Acute Abdominal Ultrasound of the RUQ in The Era of CT - HD

Introduction

Hello, my name is Deborah Rubins.

I'm a professor of radiology and an ultrasound practitioner at the University of Rochester in Rochester, New York.

And I'm gonna be speaking to you today about using right upper quadrant pain as the indication for ultrasound and when you would consider using ultrasound or consider using other modalities such as CT or MRI.

And we'll be reviewing problems related to the gallbladder bile ducts as well as the liver.

So I hope you enjoy the talk.

Welcome. Today we're gonna be talking about acute abdominal ultrasound of the right upper quadrant in the era of ct.

And the reason or the motivation behind this talk is that there are lots of people who think that all we look for is gallstones or cholecystitis, but there are many other causes of right upper quadrant pain including biliary obstruction, bowel obstruction, renal obstruction, bleeding, peritonitis, and even ischemia and infarction.

Acute Cholecystitis

So just to begin with a refresher, acute cholecystitis certainly does have gallstones as part of it.

You can see here, and it's a baseline exam.

This patient has multiple gallstones with shadowing.

But when the patient has right upper quadrant pain, you can see that there's also some mild gallbladder wall thickening.

And the important point is that this patient actually has discrete tenderness over the gallbladder.

In addition, don't forget to look at the common duct.

This patient has a distal common duct stone.

So how do we make the diagnosis of acute cholecystitis since this is of course our most common indication for performing a right upper quadrant ultrasound?

Well, these are the criteria that we've gathered from the literature over the years, and the most important thing is probably the positive Sonographic Murphy sign.

And to be specific, this is really focal tenderness over the gallbladder.

It is 87% specific. We cannot do that with ct.

Gallstones are helpful if they're present with a sonographic Murphy's or with his focal tenderness.

Remember, many stones are not visible on CAT scan and the gallstones alone are not specific because a large number of people in the United States do have gallstones.

Gallbladder wall thickening is very helpful with stones and with focal tenderness.

It is not specific on its own.

And I'll refer you all to this landmark article that still is helpful.

I think from radiology 1985 by Phil Rawls.

Difficulties with Gallstones

There are some difficulties with gallstones.

It's not so easy just to plop down your transducer and you'll see them.

Remember that if they are less than four millimeters, they may not shadow.

So you need to be sure that they're mobile.

And you can use different positions to help to put them into a plane where they can shadow.

If the gallbladder neck is out of plane, make sure you scan through the region of the neck, or turn transverse to look at it.

If they're impacted, they may be non-mobile and that may be a cause for not seeing them well.

And again, if there's no surrounding fluid, they may not stand out.

Notice that this patient, this gallstone barely casts a shadow over here.

When you turn the patient into the left lateral decubitus di position, you can see a couple of stones here with a shadow.

Remember that we need higher frequency that will resolve smaller stones.

So three megahertz, yes, you can see that there's a shadow here, but it's hard to see the discrete stones up at five megahertz.

Now you can resolve these individual stones and see their shadows.

What about this patient? Here's the gallbladder.

Are there small stones here you can see a fluid, fluid level, but are there stones within it?

Well, when you turn the patient and again, sum these stones up and increase the axial thickness of them, you can produce a shadow and convince yourself that stones are present.

Here's the mr, just in case you wanted to see them on MR as well.

You can use both positioning and technique to show the shadow here in this patient.

The focal zone, as you can see, is over here, is placed too high.

It needs to be placed at the level where you're expecting to see the stones.

Here you can see also this is the area of genicity, but no shadow.

And it's difficult to perceive that there are actually stones in this location when you added harmonics and the focal zone is in the correct place.

You can see that there are stones here.

And as well, we've also moved slightly to be in a better plane with these stones.

One issue that comes up for us often is, are there stones in the presence of sludge?

And it can be very difficult to be sure this patient does not look that they have any strong echoes or shadows.

And we would probably just call this sludge.

However, again, as you maneuver the patient, you can see that there's a different debris level here and some stronger echoes, maybe a shadow over here.

This was not immediately detected.

This patient came back 10 days later.

And on that exam, when you can con, when you can consolidate the stones here and create a shadow, you can convince yourself that that indeed stones are present.

We do have some mimics of stones as well.

And here's just such a one. Here's an echo with a shadow.

Here's an echo. Not really much of a shadow.

Here's the echo and the shadow.

However, when we went in and re-scanned this patient, they all disappeared.

And the cause here is actually bowel gas from the adjacent duodenum, which is actually being partial volume averaged into our image of the gallbladder and is creating the image of a stone when there's none present.

Why Not Use CT for Cholecystitis

Why do we not use CT to diagnose cholecystitis?

This is an elderly woman seen in the emergency room.

She had abdominal pain after a colonoscopy and the CT diagnosis was a gallbladder perforation into the wall.

I think this was felt to be all fluid here and that the lumen was indistinct here.

The patient did come to ultrasound and you can see here that there's a large gallstone that's not appreciated on the ct and the wall is in fact intact and we do see it better with ultrasound than we did at ct.

The diagnosis was acute cholecystitis, no perforation at histology.

Again, another patient using CT for abdominal pain.

Really all we see here is a dissented gallbladder.

No real evidence for stones.

However, on ultrasound there are obvious stones.

And this patient was focal tender.

This was acute cholecystitis as well.

Gallbladder Wall Thickening: Non-Specific Findings

This is a 14-year-old woman with nausea, vomiting and right upper quadrant pain.

She has gallbladder wall thickening.

Does she have a calculus cholecystitis?

Well, it's important to look not just at the gallbladder in these patients, but you're supposed to be looking at the liver as well.

And you will notice that her liver is enlarged.

It's measuring 18 centimeters and also that she has no gallstones.

Two weeks later. This is her follow-up examination.

You can see her gallbladder wall is now completely normal and she had acute mononucleosis, which basically is a viral infection involving the liver, but also involving the gallbladder wall.

Another person with right upper quadrant pain, you can see some focal gallbladder wall thickening here you can see some echoes with some C tail artifacts and you might be concerned about air, but these do not move at all.

And when you look carefully, this is a patient with adenomyosis, so he does not have acute cholecystitis.

He does have adenomyosis with his little string of pearls in the fundal location.

You can see here some small Roku tansky ash off sinuses filled with fluid.

In this T two weighted MRI, this young man had a fever, chills and abdominal pain and a rash and he'd been on Bactrim and ultrasound was ordered because of the right upper quadrant pain.

And you can see his gallbladder wall is markedly thickened.

The lumen is contracted.

This actually is a patient of drug-induced hepatitis.

So as you can see, gallbladder wall thickening is the theme here, but it is not specific certainly for gallbladder disease.

This patient has leukemia fever and right upper quadrant pain.

Again, ultrasound is the first imaging test that's ordered.

Again, the liver is quite long here, 18 centimeters.

Gallbladder is very, very thick walled.

And there's reversed flow in the portal vein, which is indicative of basically portal hypertension in this patient without cirrhosis.

And that is diagnostic of venal occlusive disease, which is obstruction of the sinusoids and creation of localized and temporally acute portal hypertension.

So gallbladder wall thickening is non-specific and it's non-specific, not only for gallbladder disease, but even for hepato biliary disease.

This is a patient with paracetic fluid.

He had a negative Murphy sign, but he did have right upper quadrant pain.

And you can see here in the adjacent ultrasound and then ct, there's a mass in the kidney, it's echogenic, it's focal.

And this is a patient who actually had focal pyelonephritis.

Another patient, again, acute gallbladder wall thickening here, patient had pain, not specific to the gallbladder.

And again, rule out cholecystitis is the indication for the exam.

This patient has pancreatitis.

You can see the fluid here on the CT quite nicely surrounding the head of the pancreas.

Also the adjacent gallbladder wall thickening.

You can see they're very closely approximated in space.

Here again, the fluid around the pancreas.

So it's no surprise that the gallbladder can easily become inflamed an emus in response to an adjacent inflammatory process.

Another pitfall, if you will, in gallbladder imaging.

This patient presents with right upper quadrant pain and has a palpable mass.

And here are the images.

This is an old case, but the sonographer came out and thought that this was the gallbladder.

It's measuring almost 10 centimeters.

And the question is, is it really the gallbladder?

And can you do more? Have you done more?

One thing you'll notice is that there's no liver near it.

So you do wanna be sure that you can see the liver.

And if you look a little bit more closely, you can see that there were CAEs and in fibula connected to this and on transverse imaging.

This mass actually is a very, very dilated and distended renal pelvis.

You can see here that this patient had obstruction of her kidney.

And here on the ct again you can see a very distended pelvis from a ureteral pelvic junction obstruction in this 65-year-old woman.

Complicated Cholecystitis

We're gonna move now from just regular old cholecystitis to complicated cholecystitis.

And it's important to recognize this phenomenon because it is fairly common, one in five patients in the literature.

It can be gangrenous, which means that you're dealing with a dead gallbladder and a small percentage of patients you'll have emus, cholecystitis, especially pronounced in diabetics.

The reason to recognize is that it does have clinical implications.

The patients have increased morbidity and mortality and there can be up to a 30% conversion from laparoscopic cholecystectomy, which is the state of the art or the norm here now, to open procedures.

And that's important for the pre surgeon to know bo both for his operative planning and also to have the right team available.

Ultrasound unfortunately for gangrenous or emphysematous cholecystitis is not specific because focal tenderness is absent in about two thirds.

We can see intraluminal membranes in about 5%, which is helpful and perforation in between five and 10%.

So sometimes here CT is useful in conjunction with the ultrasound to show inflammatory changes and also gallbladder continuity.

And I'll try to emphasize that for you.

So here's a patient who comes in with right upper quadrant pain and fever and we see CT shows a very unusual lobulated connection.

Here's the liver, here's this fluid mass and an enhancing rim, and another sort of daughter mass here with another enhancing rim.

You can see the pancreas and common duct here.

Duodenum is compressed.

And the question here is what is the gallbladder?

And when we did an ultrasound, it became obvious that this mass was all basically fluid outside the gallbladder.

This is the contracted gallbladder here, which is what this structure represented on ct.

And we were able to tell that because of the stones that were in it and notice that we're not seeing the stones as well on ct.

In fact, we don't see them at all.

So this was a perforated gallbladder with a peri, gallbladder or peric ctic fluid collection that was a large abscess.

Here's another patient with gallstones on ultrasound and a normal wall here, but there is a fluid collection adjacent to the gallbladder.

And the question is this just peric CTIC fluid or is it perforation?

Well, in my experience, most of the time that we get fluid in the wall, it's usually on this wall first between the gallbladder and the liver.

And in addition, if it's gonna be pericole cystic fluid, it's usually circumferential.

So it's concerning that you're only seeing it in one location and it's certainly not a typical location for a regian cap, which would be out at the fundus.

So if you're not sure, sometimes again CT can be helpful.

So this is the gallbladder wall.

This is a localized or walled off perforation.

You can see the marked inflammatory change here in the fat on ct.

You might be able to call that an ultrasound as well, but it's a little difficult here because you do have the through transmission from the fluid as well to call this fat to be increasingly echogenic.

This is a 72-year-old woman, abdominal pain and gallbladder and guarding and on ct, the diagnosis was a gallbladder with peric cystic fluid again, and she also had CHF.

But notice here again, the gallbladder is here.

This is a very bizarre looking fluid collection.

It's really not involving the whole wall and it's not free and it's contained.

And again, not a usual place for a ian cap.

So you should be suspicious here that you're actually dealing with a perforation and that this is the perforated component.

On ultrasound you can see here that the fluid here again is walled off.

Here is the inner wall and here were some intraluminal membranes as well.

And the final diagnosis was perforated gallbladder with intraluminal membranes.

Again, another patient population who gets complicated cholecystitis.

This is a diabetic who has fever and tenderness and you can see here some echogenic foci that do have shadowing, but they are anti dependent.

Here are the gallstones in the posterior aspect of the gallbladder, and you'd be correct to assume that this is air and emus cholecystitis.

Another patient with chest pain rule out pulmonary embolism and at the bottom of his chest ct.

There is an incidental finding and it's important again to be looking at the abdomen on your chest CT patients.

You can see here is some inflammatory change in the adjacent fat and a little bit of gas.

Notice that on ultrasound we see the gas quite well as well as sludge.

And not as much appreciation really of the inflammatory change.

So this was a gangrenous gallbladder at pathology and it did cause the surgeon to change from a laparoscopic to an open procedure.

Not all things that are genic and shadow necessarily represent stones or gas.

Is this emphysematous cholecystitis?

Well, you might be thinking, well, it looks sort of echogenic, maybe it's in the wall, maybe it's a porcelain gallbladder.

And again, this was somebody referred forret, upper quadrant pain, didn't have focal tenderness over the gallbladder.

And so we actually recalled this patient for a CT to see what was going on to see if there was gas.

And we were shocked to find out the gallbladder was fine and all of this gas was coming from adjacent colon.

So just be aware, this can mimic gas in the lumen of the gallbladder or overlying the gallbladder or even in the gallbladder wall.

This young woman had 12 hours of nausea and vomiting, right upper quadrant pain.

Again, another patient with echogenic foci with shadowing.

However, when she went to pathology, there was no gas at all.

No emphysematous cholecystitis.

These were just floating gallstones so gallstones can float.

Another pitfall, again, a patient with alcoholic hepatitis.

This patient we see a mass here. Is that a gallbladder?

It looks sort of disrupted back here.

Lots of internal echoes.

Again, the sonographer is labeling it as the gallbladder.

In this case we do see the liver adjacent to it and it's in the right position.

However, again, when you looked more carefully, you could actually see a compressed gallbladder next to it.

And this was a pancreatic pseudocyst compressing the gallbladder.

So again, be sure that you've identified the gallbladder.

Look carefully.

Biliary Duct Disease

We're gonna turn now, moving through the gallbladder into the biliary tree and talk a little bit about duct disease.

Some of the pitfalls are that stones again may be difficult for us to see by ultrasound.

It's really important to use good positioning, especially for the distal common duct.

You might try sitting the patient up or standing them up if they can, turn the patient to the right side down to cubitus position so that you can get the gas up into the fundus, have them drink some water to displace the bowel gas.

And another very important technique is transverse compression.

Following that duck down transversely until you get to the bottom of it and eliminate the bowel gas that's overlying it.

Remember, the dilated duct should have accompanying increased liver function tests to be clinically significant and that the common duct may dilate post cholecystectomy.

Again, our new machines have very great resolution, so we may see what we would perceive as dilated ducts on normals, especially with harmonics.

And by that I'm saying that not all ducks that you see are necessarily abnormal.

And lastly, we'll talk a little bit about biliary duct necrosis.

So here's a 31-year-old with right upper quadrant pain, no white counter fever, but she does have an el elevated Aly and she's seven weeks pregnant.

So we notice that she does have stones in her gallbladder and that should prompt you to look towards her duct.

And you can see here's her common duct.

It's basically it's 0.66 millimeter, six six centimeters.

But notice this is a little bit oblique here, so that's probably an overestimate.

So not particularly dilated.

And notice that we don't see anything in the distal duct.

However, with some positioning and some compression and turning on the distal duct, you can see that you can find a stone distally and there's probably one even further out as well as this one floating up here in the more proximal duct.

So technique is important, again, use that transverse view and compression to see the distal duct.

And even so the, this is looking, this is longitudinal again here as a patient transverse, you can see the splenic vein confluence here.

And sometimes as these ducts get dilated, they actually become somewhat tortuous.

So you may not see the entire longitudinal extent of this common duct.

If you're coming in from a long axis or from a sagittal plane, you need to be more oblique and even sometimes transverse to even get that distal duct.

And you can see here clearly there is a shadowing stone in the distal duct at the level of the head of the pancreas and in respect to my CT colleagues.

Here is the dilated duct on ct.

If you look very hard, you can see this little stone in there, but it's very difficult to see it on ct.

Again, harmonic imaging is another important aspect.

Positioning is important of course, but harmonic imaging is very important as well.

Non dilated duct with distal gas.

So the sonographer is tempted to say can't see the distal duct, but if you work at it, you can push on the patient and display some of the gas and you can begin to see these echoes.

Not so easy to see the shadow behind here.

Again, coated harmonic imaging you get a six megahertz trans frequency image and you can see cure quite clearly that you can see both the stone and the shadow in the distal duct.

There are some other diseases that cause dilated ducts.

And one thing to think about if you have asymmetric dilated ducts, in other words, the right lobe is pretty normal.

Left lobe is abnormal, it could be vice versa, is that you have a focal disease of the ducts that's obstructing and it could be tumor and it could be inflammation or infection or stricture.

And in this case, this patient was actually septic from these obstructed left-sided ducts.

She did not have a tumor. There's no mass.

And this is a patient who had sclerosis cholangitis after drainage, these ducts on the left side return to normal caliber.

This patient also has dilated left-sided ducts.

What you can notice about her is that she has also some hypo coic regions in the left lobe.

If you look carefully, can make out nodules here and notice that you really have lost all the normal portal triad characteristics here.

And this is a patient with a, actually with metastatic disease.

She's presenting with jaundice and right upper quadrant pain.

So she comes in for an ultrasound, but she can make the diagnosis of metastatic breast cancer based on her ducts as well as her parenchymal abnormalities in her liver.

Notice also that she has some reverse flow in her portal vein.

She has elevated portal pressure here just from the metastatic disease as well.

This man came in with again, right upper quadrant pain and here you can see dilated ducts.

And of course, in addition to stone disease and diffuse tumor, you also wanna think about biliary duct tumor.

And this person of course has a mass in his right sided duct tear heading into his common duct.

And he has unfortunately cholangiocarcinoma.

So once you've got an obstruction, certainly in a main duct or especially in the mid duct, you wanna be thinking about tumor.

As I said before, we can now see what we would call normal ducts quite frequently with very little effort.

So this is a patient who is to follow up a renal angiomyolipoma had nothing to do with her liver.

She has no LFT abnormalities, no right upper quadrant pain, and yet we can clearly see her ducts follow them all the way out along the adjacent portal vein.

And the normal duct as we know is should be less than 40% of the adjacent portal vein.

So this course of course is normal, but again, just seeing the duct doesn't make it abnormal.

In addition, we can have duct disease without dilatation.

We've been talking about dilated ducts, but this patient had a cholecystectomy.

He comes in with fever and right upper quadrant pain and you can see that his ducks are normal in caliber, but he has these echogenic foci with shadowing present in his liver.

And you can see we have him sitting up here.

And these did not move and we kept moving him around.

We turned him prone, we turned him every which way.

And you can see here is the portal vein behind.

So we've localized these echogenic foci to be in the ducts, not in the liver parenchyma, and they're unchanging with change in position so it's not air.

And sure enough, when he had his ERCP, they removed multiple stones from his common duct.

Again, patients can have stones without dilated ducts.

You can see here is a patient, again, multiple gallstones.

Common duct is normal in caliber, but obscure here, distally by gas, you might not be thinking that you've got stones.

But in addition, if you clear out the gas and you look carefully, there are several small stones in this patient's distal duct.

So other causes of dilated ducts or abnormal ducts include infection or inflammation as you can see in this patient who presents again right upper quadrant pain, evaluate for cholecystitis.

You can see here are the thickened ducts.

There's dilated, but they're mostly thick wall.

You can see here is the gallbladder. There are no stones.

There's some minimal gallbladder wall thickening as well.

Common duct is not dilated.

But again, you can see this diffuse thickening along the margin of a common duct.

Here is the MR that just shows the same thing.

Again, some sludge in the gallbladder and this patient actually has sclerosis cholangitis.

So just remember cholangitis can present with both obstruction and jaundice.

And acute cholangitis is bacterial.

It's usually due to common duck stones with distal obstruction and you'll get thick wall ducks.

You can also get viral cholangitis from aids as well as an opportunistic infection such as CMV or Cryptosporidium.

Recurrent genic cholangitis is basically HEPA LSIs or oriental cholangio hepatitis, they're all the same thing.

These are basically thick walled, stone filled ducks.

These stones are often softer and they may not shadow as well.

These produce a chronic situation.

So with long standing obstruction, you actually get some segmental atrophy of the overlying liver.

And again, we've already seen a patient with primary sclerosis and cholangitis.

These ducks can be thick walled with strictures.

And again, these patients have a higher risk of cholangiocarcinoma.

So here's a patient with AIDS cholangitis.

You can see again, these are the stones with the shadows.

Again, you can see a stone with a shadow in the position of the duct.

And here are the dilated ducts.

Sometimes with the stones it's difficult to perceive the wall thickening.

But you can see some of the enhancement here on the adjacent ct.

And again, the distal duct is dilated as well.

Another patient who has jaundice, she's also post cholecystectomy and you can see here very prominent stones and very, very dilated ducts.

I'm gonna move forward and show you what she looks like a couple years.

Hence again, here's her common duck.

She has some stones distally and two years later she really sort of looks the same.

Here's her ct and one thing you can notice on her CT is there's something missing, which is her pancreas.

And this is her common duct here, distally.

So this patient actually has fatty atrophy of her pancreas.

She has cystic fibrosis and she has poor motility and therefore she is forming stones in the ducts as well.

Gas Within the Ducts

We're gonna turn now to gas within the ducts.

It's important when you're thinking about biliary air, is it normal or abnormal?

We're all thought to or trained to sh to think that it's always abnormal, but sometimes that's not the case.

However, in this patient you can see marked echoes, again with some shadowing.

These are more like reverberant shadows, not as clean and sharp sometimes as the stone shadows that we get.

And you can see here this patient does have gallbladder and there is pain as recorded by the sonographer.

And this patient has cholecystitis stone gas, emphysematous, cholecystitis and inflammatory reaction here on the ct.

And obviously air in the biliary tree on the CT as well at a path.

This was gangrenous, a gangrenous gallbladder.

But in our patients who've had instrumentation and or have had surgery, biliary can be normal.

So here's just a side by side for you.

Here's a patient. Post-transplant has biliary air.

Here's another patient post-transplant with biliary air.

Is it normal or abnormal?

Well, in this patient what we can say is that these echoes are nice and linear and that the ducts are thin and non dilated.

Here the echoes are a little bit rounder and you can see here is an area of fluid with some through transmission, which might make you think about complication including an abscess.

And first patient has a ruin y loop, so that's normal.

You are connected up to a bowel loop and there should be good reflux of air into your biliary system.

That's a sign actually of good ducts.

But the other patient had abnormal liver function tests.

The echoes are more rounded, the ducts are thickened.

And when you look at this patient's arterial inflow to the liver, the resistive index is low in the right hepatic artery.

It's below point, well below 0.5 and this patient has biliary necrosis from inadequate oxygenation to the bile ducts.

Liver Pathology

In the time we have left, we're gonna be talking a little bit more about the liver and we've already mentioned acute hepatitis, but we'll be talking a little bit more about abscesses tumors and metastases as well as portal vein thrombosis.

Acute Hepatitis

So just a reminder, hepatitis, it's a viral etiology.

Acutely patients can present from type A, which is an orally spread viral load, that has a very high recovery rate.

These people present with jaundice, fever and hepatomegaly on gray scale.

The most common premise presentation is actually normal.

Then the next thing might be gallbladder wall thickening or gallbladder contraction.

And the decreased echogenicity that we've been taught from the literature with the prominent portal triads is extremely rare.

So I'll show you that first because it's the only case I've actually managed to confirm in about a 25 year practice.

So here is the patient.

You can see prominent portal, tri notice, also the gallbladder is contracted and the liver is hypoechoic.

With respect to the adjacent kidney, the patient had no kidney disease.

There was a normal relationship on the left side between the spleen and the left kidney, but this is the more common pattern that I see in my practice.

Thickened gallbladder wall abdominal pain.

This patient happened to have hepatitis B but very, very thick walled gallbladder, you can see it here.

It's got this striated pattern that just means that there's edema in the wall.

Doesn't mean that there's a risk of anything going on with the gallbladder in particular.

And the other pattern that I mentioned, this patient had abdominal pain, vomiting, elevated transaminases and you can see his gallbladder here is actually fairly collapsed.

The wall looks a little thickened.

That's because the gallbladder is so contracted you can't really accurately measure the wall.

I don't think he's got prominent portal triads, but he certainly does have a somewhat large liver.

And this patient does have infectious mononucleosis.

He did not actually have hepatitis.

So the CT was helpful here because it showed the splenic infarct as well as the splenic enlargement that we had not appreciated on the ultrasound.

Liver Abscess

Moving on to liver abscess.

These patients will can present with right upper quadrant pain and fever and moles.

There's often a biliary source as we saw with our patients with the perforated gallbladders.

But it can also be a vascular source.

About half of the patients have no clear source.

It can be hypoechoic, it can be or iso coic looking as this one is with some through transmission it can be hypoechoic or almost koic as this one is.

And there can be echoes with gas and shadowing as this one is.

And so about a half of them or less we'll have through transmission.

The important thing to recognize is that we are limited in liver by some positions, particularly the dome as well as areas right under the ribs.

So ultrasound frequently will underestimate the size and or the number.

And CT and MRI are useful not only to map the extent but also sometimes to define the cause of the abscess.

So here's a 59-year-old patient who's had diverticulosis, but he has, he presents with meles and there are two complex vascularized lesions noted.

One in each lobe, one on the right here as well as one on the left.

And this one looks like it's got septations and flow in the septation.

And some people might be concerned are these metastases, is this tumor.

But when you look carefully on ct, these are classic rosette patterns that are typical for abscess.

And you can see here there's a little bit more lysis of these individual little LOEs of abscess collection that are over here.

There's more lysis and more confluence and so this becomes a larger confluent collection.

Easier to think about draining.

And this came back as bilateral abscesses.

Here's another patient who has leukemia, new right upper quadrant pain.

She's a 12-year-old girl and there was a new hypo coic lesion, just one on ultrasound.

We took her ct.

You can see that there are multiple lesions and you can see quite nicely on the MRI that we even underestimated the number of lesions that we saw on ct.

So again, can be sensitive, but doesn't usually show the extent that you get with either CT or MRI.

Another patient, HIV positive nausea, vomiting, confusion, right upper quadrant ultrasound ordered.

And again, one little hypo coic lesion here, one other one here both in the right lobe.

And so question is are these abscesses?

This patient had a contrast problem and could not have a ct, couldn't have any contrast even on MRI.

But when you look on MRI, there are innumerable high T high signal intensity T two weighted lesions throughout her entire LI liver, which is helpful in case you're designing that you need to biopsy because the biopsy was performed and yielded non-Cat granulomas presumed histoplasmosis, which helped us decide the therapy.

Tumors and Hemorrhage

Another patient, right upper quadrant pain rule out cholecystitis.

This patient was on oral contraceptives, which is a clue of course.

And you can see here is the gallbladder that's compressed by this large heterogeneous mass that is basically adjacent to the gallbladder and it looks extrinsic almost to the liver.

You can see here it has somewhat of a, almost a yin yang appearance to it, a hypo coic and a hyper coic portion, which is not a typical for blood.

And you can see here on ct, again the clot is sitting here along the anterior margin and the more lysed blood is actually posterior.

Once the patient got contrast, only the medial portion enhanced and this was a hemorrhagic adenoma.

They can be very difficult to detect their borders or their extent by ultrasound.

Again, this patient 17 years of oral contraceptive pill use presents with hypotension.

Hard to know where this mass is based on the ultrasound.

And here again, where is the mass? Not really quite sure.

I think it's over here. This came out, the patient went to the OR and there's a very, very large mass with hemorrhage.

Again, hemorrhage can be difficult for us to see.

This patient has a right upper quadrant pain and has had a liver transplant.

So the question here is what is the abnormality?

And the first thing you have to do decide is where is the liver?

And if you think this whole thing is the liver, then why is part of this bright and part of this dark?

And then the next question is if this whole thing is the liver, why is there no blood flow in it?

So we wanna look and check and see, well yes, the main hepatic artery does have flow and in this case I think if you can't figure out what's going on, you need to get a CAT scan.

And the cat scan shows very clearly that you have a couple things happening.

One is profusion here of the left lobe and some of the caudate, but a large infarct occurring in the right lobe.

And then in addition, this sort of scalloped border with this hyper attenuating mass that's outside the liver that's pushing in on it is all a sub hepatic or subcapsular hemorrhage that's occurring in this patient who has infarcted and then ruptured their liver.

So this is the non perfused portion of the liver here on ultrasound and all this echogenic material that's sitting between the abdominal wall and the liver is actually acute blood.

So the clues might be that you've got a straight line interface here, which is very bizarre.

And also that this is somewhat featureless, it doesn't have any vascular pattern to it.

This patient presented with acute right upper quadrant pain and the tip, the crucial features are that you can see a somewhat dilated splenic vein and portal confluence.

And when you have color doppler added, you can see that there's flow in vessels both here and in the IVC which is posterior to this.

So this is truly absent flow and this is portal vein thrombosis.

The question is why did this happen?

Here's the CT on the same patient, a very, very hyper attenuating clot in the portal vein and the splenic vein.

And you can notice after contrast this does not enhance at all.

This patient actually had pancreatitis.

We don't know if the pancreatitis came first or second, but notice of course that the gallbladder, which was the reason for the study was normal.

This other patient 67-year-old had right upper quadrant pain and you can see a very large echogenic mass with some through transmission in the left lobe of the liver.

Now this is a CT scan from the same region three days before and here it is at the time of the ultrasound.

And the clinical things to recognize here are that you have a large clot in the portal vein now that clot is absent.

So the clinical information that was withheld and that was not appreciated at the time of this ultrasound what this patient had been on thrombolysis.

And if you look back at the prior CT and realize that this mass was not there, you might get the idea that this was an acute bleed.

So just remember acute blood can look like almost anything.

It can certainly be very hyper coic and this patient certainly was bleeding at the time of the ultrasound and another patient here for right upper quadrant pain.

I promise not to beat this to death, but you can see there are some gallstones.

However, when you look carefully, there's also a hypoechoic region that's adjacent to the gallbladder, has somewhat of a geographic shape to it, sort of a triangular.

And you notice that she does have a very large fatty liver.

So is this just gallstones incidentally noted.

And a patient who happens to have fatty sparing?

Well you wanna be careful before you call fatty sparing because you wanna be sure that there's no vascular abnormality.

And when we put doppler on, you do have to look at that with doppler because you can see these vessels are somewhat abnormal.

There's some increased vascularity around the margin, although again, it's somewhat of a straight line positioned here.

The vessels are just not quite right.

So she needs to go on for more imaging and when she did, this is right on T two, it's enhancing arterial enhancing and washing out in the portal phase.

And this was hepatocellular carcinoma on MRI as well as on biopsy.

This young man has right upper quadrant pain, elevated liver function tests, gallstones, but is that enough to give you the answer?

Well, no it's not because again, where are the portal triads notice that they're missing and you can see these hypoechoic masses in the liver.

And this patient on CT obviously has metastatic disease.

This patient again rule out gallbladder disease, innumerable metastases.

In this case you can see them quite clearly.

There are these hypo coic rings.

These are typical target metastases and you wanna go ahead and check for some common causes including lung cancer in this patient who has a large left hilar mass.

This patient was on therapy for lymphoma and she presented with right upper quadrant pain and you can see your gallbladder is fine but you wanna look carefully for other causes that could be related.

And you can see if you look carefully that there is an area with echoes and shadowing both anterior to the gallbladder here with some little reverberate shadows as well as here you're not seeing the whole liver.

So that should make you wanna pursue further.

And you wanna look around the liver and as far as you can, and these areas which would not have been immediately apparent were much better seen actually with a high frequency linear array transducer.

So this fluid here and these gas bubbles with shadows were appreciated by actually searching for them after being picked up on the initial exam.

And a plain film showed a very, very large gas collection here in her right upper quadrant.

Here's her normal bowel gas and on CT she has an extremely large peri hepatic abscess probably from perforated viscus.

Summary

So in summary, the causes of right upper quadrant pain are not limited to the gallbladder.

Consider biliary duct disease paddock sources as well as retroperitoneal and pancreatic etiologies.

Anything that's basically in the neighborhood.

Technique and positioning are critical for stone detection, especially in the ducts.

Remember, the diffuse tumor or metastases can present as architectural distortion, so be on the lookout for that.

Acute hemorrhage can be very difficult to perceive because clot will mimic solid tissue on ultrasound or can even be bright.

So keep that in the back of your mind and when you need to go on to CT or Mr to prove that.

Overall though, I think ultrasound is a very good screen for acute hepatic pathology including masses and infection and just know that you may need CT or MR to map the extent and define the cause.

And with that, thank you very much for your attention.