A 41-year-old woman presents to the clinic with right upper quadrant abdominal pain. Her medical history includes obesity. Vital signs show T of 101.2°F (38.4°C), BP of 102/64 mm Hg, HR of 101 bpm, and RR of 18/min. Physical examination shows tenderness in the right upper quadrant with inspiratory arrest on palpation of the right upper quadrant. Which of the following findings would most likely be seen on ultrasound?
A A hypoechoic focus with internal echoes within the liver parenchyma B Anechoic fluid within the right renal pelvis and calyces C Echogenic foci within the gallbladder and pericholecystic fluid D Free fluid within the hepatorenal recess E Heterogeneous material within the portal veinEvaluating the biliary system for gallstones and associated acute cholecystitis was an early application of emergency point-of-care ultrasound and still maintains its utility. Though it is subject to the skill of the sonographer, both in image acquisition and interpretation, it is a rapidly obtained, accurate study with sensitivity and specificity approaching 95%. A clinical syndrome consisting of fever and pain in the right upper quadrant in a middle-aged woman with obesity is highly suspicious for acute cholecystitis, and a biliary ultrasound should be obtained.
Biliary ultrasound is performed with a low-frequency curvilinear or phased-array probe using subcostal or intercostal windows. Images should be obtained in two perpendicular planes to visualize the gallbladder in both long and short axes. Though recent data have questioned the benefit of measuring the common bile duct, this remains part of the complete evaluation and should be done as well. Gallstones, appearing as intraluminal hyperechoic foci, are present in > 95% of cases of acute cholecystitis. However, several other findings may be present as well, including gallbladder dilation, pericholecystic fluid, biliary wall thickening, sonographic Murphy sign, and dilation of the common bile duct.
Hepatic abscesses have a variable sonographic appearance but may show as a hypoechoic focus with internal echoes (A).
Anechoic fluid within the renal pelvis and calyces (B) describes the sonographic appearance of hydronephrosis.
Free fluid within the abdomen is likely to collect in the most dependent areas, including the hepatorenal recess (D), but would be unlikely in this patient who has no risk factors for ascites or intra-abdominal hemorrhage.
Portal vein thrombus may not be readily visible in the acute setting on ultrasound but will appear as heterogeneous material within the vessel lumen (E) when visible.
Written and designed to help you understand the core concepts. Questions are just like you'll see on the actual exam, while explanations and illustrations focus on the essential information.
Give you a well-rounded perspective of your progress by illuminating any weaknesses, solidifying your strengths, and predicting your likelihood of passing the exam, so you can focus on the topics that need work.
“The most beautiful teaching images on the planet” help you further reinforce the core concepts. Visuals allow you to focus on meaning, group similar ideas, and make better use of your memory (and they're great to look at, too).
Personalized instruction from Content Education Experts who have been where you are and will help teach, uplift, and inspire you. It's like having a personal tutor!
Messages are answered by actual people—not bots—whose goal is to help and support you (with cheetah-like speed). Anything you need, we're here.
Want to revisit a helpful image or explanation? The search feature can help you quickly locate it. But you won't find any spoilers here—it searches content you've already seen.
