0:00

Okay, now we have a right upper quadrant ultrasound.

0:03

We have a number of static images and a large number of

0:06

sweep images as we frequently get on our ultrasounds.

0:10

Um, sweep images have been so advantageous 'cause

0:12

you can really look at all of the anatomy and see

0:15

what's going on besides just the static images

0:17

where you had to completely trust technologists to

0:19

take imaging of all of the important structures.

0:22

So as we come through, we're going to notice that our

0:24

technologist has already labeled some free fluid.

0:26

That's correct.

0:27

A little bit up there.

0:30

And then we're going to fly through these images

0:32

until we get to the gallbladder images.

0:34

There's a common bile duct.

0:36

It is 6.9 centimeters, so it's a little dilated.

0:38

Let's be clear.

0:39

It's above six.

0:39

You'd want to correlate that with biliary serologies.

0:42

And here is the image where we're

0:44

seeing an anechoic structure, and that is

0:49

not that well defined.

0:50

Uh, ultrasound technologist has

0:52

measured the wall at six millimeters.

0:54

So thickened, but not very

0:56

dramatic comparatively to that.

0:58

Right?

0:58

So let's take a look at the sweeps.

1:00

There's a bunch of sweep images.

1:02

Um, and I tell you, I think that looking at your

1:04

sweep images is really helpful in order not to fall

1:07

into traps of missing, um, especially choledocholithiasis.

1:10

But also some unusual entities that may not have been

1:13

well visualized by the technologists at the time.

1:15

I mean, they're really busy.

1:16

You have to remember, your technologists are

1:18

trying to take images for your appreciation,

1:20

and they're trying to do a very protocol

1:22

examination on a patient who's very sick.

1:25

They're using a lot of strength in their arm

1:27

to push that ultrasound probe against the

1:29

patient's abdomen, the patient's in pain.

1:31

So we really have to realize that they have

1:33

a lot going on during these examinations,

1:35

and we have to take our time as well to look

1:37

at all of their beautifully obtained images.

1:39

Because there can be some things hiding.

1:41

Notice this, um, fluid, anechoic

1:44

fluid here is, it's kind of unusual.

1:46

It doesn't have really that

1:46

perception of a full gallbladder.

1:48

It doesn't have the wall all the way through here.

1:50

We have a very thin appearance to it there.

1:52

But adjacent, you can see all of these echoes, echoes,

1:55

echoes, echoes with a lot of shadowing as well.

1:58

Huh?

1:59

Little bubbles.

1:59

Little echogenic foci.

2:01

So this is questionable.

2:02

I would say that this, um, examination would be

2:05

hard to interpret as given to us. Here coming down,

2:08

we'll see another

2:09

sweep image, and if I can talk you into

2:11

this, paralleling our suspected gallbladder

2:14

is probably our real gallbladder.

2:16

It's just that in this case, we have dense stones

2:19

within it and echogenic foci within the wall.

2:22

This is with dirty shadowing.

2:23

See how that shadowing is all gray?

2:25

It's not dark like the stone shadowing.

2:28

This is an appearance of emphysematous

2:31

cholecystitis on imaging on ultrasound.

2:34

Misinterpreted as a normal gallbladder adjacent

2:37

to the emphysematous gallbladder, which is just a

2:40

fluid collection, a pericholecystic fluid collection.

2:43

So always look at your sweep images,

2:45

they're given to you for a reason.

2:47

Give grace to your ultrasound technologist.

2:49

They are working at highest of rates

2:51

of speed in a really complex situation.

2:54

It is on you to spend the time to look at all the

2:56

images that are given to you, and I think you'll

2:58

make some diagnoses that will really surprise you.

3:01

Okay, so this is the CT scan

3:03

of the previous ultrasound.

3:04

I know you all are skeptical, so I wanted to make sure

3:07

that I brought you proof by photons here on a CT scan.

3:11

The don of truth has spoken.

3:12

So here is the liver and as we come down we're

3:15

going to see that emphysematous cholecystitis,

3:16

all of those little air locules within the wall

3:19

of the gallbladder, a number of stones, um,

3:21

densely packed into the gallbladder neck, and

3:25

that pericholecystic fluid collection that was

3:27

misrepresented as the gallbladder on the ultrasound.

3:30

Again, we see all that pericholecystic

3:32

fluid, a very angry right upper quadrant.

3:34

The patient definitely has a lot

3:36

of inflammatory change as well.

3:37

You can see that the colon is decompressed right

3:40

next to that in it's bad neighborhood of the

3:42

emphysematous cholecystitis with perforation.

3:45

So that's fluid collection is basically just

3:47

a perforation of the wall here, as you

3:49

can imagine, because gangrenous cholecystitis,

3:52

obviously, emphysematous cholecystitis is a gangrenous

3:54

cholecystitis, so this is just one branch of that.

3:57

So you can imagine that there could be perforation

3:59

of a distended gangrenous gallbladder here.