1. 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. 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. 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.

4. 4 Send in the Med Students Gregory Chang Gillian Lieberman, M.D.

5. 5 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.

6. 6 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.

7. 7 Initial Imaging Studies for LG Plain Films: - Chest PA and Lateral - Abdomen Supine and Upright Gregory Chang Gillian Lieberman, M.D.

8. 8 Results widened mediastinum PALateral Gregory Chang Gillian Lieberman, M.D. (images courtesy BIDMC)

9. 9 Results (cont.) Normal Abdominal Plain Films ErectSupine Gregory Chang Gillian Lieberman, M.D. (images courtesy BIDMC)

10. 10 Next Imaging Studies for LG Plain Films Ultrasound CT with and w/o contrast Gregory Chang Gillian Lieberman, M.D.

11. 11 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)

12. 12 Results Mild dilatation of thoracic aorta (4.3 x4.6 cm) Low attenuation mass (malignancy?) CT w/ contrast Gregory Chang Gillian Lieberman, M.D. (images courtesy BIDMC)

13. 13 What imaging study was performed next? Plain Films CT US MRI Gregory Chang Gillian Lieberman, M.D.

14. 14 Results T1 In Phase T1 Out of Phase water 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

15. 15 Results (cont.) Gallstone No wall thickening No pericholecystic fluid T1 w/Contrast, Fat Suppressed Gregory Chang Gillian Lieberman, M.D. (image courtesy BIDMC)

16. 16 Significant Findings So Far... Gallstone Slight gallbladder wall thickening Gregory Chang Gillian Lieberman, M.D.

17. 17 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.

18. 18 Results DISIDA Scan shows non-filling of the gallbladder, consistent w/cholecystitis. Activity is noted within the small bowel at 10 minutes. Gregory Chang Gillian Lieberman, M.D. (images courtesy BIDMC)

19. 19 Results (cont.) Post-morphine images show non-filling of the gallbladder, consistent w/cholecystitis. Gregory Chang Gillian Lieberman, M.D. (images courtesy BIDMC)

20. 20 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)

21. Let’s look at some more typical findings... Gregory Chang Gillian Lieberman, M.D.

22. 22 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.

23. 23 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. 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. 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.

26. 26 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)

27. 27 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)

28. 28 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. 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. 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.