Mar 5, 2009 0
“A second look…”
A 58 year old woman presented with a chief complaint of epigastric abdominal pain for the past 6 months. Her PMHx was significant for hypertension, and she had been evaluated with a colonoscopy and EGD 2 months prior to presentation. Her medications included Altace and Atenolol.
VS: T 98.9 P 80 BP 200/120 R 16 O2 sat 98% on RA.
A RUQ ultrasound was done to assess the gallbladder:
Figure 1: A mid-range frequency, phased array probe is used to assess the gallbladder in its long axis.
Figure 2: A dilated common bile duct is seen here. Note that a “normal” measurement for the CBD is considered to be less than 6mm; some providers allow 1 mm per decade. A patient who is s/p cholecystectomy may have a CBD that is dilated up to 1 cm.
Figure 3: In this view we see the gallbladder in short axis. We see peristaltic movement of bowel to the right of the gallbladder, but pay attention to the hypoechoic area seen within the liver tissue to the left of the gallbladder.
Figure 4: Upon closer inspection of the liver, we see multiple heterogeneous areas suspicious for metastatic disease.
The patient went for ERCP, and a pancreatic mass was noted. The incidental findings in the hepatic tissue were noted on QA, or quality assurance review, highlighting the importance of not only noting the area intended for exam, but also the surrounding tissue as normal or abnormal. “Incidentalomas” may be frequently identified when examining the RUQ on ultrasound; in one report a nonbiliary source of pain was identified in 21% of cases (1). Although specific characterization of these findings is often outside the scope of emergency ultrasound, EUS serves as a reasonable first line screening modality for identification of RUQ pathology.
1. Shuman WP, Mack LA, Rudd TG, et al. Evaluation of acute right upper quadrant pain: sonography and 99m-Tc-PIPIDA cholescintigraphy. AJR Am J Roentgenol. 1982; 139:61-64.
Recommended reading: Leeuwen MV, Nederend J, Smithuis R. What to do with incidentally found lesions in the liver? Radiology department of the University Medical Centre of Utrecht, the Leiden University and the Rijnland Hospital, Leiderdorp, the Netherlands
View link here: www.radiologyassistant.nl/en/45a5e818c709d
