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Mayra E. Lorenzo 2003
Gillian Lieberman, MD
Radiologic evaluation of RUQ pain:
Hepatic and Biliary possibilities
Mayra E. Lorenzo, Harvard Medical School Year III
Gillian Lieberman, MD
January 2003
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Mayra E. Lorenzo 2003
Gillian Lieberman, MD
RUQ pain
DDx (what lives there)
Gallbladder
Biliary tract
Liver
Subprhenic spaces
GI
GU
Mr. S is a 37y/o male with Type I DM, ESRD, hepatitis C who
presents with fevers to 104 F, GNR bacteremia and RUQ
tenderness
Patient History
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Mayra E. Lorenzo 2003
Gillian Lieberman, MD
I. RUQ pain with positive clinical Murphy’s
sign (arrested inspiration or gasping on
palpation of RUQ)
II. RUQ pain with fever with negative
Murphy’s sign
III. RUQ pain without fever and negative
Murphy’s sign
Simplifying RUQ pain
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Mayra E. Lorenzo 2003
Gillian Lieberman, MD
I. RUQ pain with positive clinical Murphy’s sign (arrested
inspiration or gasping on palpation of RUQ)
Biliary (acute cholecystitis, biliary colic)
Sonography
• Reliable for detection of gallstones
• Image entire abdomen
• Blood flow analysis without contrast (Doppler)
• Determine if stone impacted by moving patient
• Radiologic Murphy’s sign (patient’s site of max.
tenderness by compression with transducer). High
positive predictive value for acute cholecystitis in
patient with RUQ pain, fever and leukocytosis. Can be
absent in gangrenous cholecystitis
Biliary Scintigraphy (use if ultrasound inconclusive, few false-
negatives)
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Mayra E. Lorenzo 2003
Gillian Lieberman, MD
II. RUQ pain with fever with negative Murphy’s sign
Cholangitis
Hepatic abscess
Subphrenic abscess
Gangrenous cholecystitis
Perforated duodenal ulcer
Pancreatitis
RLL pneumonia
Sonography
Contrast enhanced CT
ERCP and MR for common bile duct stones
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Mayra E. Lorenzo 2003
Gillian Lieberman, MD
III. RUQ pain without fever and negative Murphy’s sign
Hepatic tumor
(internal hemorrage/rupture into peritoneal cavity)
CT
MR
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Mayra E. Lorenzo 2003
Gillian Lieberman, MD
II. RUQ pain with fever with negative Murphy’s sign
Cholangitis
Hepatic abscess
Subphrenic abscess
Gangrenous cholecystitis
Perforated duodenal ulcer
Pancreatitis
RLL pneumonia
Sonography
Contrast enhanced CT
ERCP and MR for common bile duct stones
Our patient, Mr. S, falls into:
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Mayra E. Lorenzo 2003
Gillian Lieberman, MD
Ultrasound
BIDMC PACS
round
hyperechoic
signal with
acoustic
shadowing
anechoic
area within
gallbladder
echogenic
material
within
gallbladder
DDx
-gallstone
-adenomyomatosis
-polyp
DDx
Pus
sludge
hematoma
Carcinoma
Adenomyomatosis
Polyp, cholesterol
DDx
Fluid
bile
Thickened gallbladder wall
Mr. S’s Ultrasound: Transverse view
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Mayra E. Lorenzo 2003
Gillian Lieberman, MD
Up-to-date
•Thickened wall (greater than 4 or 5 mm, double wall
sign)
•Radiologic Murphy’s sign
•Pericholecystic fluid
•Gallstones
Ultrasound findings in acute cholecystitis:
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Mayra E. Lorenzo 2003
Gillian Lieberman, MD
• Pathogenesis:
• Mechanical inflammation (obstruction, distension)
• Chemical inflammation (lysolechitinÆphospholipase A on lechitin in
bile)
• Bacterial inflammation (most common organisms found: Escherichia
coli, Enterococcus, Klebsiella, and Enterobacter)
• Complications of untreated acute cholecystitis:Edema and inflammation can
progress to necrosis and gangrene
• EmpyemaÆgangrenous cholecystitis (especially in diabetics, with
sepsis)
• Gallbladder perforation
• Chloecystoenteric fistula
• Gallstone illeus (gallstone through cholecystoenteric fistula)
• Emphysematous cholecystitis (Clostridium welchii)
Acute Cholecystitis
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Mayra E. Lorenzo 2003
Gillian Lieberman, MD
Ultrasound
BIDMC PACS
heterogeneous
echogenic
mass
no defined
border
round
hyperechoic
signal with
acoustic
shadowing
anechoic
signal
echogenic
material
within
gallbladder
DDx
-gallstone
-adenomyomatosis
-polyp
DDx
Pus
sludge
hematoma
Carcinoma
Adenomyomatosis
Polyp, cholesterol
DDx
Fluid
bile
DDx of
heterogeneous
liver mass:
Abscess
Focal nodular
hyperplasia
Hepatocellular
carcinoma
Hyatid cyst
Metastasis
Neoplasm
lymphoma
Thickened gallbladder wall
Mr. S’s Ultrasound: Transverse view
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Mayra E. Lorenzo 2003
Gillian Lieberman, MD
Echogenic
material
within
gallbladder
Gallstone
Continuation
of
heterogeneous
echogenic
mass and
gallbladder
BIDMC PACS
anechoic
signal
Mr. S’s Ultrasound: Oblique sagital view
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Mayra E. Lorenzo 2003
Gillian Lieberman, MD
Abscess (pyogenic, amebic, fungal)
adenoma
focal nodular hyperplasia
hepatocellular carcinoma
hyatid cyst
lymphoma
metastasis
Hepatocellular carcinoma
Æ Contrast enhanced MR or CT to further evaluate…
DDx for a hypoechoic liver mass on ultrasound
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Mayra E. Lorenzo 2003
Gillian Lieberman, MD
With history of Type I DM and gram negative rod bacteremia…
Most likely DDx:
1. Acute suppurative cholecystitis with comunicating
intrahepatic liver abscess
Ultrasound:
•heterogeneous liver mass
•thickened gallbladder wall with
echogenic material and gallstones
•apparent continuation between
liver mass and gallbladder lumen
RUQ pain with fever with negative Murphy’s sign
Cholangitis
Hepatic abscess
Subphrenic abscess
Gangrenous cholecystitis
Perforated duodenal ulcer
Pancreatitis
RLL pneumonia
Differential Diagnosis for our Patient after Ultrasound
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Mayra E. Lorenzo 2003
Gillian Lieberman, MD
Three phases of hepatic contrast enhancement:
1. No contrast
2. Arterial phase: 20 second delay
3. Portal venous phase: 45-60 second delay
Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 7th ed.,
Liver lessions will have a different patterns of
enhancement in the various phases
Contrast-enhanced CT for further evaluation of heterogeneous liver mass
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Mayra E. Lorenzo 2003
Gillian Lieberman, MD
Mr. S’s no-contrast CT
Difficult to appreciate fine details of lession
BIDMC PACS
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Mayra E. Lorenzo 2003
Gillian Lieberman, MD
Enhancing
border
Non-
enhancing
septated
lession
BIDMC PACS
Mr. S’s CT with contrast: arterial phase
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Mayra E. Lorenzo 2003
Gillian Lieberman, MD
BIDMC PACS
gallbladder
Mr. S’s CT with contrast: arterial phase
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Mayra E. Lorenzo 2003
Gillian Lieberman, MD
Comunication
BIDMC PACS
Mr. S’s CT with contrast: arterial phase
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Mayra E. Lorenzo 2003
Gillian Lieberman, MD
Fluid within
gallbladder
wall
Pericholecystic
fluid
BIDMC PACS
Mr. S’s CT with contrast: arterial phase
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Mayra E. Lorenzo 2003
Gillian Lieberman, MD
Fluid within
gallbladder wall
BIDMC PACS
Mr. S’s CT with contrast: arterial phase
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Mayra E. Lorenzo 2003
Gillian Lieberman, MD
Fat stranding
Pericholecystic
fluid
BIDMC PACS
Mr. S’s CT with contrast: arterial phase
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Mayra E. Lorenzo 2003
Gillian Lieberman, MD
Pyogenic Liver Abscess
•Two major mechanisms: local spread from contiguous
infections within the peritoneal cavity or hematogenous
seeding of the liver
•Usually polymicrobial
•Microabscesses from enteric organisms coalesce
•Hematogenously spread Staphylococcus results in diffuse
microabscesses throughout the liver
•Ultrasound: from hypoechoic to hyperechoic ill-defined
lessions. Gas within abscess can causes high intensity linear
echoes with acoustic shadows and reverberations
•Contrast CT scan:
•hypodense lessions
•Range from unilocular with smooth borders to complex
internal septations with irregular borders
•Rim enhancement in 6%
•Some are gas-containing. More common in diabetic
population
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Mayra E. Lorenzo 2003
Gillian Lieberman, MD
•Interventional Radiology: Ultrasound guided percutaneous drainage of
gallbladder Æ purulent fluid ÆCx: Klebsiella
Diagnosis: Suppurative Cholecystitis with Intrahepatic Liver Abscess
•Antibiotics
Patient continued to spike fevers, abdominal pain and tenderness…
•CT guided drainage of intrahepatic liver abscess-unsuccesfull
•Surgery: open cholecystectomy and incission and drainage of liver abscess
•Thickened gallbladder with stones (Path: chronic cholecystits with focal
acute inflammation).
•Edematous wall, no evidence of perforation
•2x3cm liver abscess contiguous with gallbladder
Patient did well post-operatively. Continued on antibiotics and was discharged
to home.
Diagnosis and Treatment
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Mayra E. Lorenzo 2003
Gillian Lieberman, MD
Conclusions
•Learned:
•Most useful radiologic tests to evaluate
different types of RUQ pain
•Radiologic findings of acute cholecystitis
•Radiologic findings of pyogenic liver
abcess
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Mayra E. Lorenzo 2003
Gillian Lieberman, MD
Also…
Echogenicity on ultrasound does not translate to density on CT
BIDMC PACSBIDMC PACS
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Mayra E. Lorenzo 2003
Gillian Lieberman, MD
Cecil Textbook of Medicine 21st Edition
Amebic liver abscess
Entamoeba histolytica
•10% of world population infected (Mexico, Central and South
America, India, tropical Asia, Africa)
•Liver abscess: up to 5 months after diarrheal illnessÆfever,
RUQ pain
Also interesting to note the appearance of amebic liver abscesses on CT and that
their clinical presentation can be similar to that of Mr. S…
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Mayra E. Lorenzo 2003
Gillian Lieberman, MD
References
Silverman, P.M. and Zeman, R. K., editors. CT and MRI of the Liver and Biliary System,
Contemporary Issues in CT, Vol 12, 1990.
Ros, P.R. (guest editor). Hepatic Imaging, The Radiologic Clinics of North America,
March 1998, Vol. 36:2
Gamuts in Radiology
Nino-Murcia, M. and Jeffrey, R.B. Imaging the Patient with Right Upper Quadrant Pain.
Seminars in Roentgenology, Vol 36, No. 2 April 2001, pp 81-91
www.uptodate.com
Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 7th ed.
Cecil Textbook of Medicine 21st Edition
Saini, S. Imaging of the Hepatobiliary Tract. NEJM (1997) Volume 336:1889-1894
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Mayra E. Lorenzo 2003
Gillian Lieberman, MD
Special thanks to…
James Busch, MD
Matt Spencer, MD
Marissa Heller
Gillian Lieberman, MD
Pamela Lepkowski
Our Webmasters: Larry Barbaras
and Cara Lyn D’amour
Radiologic evaluation of RUQ pain: Hepatic and Biliary possibilities
Patient History
Simplifying RUQ pain
Slide Number 4
Slide Number 5
Slide Number 6
Slide Number 7
Mr. S’s Ultrasound: Transverse view
Ultrasound findings in acute cholecystitis:
Acute Cholecystitis
Mr. S’s Ultrasound: Transverse view
Mr. S’s Ultrasound: Oblique sagital view
DDx for a hypoechoic liver mass on ultrasound�
Differential Diagnosis for our Patient after Ultrasound
Contrast-enhanced CT for further evaluation of heterogeneous liver mass
Mr. S’s no-contrast CT
Mr. S’s CT with contrast: arterial phase
Mr. S’s CT with contrast: arterial phase
Mr. S’s CT with contrast: arterial phase
Mr. S’s CT with contrast: arterial phase
Mr. S’s CT with contrast: arterial phase
Mr. S’s CT with contrast: arterial phase
Pyogenic Liver Abscess
Diagnosis and Treatment
Conclusions
Also…
Amebic liver abscess
References
Special thanks to…