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.
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Dr Neil Long BMBS FACEM FRCEM FRCPC. Emergency Physician at Kelowna hospital, British Columbia. Loves the misery of alpine climbing and working in austere environments (namely tertiary trauma centres). Supporter of FOAMed, lifelong education and trying to find that elusive peak performance.

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