Abdominal pain is consistently one of the top reasons that patients present to the ED.1 In 2009, 668970 ED visits resulted in a diagnosis of gallbladder or bile duct pathology. Overall, 39% of these cases required admission and 80% were diagnosed with acute gallbladder and bile duct-related conditions such as cholecystitis. When the emergency physician diagnosed gallstones without acute inflammatory conditions, 88% of cases were discharged from the ED.2 Consequently, emergency physicians who can effectively perform point-of-care ultrasound have the potential to efficiently impact the care of patients with right upper quadrant abdominal pain.
The primary tools in the evaluation of acute hepatobiliary disease are ultrasound, hepatobiliary iminodiacetic acid scintigraphy (commonly referred to as HIDA scan or cholescintigraphy), computed tomography (CT), and endoscopic retrograde cholangiopancreatography (ERCP). Prior to the late 1980s and early 1990s, several imaging modalities were in use to diagnose hepatobiliary disease, such as oral and IV cholangiography. These methods were time consuming, required the ingestion or injection of potentially harmful contrast agents, and exposed the patient to radiation.3 Ultrasound largely replaced these imaging modalities in the 1990s. Ultrasound can be performed rapidly at the bedside and does not expose the patient to ionizing radiation. Ultrasound also has the highest sensitivity for detecting the presence of gallstones, while HIDA has a reportedly higher sensitivity for detecting the presence of acute cholecystitis.4 Data derived solely from ED patients, however, suggest that point-of-care ultrasound of the gallbladder may prove as accurate for the detection of acute cholecystitis as HIDA.5,6 HIDA has very limited utility for the detection of acute cholecystitis when the point-of-care ultrasound examination is normal.7 Although CT is limited by its inability to detect 25% of gallstones, CT may play a greater role when other causes of abdominal pain are being considered.8,9 ERCP is time consuming and resource heavy, and its complications include iatrogenic pancreatitis, perforation, and even death.
Indications for clinicians to perform point-of-care hepatobiliary ultrasound include the evaluation of
- Biliary colic
- Acute cholecystitis
- Jaundice and biliary duct dilatation
- Hepatic abnormalities
In the United States, more patients undergo cholecystectomies (both elective and emergent) than appendectomies. Emergency physicians expect to see biliary pathology in up to a third of all patients with abdominal pain, making the differentiation of acute and subacute pathology important.10,11 The classic presentation of biliary colic portrays an obese woman of childbearing age with recurrent colicky pain in the right upper quadrant shortly after the consumption of a fatty meal. While gallstones are more prevalent in young, multiparous women than in young men, the effect of gender disappears with advancing age.12 In older patients, the pain does not wax and wane after meals but is constant and occurs mostly at night at predictable times, lasting for an average of 1–5 hours.13 Prospective data on the ...