Granulomatous Disease - Dr. Henry Gemino
41 y/o M from Chile presents with flank pain and fevers
Recently completed outpatient course of antibiotics for pyelonephritis, presumed to be refractory to outpatient therapy
GU US- did not demonstrate hydronephrosis or significant renal inflammation, however small hyperechoic areas were noted scattered throughout the parenchyma of the liver and spleen.
CT abd/pelvis was read as “innumerable calcifications in the liver, spleen, and mesentery likely a sequelae of prior granulomatous disease”
Patient ultimately left AMA
Cholangitis - Dr. Miguel Ribe
Case: 81yo male presented by EMS with severe hypotension and AMS. He was endorsing diffuse abdominal pain on exam. Initial assessment with EFAST/ HIMAP was negative, however while scanning RUQ, there was an abnormal GB with the following findings:
- Stone in GB neck, seen as the hyperechoic object with posterior acoustic shadow, which would not move with changes in patient position.
- Thickened GB wall
- Positive sonographic Murphy’s sign.
Teaching point: Hypotension + AMS... don't forget to look for all possible sources of sepsis, including the GB.
Follow-up: Workup revealed elevated liver enzymes, leukocytosis, as well as signs of end organ damage 2/2 shock. Patient was admitted on antibiotics and surgery was consulted for concerns of ascending cholangitis.
Gallbladder Stones and Polyps - Dr. Daniel Cohen
26 yo M with a PMHx of asymptomatic cholelithiasis presents with an unrelated complaint and was amenable to an educational ultrasound of his right upper quadrant.
-Denies skin changes, abdominal pain, nausea, vomiting, discomfort with PO intake
-Exam without abdominal tenderness, peritoneal signs, or Murphy’s sign
-dependent stone at the neck as well as incidentally noted polyps along the walls. The stone can be differentiated by the presence of posterior shadowing.
-Prevalence of gallbladder polyps is 4-7%, more common in men, 2/3 of polyps are diagnosed incidentally
-Polyps may decrease the likelihood of stone formation by blocking formation at the walls, making polyps and stones a more rare finding
-Patients should be worked up with a formal RUQ U/S and possibly CT/MRI imaging as indicated
-<6 mm in size do not need to be followed.
6-9 mm in size get serial U/S for growth monitoring.
> 10 mm are managed surgically because of increased risk of cancer.
Andrén-Sandberg, Åke. "Diagnosis and management of gallbladder polyps." North American journal of medical sciences 4.5 (2012): 203.
STRAWBERRY GALLBLADDER - Dr. David Vega
2yo healthy female with inconsolable crying, abdominal pain.
Afebrile, diffuse abd ttp, worse in the RLQ
Intussusception: Target Sign, Pseudokidney Sign, Crescent in a Donut Sign
•Over 75% ileo-colic likely 2/2 prominent lymphoid tissue in the area allowing for a lead point
•Enema is diagnostic and therapeutic
DIVERTICULITIS - Dr. Sam Cochran
56M p/w crampy, intermittently sharp RLQ and LLQ abd pain x 3 days.
•Pain well controlled with morphine and IVF
•No CT findings warranting surgical intervention
•Remained non-toxic appearing, d/c home with po abx