<p begin="00:00:15.335" end="00:00:17.408" style="s2">- Okay, I'm gonna take you<br />through the gallbladder exam.</p>
<p begin="00:00:17.408" end="00:00:19.520" style="s2">So in the emergency<br />department you may have</p>
<p begin="00:00:19.520" end="00:00:20.804" style="s2">a patient with abdominal pain.</p>
<p begin="00:00:20.804" end="00:00:23.268" style="s2">The question is, who are you<br />gonna do a gallbladder exam on?</p>
<p begin="00:00:23.268" end="00:00:24.703" style="s2">The patients that you suspect</p>
<p begin="00:00:24.703" end="00:00:26.397" style="s2">cholecystitis or biliary colic</p>
<p begin="00:00:26.397" end="00:00:27.783" style="s2">are the ones that we're gonna primarily be</p>
<p begin="00:00:27.783" end="00:00:29.282" style="s2">doing this exam on.</p>
<p begin="00:00:29.282" end="00:00:31.064" style="s2">The exam setup is very straightforward,</p>
<p begin="00:00:31.064" end="00:00:32.912" style="s2">let me take you through it.</p>
<p begin="00:00:32.912" end="00:00:34.695" style="s2">We have our M-Turbo system here,</p>
<p begin="00:00:34.695" end="00:00:36.405" style="s2">it's already powered up and on.</p>
<p begin="00:00:36.405" end="00:00:39.179" style="s2">We have a selection of<br />two different transducers.</p>
<p begin="00:00:39.179" end="00:00:41.564" style="s2">Most of you may already<br />have this transducer,</p>
<p begin="00:00:41.564" end="00:00:43.583" style="s2">this is a phased array transducer,</p>
<p begin="00:00:43.583" end="00:00:45.085" style="s2">this is the same<br />transducer you're gonna use</p>
<p begin="00:00:45.085" end="00:00:47.709" style="s2">for the FAST exam and echocardiography.</p>
<p begin="00:00:47.709" end="00:00:49.741" style="s2">The other transducer<br />that you may also have</p>
<p begin="00:00:49.741" end="00:00:51.790" style="s2">is a curvilinear transducer.</p>
<p begin="00:00:51.790" end="00:00:53.073" style="s2">This is an excellent transducer,</p>
<p begin="00:00:53.073" end="00:00:55.687" style="s2">though you'll sometimes have<br />problems with rib shadows.</p>
<p begin="00:00:55.687" end="00:00:57.005" style="s2">So you can use either one,</p>
<p begin="00:00:57.005" end="00:00:58.495" style="s2">but for today's demonstration</p>
<p begin="00:00:58.495" end="00:01:01.423" style="s2">I'm gonna take you<br />through the phased array.</p>
<p begin="00:01:01.423" end="00:01:03.519" style="s2">So once you've chosen the transducer,</p>
<p begin="00:01:03.519" end="00:01:06.536" style="s2">the next step is to choose<br />the exam type on the machine.</p>
<p begin="00:01:06.536" end="00:01:08.498" style="s2">To choose the examination configuration,</p>
<p begin="00:01:08.498" end="00:01:10.043" style="s2">it's very straightforward.</p>
<p begin="00:01:10.043" end="00:01:12.028" style="s2">We hit the Exam key right here,</p>
<p begin="00:01:12.028" end="00:01:14.052" style="s2">and with the selected transducer right now</p>
<p begin="00:01:14.052" end="00:01:17.957" style="s2">we can choose between<br />abdominal, OB, and cardiac.</p>
<p begin="00:01:17.957" end="00:01:20.124" style="s2">And for this exam we're<br />gonna choose abdomen,</p>
<p begin="00:01:20.124" end="00:01:21.536" style="s2">so I'm gonna hit Select,</p>
<p begin="00:01:21.536" end="00:01:23.966" style="s2">and we're gonna be<br />ready to start scanning.</p>
<p begin="00:01:23.966" end="00:01:25.025" style="s2">So I had the patient turn to</p>
<p begin="00:01:25.025" end="00:01:26.761" style="s2">the left lateral decubitus position,</p>
<p begin="00:01:26.761" end="00:01:29.442" style="s2">and I like to have their elbow up as well.</p>
<p begin="00:01:29.442" end="00:01:32.015" style="s2">The next thing I do is<br />I draw an imaginary line</p>
<p begin="00:01:32.015" end="00:01:33.682" style="s2">along the costal margin,</p>
<p begin="00:01:33.682" end="00:01:37.035" style="s2">and we have an imaginary<br />perpendicular line</p>
<p begin="00:01:37.035" end="00:01:39.370" style="s2">along the line of the shoulder.</p>
<p begin="00:01:39.370" end="00:01:40.682" style="s2">So then I'm gonna put my transducer</p>
<p begin="00:01:40.682" end="00:01:42.040" style="s2">right about in this area,</p>
<p begin="00:01:42.040" end="00:01:45.184" style="s2">and I should have a very<br />long axis of the gallbladder.</p>
<p begin="00:01:45.184" end="00:01:47.975" style="s2">So here's our transducer<br />marker right here.</p>
<p begin="00:01:47.975" end="00:01:50.097" style="s2">Again, I'm at the costal margin</p>
<p begin="00:01:50.097" end="00:01:51.847" style="s2">pointing toward the shoulder,</p>
<p begin="00:01:51.847" end="00:01:53.721" style="s2">and I'll try to find the gallbladder.</p>
<p begin="00:01:53.721" end="00:01:55.271" style="s2">So when you're scanning<br />the right upper quadrant,</p>
<p begin="00:01:55.271" end="00:01:56.299" style="s2">sometimes you'll have to have</p>
<p begin="00:01:56.299" end="00:01:58.996" style="s2">the patient take a deep breath.</p>
<p begin="00:01:58.996" end="00:02:01.675" style="s2">And what'll happen is the<br />liver will be pushed down</p>
<p begin="00:02:01.675" end="00:02:04.048" style="s2">and the gallbladder will<br />come easier into view.</p>
<p begin="00:02:04.048" end="00:02:05.695" style="s2">So that's a little trick that you can use</p>
<p begin="00:02:05.695" end="00:02:07.914" style="s2">to see organs in the upper quadrant</p>
<p begin="00:02:07.914" end="00:02:11.154" style="s2">that you may not be<br />able to identify easily.</p>
<p begin="00:02:11.154" end="00:02:14.062" style="s2">And what we see here on the screen</p>
<p begin="00:02:14.062" end="00:02:16.664" style="s2">is what we term the exclamation sign.</p>
<p begin="00:02:16.664" end="00:02:18.644" style="s2">The exclamation sign is</p>
<p begin="00:02:18.644" end="00:02:22.002" style="s2">the long part of the<br />gallbladder here, and a dot.</p>
<p begin="00:02:22.002" end="00:02:24.028" style="s2">And that dot is the portal vein.</p>
<p begin="00:02:24.028" end="00:02:27.049" style="s2">They're together, that is<br />a very important landmark.</p>
<p begin="00:02:27.049" end="00:02:29.139" style="s2">I'll be scanning through<br />the entire gallbladder</p>
<p begin="00:02:29.139" end="00:02:31.189" style="s2">in a long axis fashion,</p>
<p begin="00:02:31.189" end="00:02:32.445" style="s2">and then I'll turn the transducer</p>
<p begin="00:02:32.445" end="00:02:35.415" style="s2">just a little bit to the right,</p>
<p begin="00:02:35.415" end="00:02:39.582" style="s2">and I'll start scanning up to<br />down in a short axis plane.</p>
<p begin="00:02:40.756" end="00:02:43.058" style="s2">Things that you can do<br />to optimize that image,</p>
<p begin="00:02:43.058" end="00:02:44.723" style="s2">first thing you can do<br />is change your depth.</p>
<p begin="00:02:44.723" end="00:02:48.992" style="s2">So in this gentleman I may<br />decrease the depth just slightly</p>
<p begin="00:02:48.992" end="00:02:50.927" style="s2">to just sort of bring the gallbladder</p>
<p begin="00:02:50.927" end="00:02:53.320" style="s2">better into mod-center field of view.</p>
<p begin="00:02:53.320" end="00:02:54.833" style="s2">The other things that I can do</p>
<p begin="00:02:54.833" end="00:02:56.570" style="s2">is adjust the gain slightly.</p>
<p begin="00:02:56.570" end="00:02:59.609" style="s2">So I can try playing with<br />my gain slightly higher,</p>
<p begin="00:02:59.609" end="00:03:01.179" style="s2">and you can see the image gets brighter,</p>
<p begin="00:03:01.179" end="00:03:02.603" style="s2">or slightly lower.</p>
<p begin="00:03:02.603" end="00:03:04.626" style="s2">You want to optimize these settings</p>
<p begin="00:03:04.626" end="00:03:08.811" style="s2">so you have good contrast of<br />the fluid-filled structure,</p>
<p begin="00:03:08.811" end="00:03:10.635" style="s2">which is the gallbladder in the center,</p>
<p begin="00:03:10.635" end="00:03:13.802" style="s2">and you can also notice any artifacts.</p>
<p begin="00:03:15.179" end="00:03:16.987" style="s2">So once you've identified the gallbladder,</p>
<p begin="00:03:16.987" end="00:03:18.370" style="s2">and you're happy that you can see</p>
<p begin="00:03:18.370" end="00:03:20.333" style="s2">the gallbladder in a nice long view,</p>
<p begin="00:03:20.333" end="00:03:23.240" style="s2">you have to carefully look<br />for signs of a gallstone.</p>
<p begin="00:03:23.240" end="00:03:24.436" style="s2">Once you see the gallstone,</p>
<p begin="00:03:24.436" end="00:03:27.894" style="s2">you're gonna then press gently<br />into the right upper quadrant</p>
<p begin="00:03:27.894" end="00:03:31.175" style="s2">and see if they have signs<br />of a sonographic Murphy.</p>
<p begin="00:03:31.175" end="00:03:33.046" style="s2">Now, we're all familiar, as physicians,</p>
<p begin="00:03:33.046" end="00:03:34.272" style="s2">with what a Murphy sign is,</p>
<p begin="00:03:34.272" end="00:03:36.366" style="s2">and that's palpation of<br />the right upper quadrant,</p>
<p begin="00:03:36.366" end="00:03:38.152" style="s2">and looking for gallbladder tenderness.</p>
<p begin="00:03:38.152" end="00:03:40.961" style="s2">A sonographic Murphy<br />is much more specific,</p>
<p begin="00:03:40.961" end="00:03:43.591" style="s2">so we're gonna press on<br />the transducer gently,</p>
<p begin="00:03:43.591" end="00:03:45.392" style="s2">and to see if that elicits pain.</p>
<p begin="00:03:45.392" end="00:03:46.728" style="s2">The next things you're gonna look for</p>
<p begin="00:03:46.728" end="00:03:49.121" style="s2">are signs of inflammation<br />of the gallbladder,</p>
<p begin="00:03:49.121" end="00:03:51.000" style="s2">such as fluid around the gallbladder,</p>
<p begin="00:03:51.000" end="00:03:53.717" style="s2">that's being pericholecystic fluid,</p>
<p begin="00:03:53.717" end="00:03:55.661" style="s2">and also gallbladder wall thickening.</p>
<p begin="00:03:55.661" end="00:03:56.964" style="s2">So we're gonna look particularly</p>
<p begin="00:03:56.964" end="00:03:58.910" style="s2">at the anterior wall of the gallbladder</p>
<p begin="00:03:58.910" end="00:04:00.641" style="s2">and see that this is enlarged.</p>
<p begin="00:04:00.641" end="00:04:02.598" style="s2">And anything above four millimeters or so</p>
<p begin="00:04:02.598" end="00:04:05.939" style="s2">would be a sign of<br />gallbladder inflammation.</p>
<p begin="00:04:05.939" end="00:04:06.873" style="s2">So when you're scanning,</p>
<p begin="00:04:06.873" end="00:04:09.639" style="s2">you're gonna be carefully<br />looking for signs of a gallstone.</p>
<p begin="00:04:09.639" end="00:04:12.266" style="s2">A gallstone will have a<br />hyper-echoic appearance,</p>
<p begin="00:04:12.266" end="00:04:14.189" style="s2">meaning it's gonna be brighter in nature,</p>
<p begin="00:04:14.189" end="00:04:15.640" style="s2">and it's gonna cast a shadow.</p>
<p begin="00:04:15.640" end="00:04:17.090" style="s2">A key point here is make sure</p>
<p begin="00:04:17.090" end="00:04:19.148" style="s2">that the hyper-echoic<br />area that you're noticing</p>
<p begin="00:04:19.148" end="00:04:21.427" style="s2">actually lies within the gallbladder.</p>
<p begin="00:04:21.427" end="00:04:24.267" style="s2">A common mistake would<br />be to identify an area</p>
<p begin="00:04:24.267" end="00:04:25.395" style="s2">outside the gallbladder</p>
<p begin="00:04:25.395" end="00:04:27.042" style="s2">that would look just like a gallstone,</p>
<p begin="00:04:27.042" end="00:04:29.792" style="s2">and that would be a bowel shadow.</p>