Pathology

This video (part 3 of 3) reviews the use of medical ultrasound imaging, the spectrum of findings in acute cholecystitis, as well as primary and secondary diagnostic findings in this disease.

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- Hello, my name is Phil Perera,
and I'm the Emergency Ultrasound Coordinator
at the New York Presbyterian Hospital in New York City.
And welcome to SoundBytes Cases.
In this SoundBytes module entitled,
Part Three of Bedside Ultrasound of the Gallbladder,
we're going to go on further on our discussion
of the pathology found on bedside imaging
of the Right Upper Quadrant.
Hopefully, first you've reviewed Parts One and Two
in the series on bedside ultrasound of the gallbladder
and understand the Right Upper Quadrant exam performance
and normal anatomy, as well as the
ultrasound findings of gallstones.
In this module, part three, we're going to specifically
review the spectrums of findings found in
Acute Cholecystitis, and we'll learn the primary
and secondary diagnostic findings in this disease.
The majority of cases of Acute Cholecystitis that present
to the Emergency Department are going to be calculous
or associated with cholesterol gallstones.
While a calculous cholecystitis does exist,
it's rarely seen in the Emergency Department.
Usually seen in patients who have been hospitalized,
those who have had surgery recently,
or those who have immunocompromised states
such as HIV or diabetes.
Acute Cholecystitis is usually caused by obstruction of
the cystic duct by a gallstone resulting in pathology.
And the list of sequelae include: gallbladder distension,
gallbladder edema, infection, or acute cholecystitis,
ischemia of the gallbladder wall, resulting in
necrosis and perforation of the actual gallbladder.
What are the clinical signs of acute cholecystitis that
we're examining for at the bedside of the patient
with acute Right Upper Quadrant abdominal pain?
Well, the primary diagnostic ultrasound finding
is going to be the presence of gallstones
with a positive sonographic Murphy's sign,
or tenderness over the gallbladder with pressure down
on the ultrasound probe.
These findings have a 92% positive predictive value for
Acute Cholecystitis as found in this article
by Dr. Ralls et al and radiology.
It's an older article from 1985, but one that's often
mentioned on discussion of Acute Cholecystitis.
Now there's multiple secondary signs of cholecystitis
that we should go through, and these include: a distended
gallbladder greater than 10 centimeters in length,
a thickened gallbladder wall that's usually mentioned
as greater than three millimeters in width.
Also, one may be able to see fluid in the gallbladder wall,
or edema within the gallbladder wall, as shown by
a stripe of fluid within the wall.
Also, we can have pericholecystic fluid, or a line of fluid
outside the gallbladder wall as a result of inflammation
or early perforation.
Now the presence of these secondary signs
of Acute Cholecystitis does improve our
diagnostic positive predictive value,
but only increases the yield from 92% to 95%.
So, it's really most important to look for the
primary diagnostic signs of Acute Cholecystitis.
Here's a video clip from a patient who presented with
Right Upper Quadrant pain and fever.
And as we look at the gallbladder, the first thing we see
is the presence of multiple gallstones
within the neck of the gallbladder.
Also, we're going to examine here the
anterior wall of the gallbladder.
And notice with the small indicator arrow,
I'm just pointing out that anterior wall.
Notice that it appears thickened.
Now here I'm just indicating the posterior wall
of the gallbladder, and notice that it's difficult
to measure the posterior wall due to an artifact
known as posterior acoustic enhancement.
The sound waves race through the gallbladder,
making it difficult to measure that
posterior wall as it lights up.
Here we're going to put calipers down on the
anterior gallbladder wall, and notice that we have
a measurement of four millimeters,
indicative of a thickened gallbladder wall
as we defined prior in the last slide
as greater than three millimeters in width.
This is a video showing two views of the gallbladder,
taken from a patient with
Right Upper Quadrant pain and fever.
We see long axis to the left
and short axis view to the right.
This shows that it's important to image the gallbladder
in both long and short axis configurations,
as I think on these two video clips that
the gallbladder wall anteriorly is better seen
on the short axis view to the right.
And we see here a concretion of gallstones
within the gallbladder lumen
and a thickened anterior wall of the gallbladder.
This patient also had a positive sonographic Murphy's sign.
Here I'm going to still that last image down
of the gallbladder in short axis configuration
and we see the anterior wall of the gallbladder
well-delineated here.
Notice the calipers across with the measurement
of nine millimeters, fulfilling the criteria
of a thickened wall.
This video clip shows another finding of Acute Cholecystitis
in addition to the multiple gallstones that we see
within the gallbladder lumen,
we appreciate a thickened anterior gallbladder wall.
And within the wall of the gallbladder, we see a stripe
of black fluid, consistent with gallbladder wall edema.
And here with the small indicator arrow I'm just going to
trace out that area of gallbladder wall edema within
that anterior wall of the gallbladder.
Interestingly enough, that surgery, the gallbladder
was found to be very edematous, inflamed,
and the wall was necrotic.
Let's now inspect another video clip from
an elderly patient with Right Upper Quadrant pain and fever.
And we see here on imaging of the gallbladder,
a distended gallbladder stretching out
across the video clip here.
Notice the large concretion of gallstones packed in
at the neck of the gallbladder.
But let's look closely at the anterior wall
of the gallbladder.
And we notice as shown with a small indicator arrow,
a stripe of fluid that is going to be pericholecystic fluid
outside that anterior wall of the gallbladder.
Now the patient also had a positive sonographic
Murphy's sign with a great deal of tenderness
on pressure down with the probe over this gallbladder.
So, as we mentioned in part one of the ultrasound modules
on gallbladder sonography, it's always important to
look at a different plane on imaging of the gallbladder.
So here's a subcostal view of the same gallbladder.
We see again the multiple concretion of gallstones
within the gallbladder neck as seen inferiorly
towards the image here.
Notice the shadowing off the back of the gallbladder.
And we can see here the large stripe of
pericholecystic fluid that is shown by that
dark area of fluid that wraps around
the anterior wall of the gallbladder.
So, Acute Cholecystitis on bedside sonography.
Let's wrap this module by looking at this video clip
for the multiple signs of Acute Cholecystitis
that are present here.
First of all, we notice the distended gallbladder
with a significant load of gallstones
stretching across the posterior wall of the gallbladder.
Incidentally, the patient had a positive sonographic
Murphy's sign, fulfilling the primary diagnostic signs
of Acute Cholecystitis.
Next, let's take a look at this video clip for some of the
secondary diagnostic signs of Acute Cholecystitis.
As we look at the anterior wall of the gallbladder,
we see here that it's thickened and inflamed.
We also see a stripe of pericholecystic fluid
just outside the anterior wall of the gallbladder.
So we see here some more of the secondary signs
of Acute Cholecystitis.
In conclusion, thanks for tuning in
for this SoundBytes module going over Part Three
of Bedside Ultrasound of the Gallbladder.
Hopefully now you understand the primary diagnostic signs
of Acute Cholecystitis on bedside imaging.
That is the presence of gallstones
and a sonographic Murphy's sign.
Recall that these two findings have a very high yield
for the presence of Acute Cholecystitis.
I hope also that you can identify some of the
secondary diagnostic signs of Acute Cholecystitis.
That is a large gallbladder,
a distended gallbladder greater than 10 centimeters,
with gallbladder wall thickening
greater than three millimeters,
the presence of gallbladder wall edema,
and also, finally, the presence of pericholecystic fluid.
So now, I believe you're ready to evaluate patients
during your next shift for gallbladder disease
and Acute Cholecystitis.
And I look forward to seeing you in the future
as SonoAccess continues.

Brightcove ID

5733899294001

https://youtube.com/watch?v=Xsj5j2hzjtA

Case: Gallbladder Ultrasound - Introduction

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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.

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- Hello.
My name is Phil Perera and I'm the
emergency ultrasound coordinator at the
New York Presbyterian Hospital in New York City.
And welcome to Soundbytes Cases.
In this Soundbytes module, we're going to focus on
bedside ultrasound of the gallbladder.
I've divided this module up into parts one, two, and three,
and in this module, part one, we're going to focus on the
normal hepatobilliary imaging and ultrasound findings.
Bedside ultrasound of the gallbladder allows rapid
evaluation of patients presenting with acute abdominal pain
to the emergency department and interestingly enough,
gall stone related disease is now more commonly diagnosed
in the emergency department with the increased advent of
bedside scanning.
Gall stone related disease is not only seen in traditional
females population, as described in textbooks.
It's also being seen in men with rapid weight loss or
weight gain changes, and also in the elderly.
So, let's begin this module with a review of the anatomy of
the right upper quadrant, how to perform the exam,
and the ultrasound findings in hepatobilliary imaging.
Let's begin with a review for the positions
for gallbladder sonography.
As shown in probe position one, the first position that's
often used for gallbladder sonography is going to be known
as the high/lateral view, in which we're looking through
the ribs.
It's best to use a smaller footprint probe for this exam
so that we can easily sit the probe between the ribs.
We're going to be coming in in a view that's very similar
to the right upper quadrant view for the trauma FAST Exam,
however, the probe here is angled more anteriorly than for
the FAST Exam to image the gallbladder.
The second position is known as the subcostal view, as shown
in probe position two here, and it's best to roll
the patient into the left lateral decubitus position
so that the gallbladder is closer to the probe.
From the subcostal position, we can push down directly
on the gallbladder to illicit the sonographic murphy's sign.
Now from both of these positions, we should rotate the probe
from long axis, with the probe marker toward the patient's
right shoulder to the short axis configuration, with the
probe marker over towards the right side, to completely
inspect through the gallbladder for any pathology.
Here's an illustration reviewing
the anatomy of the gallbladder and billiary tracts
important to bedside sonography.
Here we see the gallbladder,
shaped as a pear-like structure,
and we see the parts of the gallbladder,
the upper fundus, the intermediate body,
and the neck of the gallbladder toward the top of the image.
Recall that it's impacted stones at the neck of the
gallbladder that often cause symptomatic billiary colic
and can lead to acute cholecystitis.
We also see the cystic duct draining the bile from
the neck of the gallbladder and joining into the
hepatic duct, which is draining the bile from the liver.
The confluence of the cystic duct and hepatic duct forms
the common bile duct and stones lodged within this
area can cause choledocholithiasis.
We also the pancreatic duct joining to the bile duct and
dumping into the duodenum at the second part of the
duodenum, located at the ampulla of vater.
Stones that may lodge here can cause
gall stone pancreatitis.
Now let's take a look at the ultrasound findings of a
normal gallbladder.
We see the liver to the left and the gallbladder just
inferior to the liver to the right.
Notice the areas of the gallbladder.
We see the upper fundus towards
the upper right part of the image,
the body of the gallbladder, the intermediate part,
and the neck of the gallbladder all the way down towards
the left of the image.
As we look closely through this gallbladder,
we see that it has the typical darker or anechoic type
appearance on bedside sonography and that's because of the
fluid within the gallbladder, that is bile.
We see here the absence of any significant stones,
and remember that gall stones would appear as brighter
or hyperechoic foci within the gallbladder lumen.
Here's a normal variant, known as a septated gallbladder
and we see a little septi, that little white line,
going through the middle of the gallbladder.
This can be seen on bedside sonography and is not to be
mistaken as pathology.
Here's an illustration showing
the relation of the gallbladder to the portal vein
known as the exclamation dot sign.
The exclamation would be made up by the gallbladder
and the dot would be the portal vein.
We see a thin white line connecting the gallbladder to
the portal vein, known as
the median lobar fissure of the liver
and this can be a very helpful landmark as one looks
to find the gallbladder in relation to the portal vein.
Also, we see the common bile duct and the hepatic artery
on top of the portal vein, making up the structures of the
portal triad.
Here's an ultrasound image showing the portal vein,
exclamation dot sign.
And we see the gallbladder to the right,
making the exclamation,
and the dot, the portal vein, to the left.
Notice that the dot, the portal vein,
has hyperechoic walls, due to the fact that it's bringing
greasy blood from the intestine to be filtered
by the liver.
We see the white line connecting the gallbladder to the
portal vein that is median lobar fissure and posteriorly
we see the inferior vena cava.
Here's an ultrasound image showing the median lobar fissure
of the liver in greater detail.
Here we see the gallbladder, the pear-like structure,
to the right of the image and the branching portal vein
over towards the left.
As we look in between the two structures we see the
thin white line known as the median lobar fissure
of the liver.
Now the MLF can be a very important landmark as we look
from the portal vein up to the neck of the gallbladder
to inspect the neck of the gallbladder for any small stones
that might be lodged there and causing billiary colic.
Here's another video clip in which we can see the
relation of the portal vein to the gallbladder
in explicit detail.
Notice the gallbladder to the right,
the portal vein, the branching structure with hyperechoic,
or whiter, walls, towards the left,
and we can see the area of the MLF, the
median lobar fissure, connecting to two structures.
And again, this is a very important landmark for
walking your way up to the neck of the gallbladder to
look for any small stones impacted at the neck.
Also, looking for the portal vein can be very helpful in
looking for a contracted gallbladder that can be difficult
to identify on bedside sonography.
Now let's review an image showing the anatomy of the
portal triad.
We see the first the first structure of the portal triad,
the common bile duct, marked in green.
Notice that it connects the gallbladder
down to the duodenum.
While it's located to the left in this picture,
in a real patient it would be located over toward the
patient's right side.
We see the posterior structure of the portal triad,
the portal vein, marked in blue, and we see the
hepatic artery, which would be the third structure of
the portal triad. over towards the right of this image, but
would be located towards the patient's left side on
real-time scanning.
Here's a video clip showing the sonographic appearance
of the portal triad, which we refer to as
the Mickey Mouse Sign.
And here we see the gallbladder over toward the left
of the image and the portal triad, making up
the Mickey Mouse Sign.
The portal vein, making up Mickey's face, and
the ears of Mickey, the common bile duct making up
the left ear of Mickey and the hepatic artery making up
Mickey's right ear.
And this image is best obtained from a subcostal plane
and a transverse axis and a probe marker over towards
the patient's right side.
Now we can place Doppler sonography onto
the Mickey Mouse Sign to further delineate the structures
and we see that the portal vein, making up
Mickey's face, the posterior most structure of the portal
triad, will actually light up with Doppler sonography.
We can also see that Mickey's right ear, the hepatic artery,
also has Doppler flow on Doppler sonography.
However, the common bile duct, Mickey's left ear, fails to
appreciate any Doppler flow due to the sluggish flow within
the common bile duct.
In this video clip, we can appreciate the common bile duct
and portal vein in more of a long axis configuration.
We've turned the probe, so now the probe marker is over
toward the patient's right shoulder
and we see the gallbladder towards the top of the image
and notice here we see two parallel channels towards
the bottom aspect of the image here.
Notice the portal vein with Doppler flow, and on top of
the portal vein, we can appreciate the common bile duct.
As the common bile duct enlarges with obstruction,
it will become as large or larger than
the accompanying portal vein.
Normal dimensions for the common bile duct is that it
should be no more than one millimeter for each decade of
the patient's life.
A common bile duct that measures across in diameter
greater than eight millimeters is universally enlarged.
And when we measure the common bile duct,
we're going to measure from inner wall to inner wall
across the lumen of of the common bile duct.
My conclusion points for this Soundbytes module,
going over part one of gallbladder sonography,
gallbladder ultrasound at the patient's bedside is a
very helpful ultrasound exam in evaluating the
patient presenting to the emergency department with
acute abdominal pain.
And hopefully through looking at this module,
you know how to perform the right upper quadrant
ultrasound examination and understand the anatomy
of the hepatobilliary tract essential to bedside sonography.
And also, by going through the footage, looking at the
ultrasound imaging of the gallbladder and portal triad,
you now know how to interpret the ultrasound images
that you will obtain at the patient's bedside.
So I look forward to seeing you back as
Sono Access continues and we go on to future modules
focusing on gall stones and acute cholecystitis.

Brightcove ID

5733888191001

https://youtube.com/watch?v=FY3dBuQV03w

Case: Gallbladder Ultrasound - Gallstones

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This video (part 2 of 3) focuses on normal hepatobiliary imaging and anatomy of and near the gallbladder.

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- Hello, my name is Phil Perera,
and I'm the emergency ultrasound coordinator
at the New York Presbyterian Hospital in New York City.
And welcome to SoundBytes Cases.
In this SoundBytes module, entitled
Part Two of Bedside Ultrasound of the Gallbladder,
we're gonna go further on
to our discussion of gallbladder sonography.
Hopefully, first of all, you've reviewed
part one in the series
and have a basic understanding of how to perform
the right upper quadrant exam
and also how to interpret the images that you will obtain.
In this module, entitled Part Two of Gallbladder Sonography,
we're going to focus specifically on the spectrum
of gallstone-related disease, beginning
with a deposition of cholesterol crystals
known as gallbladder sludge and microlithiasis,
on to the ultrasound findings with large stone concretions
that may cause biliary colic and acute cholecystitis.
Here's a video clip from a patient who presented with
right upper quadrant pain,
and we see here the gallbladder in the middle of the image.
Let's look towards the neck of the gallbladder,
and we appreciate a fluid level
that's made up of gallbladder sludge.
We see here that the gallbladder sludge
is tucked in there towards the neck of the gallbladder,
but we see crystals moving up towards the fundus
and towards the body of the gallbladder.
I'd like to make a couple points
with regard to gallbladder sludge,
and the first is that occasionally beam artifact
can masquerade as gallbladder sludge.
However, sludge is going to be defined as having
a fluid level that is going to layer out with gravity.
Also, remember that gallbladder sludge can occasionally
cause symptoms of acute biliary colic
and acute cholecystitis in patients,
so it's not a benign finding.
Here's a video clip from a young male presenting with
right upper quadrant pain,
and as we're looking through the gallbladder,
we notice here a finding within the neck of the gallbladder.
We see a concretion of gallbladder sludge and also
tiny gallbladder stones known as microlithiasis.
Notice that the microlithiasis has a posterior
acoustic shadowing, due to the blocking of sound waves
through the concretions of the cholesterol crystals.
So, an interesting finding on
the spectrum of gallbladder disease.
Here's another video clip,
again from a male presenting with right upper quadrant pain,
and what we see here is a gallbladder
in the middle of the image,
and notice the layering out of multiple small stones
on the back wall of the gallbladder.
We see the characteristic appearance of a gallstone here.
Notice it has a hyperechoic, or bright, appearance,
and we can see shadows coming off the back,
as the sound waves can't permeate
the hard cholesterol crystals.
Here's a still image showing the classic appearance of
an impacted stone at the gallbladder neck.
Here, we're looking through the lateral intercostal view,
so we get a nice long axis view of the gallbladder.
We can see here a gallstone that's located
within the neck of the gallbladder.
Notice that it has the classic bright, or hyperechoic,
appearance, and we see the hard shadow,
the blackout of sound waves posterior to the gallstone.
Interestingly enough, as we rolled the patient around
and inspected the gallstone,
the gallstone failed to move, showing that it was impacted
and the cause of the patient's biliary colic.
Here's a video clip showing an impacted stone
at the gallbladder neck, again taken from that lateral
intercostal view that gives us those great long axis
views of the gallbladder.
We see the liver to the top of the image
and the gallbladder inferior to the liver.
Towards the neck of the gallbladder, we see a white,
hyperechoic gallstone, and we see
the classic posterior acoustic shadowing.
As we mentioned in module one, it's always important to
look at the gallbladder in two orientations.
Here we've moved the patient into
the left lateral decubitis position,
and we're looking from the subcostal plane.
Again, we see the gallbladder stretched out inferior
to the liver, and within the neck of the gallbladder,
we see the hyperechoic, bright gallstone,
and notice also the posterior acoustic shadow.
As we pressed down on this gallbladder, the patient
had a lot of pain, confirming a sonographic Murphy sign.
Here we're going to change the orientation of the probe
into a short axis configuration.
The probe is located in the subcostal plane
with a marker over towards the patient's right.
Thereby we're cutting the gallbladder into cross sections,
so the gallbladder will appear as a circle
on the ultrasound screen.
We see here a gallstone, that hyperechoic area within
the gallbladder lumen, and again the posterior acoustic
shadowing confirming the presence of a gallstone.
Here's a video clip taken from a elderly patient
with acute right upper quadrant pain.
We're scanning back and forth through the gallbladder.
This view is taken from that lateral intercostal view.
And we see here the presence of multiple shadowing
gallstones within the lumen of the gallbladder.
So the end result of cholesterol deposition within
the gallbladder, forming multiple stones
within the gallbladder lumen.
And we can see here, as we scan back and forth,
the multiple hyperechoic foci
with a posterior acoustic shadow.
Here's an interesting video clip from another patient
with acute right upper quadrant pain.
And we see a distended gallbladder,
stretching across the screen here,
the fundus located towards the right,
and the neck over towards the left.
Within the lumen of the gallbladder, we see multiple
gallstones layering across the back wall of the gallbladder.
And notice that they have almost
like a small pea-like type appearance.
And we can see also the posterior acoustic shadowing
as we scan back and forth through the gallstones.
So, multiple gallstones within a distended gallbladder.
A sonographic finding that can be seen with
a gallbladder that's completely filled with stones
and in a contracted state is the wall echo sign.
And here we see an example of the wall echo sign,
long axis to the left and short axis view to the right.
What we see here is the gallbladder filled with stones,
and all we see is the anterior wall of the gallbladder,
the echo from the concretion of stones,
and the shadow off the back of the stones
making the sign.
Thus the wall echo sign pathognomonic for a gallbladder
completely packed with stones in a contracted state.
And it can be occasionally difficult to find the gallbladder
when all you see is the wall echo sign.
One potential pitfall in performance of
right upper quadrant sonography
is that occasionally a loop of bowel may come
right up against the wall of the gallbladder
and be mistaken for a gallstone.
Let's take a look at two video clips
that show the difference between these two appearances.
In the video clip to the left,
we see a loop of bowel that's right up against
the posterior wall of the gallbladder.
Notice that it has a bright, or hyperechoic, appearance
that could be mistaken for a gallstone.
However, the loop of bowel is clearly
outside the gallbladder wall and not inside,
as a gallstone would be.
Also, let's look at the shadows that come off
the back of the air-filled bowel.
What we see is that there are dirty shadows,
as I characterize, that are not completely dark
as those that would be seen off of a gallstone.
Notice that there's areas of white
within the dark areas, characterizing a dirty shadow.
Let's take a look at the video clip to the right,
and what we see here is an impacted gallstone
at the neck of the gallbladder.
Notice that it has a hyperechoic appearance that shadows
and that the gallstone is clearly within
the lumen of the gallbladder.
And we see the shadow that comes off the back
is a clean shadow, completely dark without
those light areas that characterize air shadows.
My conclusion points for this SoundBytes module, going over
part two of Bedside Ultrasound of the Gallbladder.
Hopefully, through this module you now understand
the ultrasound imaging findings in the
spectrum of gallstone disease that may be seen
in patients presenting to the emergency department
with abdominal pain.
I hope also that you can identify the presence of
biliary sludge, or microlithiasis, that can be seen
as the first finding of deposition
of cholesterol crystals,
on to the identification of large gallstone concretions.
And last, I look forward to seeing you back
as SoundBytes continues,
and as we go on to Gallbladder Sonography, part three,
that'll focus entirely on the ultrasound findings
in acute cholecystitis.

Brightcove ID

5733895942001

https://youtube.com/watch?v=L3e-YdQRa-A

S Series: Subxiphoid View

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S Series: Subxiphoid View

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M-Turbo: Parasternal Short Axis

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M-Turbo: Parasternal Short Axis

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M-Turbo: Parasternal Long Axis

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M-Turbo: Parasternal Long Axis

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Sonosite M-Turbo

How to: Focused Echo: Subcostal View

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Learn to examine the heart using the subcostal window and four chamber plane. This view is commonly taught as part of the cardiac evaluation during the trauma FAST exam.

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- The next view I'm gonna take you through
in the FAST exam is the subcoastal view
of the heart in a four-chamber plane.
For this, we're gonna put our transducer
to phased array
to the subxiphoid area,
aiming towards the patient's left shoulder.
Here is the probe marker here,
which I'm going to angle towards
the patient's right.
When I do this exam, I wanna make sure this transducer is
along the frontal plane
and aiming toward the chest.
A common mistake is to go too
inferior into the abdomen,
so you want to go deep into the chest.
When you're in this location,
the other thing you're gonna need to do
is increase your depth.
I'm gonna use my depth key right here
and I'm gonna increase,
so I can see the full heart in view
and now you can see we're at 21 centimeters.
Some common landmarks that you need to identify,
the first thing you see is that we see liver
at the top of the screen.
That liver is our coustic window into the heart.
The beating thing in the center is obviously the heart
and we can identify the entire heart
and the perimeter of the heart with the pericardium.
The pericardium is the white line that I'm seeing,
you can see that's surrounding the full heart.
Then we can identify the chambers.
The chambers are relatively easy to identify
in this view.
The chambers on the right side
of the heart are over here
and the easy way to identify those,
remember the liver's on the right side of the body,
so these chambers that are adjacent to the liver would be
right-sided chambers.
The large chamber, which is adjacent to the liver
is the right ventricle,
on the other side we see the left ventricle
and we see the two atria.
Again, our focus
on this exam is to identify the pericardium
and to look for free fluid within it.
What we're gonna look for
is an anechoic area within that pericardium
which would be signs of a hemopericadium.
Now if you can't get this view,
a great alternate view is the parasternal view
of the heart in a long axis plane.
We're gonna take you through that in the
echocardiography section.

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Learn how to measure the common bile duct.

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Double Barrel Shotgun Sign

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- The more advanced area that you may want to look at
is actually measuring the bile duct.
That's a pretty straight forward procedure.
First thing you do is again find that exclamation sign.
And again we see it here with the gallbladder in length
we see the portal vein,
and just above the portal vein lies the bile duct.
So when we carefully scan you can see an area.
Just above the portal vein which is anechoic.
I'm going to freeze this here in a moment.
And you should be able to see a very tiny duct.
If you are squinting at the screen like I am
trying to see where the duct is.
You are dealing with a patient with a normal duct.
Usually if the duct is enlarged it will be quite evident,
and it can be as large as the portal vein itself.
So I'm going to freeze this here.
So on the screen right now I have a reasonably good image
of the portal vein,
and the associated structures around it.
Right above it we see a very tiny anechoic stripe,
that is the bile duct.
In addition, we also note a very small area which is the
hepatic artery which I'll point out in a moment.
So what we are going to do now is go ahead
and do the measurement of the bile duct.
A normal bile duct measurement is about four millimeters
or less or about one millimeter per decade of life.
So I'm going to go ahead and hit caliper.
And I'm going to drag one end of this to the inter aspect
of the bile duct.
Once I have found that I'm going to hit select,
and I'm going to drag this down.
Just adjacent to it and you can see we are getting
a measurement here of .14 centimeters or 1.4 millimeters,
so well within the normal limits.
Okay I'm going to illustrate to you where
the hepatic artery is.
We can see first this is the portal vein right here.
Right above it is that little anechoic stripe,
which is very tiny and difficult to see,
because this bile duct is normal.
This is the common bile duct.
But right adjacent to here is another anechoic structure,
which is an hepatic artery.
If there is ever any confusion of what you're measuring
you can easily turn the color flow on
to differentiate the two.

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