The Red Flags of Impending Gallbladder Rupture

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Ultrasound and subtle lab findings may convince you to admit that patient with RUQ pain.

It’s another hectic day in paradise when your resident asks if she can present a case to you. The patient is a 49-year-old female who presents to the ED for abdominal pain. The patient states that three days ago she had an episode of epigastric pain that came on suddenly, was bad for about an hour, and then gradually resolved over about three hours. Today it recurred, but is more severe, 9 out of 10, and radiates to the right upper quadrant. It has been present for over 10 hours and is getting no better. She states that she vomited once and has chills but doesn’t think she has had a fever. She took ibuprofen about an hour ago for the pain, noting that it hasn’t really helped. She denies any other complaints.

For her physical exam, your resident notes “stable” vital signs although the vitals have only been taken once. Pulse is 97, blood pressure is 93/61, respirations are 22, and temperature is 98.9. She is described to you as obese with right-upper-quadrant tenderness and a positive Murphy’s sign, but not other positive findings.


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The PA in triage ordered labs about an hour and a half ago, and they are already resulted and show the following: WBC 5.7, hemoglobin 12.3, chemistry and LFTs all within normal limits. Your resident brings you the following images that she saved with her own bedside sonogram. She tells you her plan, “This looks like simple gallstones with no real red flags. Can we send her home with hydrocodone and arrange for a formal ultrasound and surgical consult as an outpatient?”

Q: Do you sign off on your resident’s management plan? What do the images show?


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Do not sign off on this plan! Before we get to the images, there are indeed multiple red flags here. First, the duration of the pain: pain of a presumed biliary origin that lasts more than six hours is cholecystitis until proven otherwise, so formal imaging is indicated here (see the EM 1-minute consult on cholecystitis below for more clinical pearls and pitfalls). The second red flag is the vital signs: a pulse of 97 is under 100, but is a little on the high side and a blood pressure of 93/61 is probably not normal in a 49-year-old obese female with 9/10 pain, neither are respirations of 22, and a temperature of 98.9 an hour or two after ibuprofen could represent a fever, especially in a patient with chills.

The third red flag is the physical exam: a positive Murphy’s sign is an exam finding that has been described in cholecystitis, not biliary colic.

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The labs are reassuring, but did you notice that the differential was not reported? This patient actually had 22 bands. Always wait for the results of the differential if one was ordered. A normal white count is usually reassuring, but in the setting of possible infection the differential includes severe sepsis. It is important to be aware that no single lab value is better than 50% sensitive for cholecystitis, and not infrequently all the labs will be normal.

The images show two transabdominal views of the gallbladder. The first shows a large gallstone with posterior shadowing that is possibly impacted in the gallbladder neck. To the right side of the image, near the gallbladder fundus, there is also shadowing but no evidence of stones. This could be due to an air collection from gallbladder rupture (see labeled ultrasound below). The second image above focuses on this area and shows a non-descript area with shadowing that is probably free air, consistent with a perforated gallbladder from cholecystitis.

A confirmatory CT scan (shown below) was requested by the surgical consult. Note the pericholecystic fluid but also the fluid collection medial to the posterior liver and lateral to the right kidney, as well as free air anterior and medial to the gallbladder.

The patient received IV ampicillin/sulbactam and was taken emergently to the operating room. Fortunately, she did well and followed up in the post-operative surgical clinic rather than in the septic-shock or ascending cholangitis clinic.


Pearls and Pitfalls: Gallbladder & RUQ Ultrasound

  1. Know Your Limits: Ultrasound may help clarify findings elicited by a thorough history and physical exam. When used correctly, it can greatly improve diagnostic accuracy and help guide patient management, especially for time-critical diagnoses and treatment of unstable patients. It can also decrease the use of CT scan and thereby minimize radiation exposure. However, you need to consider your skill level and know your limitations. When unsure, order a formal study. If your department has an ED dedicated ultrasound machine, it should consider implementing a quality improvement program that is approved by both ED administration and radiology.
  2. Finding the Gallbladder: Lying the patient on their left side and starting by locating the inferior liver edge can help.
  3. The Sonographic Murphy’s Sign: To check for a sonographic Murphy’s sign, which is a sign of cholecystitis, place the ultrasound probe at the maximal point of tenderness in the right upper quadrant. If the probe is placing direct pressure on the gallbladder fundus, you have a positive sonographic Murphy’s sign. False negatives may occasionally occur if the patient has received opiates prior to examination.
  4. The Gallbladder Wall: One sign of cholecystitis is a thickened gall-bladder wall. The normal gallbladder wall can be up to 3mm thick. The most common conditions other than cholecystitis that may cause thickening of the gallbladder wall include hepatitis, hypoalbuminemia, tumor, hyperplastic cholecystosis, adenomyomatosis, and CHF. In the absence of ascites, the presence of pericholecystic fluid, also supports the diagnosis of acute cholecystitis. If there is clinical uncertainty, a nuclear biliary scan (HIDA or DESIDA scan) may be performed.
  5. The Common Bile Duct: A dilated common bile duct is another sign of acute cholecystitis. The normal common bile duct inner diameter should be less than 4mm, but may be higher, up to 10mm, post-cholecystectomy. In addition, the diameter may be higher in older patients, up to 1mm per decade of life.
  6. The Gallbladder Contents: Look for a dilated gallbladder, evidence of stones, and for sludge. Gallstones should be mobile, unless they are impacted in the gallbladder neck, and should cast an acoustic shadow. If all stones are mobile in a patient who remains symptomatic, consider that they may be a red herring and not the true cause of the patient’s pain. Remember that approximately 15% of adults have asymptomatic gallstones. If there are no sonographic signs of cholecystitis, but a gallstone is impacted (non-mobile) in the gallbladder neck, be suspicious for early cholecystitis and consider admission, additional imaging, or at least next-day follow-up. Always also consider early cholecystitis when pain lasts for more than six hours, even when the ultrasound is normal except for the presence of a stone. Uncomplicated gallstone attacks usually should only last a few hours. Make sure to explain this to patients if you for some reason decide to send them home with opiates. Attacks lasting longer than that may be something more serious.
  7. Pitfalls: Don’t miss a single obstructing gallstone hidden in the gallbladder neck. It can sometimes be hard to see. Also, do not get faked out by an incidental “red herring” gallstone. As previously mentioned, many people have gallstones for years with no symptoms, so if everything does not fit clinically, look further for something else causing the abdominal, flank, or rib pain. Some examples include aortic aneurysm, Fitz-Hugh-Curtis syndrome, high appendicitis, PE, kidney stone, and pneumonia. Finally, don’t miss an AAA, even if it is also incidental, because you did not look for it. Ultrasound techs look. The aorta is not that far away, and should be checked routinely in anyone over the age of 50 who is having an abdominal ultrasound for another reason. Screening saves lives!

ABOUT THE AUTHOR

EMERGENCY ULTRASOUND SECTION EDITOR Dr. Pregerson manages a free online EM Ultrasound Image Library. He is the author of the Emergency Medicine 1-Minute Consult Pocketbook and the A to Z Pocket Emergency Pharmacopoeia & Antibiotic Guide (available at EMresource.org) and the Tarascon Emergency Department Quick Reference Guide (Tarascon.com).  

8 Comments

  1. I have had upper right quadrant pain on and off for years.
    the past year its been bad, but not always when I eat, it can start just with excise, or movements.
    I am beside myself, I had a cat scan in 9/22/17 also a ultra sound, A MRI in 8/2018 one show the gallbladder minimal dilated. pain almost like a spasm goes from 3- to a 10. then leaves and comes back.
    I also had a gallbladder empty study which they said was ok……Any suggestions? I am desperate

  2. I had pain basically below the breast bone varying levels of pain and not related to eating. Varying levels of pain extending to the right and earlier in the piece to the left just below the ribs and finally in my back on the right side where the right lung would be. I had this pain for 12 months and was treated for IBS which my symptoms did not support.

    The gall bladder was removed and initially had stones in the bile ducts that were not able to be removed but seemingly cleared them selves based on the outcome of the follow up blood test.

    No more chronic and repeated pain.. Seems that the US an CT can’t see the issue but after I receive pathology results this week I am going to request a re-read of the CT so that the doctors learn and can hopefully pinpoint the issue for other patients.

  3. I have ha gallbladder stones for over three months now. I only found out two months ago, because I had been having chronic diarrhea everyday for a month. And had 5-8 episodes that day. My abdomen was super tight, and my liver enzymes were elivated.
    So they did an ultrasound, and saw the stones and sludge. They admitted me and gave me fluids overnight, then discharged me, telling me I should find a surgeon.

    I finally found one, and have been to the ER again since then, because of servere pain in my upper right flank that made me cry, but they just keep saying it’s just stones, and I should look into having the organ removed.

    I’ve been having servere pain, chills and diarrhea daily. I feel a stabbing pain under my ribs that runs down my right flank burning, and even got so disoriented, I almost fell and fainted several times at the doctor’s.. I’m scared, and my appointment isn’t for 11 days to even get examined for surgery. I also have a MRSA skin infection that my doctor’s refuse to treat for over a year. I don’t know what to do.
    Any tips? Could my gallbladder already be leaking?

    • Am I reading this right? Your doctor won’t treat your MRSA? You need a new doctor. They work for you, not the other way round!

    • Hi AMBER, you MUST read “The Liver and Gallbladder Miracle Cleanse” by ANDREAS MORITZ / the title literally speaks for itself, and the REVELATION will amaze you I’m sure, like it has for me. Started reading the book end-2019; and started my journey January 2020 – I do very much recommend reading the book for yourself, and not rely on 2nd hand download. There are many “testimonies ” on the internet; sure I’ve listened, but one will find the exact information in this book. I can chat about this all day long…

  4. What effect on digestion system would you expect from gallbladder during attack, if any?
    Not a doctor, but have been told that I do have stones, that were picked up on unrelated MRI of spine.
    My right side in tender to touch right below rib.

  5. I have had chronic diarrhea for around 7 months now. Some days I got 2-3 times and other 10 times . I got into my gi dr but it was when this whole COVID thing started and non emergent procedures were cancelled. One day I started having pains in my chest that keep coming back. I went to the Ed when it went on for about 2 hours because I have a history of coronary artery disease and it scared me. They ran all kinds of tests and had a stress test that all were fine. Pains have continued. My gi did an endoscopy scope down into my stomach with no findings. I had a gall bladder ultrasound with no findings except a possible kidney issue. Gi decided to try me on nitroglycerin to see if it is esophageal spasms but that is not working either. I feel tired all the time and still have pain. Family history of gallbladder disease. I don’t know what I should do. I’m in pain while writing this.

  6. Sylviane Bloss on

    I’m veryyy discouraged at the medical care in emergency rooms I’m 69 and finally went to ER for after five days constant on and off upper right side,, had no fever, blood pressure 135/83,, no chills just horrible pain and nausea,, doctor never examined me, just ordered labs and ultrasound, comes back in room an hour later says allll is well,what the heck!! I asked him to please do catscan because I have brain tumor and was told several years ago I have a growth also on my liver, I explain to the doctor that my stools had turned yellow within a week that is not normal so I thought it was my gallbladder he insisted that it was not the gallbladder never said anything else they did the CAT scan and within 15 minutes they came in my room and told me I was fine,, they had the clipboard ready to zoom me out of the hospital room like I said I’m 69-year-old female with brain tumor and I have another tumor in my left long as well they treated me and shoved me out!! My son drove me home and I am still at home suffering not knowing what to do

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