February SonoProps
Hello all, welcome to our SonoProps February edition!
The first of our SonoProps goes to Dr. Hardeep Singh.
He performed this great POCUS on a 37-year-old female with RUQ pain. The patient had a CT that was read as: “Nonspecific heterogeneous enhancement of the liver with periportal edema and pericholecystic fluid, as may be seen in systemic inflammation, congestive hepatopathy or venoocclusive disease. Cholelithiasis without pericholecystic fat edema or biliary dilatation.”
Dr. Singh’s POCUS confirmed the diagnosis:
Anterior gallbladder wall measuring 0.63cm in an area of focal thickening.
The ultrasound above shows, what in lay terms would be a sick gallbladder. There are multiple areas of irregular gallbladder wall thickening with a significantly distended gallbladder and an impacted stone in the neck. There was a positive sonographic Murphy’s. These findings are consistent with acute cholecystitis. Surgery took the patient for a robotic cholecystectomy and noted that gallbladder appeared edematous, distended, acutely inflamed with hydrops.
Learning points:
There are six signs of cholecystitis to remember:
Sonographic Murphy’s — maximal tenderness when the probe is pressured directly over the gallbladder. Many sources consider the presence of cholelithiasis with a sonographic Murphy’s to be the most sensitive sign of acute cholecystitis and EP performed POCUS may be more sensitive in detecting this sign.
Anterior gallbladder wall thickening > 4mm — different from edema, thickening can be present without layering of fluid within the gallbladder wall. Many sources say 3mm, but I prefer 4mm due to the increased specificity and this was taught in my fellowship.
Hydropic gallbladder — significantly distended gallbladder >10cm x 5cm, with a transverse diameter of 5cm being more specific.
Stone-in-Neck (SIN) sign — an impacted immobile stone lodged in the neck of the gallbladder without anechoic space, highly predictive of cholecystitis even in the absence of other signs (93% PPV, 97% specificity).
Pericholecystic fluid — less common finding but highly predictive for cholecystitis in some studies (LR +10.7)
Gallbladder wall edema — covered in the December 2023 SonoProps.
95-99% of patients with cholecystitis have cholelithiasis. However, aside from the SIN sign, there is no requirement for stones or sludge to be present for the diagnosis of cholecystitis. Consider acalculous cholecystitis especially in ICU settings or chronically ill patients (eg, cirrhotics).
No one sonographic sign can definitively confirm the diagnosis of cholecystitis, however the combination of multiple signs and the clinical picture can help make the diagnosis.
Great scan Dr. Singh!
Our second SonoProps goes to Dr. Nina Vazquez and Dr. Daniel Herzog. I actually like this scan because it shows a very good approach to a internal jugular central venous catheter placement. They had an acutely ill 83-year-old female who required pressors for septic shock and multiple blood transfusions for profound anemia.
For billing purposes for a vascular access procedure, only a still image of the intended vessel is required.
However, it is good if you have an extra set of hands (in this case a great instructor, and Dr. Nkemakolam to hit record) to record clips showing the needle entry and the needle tip in the center of the vessel as demonstrated in the clips above.
I am not personally a fan of using the midline (yellow) line. It often obstructs the visualization of the needle, although for beginners it may be slightly helpful. It is better to practice without it.
It is also good practice to demonstrate the wire within the vessel (clip from different procedure).
Learning points:
Always use dynamic ultrasound guidance to watch the needle enter your intended vessel, in this case the IJ. This requires fine motor skills that are learned with time so do not be discouraged if you have a hard time visualizing the needle tip. It is a skill that requires practice, practice, practice.
Using ultrasound guidance for central venous access is not only safer, it is faster. Compared with blind insertion, ultrasound guidance for femoral central venous access was not only faster, but reduced the rate of arterial puncture, and had higher rates of success.
Demonstrate the wire within the vessel which can be more apparent than the needle and can prevent inadvertent arterial dilation and cannulation.
Great scan Dr’s Vazquez and Herzog!
