This video (part 1 of 3) details how bedside medical ultrasound imaging of the gallbladder allows for rapid evaluation of patients presenting with acute abdominal pain.
Subtitles
<p begin="00:00:17.347" end="00:00:18.589" style="s2">- Hello.</p>
<p begin="00:00:18.589" end="00:00:19.838" style="s2">My name is Phil Perera and I'm the</p>
<p begin="00:00:19.838" end="00:00:21.890" style="s2">emergency ultrasound coordinator at the</p>
<p begin="00:00:21.890" end="00:00:24.608" style="s2">New York Presbyterian<br />Hospital in New York City.</p>
<p begin="00:00:24.608" end="00:00:27.275" style="s2">And welcome to Soundbytes Cases.</p>
<p begin="00:00:28.846" end="00:00:31.179" style="s2">In this Soundbytes module,<br />we're going to focus on</p>
<p begin="00:00:31.179" end="00:00:33.421" style="s2">bedside ultrasound of the gallbladder.</p>
<p begin="00:00:33.421" end="00:00:36.217" style="s2">I've divided this module up<br />into parts one, two, and three,</p>
<p begin="00:00:36.217" end="00:00:39.080" style="s2">and in this module, part one,<br />we're going to focus on the</p>
<p begin="00:00:39.080" end="00:00:43.210" style="s2">normal hepatobilliary imaging<br />and ultrasound findings.</p>
<p begin="00:00:43.210" end="00:00:45.742" style="s2">Bedside ultrasound of the<br />gallbladder allows rapid</p>
<p begin="00:00:45.742" end="00:00:48.688" style="s2">evaluation of patients presenting<br />with acute abdominal pain</p>
<p begin="00:00:48.688" end="00:00:51.187" style="s2">to the emergency department<br />and interestingly enough,</p>
<p begin="00:00:51.187" end="00:00:53.840" style="s2">gall stone related disease is<br />now more commonly diagnosed</p>
<p begin="00:00:53.840" end="00:00:56.782" style="s2">in the emergency department<br />with the increased advent of</p>
<p begin="00:00:56.782" end="00:00:58.343" style="s2">bedside scanning.</p>
<p begin="00:00:58.343" end="00:01:01.018" style="s2">Gall stone related disease is<br />not only seen in traditional</p>
<p begin="00:01:01.018" end="00:01:03.444" style="s2">females population, as<br />described in textbooks.</p>
<p begin="00:01:03.444" end="00:01:06.183" style="s2">It's also being seen in men<br />with rapid weight loss or</p>
<p begin="00:01:06.183" end="00:01:09.612" style="s2">weight gain changes,<br />and also in the elderly.</p>
<p begin="00:01:09.612" end="00:01:12.347" style="s2">So, let's begin this module<br />with a review of the anatomy of</p>
<p begin="00:01:12.347" end="00:01:13.180" style="s2">the right upper quadrant,<br />how to perform the exam,</p>
<p begin="00:01:13.180" end="00:01:17.982" style="s2">and the ultrasound findings<br />in hepatobilliary imaging.</p>
<p begin="00:01:17.982" end="00:01:20.278" style="s2">Let's begin with a<br />review for the positions</p>
<p begin="00:01:20.278" end="00:01:22.024" style="s2">for gallbladder sonography.</p>
<p begin="00:01:22.024" end="00:01:24.853" style="s2">As shown in probe position<br />one, the first position that's</p>
<p begin="00:01:24.853" end="00:01:27.947" style="s2">often used for gallbladder<br />sonography is going to be known</p>
<p begin="00:01:27.947" end="00:01:30.287" style="s2">as the high/lateral view, in<br />which we're looking through</p>
<p begin="00:01:30.287" end="00:01:31.401" style="s2">the ribs.</p>
<p begin="00:01:31.401" end="00:01:33.810" style="s2">It's best to use a smaller<br />footprint probe for this exam</p>
<p begin="00:01:33.810" end="00:01:36.906" style="s2">so that we can easily sit<br />the probe between the ribs.</p>
<p begin="00:01:36.906" end="00:01:39.527" style="s2">We're going to be coming in<br />in a view that's very similar</p>
<p begin="00:01:39.527" end="00:01:41.925" style="s2">to the right upper quadrant<br />view for the trauma FAST Exam,</p>
<p begin="00:01:41.925" end="00:01:44.976" style="s2">however, the probe here is<br />angled more anteriorly than for</p>
<p begin="00:01:44.976" end="00:01:47.889" style="s2">the FAST Exam to image the gallbladder.</p>
<p begin="00:01:47.889" end="00:01:51.177" style="s2">The second position is known<br />as the subcostal view, as shown</p>
<p begin="00:01:51.177" end="00:01:53.408" style="s2">in probe position two<br />here, and it's best to roll</p>
<p begin="00:01:53.408" end="00:01:55.809" style="s2">the patient into the left<br />lateral decubitus position</p>
<p begin="00:01:55.809" end="00:01:58.711" style="s2">so that the gallbladder<br />is closer to the probe.</p>
<p begin="00:01:58.711" end="00:02:01.267" style="s2">From the subcostal position,<br />we can push down directly</p>
<p begin="00:02:01.267" end="00:02:04.830" style="s2">on the gallbladder to illicit<br />the sonographic murphy's sign.</p>
<p begin="00:02:04.830" end="00:02:07.459" style="s2">Now from both of these positions,<br />we should rotate the probe</p>
<p begin="00:02:07.459" end="00:02:09.865" style="s2">from long axis, with the probe<br />marker toward the patient's</p>
<p begin="00:02:09.865" end="00:02:12.303" style="s2">right shoulder to the short<br />axis configuration, with the</p>
<p begin="00:02:12.303" end="00:02:14.839" style="s2">probe marker over towards<br />the right side, to completely</p>
<p begin="00:02:14.839" end="00:02:18.922" style="s2">inspect through the<br />gallbladder for any pathology.</p>
<p begin="00:02:18.922" end="00:02:20.513" style="s2">Here's an illustration reviewing</p>
<p begin="00:02:20.513" end="00:02:22.536" style="s2">the anatomy of the gallbladder<br />and billiary tracts</p>
<p begin="00:02:22.536" end="00:02:24.499" style="s2">important to bedside sonography.</p>
<p begin="00:02:24.499" end="00:02:25.755" style="s2">Here we see the gallbladder,</p>
<p begin="00:02:25.755" end="00:02:27.587" style="s2">shaped as a pear-like structure,</p>
<p begin="00:02:27.587" end="00:02:29.266" style="s2">and we see the parts of the gallbladder,</p>
<p begin="00:02:29.266" end="00:02:31.769" style="s2">the upper fundus, the intermediate body,</p>
<p begin="00:02:31.769" end="00:02:34.715" style="s2">and the neck of the gallbladder<br />toward the top of the image.</p>
<p begin="00:02:34.715" end="00:02:37.098" style="s2">Recall that it's impacted<br />stones at the neck of the</p>
<p begin="00:02:37.098" end="00:02:40.010" style="s2">gallbladder that often cause<br />symptomatic billiary colic</p>
<p begin="00:02:40.010" end="00:02:42.614" style="s2">and can lead to acute cholecystitis.</p>
<p begin="00:02:42.614" end="00:02:45.093" style="s2">We also see the cystic<br />duct draining the bile from</p>
<p begin="00:02:45.093" end="00:02:46.572" style="s2">the neck of the gallbladder<br />and joining into the</p>
<p begin="00:02:46.572" end="00:02:49.766" style="s2">hepatic duct, which is draining<br />the bile from the liver.</p>
<p begin="00:02:49.766" end="00:02:52.485" style="s2">The confluence of the cystic<br />duct and hepatic duct forms</p>
<p begin="00:02:52.485" end="00:02:55.426" style="s2">the common bile duct and<br />stones lodged within this</p>
<p begin="00:02:55.426" end="00:02:58.451" style="s2">area can cause choledocholithiasis.</p>
<p begin="00:02:58.451" end="00:03:01.070" style="s2">We also the pancreatic duct<br />joining to the bile duct and</p>
<p begin="00:03:01.070" end="00:03:04.573" style="s2">dumping into the duodenum<br />at the second part of the</p>
<p begin="00:03:04.573" end="00:03:08.262" style="s2">duodenum, located at the ampulla of vater.</p>
<p begin="00:03:08.262" end="00:03:10.119" style="s2">Stones that may lodge here can cause</p>
<p begin="00:03:10.119" end="00:03:12.119" style="s2">gall stone pancreatitis.</p>
<p begin="00:03:13.249" end="00:03:15.670" style="s2">Now let's take a look at<br />the ultrasound findings of a</p>
<p begin="00:03:15.670" end="00:03:17.043" style="s2">normal gallbladder.</p>
<p begin="00:03:17.043" end="00:03:19.291" style="s2">We see the liver to the left<br />and the gallbladder just</p>
<p begin="00:03:19.291" end="00:03:21.976" style="s2">inferior to the liver to the right.</p>
<p begin="00:03:21.976" end="00:03:23.880" style="s2">Notice the areas of the gallbladder.</p>
<p begin="00:03:23.880" end="00:03:25.459" style="s2">We see the upper fundus towards</p>
<p begin="00:03:25.459" end="00:03:27.527" style="s2">the upper right part of the image,</p>
<p begin="00:03:27.527" end="00:03:30.205" style="s2">the body of the gallbladder,<br />the intermediate part,</p>
<p begin="00:03:30.205" end="00:03:32.707" style="s2">and the neck of the gallbladder<br />all the way down towards</p>
<p begin="00:03:32.707" end="00:03:34.377" style="s2">the left of the image.</p>
<p begin="00:03:34.377" end="00:03:36.114" style="s2">As we look closely<br />through this gallbladder,</p>
<p begin="00:03:36.114" end="00:03:38.546" style="s2">we see that it has the typical<br />darker or anechoic type</p>
<p begin="00:03:38.546" end="00:03:41.591" style="s2">appearance on bedside sonography<br />and that's because of the</p>
<p begin="00:03:41.591" end="00:03:44.335" style="s2">fluid within the<br />gallbladder, that is bile.</p>
<p begin="00:03:44.335" end="00:03:47.391" style="s2">We see here the absence<br />of any significant stones,</p>
<p begin="00:03:47.391" end="00:03:49.944" style="s2">and remember that gall stones<br />would appear as brighter</p>
<p begin="00:03:49.944" end="00:03:54.340" style="s2">or hyperechoic foci within<br />the gallbladder lumen.</p>
<p begin="00:03:54.340" end="00:03:57.422" style="s2">Here's a normal variant, known<br />as a septated gallbladder</p>
<p begin="00:03:57.422" end="00:03:59.610" style="s2">and we see a little septi,<br />that little white line,</p>
<p begin="00:03:59.610" end="00:04:01.801" style="s2">going through the middle<br />of the gallbladder.</p>
<p begin="00:04:01.801" end="00:04:04.220" style="s2">This can be seen on bedside<br />sonography and is not to be</p>
<p begin="00:04:04.220" end="00:04:06.807" style="s2">mistaken as pathology.</p>
<p begin="00:04:06.807" end="00:04:08.058" style="s2">Here's an illustration showing</p>
<p begin="00:04:08.058" end="00:04:10.403" style="s2">the relation of the<br />gallbladder to the portal vein</p>
<p begin="00:04:10.403" end="00:04:13.154" style="s2">known as the exclamation dot sign.</p>
<p begin="00:04:13.154" end="00:04:15.290" style="s2">The exclamation would be<br />made up by the gallbladder</p>
<p begin="00:04:15.290" end="00:04:17.490" style="s2">and the dot would be the portal vein.</p>
<p begin="00:04:17.490" end="00:04:19.786" style="s2">We see a thin white line<br />connecting the gallbladder to</p>
<p begin="00:04:19.786" end="00:04:21.415" style="s2">the portal vein, known as</p>
<p begin="00:04:21.415" end="00:04:23.409" style="s2">the median lobar fissure of the liver</p>
<p begin="00:04:23.409" end="00:04:25.853" style="s2">and this can be a very<br />helpful landmark as one looks</p>
<p begin="00:04:25.853" end="00:04:28.198" style="s2">to find the gallbladder in<br />relation to the portal vein.</p>
<p begin="00:04:28.198" end="00:04:31.891" style="s2">Also, we see the common bile<br />duct and the hepatic artery</p>
<p begin="00:04:31.891" end="00:04:34.687" style="s2">on top of the portal vein,<br />making up the structures of the</p>
<p begin="00:04:34.687" end="00:04:35.770" style="s2">portal triad.</p>
<p begin="00:04:36.791" end="00:04:39.303" style="s2">Here's an ultrasound image<br />showing the portal vein,</p>
<p begin="00:04:39.303" end="00:04:41.131" style="s2">exclamation dot sign.</p>
<p begin="00:04:41.131" end="00:04:42.224" style="s2">And we see the gallbladder to the right,</p>
<p begin="00:04:42.224" end="00:04:44.045" style="s2">making the exclamation,</p>
<p begin="00:04:44.045" end="00:04:46.182" style="s2">and the dot, the portal vein, to the left.</p>
<p begin="00:04:46.182" end="00:04:47.973" style="s2">Notice that the dot, the portal vein,</p>
<p begin="00:04:47.973" end="00:04:49.575" style="s2">has hyperechoic walls, due to<br />the fact that it's bringing</p>
<p begin="00:04:49.575" end="00:04:52.451" style="s2">greasy blood from the<br />intestine to be filtered</p>
<p begin="00:04:52.451" end="00:04:53.772" style="s2">by the liver.</p>
<p begin="00:04:53.772" end="00:04:55.914" style="s2">We see the white line connecting<br />the gallbladder to the</p>
<p begin="00:04:55.914" end="00:04:59.213" style="s2">portal vein that is median<br />lobar fissure and posteriorly</p>
<p begin="00:04:59.213" end="00:05:02.513" style="s2">we see the inferior vena cava.</p>
<p begin="00:05:02.513" end="00:05:04.895" style="s2">Here's an ultrasound image<br />showing the median lobar fissure</p>
<p begin="00:05:04.895" end="00:05:06.914" style="s2">of the liver in greater detail.</p>
<p begin="00:05:06.914" end="00:05:09.316" style="s2">Here we see the gallbladder,<br />the pear-like structure,</p>
<p begin="00:05:09.316" end="00:05:12.180" style="s2">to the right of the image<br />and the branching portal vein</p>
<p begin="00:05:12.180" end="00:05:13.735" style="s2">over towards the left.</p>
<p begin="00:05:13.735" end="00:05:15.784" style="s2">As we look in between the<br />two structures we see the</p>
<p begin="00:05:15.784" end="00:05:18.075" style="s2">thin white line known as<br />the median lobar fissure</p>
<p begin="00:05:18.075" end="00:05:19.340" style="s2">of the liver.</p>
<p begin="00:05:19.340" end="00:05:22.574" style="s2">Now the MLF can be a very<br />important landmark as we look</p>
<p begin="00:05:22.574" end="00:05:24.957" style="s2">from the portal vein up to<br />the neck of the gallbladder</p>
<p begin="00:05:24.957" end="00:05:28.162" style="s2">to inspect the neck of the<br />gallbladder for any small stones</p>
<p begin="00:05:28.162" end="00:05:31.339" style="s2">that might be lodged there<br />and causing billiary colic.</p>
<p begin="00:05:31.339" end="00:05:33.738" style="s2">Here's another video clip<br />in which we can see the</p>
<p begin="00:05:33.738" end="00:05:35.777" style="s2">relation of the portal<br />vein to the gallbladder</p>
<p begin="00:05:35.777" end="00:05:37.649" style="s2">in explicit detail.</p>
<p begin="00:05:37.649" end="00:05:39.410" style="s2">Notice the gallbladder to the right,</p>
<p begin="00:05:39.410" end="00:05:41.848" style="s2">the portal vein, the branching<br />structure with hyperechoic,</p>
<p begin="00:05:41.848" end="00:05:43.319" style="s2">or whiter, walls, towards the left,</p>
<p begin="00:05:43.319" end="00:05:45.139" style="s2">and we can see the area of the MLF, the</p>
<p begin="00:05:45.139" end="00:05:47.809" style="s2">median lobar fissure,<br />connecting to two structures.</p>
<p begin="00:05:47.809" end="00:05:49.580" style="s2">And again, this is a very<br />important landmark for</p>
<p begin="00:05:49.580" end="00:05:51.921" style="s2">walking your way up to the<br />neck of the gallbladder to</p>
<p begin="00:05:51.921" end="00:05:54.071" style="s2">look for any small stones<br />impacted at the neck.</p>
<p begin="00:05:54.071" end="00:05:57.584" style="s2">Also, looking for the portal<br />vein can be very helpful in</p>
<p begin="00:05:57.584" end="00:06:02.007" style="s2">looking for a contracted<br />gallbladder that can be difficult</p>
<p begin="00:06:02.007" end="00:06:04.187" style="s2">to identify on bedside sonography.</p>
<p begin="00:06:04.187" end="00:06:07.375" style="s2">Now let's review an image<br />showing the anatomy of the</p>
<p begin="00:06:07.375" end="00:06:08.584" style="s2">portal triad.</p>
<p begin="00:06:08.584" end="00:06:10.731" style="s2">We see the first the first<br />structure of the portal triad,</p>
<p begin="00:06:10.731" end="00:06:12.183" style="s2">the common bile duct, marked in green.</p>
<p begin="00:06:12.183" end="00:06:13.800" style="s2">Notice that it connects the gallbladder</p>
<p begin="00:06:13.800" end="00:06:15.340" style="s2">down to the duodenum.</p>
<p begin="00:06:15.340" end="00:06:17.180" style="s2">While it's located to<br />the left in this picture,</p>
<p begin="00:06:17.180" end="00:06:19.533" style="s2">in a real patient it would<br />be located over toward the</p>
<p begin="00:06:19.533" end="00:06:21.356" style="s2">patient's right side.</p>
<p begin="00:06:21.356" end="00:06:22.948" style="s2">We see the posterior<br />structure of the portal triad,</p>
<p begin="00:06:22.948" end="00:06:26.309" style="s2">the portal vein, marked<br />in blue, and we see the</p>
<p begin="00:06:26.309" end="00:06:29.603" style="s2">hepatic artery, which would<br />be the third structure of</p>
<p begin="00:06:29.603" end="00:06:31.789" style="s2">the portal triad. over towards<br />the right of this image, but</p>
<p begin="00:06:31.789" end="00:06:34.154" style="s2">would be located towards<br />the patient's left side on</p>
<p begin="00:06:34.154" end="00:06:35.737" style="s2">real-time scanning.</p>
<p begin="00:06:36.937" end="00:06:39.097" style="s2">Here's a video clip showing<br />the sonographic appearance</p>
<p begin="00:06:39.097" end="00:06:41.213" style="s2">of the portal triad, which we refer to as</p>
<p begin="00:06:41.213" end="00:06:42.947" style="s2">the Mickey Mouse Sign.</p>
<p begin="00:06:42.947" end="00:06:45.295" style="s2">And here we see the gallbladder<br />over toward the left</p>
<p begin="00:06:45.295" end="00:06:47.262" style="s2">of the image and the<br />portal triad, making up</p>
<p begin="00:06:47.262" end="00:06:48.636" style="s2">the Mickey Mouse Sign.</p>
<p begin="00:06:48.636" end="00:06:50.864" style="s2">The portal vein, making<br />up Mickey's face, and</p>
<p begin="00:06:50.864" end="00:06:52.390" style="s2">the ears of Mickey, the<br />common bile duct making up</p>
<p begin="00:06:52.390" end="00:06:56.345" style="s2">the left ear of Mickey and<br />the hepatic artery making up</p>
<p begin="00:06:56.345" end="00:06:58.085" style="s2">Mickey's right ear.</p>
<p begin="00:06:58.085" end="00:07:00.956" style="s2">And this image is best<br />obtained from a subcostal plane</p>
<p begin="00:07:00.956" end="00:07:02.701" style="s2">and a transverse axis and<br />a probe marker over towards</p>
<p begin="00:07:02.701" end="00:07:04.784" style="s2">the patient's right side.</p>
<p begin="00:07:05.628" end="00:07:07.381" style="s2">Now we can place Doppler sonography onto</p>
<p begin="00:07:07.381" end="00:07:09.601" style="s2">the Mickey Mouse Sign to<br />further delineate the structures</p>
<p begin="00:07:09.601" end="00:07:12.006" style="s2">and we see that the portal vein, making up</p>
<p begin="00:07:12.006" end="00:07:15.153" style="s2">Mickey's face, the posterior<br />most structure of the portal</p>
<p begin="00:07:15.153" end="00:07:18.317" style="s2">triad, will actually light<br />up with Doppler sonography.</p>
<p begin="00:07:18.317" end="00:07:21.446" style="s2">We can also see that Mickey's<br />right ear, the hepatic artery,</p>
<p begin="00:07:21.446" end="00:07:24.673" style="s2">also has Doppler flow<br />on Doppler sonography.</p>
<p begin="00:07:24.673" end="00:07:27.444" style="s2">However, the common bile duct,<br />Mickey's left ear, fails to</p>
<p begin="00:07:27.444" end="00:07:31.074" style="s2">appreciate any Doppler flow<br />due to the sluggish flow within</p>
<p begin="00:07:31.074" end="00:07:32.643" style="s2">the common bile duct.</p>
<p begin="00:07:32.643" end="00:07:34.928" style="s2">In this video clip, we can<br />appreciate the common bile duct</p>
<p begin="00:07:34.928" end="00:07:37.423" style="s2">and portal vein in more of<br />a long axis configuration.</p>
<p begin="00:07:37.423" end="00:07:40.334" style="s2">We've turned the probe, so<br />now the probe marker is over</p>
<p begin="00:07:40.334" end="00:07:41.782" style="s2">toward the patient's right shoulder</p>
<p begin="00:07:41.782" end="00:07:44.201" style="s2">and we see the gallbladder<br />towards the top of the image</p>
<p begin="00:07:44.201" end="00:07:47.459" style="s2">and notice here we see two<br />parallel channels towards</p>
<p begin="00:07:47.459" end="00:07:49.428" style="s2">the bottom aspect of the image here.</p>
<p begin="00:07:49.428" end="00:07:51.674" style="s2">Notice the portal vein with<br />Doppler flow, and on top of</p>
<p begin="00:07:51.674" end="00:07:54.667" style="s2">the portal vein, we can<br />appreciate the common bile duct.</p>
<p begin="00:07:54.667" end="00:07:57.380" style="s2">As the common bile duct<br />enlarges with obstruction,</p>
<p begin="00:07:57.380" end="00:07:59.540" style="s2">it will become as large or larger than</p>
<p begin="00:07:59.540" end="00:08:01.367" style="s2">the accompanying portal vein.</p>
<p begin="00:08:01.367" end="00:08:03.834" style="s2">Normal dimensions for the<br />common bile duct is that it</p>
<p begin="00:08:03.834" end="00:08:06.365" style="s2">should be no more than one<br />millimeter for each decade of</p>
<p begin="00:08:06.365" end="00:08:07.964" style="s2">the patient's life.</p>
<p begin="00:08:07.964" end="00:08:11.032" style="s2">A common bile duct that<br />measures across in diameter</p>
<p begin="00:08:11.032" end="00:08:14.143" style="s2">greater than eight millimeters<br />is universally enlarged.</p>
<p begin="00:08:14.143" end="00:08:15.785" style="s2">And when we measure the common bile duct,</p>
<p begin="00:08:15.785" end="00:08:18.130" style="s2">we're going to measure from<br />inner wall to inner wall</p>
<p begin="00:08:18.130" end="00:08:20.673" style="s2">across the lumen of of<br />the common bile duct.</p>
<p begin="00:08:20.673" end="00:08:22.886" style="s2">My conclusion points for<br />this Soundbytes module,</p>
<p begin="00:08:22.886" end="00:08:25.090" style="s2">going over part one of<br />gallbladder sonography,</p>
<p begin="00:08:25.090" end="00:08:27.428" style="s2">gallbladder ultrasound at<br />the patient's bedside is a</p>
<p begin="00:08:27.428" end="00:08:30.015" style="s2">very helpful ultrasound<br />exam in evaluating the</p>
<p begin="00:08:30.015" end="00:08:32.158" style="s2">patient presenting to the<br />emergency department with</p>
<p begin="00:08:32.158" end="00:08:34.669" style="s2">acute abdominal pain.</p>
<p begin="00:08:34.669" end="00:08:36.350" style="s2">And hopefully through<br />looking at this module,</p>
<p begin="00:08:36.350" end="00:08:38.463" style="s2">you know how to perform<br />the right upper quadrant</p>
<p begin="00:08:38.463" end="00:08:40.808" style="s2">ultrasound examination<br />and understand the anatomy</p>
<p begin="00:08:40.808" end="00:08:44.920" style="s2">of the hepatobilliary tract<br />essential to bedside sonography.</p>
<p begin="00:08:44.920" end="00:08:47.663" style="s2">And also, by going through<br />the footage, looking at the</p>
<p begin="00:08:47.663" end="00:08:49.601" style="s2">ultrasound imaging of the<br />gallbladder and portal triad,</p>
<p begin="00:08:49.601" end="00:08:52.630" style="s2">you now know how to interpret<br />the ultrasound images</p>
<p begin="00:08:52.630" end="00:08:56.420" style="s2">that you will obtain at<br />the patient's bedside.</p>
<p begin="00:08:56.420" end="00:08:57.700" style="s2">So I look forward to seeing you back as</p>
<p begin="00:08:57.700" end="00:09:00.036" style="s2">Sono Access continues and<br />we go on to future modules</p>
<p begin="00:09:00.036" end="00:09:04.119" style="s2">focusing on gall stones<br />and acute cholecystitis.</p>