Case Presentation:

85 year old female with HTN, HLD, DM, and dementia presents to ED for a syncopal episode and generalized weakness for one day. Per the family, she had started on a new antidepressant and had increased lethargy since. During outpatient evaluation by her PCP was noted to have right sided abdominal pain which was pending workup with CT. Of note she also has had dark urine as reported by the daughter and has reported subjective fevers, chills and poor PO intake over the past three days. She has become less conversant and sleepier than usual.

Physical Exam:

HR 114, BP 82/45, RR 22, T 39.1C rectally

General: confused, appears jaundiced, opens eyes to abdominal exam only.

Abdomen: soft, tenderness to epigastric region and RUQ, non-distended, no palpable masses, no rebound/guarding

Right Upper Quadrant Ultrasound

On bedside US, our patient had the following findings:

Patient was seen with borderline hydrops (distention) of the gallbladder, measured to be 9.7 cm by 3.13 cm. Gallbladder hydrops is defined by a gallbladder with dimensions greater than a length of 10 cm and width of 5 cm on ultrasound.

CBD seen nearfield to portal vein (red)

Visualization of the common bile duct (CBD) was difficult, however was measured to be 1.15 cm in diameter as seen above. Color doppler over the region confirmed that the dilated structure was not in fact vasculature, which can commonly be mistaken.

Patient was also seen with intrahepatic dilatation, as evidenced by the images below. Intrahepatic ducts measured >2mm are considered dilated on ultrasound. Color doppler over the region can be used to ensure that the dilated structures are not intrahepatic vasculature.

There are multiple tips to visualizing the CBD, which can be tricky to identify.

In the short view of the gallbladder, you can look for the “Mickey Mouse Sign”, in which the portal triad is visualized. Mickey’s left ear is the CBD, his right ear is the hepatic artery, and the head is the portal vein.

In the long view of the gallbladder, the “Exclamation Point Sign” is seen with the portal vein as the little “period” and the gallbladder as the long structure. The CBD can be found by following the main lobar fissure down to the portal vein and typically should be located anterior to the portal vein. Color doppler can be used to confirm that the structure is a duct rather than vasculature.

Acute Cholangitis

Acute cholangitis is caused by an ascending bacterial infection of the biliary tree. Most common cause is choledocholithiasis (stone in the common bile duct), however other causes include malignancy, strictures of the biliary ducts, biliary stent obstructions, and parasitic infections.

The patient arrived jaundiced, febrile, and with right upper quadrant tenderness. She also was found to be altered, hypotensive (Reynold’s Pentad), which further brought on the concern for concurrent acute cholangitis.

Hospital Course

A CT scan of the abdomen and pelvis revealed biliary and pancreatic ductal dilatation, mild gallbladder wall thickening and borderline hydropic gallbladder. Upon admission, the patient was taken for an ERCP, which was notable for a mass/obstruction in her mid-CBD. She underwent a sphincterotomy with stent placement. Patient continued to deteriorate with increasing vasopressor requirements, which prompted placement of a percutaneous cholecystostomy drain by IR. Repeat imaging showed numerous metastatic lesions. Patient ultimately had escalating pressor requirements despite antibiotics. Numerous discussions with family were conducted regarding worsening infection despite appropriate treatment and family wished efforts to maintain comfort were most important and she was made DNR/DNI and requested no more invasive procedures. She was maintained on vasoactive agents and antibiotics but ultimately passed away.

References

1. Morgan M, Baba Y, Jones J, et al. Bile duct dilatation. Reference article, Radiopaedia.org (Accessed on 21 Jan 2023) https://doi.org/10.53347/rID-34179

2. https://www.emra.org/emresident/article/common-bile-duct/