Duodenum over time should reveal peristalsis this

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duodenum over time should reveal peristalsis; this will not occur in the gallbladder. The gallbladder is “finite,” and clear boundaries can be visual- ized by scanning through from top to bottom, left to right. In contrast, the duodenum leads to the stomach proximally and jejunum distally. On ultra- sound, this creates an appearance of a structure which continues for some time in either direction, lacking the gallbladder’s clear boundaries. Another mimic to note is that polyps can be mistaken for gallstones. Note that polyps should not create acoustic shadows ( Figure 7.25 ) and they do not move as the patient moves. Changing position will cause gravity to act on gallstones, whereas polyps will remain fixed in position. Although the lack of gallstones may be reassuring in a patient with acute abdominal pain, remem- ber that polyps may represent malignancy and require close follow-up regardless of the acute clinical course. Sample clinical protocol Figure 7.26 demonstrates how bedside sonography can be incorporated into the evaluation of patients with possible biliary disease. Application of similar protocols varies widely. In some centers, surgeons will operate based on an appropriate clinical picture and bedside ultrasound. In other centers, a normal bedside ultrasound may direct the clinician to perform a CT scan as a first-line study in undifferentiated abdominal pain. It is important to adopt an algorithm which is compatible with the emergency physician and consultant practice at your own institution. Figure 7.25 Gallbladder polyp (arrow). In this image a normal gallbladder wall (caliper A) and common bile duct (caliper B) are visible as well. 168 Diagnostic ultrasound Gallbladder ultrasound
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Literature review Abdominal pain Gallbladder visualized Stones and sonographic Murphys No stones and no sonographic Murphys Stones but no sonographic Murphys Gallbladder not visualized Standard radiological test ordering Clinical suspicion not confirmed Surgical consultation, tx for cholecystitis Clinical suspicion confirmed Tx for biliary colic Clinical suspicion confirmed Clinical suspicion not confirmed Further diagnostic testing Figure 7.26 Sample clinical protocol for the evaluation of possible acute cholecystitis. Reference Methods Results Notes Ralls et al. 1985 [ 1 ] Compared results for focused gallbladder US exam (look for stones and/or sonographic Murphy sign) and full gallbladder US exam (including CBD, pericholecystic fluid, gallbladder wall thickness). PPV of focused exam for cholecystitis 92.2%. NPV of focused exam was 95%. Provided radiology literature support for performing focused US gallbladder exam without compromising diagnostic accuracy. Johnston & Kaplan 1993 [ 7 ] Evaluated prevalence and incidence data in biliary disease.
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