Wednesday Image Review

From the Archives: What’s the Diagnosis? By Dr. Alyse Volino

A 24 year old female with a history of gallstones presents to the ED with 2 hours of severe, aching right upper quadrant abdominal pain that woke her from sleep associated with nausea and vomiting. Patient has had similar episodes of pain in the past, often after eating fatty foods. On exam, she is tender in RUQ of the abdomen and is actively vomiting. A right upper quadrant abdominal ultrasound is performed and shown below. What’s the diagnosis?

Answer: Symptomatic Cholelithiasis

  • Characterized by episodes of RUQ pain that are brought on by obstructing gallstone and relieved when gallstone moves from that position
  • Can progress to cholecystitis if gallstone remains in obstructing position and gallbladder subsequently becomes inflamed or infected.
  • Differential: cholecystitis, choledocholithiasis, cholangitis.
  • If simple symptomatic cholelithiasis (no signs of infection or other biliary obstruction) and pain is controlled, patient can often be discharged from ED with outpatient surgical follow-up.

Symptomatic Cholelithiasis vs Cholecystitis on Ultrasound

Cholecystitis may have the following:

  1. Gallstones present in gallbadder
  2. Sonographic Murphy’s sign
    • Maximal tenderness over the most anterior portion of GB as defined with US imaging
  3. Wall thickness of gallbladder over 3 mm
    • Be sure to measure GB wall thickness at anterior aspect to avoid false positive increased secondary to posterior acoustic enhancement!
  4. Pericholecystic fluid

These findings should be used in conjunction with lab results to help identify diagnosis on spectrum of biliary disease.


Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8th Edition. Ch 79: Pancreatitis and Cholecystitis. Judith E. Tintinalli

Soni, Nilam, et. al. Point of Care Ultrasound, 2nd Edition. Ch 27: Gallbladder 

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