0:00

Okay, so emphysematous cholecystitis, as I

0:03

told you, it's a very difficult diagnosis.

0:05

Here, again, is that image of the pericholecystic

0:07

fluid that looks a lot like cholecystitis.

0:10

It looks like a gallbladder as opposed to the

0:12

real gallbladder that was only seen on the edge

0:15

of the images with those dense stones as well.

0:19

Just to let you know, emphysematous

0:21

cholecystitis is a trap.

0:22

Frequently, we do not diagnose it well, not

0:25

on ultrasound, not on physical exam, not

0:27

on even the patient's presenting history.

0:29

It's one of the few cholecystitides

0:31

that is more common in men.

0:33

Usually the patients are really

0:34

sick, and they can have zero

0:36

symptomatology to the right upper quadrant.

0:38

So frequently we're making this diagnosis

0:40

on studies other than ultrasound.

0:42

Here's a patient who came for an ultrasound,

0:45

and they just said, oh, there's no gallbladder.

0:47

The patient, you can't see the gallbladder at all.

0:49

You know, here, okay, I would believe that.

0:51

I don't see a gallbladder; that could be bowel gas.

0:52

How am I to know, right?

0:53

Like, that's a very hard diagnosis.

0:55

But on CT scan, we saw a

0:56

beautiful emphysematous cholecystitis.

0:58

So again, beware.

1:00

It's a trap.

1:01

Emphysematous cholecystitis is a trap.

1:04

If you make the diagnosis, you may see some of the

1:06

classic signs of, uh, emphysematous cholecystitis.

1:09

Here are those very echogenic little

1:11

bubbles in the wall of the gallbladder.

1:13

Sometimes that's referred to as the champagne sign.

1:16

Anytime I can equate anything to champagne,

1:19

that is always fun.

1:20

But I have to tell you, although champagne

1:21

is fun, emphysematous cholecystitis is

1:24

not; it has a very high mortality rate.

1:26

It is a surgical emergency.

1:28

So, um, yeah, you have to toast to New Year's,

1:30

but you don't have to toast to emphysematous cholecystitis.

1:33

Let's just talk a tiny bit about

1:35

shadowing, remembering that

1:37

the dense posterior shadowing of

1:39

a stone is a strong attenuator.

1:41

You don't have any of your sound

1:43

waves posterior to it; it should be black-

1:45

black.

1:46

Unlike that echogenic dirty shadowing of

1:49

a patient with air in the wrong place.

1:51

So that's when your ultrasound

1:53

waves are basically scattered by little, uh,

1:56

tetrahedral of bubbles of air within fluid.

2:00

So these little tiny bubbles of air will

2:01

basically reverberate your sound waves and

2:04

will make it so that you can't see distal,

2:07

and it's a very different kind of shadowing.

2:09

So here's the pylorus.

2:10

That's a recognizable aspect

2:12

of the right upper quadrant.

2:13

Here we have the left lobe of the liver.

2:14

We have that dark muscularis level of

2:16

the pylorus with that echogenic mucosa.

2:19

And then when I let the probe up,

2:21

you can see that air is within that

2:23

pylorus now.

2:24

And now you can see that dirty shadowing.

2:26

Notice the shadowing is very, we call

2:27

it dirty 'cause it's gray, as opposed

2:29

to the dark black shadowing of a stone.

2:32

So air will have this dirty shadowing.

2:34

You may not see distal to it.

2:35

That's why emphysematous cholecystitis on ultrasound is so hard.

2:39

Basically, that air can block visualization

2:41

of the gallbladder in general,

2:43

and then you're gonna have the trap.

2:45

So, beware of cholecystitis and emphysematous cholecystitis on 81 00:02:45,810 --> 00:02:49,830

2:49

ultrasound, and have a high index of suspicion in very

2:52

sick patients that you may have to go on to CT scan.