Download Quick! Somebody Call a Doctor (Radiologist)!

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
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.
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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.
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Gregory Chang
Gillian Lieberman, M.D.
Send in the Med Students
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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)
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Gregory Chang
Gillian Lieberman, M.D.
Differential Diagnoses
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•
•
•
•
•
•
•
•
•
•
Aortic dissection
Right-sided pneumonia
Acute cholecystitis
Acute pancreatitis
Chronic pancreatitis
Appendicitis
Acute hepatitis
PUD
Perforated viscus
Right kidney disease
Subhepatic abscess
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Gregory Chang
Gillian Lieberman, M.D.
Initial Imaging Studies for LG
• Plain Films:
- Chest PA and Lateral
- Abdomen Supine and Upright
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Gregory Chang
Gillian Lieberman, M.D.
Results
PA
Lateral
widened mediastinum
(images courtesy BIDMC)
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Gregory Chang
Gillian Lieberman, M.D.
Results (cont.)
Erect
Supine
Normal
Abdominal
Plain Films
(images courtesy BIDMC)
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Gregory Chang
Gillian Lieberman, M.D.
Next Imaging Studies for LG
• Plain Films
• Ultrasound
• CT with and w/o contrast
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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”
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Gregory Chang
Gillian Lieberman, M.D.
Results
CT w/ contrast
Mild dilatation of thoracic aorta
(4.3 x4.6 cm)
CT w/ contrast
Low attenuation mass (malignancy?)
(images courtesy BIDMC)
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Gregory Chang
Gillian Lieberman, M.D.
What imaging study was performed next?
• Plain Films
• CT
• US
• MRI
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Gregory Chang
Gillian Lieberman, M.D.
Results
The area called into question on the CT scan represents focal fat.
T1 In Phase
water
fat
T1 Out of Phase
water
fat
decreased signal intensity
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(images courtesy BIDMC)
Gregory Chang
Gillian Lieberman, M.D.
Results (cont.)
T1 w/Contrast, Fat Suppressed
• Gallstone
• No wall thickening
• No pericholecystic
fluid
(image courtesy BIDMC)
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Gregory Chang
Gillian Lieberman, M.D.
Significant Findings So Far...
• Gallstone
• Slight gallbladder wall thickening
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Gregory Chang
Gillian Lieberman, M.D.
What imaging study was performed next?
• Plain Films
• CT and Ultrasound
• MRI
• DISIDA Scan - peripheral injection of 99Tclabeled 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.
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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.
Quick Time™a nd a
GIF dec ompr esso r
ar e nee ded to see this pictur e.
(images courtesy BIDMC)
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Gregory Chang
Gillian Lieberman, M.D.
Results (cont.)
• Post-morphine images
show non-filling of the
gallbladder, consistent
w/cholecystitis.
Quick Time™a nd a
GIF dec ompr esso r
ar e nee ded to see this pictur e.
(images courtesy BIDMC)
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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)
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Gregory Chang
Gillian Lieberman, M.D.
Let’s look at some more typical findings ...
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
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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”:
calcified gallbladder wall
biliary sludge formed from
precipitated calcium carbonate
crystals (or calcium
bilirubinate)
http://www.uhrad.com/ctarc/ct186.htm
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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
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Gregory Chang
Gillian Lieberman, M.D.
More Typical Radiologic Findings (cont.)
• CT- Not the modality
of choice, but very
useful. You can
detect:
Gas within gallbladder wall
- pericholecystic fluid
- gb wall thickening
- gallstones
- complications
- emphysema
- gangrene
- perforation
- liver abscess
http://www.vh.org/Providers/TeachingFiles/RCW2/121296/
121296.html
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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)
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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)
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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
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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
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Gregory Chang
Gillian Lieberman, M.D.
References
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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
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