Emergency Biliary Sonography: Utility of Common Bile Duct Measurement in the Diagnosis of Cholecystitis and Choledocholithiasis

doi:10.1016/j.jemermed.2013.03.024

The Journal of Emergency Medicine

Volume 46, Issue 1, January 2014, Pages 54-60

https://doi.org/10.1016/j.jemermed.2013.03.024 Get rights and content

Abstract

Background

Measurement of the common bile duct (CBD) has traditionally been considered an integral part of gallbladder sonography, but accurate identification of the CBD can be difficult for novice sonographers.

Objective

To determine the prevalence of isolated sonographic CBD dilation in emergency department (ED) patients with cholecystitis or choledocholithiasis without laboratory abnormalities or other pathologic findings on biliary ultrasound.

Methods

We conducted a retrospective chart review on two separate ED patient cohorts between June 2000 and June 2010. The first cohort comprised all ED patients undergoing a biliary ultrasound and subsequent cholecystectomy for presumed cholecystitis. The second cohort consisted of all ED patients receiving a biliary ultrasound who were ultimately diagnosed with choledocholithiasis. Ultrasound data and contemporaneous laboratory values were collected. Postoperative gallbladder pathology reports and endoscopic retrograde cholangiopancreatography (ERCP) reports were used as the criterion standard for final diagnosis.

Results

Of 666 cases of cholecystitis, there were 251 (37.7%) with a dilated CBD > 6 mm and only 2 cases (0.3%; 95% confidence interval [CI] 0.0–0.7%) of isolated CBD dilation with an otherwise negative ultrasound and normal laboratory values. Of 111 cases of choledocholithiasis, there were 80 (72.0%) with a dilated CBD and only 1 case (0.9%; 95% CI 0.0–2.7%) with an otherwise negative ultrasound and normal laboratory values.

Conclusion

The prevalence of isolated sonographic CBD dilation in cholecystitis and choledocholithiasis is <1%. Omission of CBD measurement is unlikely to result in missed cholecystitis or choledocholithiasis in the setting of a routine ED evaluation with an otherwise normal ultrasound and normal laboratory values.

Introduction

Right upper quadrant (RUQ) abdominal pain is common in patients in the emergency department (ED). The goal of ED evaluation is to identify clinically significant biliary pathology, such as cholecystitis and choledocholithiasis, that may merit prompt surgical consultation, operative intervention, or admission. These patients typically undergo serum laboratory testing and most often receive a RUQ ultrasound as the first-line imaging modality. Focused point-of-care (POC) biliary ultrasound has been shown to expedite the care of patients presenting with possible biliary disease and decrease duration of stay in the ED (1). POC biliary ultrasound typically includes sagittal and transverse views of the gallbladder to assess for the presence or absence of gallstones and sonographic evidence of cholecystitis, such as gallbladder wall thickening > 3 mm (GWT), pericholecystitic fluid (PCF), and sonographic Murphy’s sign (SMS). Views of the portal triad are also obtained and the common bile duct (CBD) diameter is measured 2, 3. From our experience teaching emergency physicians, residents, and medical students, it is the proper and timely identification of the CBD that proves most difficult for the novice sonographer.

The typical presentation of cholecystitis includes sonographic cholelithiasis with variable combinations of SMS, GWT, PCF, and abnormalities in serum blood testing 2, 4. CBD diameter is not generally included in the diagnostic criteria for cholecystitis, but there is a paucity of published data looking specifically at the prevalence of CBD dilation in the setting of acute cholecystitis (2). Conversely, CBD dilation has been a traditional diagnostic marker for possible choledocholithiasis; however, the literature suggests that a significant proportion of ductal stones occur without sonographic CBD dilation and a majority of choledocholithiasis cases have concurrent serum laboratory abnormalities 5, 6, 7. We sought to determine what unique information CBD diameter adds to the evaluation for cholecystitis and choledocholithiasis in ED patients.

The aim of this study was to determine the prevalence of isolated sonographic CBD dilation in ED patients with cholecystitis or choledocholithiasis without laboratory abnormalities or other pathologic findings on biliary ultrasound.

Section snippets

Study Design and Setting

This was a retrospective chart review performed at a single academic, tertiary care hospital with Emergency Medicine and Radiology residency programs. The research team comprised two emergency ultrasound fellows, one emergency medicine resident, one medical student, and four undergraduate research assistants.

After approval by the institutional review board, master patient lists were obtained via a medical records query using codes from the International Classification of Diseases, 9th revision

Results

The first cohort included 734 patients undergoing cholecystectomy between June 2000 and July 2010. Patients were 9–90 years of age, and the cohort was 70.8% female. A total of 666 charts were included after 40 (5.4%) exclusions for missing ultrasound or CBD measurements and 28 (3.8%) for missing pathology reports. Of the 666 inclusions, 633 (95.1%) had confirmed cholecystitis according to the final pathology report.

There were 301 (45.2%) unique patient charts that revealed ≥1 equivocal or

Discussion

Few (<1%) ED patients with cholecystitis requiring cholecystectomy or choledocholithiasis present with isolated sonographic CBD dilation. In the setting of an ultrasound without GWT, PCF, or SMS and normal laboratory testing, our results suggest sonographic CBD measurement has limited use in diagnosing cholecystitis and choledocholithiasis.

Clinical medicine has traditionally eschewed sonographic CBD measurement as a diagnostic marker for acute cholecystitis, and the results of the first cohort

Conclusions

Article Summary

1. Why is this topic important?

Emergency physicians are using more point-of-care biliary ultrasound, but less experienced sonographers often identify the common bile duct (CBD) incorrectly. This raises concern for biliary

Acknowledgments

We thank Stacy Hata, Catherine Kelly, Erik Kochert, Michael Menchine, Natalie Nguyen, Andrew Richardson, Amy Stacey, and Maryjane Vennat.

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Cited by (12)

Utility of common bile duct measurement in the diagnosis of cholecystitis and choledocholithiasis in children
2024, American Journal of Emergency Medicine
Ultrasound is an integral part of evaluating for acute cholecystitis and choledocholithiasis in pediatric patients. Finding the common bile duct (CBD), a structure which is normally <4 mm in children, can be very challenging.
The primary objective of this study was to determine the prevalence of isolated sonographic CBD dilation in pediatric patients with acute cholecystitis and/or choledocholithiasis without laboratory abnormalities or pathologic findings on radiology based biliary ultrasound, apart from cholelithiasis.
We conducted a retrospective chart review of patients ≤21-years-old, at a single free-standing tertiary care children's hospital, who received a biliary ultrasound in the radiology department (RADUS) from September 2005 to February 2020. We identified patients who had a diagnosis of acute cholecystitis and/or choledocholithiasis on RADUS. Based on prior studies, a positive ultrasound was defined as having gallbladder wall thickening (GWT), pericholecystic fluid (PCF), or sonographic Murphy's sign (SMS). The final diagnosis was confirmed using the gold standard, cholecystectomy pathology diagnosis for patients with cholecystitis and endoscopic retrograde cholangiopancreatography (ERCP) diagnosis for patients with choledocholithiasis. Ultrasound data and contemporaneous laboratory values were collected.
180 patients met inclusion criteria. For the study population, 97 (53.9%) had a positive ultrasound, 127 patients (70.6%) had a dilated CBD, and 170 (94.4%) had at least one abnormal laboratory finding. Within the study population there were 76 patients (42.3%) with acute cholecystitis, 55 patients (30.5%) with choledocholithiasis, and 49 patients (27.2%) with acute cholecystitis and choledocholithiasis. Of the 127 patients with a dilated CBD, 80 (62.9%) had a normal ultrasound, apart from cholelithiasis. In this group of 80, 78 patients (97.5%) had at least one abnormal laboratory finding. Thus, for the entire study population, isolated CBD dilation without a positive ultrasound or laboratory abnormalities occurred in 2 patients (1.1%). Of note, these 2 patients had an ultrasound diagnosis of choledocholithiasis.
The prevalence of isolated sonographic CBD dilation in pediatric patients with cholecystitis and/or choledocholithiasis was 1.1%. Thus, biliary ultrasound without CBD measurement is unlikely to result in missed cholecystitis and/or choledocholithiasis if the biliary ultrasound does not demonstrate GWT, PCF, SMS, or choledocholithiasis, and the patient has normal laboratory values.
Point-of-Care Ultrasound Assists Diagnosis of Spontaneously Passed Common Bile Duct Stone
2021, Journal of Emergency Medicine
Citation Excerpt :
The CBD diameter should measure approximately 4 mm in adult patients 40 years old and under, then 1 mm is added for each decade (i.e., 5 mm by age 50, 6 mm by age 60, etc.). The utility of POCUS for isolated CBD assessment has not been shown to be as good for decision-making as other findings such as gallstones, wall thickening, and pericholecystic fluid are for diagnosing cholecystitis (12). However, there may be utility in evaluating the CBD for normalization of duct diameter among patients who clinically have passed a stone (13).
Choledocholithiasis complicates approximately 10% of gallstone disease. Spontaneous stone migration out of the common bile duct (CBD) may occur in as many as 20% of choledocholithiasis cases. A decrease in CBD caliber occurs in the setting of spontaneous stone passage, but to our knowledge, this finding has not been appreciated using point-of-care ultrasound (POCUS) in the emergency medicine setting.
A 49-year-old woman presented to our Emergency Department (ED) with a complaint of epigastric pain radiating to the left shoulder. On examination she was found to have epigastric tenderness to palpation, but no guarding or rebound. POCUS demonstrated a dilated common bile duct, and her liver function tests were abnormally high. She was admitted to Medicine with concern for choledocholithiasis and plan for endoscopic retrograde cholangiopancreatography (ERCP), but her pain had resolved shortly after ED arrival. A repeat ultrasound examination demonstrated a normal-caliber common bile duct approximately 3 h after the initial scan.
Choledocholithiasis often requires admission and invasive testing. Using POCUS in conjunction with liver function tests and patient assessments may obviate a need for ERCP.
Standardization of common bile duct size using ultrasound in pediatric patients
2019, Journal of Pediatric Surgery
Citation Excerpt :
This proposed guide for pediatric CBD size should be used in conjunction with patient history, exam, additional signs on imaging, and laboratory studies including LFTs and TB. It is likely that, just as in the adult population, the ultimate diagnosis of CDL will depend on multiple factors and not just the CBD size [5,19,20]. It is important to more clearly define the diagnostic criteria for pediatric CBD obstruction in order to better understand the prevalence of the disease and also to determine the best treatment option for the patient.
The incidence of choledocholithiasis is increasing. The diagnosis of common bile duct (CBD) obstruction is based on abnormal CBD size. Establishing norms for CBD size in children would improve diagnostic accuracy. We analyzed ultrasounds (US) to determine normal pediatric CBD size based on age and then validated this against patients with choledocholithiasis.
A retrospective review was conducted for children less than 21 years of age with US defined CBD size. Patients were stratified into age groups by ANOVA statistical analysis. Secondary analysis included patients with confirmed choledocholithiasis in comparison to the normal cohort.
A total of 778 patients had US without pathology. Group 1 (< 1 year) had a mean CBD of 1.24 ± 0.54 mm, group 2 (1–10 years) 1.97 ± 0.71 mm, and group 3 (> 10 years) 2.98 ± 1.17 mm, p < 0.05. Fourteen additional patients were found to have choledocholithiasis with a mean CBD size of 8.1 mm. All patients with choledocholithiasis had CBD sizes outside of our normal range, but only 50% of patients had enlarged CBD size based on adult normal range of values.
Normal CBD size in children is less than a normal adult patient. More accurate normal values will aid in determining if a child needs further evaluation for possible obstruction of the CBD.
Type of study: diagnostic
Level of evidence: III
Utility of common bile duct measurement in ED point of care ultrasound: A prospective study
2018, American Journal of Emergency Medicine
Citation Excerpt :
In the face of uncertain CBD identification, the ability of normal laboratory tests and an otherwise normal RUQ US to exclude complicated biliary pathology would be of great clinical benefit. Prior research has suggested that CBD diameter yields limited unique clinical information in patients with cholecystitis and choledocholithiasis with normal laboratory values; however, there are no prospective studies to date that have confirmed these findings [17-21]. We sought to prospectively assess the importance of sonographic CBD measurement in evaluating patients for biliary pathology, particularly in the setting of normal laboratory values and an otherwise unremarkable biliary US.
Measurement of the common bile duct (CBD) is considered a fundamental component of biliary point-of-care ultrasound (POCUS), but can be technically challenging.
The primary objective of this study was to determine whether CBD diameter contributes to the diagnosis of complicated biliary pathology in emergency department (ED) patients with normal laboratory values and no abnormal biliary POCUS findings aside from cholelithiasis.
We performed a prospective, observational study of adult ED patients undergoing POCUS of the right upper quadrant (RUQ) and serum laboratory studies for suspected biliary pathology. The primary outcome was complicated biliary pathology occurring in the setting of normal laboratory values and a POCUS demonstrating the absence of gallbladder wall thickening (GWT), pericholecystic fluid (PCF) and sonographic Murphy's sign (SMS). The association between CBD dilation and complicated biliary pathology was assessed using logistic regression to control for other factors, including laboratory findings, cholelithiasis and other sonographic abnormalities.
A total of 158 patients were included in the study. 76 (48.1%) received non-biliary diagnoses and 82 (51.9%) were diagnosed with biliary pathology. Complicated biliary pathology was diagnosed in 39 patients. Sensitivity of CBD dilation for complicated biliary pathology was 23.7% and specificity was 77.9%.
Of patients diagnosed with biliary pathology, none had isolated CBD dilatation. In the absence of abnormal laboratory values and GWT, PCF or SMS on POCUS, obtaining a CBD measurement is unlikely to contribute to the evaluation of this patient population.
Point-of-care ultrasonography of the digestive system in children
2023, Chronic Disease and Disability: The Pediatric Gastrointestinal Tract, Second Edition. Medical and Surgical Perspectives including Infection and Pain
Effectiveness of ultrasound screening in right upper quadrant pain: A comparative study in a basic emergency service
2023, Health Science Reports

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: The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the US Army, Department of Defense, or the US Government.

: Reprints are not available from the authors.

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Ultrasound in Emergency MedicineEmergency Biliary Sonography: Utility of Common Bile Duct Measurement in the Diagnosis of Cholecystitis and Choledocholithiasis

Abstract

Background

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Study Design and Setting

Results

Discussion

Conclusions

Article Summary

Acknowledgments

Clin Radiol

Ann Emerg Med

Decreasing length of stay with emergency ultrasound examination of gallbladder

Acad Emerg Med

Emergent right upper quadrant sonography

J Ultrasound Med

Emergency ultrasound guidelines

Ann Emerg Med

A systematic review and meta-analysis of diagnostic performance of imaging in acute cholecystitis

Radiology

The role of serum liver enzymes in the diagnosis of choledocholithiasis

Hepatogastroenterology

Ultrasound in Emergency Medicine
Emergency Biliary Sonography: Utility of Common Bile Duct Measurement in the Diagnosis of Cholecystitis and Choledocholithiasis