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2004 Vol.42 Issues 2 Emergency Ultrasound

2004 Vol.42 Issues 2 Emergency Ultrasound

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Published by Nguyen Tran Canh

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Published by: Nguyen Tran Canh on Feb 15, 2013
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Emergency ultrasound
Ultrasonography has undergone many technologicchanges resulting in its present state-of-the-art equip-ment that is capable of high-resolution real-timegray-scale imaging and tissue harmonics, includingcolor and power Doppler. These advances in ultra-sound technology have resulted in improved work-upof patients undergoing evaluation in emergency de- partments because it is the first imaging performed onalmost all patients presenting to an emergency facil-ity. This easily available imaging modality remainsthe primary workhorse in diagnostic radiology not only in day-to-day practice but also in emergencysituations. There has been a need for the
RadiologicClinics of North America
to dedicate an issue solelyto the practice of emergency ultrasound and I amhonored to be the guest editor of this issue. Great carehas been given to the selection of topics for this issue,and pertinent findings have been summarized in theform of tables for easy reference in most of thearticles where problem-solving algorithms are alsoincluded. Relevant topics have been included thaare helpful to all clinicians involved in emergency pa-tient care. Most of the articles describe sonographytechniques and pertinent sonographic anatomy to helpthose who are new to the field of ultrasonography.This issue on emergency ultrasound provides thereader with up-to-date information on what is new,exciting, and relevant in the practice of ultrasonog-raphy as it pertains to acutely ill patients.I wish to express my thanks to Joseph Molter for  preparing the illustrations, to Bonnie Hami, MA, for her editorial assistance, and to Adrienne Jones for her secretarial assistance. In addition, my sincere thanksgo to Barton Dudlick at Elsevier Science for hisadministrative and editorial assistance.Vikram Dogra, MD
 Division of Ultrasound  Department of RadiologyCase Western Reserve UniversityUniversity Hospitals11100 Euclid AvenueCleveland, OH 44106, USA E-mail address:
0033-8389/04/$ – see front matter 
2004 Elsevier Inc. All rights reserved.doi:10.1016/j.rcl.2004.01.004Vikram Dogra, MD
Guest Editor 
Radiol Clin N Am 42 (2004) xi
Hepatobiliary imaging and its pitfalls
Deborah J. Rubens, MD
 Departments of Radiology and Surgery, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642-8648, USA
Diagnosis of acute cholecystitis
Acute cholecystitis is the result of obstruction of the gallbladder and accompanying inflammation of the gallbladder wall with associated infection andsometimes necrosis. Ninety percent to 95% of casesof acute cholecystitis are caused by obstruction bygallstones in either the gallbladder neck or the cysticduct [1].Acute cholecystitis occurs in only approxi- mately 20% of patients who have gallstones[2].This means that many patients with gallstones have nosymptoms, and their right upper quadrant pain may be caused by a different etiology[3].Of patients who  present with right upper quadrant pain, only 20% to35% have acute cholecystitis[1,2].As the definition of ‘‘right upper quadrant pain’’ becomes less specific,especially lacking an accompanying elevated white blood cell count and fever, the percentage of patientswho actually have acute cholecystitis given the his-tory of right upper quadrant pain diminishes further.Specific criteria for the diagnosis of acute cholecys-titis are important, because many patients have gall-stones but may not have acute cholecystitis. The primary diagnostic criterion is a positive sonographicMurphy’s sign in the presence of gallstones. Second-ary signs of acute cholecystitis include gallbladdewall thickening more than 3 mm, a distended or hydropic gallbladder (loss of the normal tapered neck and development of an elliptical or rounded shape),and pericholecystic fluid.
Sonographic Murphy’s sign
The sonographic Murphys sign is defined asspecific reproducible point tenderness over the gall- bladder as the transducer applies pressure. In a classicarticle by Dr. Phillip Ralls[4],which included only  patients with right upper quadrant pain, fever, and anelevated white blood cell count, a sonographic Mur- phy’s sign was 87% specific for the diagnosis of acute cholecystitis. When a positive sonographicMurphy’s sign is used in conjunction with the pres-ence of gallstones, it has a positive predictive value of 92% for diagnosing acute cholecystitis. Persons inwhom a sonographic Murphy’s sign may be absent include persons who are medicated; therefore, carefulattention to a patient’s clinical status is important.Denervated gallbladders in patients who have diabe-tes or gangrenous cholecystitis may result in the lossof a sonographic Murphy’s sign.
Gallstone diagnosis and pitfalls
Gallstones are diagnosed by the presence of gravity-dependent, mobile intraluminal echoes withinthe gallbladder, which cast a posterior shadow(Fig. 1).Although ultrasound (US) has a high accu-racy (>95%) for the diagnosis of gallstones, somestones may be missed[3].False-negative results occur because of stones that are too small to cast ashadow (usually smaller than 1 mm), soft stones that lack strong echoes[1],and gallstones that are im-  pacted in the gallbladder neck or in the cystic duct and may not be as readily visible (seeFig. 1)[5].If  the gallbladder is focally tender but no gallstones areappreciated, the patient should be examined from
0033-8389/04/$ – see front matter 
2004 Elsevier Inc. All rights reserved.doi:10.1016/j.rcl.2003.12.004
 E-mail address:
Deborah_Rubens@urmc.rochester.eduRadiol Clin N Am 42 (2004) 257–278

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