Post cholecystectomy pain

History

Right upper quadrant pain 3 weeks post cholecystectomy.

Ultrasound Findings

There is choledocholithiaisis. A single, echogenic, shadow casting lesion is seen within the distal common bile duct (CBD), with associated proximal CBD dilation but no intrahepatic duct dilation.

The gallbladder is absent in keeping with recent cholecystectomy, and the gallbladder bed appears unremarkable with no collection identified.

Discussion

Generally an intraoperative cholangiogram is performed at the time of laparascopic cholecystectomy. In this case a technical difficulty meant the cholangiogram was abandoned. Unfortunately this meant a stone within the CBD was missed and the patient presented with symptoms 3 weeks post operatively.

Ultrasound of the CBD is difficult and completely excluding choledocholithiasis even more challenging.

Questions to answer:

  1. Is that tubular structure next to the portal vein definitely the CBD?
    • The portal vein, common bile duct and common hepatic artery run together
    • Put colour Doppler over the region of interest ensuring not perpendicular to the vessels
  2. Is the CBD dilated?
    • Usually less than 6mm, add a mm per decade after 60 years of age (ie 70 years, 7mm CBD is OK)
    • Post cholecystectomy up to 10mm is accepted
  3. Is there intrahepatic duct dilation?
    • Dilated intrahepatic ducts have been described to look like a gnarled old oak tree
    • Look for the shotgun barrell sign where dilated bile ducts run adjacent to normal branches of the portal vein, creating two parallel hypoechoic tubular structures
  4. Have I imaged the entire CBD?
    • It is important to follow the CBD to its distal end where it curves, is joined by the pancreatic duct and enters the second part of the duodenum
    • This is often not possible due to overlying bowel gas, patient discomfort, or obesity
  5. Be a clinician – does it all fit?

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Lectures

Abdominal Aortic Ultrasound

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(AAA scan)

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Ultrasound, post partum sepsis and pyometra

History

This woman was 4 days post partum when she was transferred to our tertiary hospital Emergency Department from a smaller regional centre. She had developed a fever, tachycardia and hypotension on day 3 as well as some offensive PV loss. She had been treated aggressively with large volumes of IV fluids and broad spectrum antibiotics assuming she had endometritis. She then developed some shortness of breath and was transferred for ICU review.

The first video and second video show her pelvic scan. The first is without commentary so you can test yourself. The second describes and discusses the findings.

The third video shows her right and left upper quadrant views and demonstrates note worthy thoracic findings.

Video 1 : Pelvic scan without commentary

https://gmep.org/media/13477

Video 2: Pelvic scan with discussion

https://gmep.org/media/13478

Transabdominal and then transvaginal scans are performed.

The transabdominal image shows a catheter balloon in an empty bladder.

Behind this lies the distended uterus. It is filled with layering fine echogenic debris that would be consistent with blood or pus. In the clinical context it is most likely infected blood.

Transvaginal scan confirms the presence of pyometra / haematometra.

Free pelvic fluid containing some echogenic debris is also seen within the pelvis.

Video 3: Upper quadrant scans reveal thoracic pathology

https://gmep.org/media/13478

Scans are performed in both the right and left upper quadrant. This allows the lung bases to be examined.

On the right a small pleural effusion and consolidation with ultrasound air bronchogram is seen. In this view the well filled inferior vena cava is demonstrated with no respiratory variation.

On the left another small basal pleural effusion is seen.

This patient had developed post partum sepsis, with a distended

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uterine cavity, filled with infected blood.

This is unusual because in the post vaginal delivery patient the cervix usually allows free passage of its content.

Sepsis combined with aggressive fluid resuscitation had led to the basal consolidation / collapse and pleural effusions.

Simple gentle opening of the cervix allowed passage of the uterine content and recovery without further aggressive intervention occurred over the next 72 hours.

James Rippey

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