The Generalist: POCUS Gallstones
Casey Parker, MD, and Vanessa Cardy, MD
Casey joins Vanessa to review a basic approach for point-of-care ultrasound (POCUS) of the gallbladder in the office setting.
- There are many important differential diagnoses to consider when patients present with upper abdominal pain.
- POCUS is a useful office tool for assessing the gallbladder and diagnosing gallbladder/gallstone disease.
- Beware – the rate of asymptomatic, innocent gallstones in middle-aged patients is quite high.
- Be sure to employ careful clinical correlation when using POCUS in this context, so as not to get distracted from more serious problems by the incidental presence of a few chronic stones.
- Procedural tips and tricks:
- Use a curvilinear probe on the “Abdo” preset.
- Start midline and search along the right liver margin.
- Beware that the colon and duodenum can look like a gallbladder.
- Ask the patient to take a deep breath to improve the window to view the gallbladder.
- Roll the patient to the left lateral decubitus position to improve your view.
- Once the gallbladder has been identified, ask yourself the following key questions:
- Are there gallstones present?
- Are the gallstones mobile or impacted in the gallbladder neck?
- Are there features of inflammation suggesting cholecystitis?
1. Thickened wall (>3 mm)
2. Pericholecystic free fluid
3. Hyperemia of the walL
4. Is there probe tenderness - a sonographic Murphy’s sign over the gallbladder?
- Clinical correlation
- Impacted stone with the right history makes us think of biliary colic.
- This is often benign but can progress to more serious problems such as cholecystitis or cholangitis.
- Signs of inflammation suggest cholecystitis and the patient should be referred for emergency assessment.
- If there are no stones seen, then you probably need to find another cause for the patient’s symptoms.
PEARL: The rate of asymptomatic, innocent gallstones in middle-aged patients is quite high, so be sure to correlate POCUS findings with the clinical picture of the patient. Chronic stones are not always the cause of the symptoms.