It is another busy night in ED. The ‘Bat-Phone’ rings, gently pricking the ear to attention in anticipation of the next code…
We are bringing in a 60 year old lady with profuse diaphoresis, hypotensive with a systolic of 70 and altered conscious state…
Initial examination confirms an unwell lady, drained of colour, drenched in sweat taking short shallow breaths. Following application of oxygen, comprehensive non-invasive monitoring, IV access and analgesia you decide to perform a rapid bedside abdominal USS (even though you are by no means an expert in wielding the mighty sono sword)…but it is late, the really clever sonoboys are all tucked up in bed…so it’s all up to you – SonoMan®
Through the vagaries of shadows that are beholden to the sonographic snowland you think you see a cave-like compressible opening around 5-6cm in diameter…but lets face it – the howling blizzard you just demonstrated on the sono-machine-thing hasn’t really helped you refine your differential diagnosis
So you send your patient to the ‘Donut of Death’ for a dose of real radiation
Now what Doc?
Abdominal CT scan
Acalculous Cholecystitis
Acalculous Cholecystitis
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In the 'Fast Lane': Radiology Oddity #016 http://tinyurl.com/yfbftpk
Disclaimer: It’s not fair to ask a radiologist to comment on a single CT section, chosen by an absent-minded Emergency Physician.
Still, I will answer because the gauntlet has been thrown (tweeted) in my face.
Based on this single CT axial section (part of what is no doubt hundreds of such axial sections from a multislice CECT Abdomen) i opine that this old lady has Acalculous Cholecystitis.
(Ducking & cowering. Waiting for the brickbats.)
Once more, this isn’t fair, mate.
Vijay – so glad to see you rise to the challenge set by the ‘absent’ minded ED physician.
No ducking, no cowering, no brickbats (this time)
- the fairness of a joust can only be determined by reciprocity
Hildy – Other labs surprising normal with normal LFT and bilirubin levels.
Abdominal examination revealed generalised guarding only.
Thanks for another comprehensive answer comment
What you can see:
A suprarenal aorta of normal diameter with some calcification –> not a AAA despite the name.
An IVC which is being compressed by something (presumably the gallbladder) but which may be a reflection of inadequate intravascular volume (it doesn’t really look big enough)
This thing in the RUQ:
- fluid density ~3.5-4cm (less dense than the spinous muscles, more dense than fat)
- thin ring of ? enhancing soft tissue density
- eccentric 0.5-1cm rim of fluid density around the soft tissue density ring.
I’m thinking that this represents some pericholecystic free fluid. There seems to be a thin layer of free fluid between the liver and the diaphragm too (presuming the enhancing bit is liver and the nonenhancing STD is diaphragm).
Is that thin ring of STD the gall bladder wall? It’s hard to tell how thick it is.
What’s the lady’s abdo exam like? Other labs?