fundus to the gallbladder neck.
• How to diagnosis cholecystitis = STONES + thickened gallbladder wall or sonographic Murphy’s or pericholecystic fluid.
• Anterior wall thickening >3mm is indicative of cholecystitis. To be more specific some authors pick >4mm. Be careful of an ultrasound post-prandial gallbladders – they contract and give you a false positive gallbladder thickened wall. Other false positives include patients with ascites and CHF and pancreatitis.
• Choledocholithiasis – sometimes its hard to find the common bile duct but if the patient has a normal biliary ultrasound and normal LFTs it is very rare you will miss this diagnosis. If you want to know how to locate the CBD then seek more advanced videos.
• Beware heterogenous material in the gallbladder, differentials include haemorrhagic cholecystitis or cancer.
• Grab an ultrasound and compare what the radiology department find with what you find in the department. Its perfect feedback.