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.
November 2001
2
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.
Gregory Chang
Gillian Lieberman, M.D.
3
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.
Gregory Chang
Gillian Lieberman, M.D.
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Send in the Med Students
Gregory Chang
Gillian Lieberman, M.D.
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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)
Gregory Chang
Gillian Lieberman, M.D.
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Differential Diagnoses
• Aortic dissection
• Right-sided pneumonia
• Acute cholecystitis
• Acute pancreatitis
• Chronic pancreatitis
• Appendicitis
• Acute hepatitis
• PUD
• Perforated viscus
• Right kidney disease
• Subhepatic abscess
Gregory Chang
Gillian Lieberman, M.D.
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Initial Imaging Studies for LG
• Plain Films:
- Chest PA and Lateral
- Abdomen Supine and Upright
Gregory Chang
Gillian Lieberman, M.D.
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Results
widened mediastinum
PA Lateral
Gregory Chang
Gillian Lieberman, M.D.
(images courtesy BIDMC)
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Results (cont.)
Normal
Abdominal
Plain Films
Erect Supine
Gregory Chang
Gillian Lieberman, M.D.
(images courtesy BIDMC)
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Next Imaging Studies for LG
• Plain Films
• Ultrasound
• CT with and w/o contrast
Gregory Chang
Gillian Lieberman, M.D.
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Results
• slight gallbladder wall
thickening
• 1 cm gallstone in
gallbladder neck
• No pericholecystic fluid
• No gallbladder dilatation
• No sonographic Murphy’s
“cholelithiasis with slight wall thickening”
Gregory Chang
Gillian Lieberman, M.D.
(image courtesy BIDMC)
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Results
Mild dilatation of thoracic aorta
(4.3 x4.6 cm) Low attenuation mass (malignancy?)
CT w/ contrast CT w/ contrast
Gregory Chang
Gillian Lieberman, M.D.
(images courtesy BIDMC)
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What imaging study was performed next?
• Plain Films
• CT
• US
• MRI
Gregory Chang
Gillian Lieberman, M.D.
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Results
T1 In Phase T1 Out of Phase
water water
fat fat
Gregory Chang
Gillian Lieberman, M.D.
(images courtesy BIDMC)
The area called into question on the CT scan represents focal fat.
decreased signal intensity
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Results (cont.)
• Gallstone
• No wall thickening
• No pericholecystic
fluid
T1 w/Contrast, Fat Suppressed
Gregory Chang
Gillian Lieberman, M.D.
(image courtesy BIDMC)
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Significant Findings So Far...
• Gallstone
• Slight gallbladder wall thickening
Gregory Chang
Gillian Lieberman, M.D.
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What imaging study was performed next?
• Plain Films
• CT and Ultrasound
• MRI
• DISIDA Scan - peripheral injection of 99Tc-
labeled 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.
Gregory Chang
Gillian Lieberman, M.D.
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Results
• DISIDA Scan shows
non-filling of the
gallbladder, consistent
w/cholecystitis.
• Activity is noted
within the small bowel
at 10 minutes.
QuickTime™ and a
GIF decompressor
are needed to see this picture.
Gregory Chang
Gillian Lieberman, M.D.
(images courtesy BIDMC)
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Results (cont.)
QuickTime™ and a
GIF decompressor
are needed to see this picture.
• Post-morphine images
show non-filling of the
gallbladder, consistent
w/cholecystitis.
Gregory Chang
Gillian Lieberman, M.D.
(images courtesy BIDMC)
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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
Gregory Chang
Gillian Lieberman, M.D.
(Not LG’s gallbladder)
Let’s look at some more typical findings ...
Gregory Chang
Gillian Lieberman, M.D.
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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
Gregory Chang
Gillian Lieberman, M.D.
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More Typical Radiologic Findings of Cholecystitis
• Plain Films also allow
you to detect:
– gallbladder wall
calcification
– “milk of calcium”:
biliary sludge formed from
precipitated calcium carbonate
crystals (or calcium
bilirubinate)
calcified gallbladder wall
http://www.uhrad.com/ctarc/ct186.htm
Gregory Chang
Gillian Lieberman, M.D.
24
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
Gregory Chang
Gillian Lieberman, M.D.
25
More Typical Radiologic Findings (cont.)
• CT- Not the modality
of choice, but very
useful. You can
detect:
- pericholecystic fluid
- gb wall thickening
- gallstones
- complications
- emphysema
- gangrene
- perforation
- liver abscess
Gas within gallbladder wall
http://www.vh.org/Providers/TeachingFiles/RCW2/121296/
121296.html
Gregory Chang
Gillian Lieberman, M.D.
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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)
Gregory Chang
Gillian Lieberman, M.D.
(images courtesy BIDMC)
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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.
Gregory Chang
Gillian Lieberman, M.D.
(image courtesy BIDMC)
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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
Gregory Chang
Gillian Lieberman, M.D.
29
Acknowledgments
• Dr. Chad Brecher, Dr. Bettina Siewert, Dr.
Haldon Bryer, Dr. Joseph Makris, Dr.
Daniel Saurborn
• Dr. Gillian Lieberman
• Pamela Lepkowski
• Kevin Reynolds
Gregory Chang
Gillian Lieberman, M.D.
30
References
• 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
Gregory Chang
Gillian Lieberman, M.D.
Quick! Somebody Call a Doctor (Radiologist)!� Diagnosing RUQ Pain in an ED Patient
Objectives
Let’s Meet Our Patient
Send in the Med Students
After further questioning…
Differential Diagnoses
Initial Imaging Studies for LG
Results
Results (cont.)
Next Imaging Studies for LG
Results
Results
What imaging study was performed next?
Results
Results (cont.)
Significant Findings So Far...
What imaging study was performed next?
Results
Results (cont.)
To the OR
Let’s look at some more typical findings ...
More Typical Radiologic Findings of Cholecystitis
More Typical Radiologic Findings of Cholecystitis
More Typical Radiologic Findings (cont.)
More Typical Radiologic Findings (cont.)
More Typical Radiologic Findings (cont.)
More Typical Radiologic Findings (cont.)
Summary
Acknowledgments
References