Gallbladder Gems

55 year old obese female with history of IBS, GERD, and asthma brought in by her daughter for intermittent right upper quadrant pain x 4 months, worsened in intensity over the past day. The patient denied fever, chills, changes in mental status, jaundice, nausea, or vomiting. Patient was afebrile with vitals within normal limits in the ED. On ultrasound, the gallbladder was difficult to visualize due to prominent acoustic shadowing created by multiple and/or large stones within the gallbladder lumen. Sonographic Murphy’s sign was not present and the gallbladder wall was within normal limits (2 mm). Although no stone was visualized within the common bile duct, the lumen was dilated to 0.63 cm, suggesting choledocholithiasis.

Important points to remember when evaluating for gallbladder pathology:

  • Cholelithiasis is characterized by echogenic foci within the gallbladder lumen with posterior acoustic shadowing. Stones will move with change in patient positioning.
  • Gallbladder sludge and gallbladder polyps may be distinguished from gallstones by a lack of shadowing (polyps will also be immobile)
  • Positive sonographic Murphy’s sign + cholelithiasis with gallbladder wall thickening > 3 mm is suggestive of acute cholecystitis
  • Common bile duct lumen normal range is 6 mm, with + 1 mm increase in upper limit of normal per each decade past the age of 60 years
  • Choledocholithiasis with biliary dilation in patient with Charcot’s triad is diagnostic for ascending cholangitis

– Tabitha Crane, MS4

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