Murphy's Sign Research Articles

Functional Gallbladder Disorder

Objective: To shed light on the clinical presentation and approach to diagnosis. Introduction: Functional gallbladder disorder is a dysfunction in gallbladder motility, the exact etiology remains unclear. As in all gastrointestinal motility disorders the diagnosis of functional gallbladder disorder is a diagnosis of exclusion. It is estimated that 21% of females and 8% of males with biliary-like pain and a normal transabdominal gallbladder ultrasound have functional gallbladder disorder. Case: A 30 year old Caucasian female with no significant past medical history presented with recurrent right upper quadrant (RUQ) pain. The pain has been persistent for several months and was associated with nausea and vomiting. The patient was recently diagnosed with a small gastric ulcer for which she was taking dexlansoprazole. Despite taking the medication as prescribed for a month, her symptoms were not alleviated. The patient continued to have pain that interfered with her daily activities and resulted in multiple visits to the emergency room (ER) where she was treated symptomatically. On her last visit to the ER the patient had a typical biliary-type pain, her physical exam was positive for RUQ pain, but Murphy's sign was negative. Initial work up including liver and pancreas blood tests were normal. Transabdominal gallbladder ultrasound revealed no cholelithiasis, sludge or signs of acute cholecystitis. CT abdomen was unimpressive as well. The patient was admitted to the hospital to control her symptoms and to further investigate the cause of the pain. The Gastroenterology service was consulted and the patient was scheduled to undergo cholecystokinin (CCK)-stimulated cholescintigraphy. The cholescintigraphy revealed decreased appearance of gallbladder activity and a reduced gallbladder ejection fraction (GBEF) of 34%, subsequently the patient was diagnosed with functional gallbladder disorder and she underwent cholecystectomy. The patient's symptoms significantly improved after surgery. Conclusion: In the case of typical biliary-like pain, normal blood work and normal transabdominal gallbladder ultrasound, clinicians should have a high index of suspicion for functional gallbladder disease.

ST-Segment Elevation Disguised as Cholecystitis

Introduction: Chest pain accounts for around 6 million annual visits to emergency department (ED) in United States.Chest pain in these cases might be secondary to other cardiac conditions other than acute coronary events or extra cardiac causes. We present a rare case of ST-Segment elevation disguised as Cholecystitis. Case Report: A 43 year old female with a history of hypertension, gastroesophageal reflux, and obesity presented to the ED with severe sharp chest pain and abdominal pain which started one hour prior to presentation. On physical exam her BP 200/100 mm Hg, HR 96 bpm, RR 22 breaths and was temperature 100.5 F. She was alert but looked pale and diaphoretic. On cardiac exam there were no murmurs. Abdominal exam revealed positive murphy sign and right upper quadrant tenderness. EKG showed ST segment elevation in leads II, III, AVF with reciprocal changes in the lateral leads (Image 1). Her troponins were minimally elevated at 0.66. STEMI protocol was initiated and she was taken for urgent cardiac catheterization in keeping with the door to balloon time of 90 minutes. Cardiac catheterization revealed normal coronaries. Other lab work done showed WBC count of 14,000, liver enzymes, amylase and lipase were within normal limits. CT scan of abdomen was done given right upper quadrant pain which revealed emphysematous cholecystitis with no gall stones (Image 2). Surgery was consulted and she underwent a cholecystectomy. Repeat EKG no longer showed the ST elevation. The patient was discharged in stable condition. Conclusion: A 2.3% incidence of alternative conditions mimicking STEMI is found in patients referred for primary percutaneous coronary intervention.Abdominal etiologies like pancreatitis and cholecystitis can also cause troponin elevation. Release of pancreatic proteolytic enzymes causing transient myonecrosis and coronary vasospasm have been the hypothesized pathophysiologic mechanism. The electrocardiographic changes in patients with acute cholecystitis and pancreatitis which have been reported are mostly transient. These changes usually are in the form of T-wave inversion, ST-segment depression, and rarely ST-segment elevation in the absence of coronary artery disease. Physicians should therefore consider intra-abdominal etiologies when faced with transient inferior ST segment elevations in patient without significant coronary disease.Figure 1Figure 2

Case Report of Situs Inversus Totalis and Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy (LC) in patients with situs inversus totalis (SIT) characterized by transposition of organs to the opposite side of the body can be technically challenging. A 43-year-old Hispanic woman presented with epigastric pain radiating to the chest and back, intermittently over 3 months, but worse on day of admission. During the cardiac workup, she was noted to have dextrocardia. The patient had a left-sided Murphy's sign, propagating a workup that confirmed SIT, including an ultrasound showing cholelithiasis and normal ducts. The patient underwent an LC and was found to have choledocholithiasis. An endoscopic retrograde cholangiopancreatography cleared the common bile duct of a choledocholith. LC is the gold standard for cholecystitis. It is the second most common laparoscopic procedure conducted worldwide. When SIT is encountered, feasibility and technical difficulty in diagnosis and treatment of such cases pose challenges due to contralateral transposition of the visceral organs. Difficulty is encountered when exposing the triangle of Calot/critical view of safety and especially when conducting a cholangiogram. As such, added time is usually required to conduct the procedure. Conducting an LC in a patient with SIT is feasible when performed by an experienced laparoscopic surgeon. The diagnosis and initial presenting signs and symptoms are different from the patient with a normal anatomy. The surgical skills of the surgeon are challenged, especially in the right hand–dominant individual. The mindset of the surgeon requires changing the critical thinking when conducting a mirror image dissection.

99mTc-BrIDA cholescintigraphy in a spontaneous biliary perforation of an infant

Acute cholecystitis is a common condition which may be difficult to diagnose with confidence on clinical grounds alone. A large number of techniques are now available for imaging the gall bladder but, in practice, ultrasonography and cholescintigraphy are of greatest value. The former is cheap, readily available and features such as the presence of gall stones, gall bladder wall inflammation and a positive sonographic Murphy sign strongly suggest the diagnosis of acute cholecystitis. In addition to its diagnostic uses, ultrasonographically guided percutaneous cholecystostomy provides an alternative and sometimes life-saving form of treatment in those patients who are unfit for surgery. Cholescintigraphy is a highly accurate, non-invasive method for assessing patency of the cystic duct but is not always available in the emergency situation and takes longer to perform than an ultrasound examination. Acute cholecystitis, however, has many manifestations and may be calculous or acalculous, be associated with a patent or obstructed cystic duct, and may be complicated or uncomplicated. Imagining modalities other than those mentioned above may be useful in certain circumstances and this chapter aims to present the advantages and disadvantages of each technique in order to provide guidance for the clinician caring for a patient with suspected acute cholecystitis.

Surgical management of the common bile duct in Mirrizzi syndrome: a case report

This case report describes a 44 year old Mexican male with suspected cholangiocarcinoma or pancreatic cancer due to a 2 month progressive jaundice, chyluria, acholic feces with intense pruritus and weight loss. Referred to general surgery consult after 2 failed ERCP and 2 failed transhepatic biliary catheterization. He denied any history of liver or gastrointestinal problems. On physical examination the patient was afebrile with blood pressure 100/60, pulso of 70, and a respiratory rate of 15 with no neurological alterations, icteric. Abdomen with liver normal in size, no tenderness and no Murphy sign. The serum liver profile showed total bilirubin of 16.4 mg/dL, direct bilirubin of 14.7 mg/dL, GGT 617 U/L, AST and ALT 272 and 264 mg/dL, respectively, alkaline phosphatase of 1700 UL. CA 19-9 greater than 1000. Hemoglobin 9.7 g/dL with white blood cell count 8, 170 UL. The patient underwent computed tomography and ultrasound imaging with reports of dilated common bile duct. The patient was protocoled with preoperative nutrition and underwent an open cholecystectomy with a simple closure of the fistula. The patient was followed with liver profile controls with a decrease total bilirubin levels. The postoperative diagnosis of Mirizzi syndrome IIIa, following the new proposed classification of Beltran 2012, was established. Encouraging with a full recovery, the surgical proposition of the simplified classification due to the surgical outcomes.

Renal Cell Carcinoma Presenting as Radiating Rib Pain: A 65-Year-Old Woman

ObjectiveThe purpose of this case report is to describe chiropractic management and referral of a patient with rib pain who was subsequently diagnosed with renal cell carcinoma. Clinical FeaturesA 65-year-old woman presented with radiating rib pain to a chiropractic clinic. She was treated with a 2-week course of conservative care. On follow-up evaluation, she reported a deep ache over her lower ribs, wrapping around to her abdomen. Palpation under the anterior rib cage reproduced her pain, and she also had a positive Murphy Sign. She was referred for an abdominal ultrasonography. Intervention and OutcomeUltrasonography showed a 12-cm solid vascular mass of the right kidney. Further imaging studies using computerized tomography and magnetic resonance imaging confirmed the ultrasonography findings. She was referred to a cancer center for staging of the cancer and subsequent surgical treatment. The involved tissue, as well as the kidney and part of the inferior vena cava, was removed, and the pathology report determined that the mass was clear cell carcinoma. ConclusionThis case describes an unusual presentation of a patient with rib pain that had previously undiagnosed renal cancer. Referral by her doctor of chiropractic resulted in detection of the tumor and treatment.

Does ultrasongraphy predict intraoperative findings at cholecystectomy? An institutional review.

Ultrasonography (US) is the mainstay of biliary tract imaging, but few recent studies have tested its ability to diagnose acute cholecystitis (AC). Our objective was to determine how well a US diagnosis of AC correlates with the intraoperative diagnosis. We hypothesize that US underestimates this diagnosis, potentially leading to unexpected findings in the operating room (OR). This retrospective review included all patients admitted to the acute care surgical service of a tertiary hospital in 2011 with suspected biliary pathology who underwent US and subsequent cholecystectomy. We determined the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of US using the intraoperative diagnosis as the gold standard. Further analysis identified which US findings were most predictive of an intraoperative diagnosis of AC. We used a recursive partitioning method with random forests to identify unique combinations of US findings that, together, are most predictive of AC. In total, 254 patients underwent US for biliary symptoms; 152 had AC diagnosed, and 143 (94%) of them underwent emergency surgery (median time to OR 23.03 hr). Ultrasonography predicted intraoperative findings with a sensitivity of 73.2%, specificity of 85.5% and PPV of 93.7%. The NPV (52.0%) was quite low. The US indicators most predictive of AC were a thick wall, a positive sonographic Murphy sign and cholelithiasis. Recursive partitioning demonstrated that a positive sonographic Murphy sign is highly predictive of intraoperative AC. Ultrasonography is highly sensitive and specific for diagnosing AC. The poor NPV confirms our hypothesis that US can underestimate AC.

Update on bedside ultrasound (US) diagnosis of acute cholecystitis (AC).

Acute cholecystitis (AC) represents a principal cause of morbidity worldwide and is one of the most frequent reasons for hospitalization due to gastroenteric tract diseases. AC should be suspected in presence of clinical signs and of gallstones on an imaging study. Upper abdominal US represents the first diagnostic imaging step in the case of suspected AC. Computed tomography (CT) with intravenous contrast (IV) or magnetic resonance imaging (MRI) with gadolinium contrast and technetium hepatobiliary iminodiacetic acid (Tc-HIDA) can be employed to exclude complications. US examination should be performed with right subcostal oblique, with longitudinal and intercostal scans. Normal gallbladder US findings and AC major and minor US signs are described. Polyps, sludge and gallbladder wall thickening represent the more frequent pitfalls and they must be differentiated from stones, duodenal artifacts and many other non-inflammatory conditions that cause wall thickening, respectively. By means of bedside ultrasound, the finding of gallstones in combination with acute pain, when the clinician presses the gallbladder with the US probe (the sonographic Murphy's sign), has a 92.2% positive predictive value for AC. In our preliminary experience, bedside US-performed by echoscopy (ES) and/or point-of-care US (POCUS) demonstrated good reliability in detecting signs of AC, and was always integrated with physical examination and performed by a skilled operator.

Unusual presentation of a distal cholangiocarcinoma

We report a case of a 51-year-old male presented with abdominal pain and itching, whereas jaundice occurred afterwards. Diagnosis was made by means of CT and better assessed by MRI and endoscopic ultrasounds. Patient was treated with an open Whipple's procedure, and after an 18-month follow-up he was doing well.

Obliterative Portal Venopathy Masquerading Large Bile Duct Obstruction in a Patient on Oral Contraceptive Pills

Introduction: Oral contraceptives pills (OCP) are generally safe but can cause wide range of side effects. We report a case of obliterative portal venopathy (OPV) causing large bile duct obstruction picture from OCP use and slow resolution after discontinuation of the medication. Case: A 19-year-old woman with medical history of Down's syndrome and hypothyroidism presented with acute jaundice, pruritus and RUQ abdominal pain. She denied any fever, alcohol use, recent travel, sick contacts, new medications or herbal supplements. Her medications included levothyroxine, fexofenadine and OCP. Physical exam was remarkable for icterus and RUQ tenderness with positive Murphy's sign. Labs showed a total bilirubin of 8.0 with direct bilirubin of 5.1, alk phos of 245, AST of 50, ALT of 100 and lipase of 23. Acute and chronic hepatitis work up was negative for acetaminophen toxicity, viral hepatitis, EBV, CMV and HSV serologies, autoimmune hepatitis, primary biliary cirrhosis, primary sclerosing cholangitis, Wilson disease, hemochromatosis, α1 antitrypsin deficiency, and HIV. Urine toxicology was negative. Ultrasound showed no evidence of cholecystitis, cholelithiasis or choledocholithiasis. There was no intra or extra hepatic biliary obstruction on EUS and MRCP. CT scan was unremarkable. Alk phos progressively increased to 500 and the bilirubin slowly improved. The liver biopsy showed histologic features of large bile duct obstruction, and features suggestive of OPV and nodular regenerative hyperplasia. This was most likely thought to be due to OCP use in the absence of other etiologies. OCP was discontinued and LFT's slowly improved with normalization in 5 months. Discussion: OCPs are currently prescribed to 62 million women of reproductive age in the US. While deemed mostly safe, they can cause hepatic and biliary dysfunction, and a small subset of women develop intrahepatic cholestasis. Liver biopsy shows bland cholestasis without significant inflammation. Obstructive picture with OPV has not been described. A prothrombotic state caused by OCP probably resulted in OPV-induced large duct injury and obstruction picture in the biopsy. This report highlights that OCP can present with OPV and secondary changes such as large duct injury due to their prothrombotic effects. OPV should be considered as a differential diagnosis if the labs and biopsy show findings suggestive of large bile duct obstruction before proceeding with invasive procedures like ERCP.

Abdominal Pain: An Omental Occasion: Presidential Poster

A 45-year-old woman with no significant medical history presented with two days of right upper quadrant (RUQ) pain. The pain started as vague, diffuse abdominal discomfort but progressed to severe RUQ pain that worsened with inspiration, movement and food intake. Bowel movements were unchanged. On initial examination she was afebrile with normal vital signs. Abdominal exam revealed RUQ tenderness and positive Murphy's sign. Blood work was significant for WBC of 20,200/mm (83% neutrophil), total bilirubin 1.0mg/dL, and direct bilirubin 0.2mg/dL. Abdominal ultrasound demonstrated a mildly enlarged liver without focal masses or nodularity and normal gallbladder; CT abdomen was initially unremarkable. The severe RUQ pain persisted; MRCP revealed stranding and edema in omental fat at the dome of the liver and small right pleural effusion. The patient was treated with analgesics with subsequent resolution of her pain. Omental infarction, until recently, has been an elusive diagnosis in patients presenting with abdominal pain because of its relative rarity and nonspecific clinical presentation. A result of vascular compromise, omental infarction typically presents with sudden-onset right lower quadrant abdominal pain without fever or gastrointestinal symptoms. Secondary infarction is caused by omental torsion, thrombosis from hypercoagulopathy or vascular abnormalities. Idiopathic infarction may be related to obesity, heavy food intake, local trauma or use of laxatives. Imaging findings on ultrasound or CT include a focal area of increased echogenicity in the omental fat or as fat stranding and swirling of omental vessels. Radiographic diagnosis of omental infarction is critical as laparoscopic evaluation can be avoided. Abdominal pain from omental infarction is often managed conservatively with analgesics and anti-inflammatory drugs due to the self-limited disease course. However, a standard treatment modality has yet to be established. Rarely, persistent pain, bleeding, adhesions or abscesses may develop and require surgical intervention.Figure 1Figure 2This patient, with no known abdominal pathology or risk factors, had an atypical presentation of a rare clinical disease, in which imaging was paramount for diagnosis. There have been no reported cases of omental trapping in the liver dome and thus is a newly reported mechanism of infarction. The abdominal pain was initially attributed to hepatobiliary disease given location and thus multiple imaging modalities were utilized before a final diagnosis was made. In patients presenting with acute abdomen, regardless of location, omental infarction should remain on the differential as it may minimize diagnostic imaging and avoid surgery.

Hitting Two Liver Diagnoses With One Needle

Introduction: In hepatic amyloidosis, excess deposition of misfolded proteins into liver tissues may lead to liver dysfunction, portal hypertension, liver failure, and even death. Hepatic amyloidosis is most commonly attributed to systemic light chain amyloidosis; however, other subtypes of amyloid are increasingly recognized. We present a case of rare and novel amyloid subtype, previously described mostly in cases in renal amyloidosis. Case Description: A 54-year-old Hispanic woman with history of diabetes mellitus and chronic kidney disease stage 4 presented with two months of abdominal pain. The pain was not associated with any fever, chills, night sweats, weight loss, or hematemesis. On exam, she was afebrile and noted to have RUQ tenderness without Murphy's sign, jaundice or ascites. White blood cell count and hemoglobin level were 14,600/mm3 and 11.3 g/dL, respectively. Liver panel was unremarkable except elevated alkaline phosphatase level of 137 U/L. Abdominal ultrasound showed a smooth-surfaced liver with a 6.7 x 5.4 x 5.3 cm irregularly shaped heterogeneous lesion within the right hepatic lobe, and a 0.9cm hyperechoic lesion in the anterior left hepatic lobe. Further imaging studies, including CT and MRI, confirmed the ultrasound findings. Technetium-Labeled Red Blood Cell Bleeding scan showed liver lesions with characteristics not definitive for hemangioma. Patient underwent an ultrasound-guided liver biopsy, which showed a globular amyloidosis and a capillary hemagioma. Further pathology staining showed negative kappa and lambda stains; the results of patient's serum protein electrophoresis, serum light chain assays, and quantitative immunoglobulins were not compatible with AL amyloidosis. On mass spectrometry (MS), the liver specimen was shown to have an Alect-2 (Leukocyte Chemotactic factor-associated Amyloidosis) amyloid. Discussion: ALect-2 amyloidosis is a rare type of systemic amyloidosis that primarily involves the kidneys, spleen, and liver. Although there are limited numbers of cases reported in the literature, most patients appear to be of Hispanic ethnicity, and show a globular pattern of amyloid deposition on biopsy. Subtyping hepatic amyloid deposits by an accurate analytic method such as MS is required for optimal diagnosis of hepatic amyloidosis patients and avoiding incorrect and unnecessarily toxic therapies. To date, no specific therapy for ALect-2 has been reported.

Spontaneous Rupture of an Intrahepatic Biliary Duct Causing a Right Pleural and Retroperitoneal Biloma

Bilomas are encapsulated collections of bile outside of the biliary tree and are mainly caused by iatrogenic injury or abdominal trauma. Spontaneous rupture of the biliary tree is not common. We report a case of a patient with spontaneous rupture biloma treated with percutaneous and internal-external biliary drainage. A 68-year-old man with significant history of amyloidosis and monoclonal paraproteinemia was admitted for progressively worsening right upper quadrant abdominal pain and nausea for the last week. Vital signs were unremarkable and physical exam revealed mild jaundice and a positive Murphy sign. No rebound or guarding. Laboratory results revealed total bilirubin of 1.7 mg/dL, direct bilirubin of 0.8 mg/dL, alkaline phosphatase of 328 IU/L, AST of 190 IU/L, ALT 154 IU/L. Pancreatic enzymes and Ca 19-9 were within normal limits. Right upper quadrant ultrasound showed a distended gallbladder with biliary sludge and a dilated common bile duct (CBD) measuring 11mm. MRCP suggested a pancreatic head mass. Subsequent ERCP showed narrowing at the CBD making it difficult for cannulation. However fine needle aspiration samples were obtained and came back positive for malignancy. Over the next few days, the patient became febrile, continued having the abdominal pain and developed worsening liver function tests. CT of the abdomen revealed a large retroperitoneal fluid collection, intra and extrahepatic biliary duct dilation and a right pleural effusion. Patient underwent right chest tube placement, which drained 2 L of bilious pleural fluid. She also underwent percutaneous transhepatic cholangiogram, which showed bilious leakage from third order branch of the right hepatic duct at the level of the superior aspect of the right lobe of the liver, which was causing complete obstruction of the distal CBD. Subsequent internal-external biliary drain was placed without complications, followed by resolution of the patient's jaundice over the next days. Follow up CT of the abdomen confirmed resolution of the retroperitoneal and right pleural bilomas. After discharge, patient underwent Whipple procedure for resection of what was found to be a well differentiated cholangiocarcinoma of the CBD. He has been following with general surgery and hematology/oncology since then. Spontaneous biloma is a rare occurrence which needs to be promptly assessed and treated. Percutaneous biliary drainage with placement of an internal-external drain is an effective procedure which can be used, especially if endoscopic sphincterotomy is not feasible.

Clinical Presentation, Imaging, and Management of Acute Cholecystitis

Acute cholecystitis (AC) is a life-threatening emergency that commonly occurs as a complication of gallstones. Severe right upper quadrant pain, abdominal guarding, fever, and a positive Murphy's sign with an elevated white blood cell count are the classical clinical manifestations of AC. Although ultrasonography is typically the initial diagnostic examination in patients with suspected AC, computed tomography and magnetic resonance imaging are commonly performed to identify complications; cholescintigraphy is recommended in patients with equivocal findings on the other imaging modalities, as this technique has the highest diagnostic accuracy in the diagnosis of AC. Imaging studies are also helpful in the timely detection of complications associated with AC. Although laparoscopic cholecystectomy is considered the gold-standard treatment for AC, percutaneous gallbladder drainage with or without cholecystostomy tube placement is a safe, effective management technique for surgically high-risk patients with multiple medical conditions. This treatment can be used as either a bridging therapy, with elective cholecystectomy performed at a later time after improvement of the patient's condition, or as definitive treatment in surgically unfit patients. Radiologists play a pivotal role in the initial diagnosis and management of patients with AC.

Drainage of amoebic liver abscess by single incision laparoscopic surgery. Report of a case

Abstract Background Single incision laparoscopic surgery has increased recently due to successful results, achieved in several procedures. The aim of the present work is to present the first case in which single incision laparoscopy is used for the drainage of an amoebic liver abscess. Clinical case A 44-year-old man presented with intense right upper quadrant pain, generalised jaundice, tachycardia, fever, hepatomegaly and a positive Murphy's sign. Laboratory results revealed an increased plasma bilirubin, elevated alkaline phosphatase and transaminases, leucocytosis, negative viral panel for hepatitis, and positive antibodies against Entamoeba histolytica . On an abdominal computed tomography a 15 cm × 12.1 cm hypodense lesion was observed in the patient's liver, identified as an amoebic liver abscess. Analgesics and antibiotics were started and subsequently the patient was submitted to laparoscopic drainage of the abscess using a single port approach. Drainage and irrigation of the abscess was performed. Four days later the patient was discharged without complications. Conclusion Management of amoebic liver abscess is focused on the elimination of the infectious agent and obliteration of the abscess cavity in order to prevent its complications, especially rupture. Laparoscopic surgery has proved to be a safe and effective way to manage this entity.

The Surgical Clerkship and Medical Student Performance in a Standardized Patient Case of Acute Cholecystitis

Although an Observed Structured Clinical Examination (OSCE) has been used to evaluate patient interaction and general knowledge competencies of third-year students during their required surgical clerkships, whether surgical clerkship experience predicts satisfactory performance with a surgical patient in an OSCE environment has not been investigated. We hypothesized that completion of the third-year surgery clerkship would improve student ability to diagnose acute cholecystitis and recognize the further need for hospital admission and treatment. An observational study design was used to determine student skills in evaluating a simulated surgical patient with abdominal pain from acute cholecystitis. The skills included key data gathering, physical examination, and information-sharing tasks. Tertiary care academic medical center. Performance was compared between a cohort of 101 medical students who had completed the third-year surgical clerkship and 72 who had not. A secondary analysis compared performance for 91 students who had completed their third-year clerkship in sites near the University of California, San Francisco School of Medicine, and 10 who did so at a regional campus geographically distant from the medical school. Of the 173 students who participated in the OSCE, only 42% correctly identified the diagnosis of acute cholecystitis, though 71% did suggest the possibility of a biliary process to the standardized patient. Most of the students who identified the condition as acute cholecystitis or gallbladder-related process had completed their third-year surgical clerkship (odds ratio [OR] = 3.26). Students who completed their surgical clerkship were also better able to recommend appropriate treatment for the patient (OR = 2.35), and recommend admission to the hospital or emergency department (OR = 2.00). Approximately one-third (35.3%) of all students documented a positive Murphy's sign, but only 6.4% identified the triad of leukocytosis, fever, and a Murphy's sign as diagnostic of acute cholecystitis and the need for surgical intervention. Student performance on the clinical examination did not differ depending on whether the students completed their clerkship at a Bay Area or regional hospital. Student recognition of the key physical examination and laboratory findings diagnostic of acute cholecystitis was low, but students were better able to recommend further treatment for a patient with acute cholecystitis after completing the third-year surgical clerkship. Our study reveals areas where surgical educators can improve medical student ability to accurately diagnose acute cholecystitis and evaluate acute abdominal processes.

急性期診療におけるpoint–of–care ultrasonography(Point–of–care ultrasonography in acute care settings)

要旨超音波（Ultrasonography，以下US）装置は小型化，画質の向上，価格の低下が進み，ベットサイドで広く利用されるようになった。近年point–of–care USという考え方が注目され，世界中で広く受け入れられるようになった。Point–of–care USに関する臨床研究は，「抽出」，「創出」，そして「統合」の考え方で行われた。「抽出」というのは，検査室で包括的に行われる心臓US，腹部US，下肢USの各チェック項目から，point–of–care USに適した項目が抽出されたことを意味する。「創出」というのは，これまで検査室レベルで着目されなかった肺や気道のUS所見がベットサイドで診療医により創出されたことを意味する。「統合」というのは，重症外傷患者，ショックや呼吸困難を呈する患者などにおいて，より的確な評価を行うために，それぞれの領域のUS所見が統合されたことを意味する。急性期診療におけるpoint–of–care USは，病院内外において，トリアージ，蘇生，診断，経過観察，モニタリングのために，またガイド下手技として利用されるが，急性期診療に関わる医師にとって，今後さらに重要性が高まると考えられる。本邦において急性期診療におけるpoint–of–care USが発展していくためには，臨床研究に基づいたガイドラインの整備や教育プログラムの開発が必要である。

Abdominal Pain Following Drug-eluting Bead Transarterial Chemoembolization

A 60 year old male presented with a two day history of fevers and right upper quadrant pain. His past medical history was significant for Child Pugh B cirrhosis secondary to chronic hepatitis B and he had received drug-eluting bead transarterial chemoembolization (DEB-TACE) for a 14 mm segment 7 hepatocellular carcinoma three weeks prior to this presentation. His other co-morbidities included a non-occlusive chronic portal vein thrombosis and stage III chronic kidney disease related to previous obstructive uropathy and nephrolithiasis. His only medication was entecavir 0.5 mg daily. Computed tomography (CT) of the abdomen and ultrasound of the gallbladder prior to therapy with DEB-TACE are shown in Figures 1 and 2, respectively. Figure 1 Computed tomography (CT) of the abdomen. Figure 2 Ultrasound of the gallbladder prior to therapy with DEB-TACE. At presentation he had a temperature of 37.6 °C and abdominal examination revealed a soft and non-tender abdomen and Murphy's sign was negative. Bowel sounds were present and there was no jaundice. Investigations showed a white cell count of hemoglobin of 128 g/L (normal range 130–170 g/L) 1.5 × 109/L (normal range 4.0–10.0 × 109/L) with neutrophils of 0.66 × 109/L (normal range 2.0–7.0 × 109/L) and lymphocytes of 0.36 × 109/L (normal range 0.20–1.0 × 109/L) and platelets of 54 × 109/L (normal range 150–410 × 109/L). Liver function tests were similar to previous levels, with a normal bilirubin, alkaline phosphatase and alanine transferase, an albumin of 26 g/L and an International Normalised Ratio (INR) of 1.3. A triple phase CT of the abdomen was performed, with the arterial phase image shown in Figure 3. An ultrasound of the abdomen was also performed, with gallbladder views shown in Figure 4. Figure 3 Triple phase CT of the abdomen, with the arterial phase image. Figure 4 Ultrasound of the abdomen was also performed, with gallbladder views.

Clinical Chameleon: To Be or Not To Be Metastasis

Question: A 65-year-old woman with a prior history of renal cell carcinoma, status post left nephrectomy, presented with vague right upper quadrant abdominal pain. Physical examination revealed no jaundice and a negative Murphy sign. Alanine and aspartate aminotransferases were elevated at 102 and 124 U/L, respectively, prompting subsequent imaging. Right upper quadrant ultrasonography demonstrated multiple hepatic masses with peripheral hypoechoic halo (Figure A). Computed tomography (CT) and magnetic resonance imaging (MRI; Figure B) showed innumerable hepatic masses with central T2 hyperintensity and incomplete peripheral enhancement on arterial and portal venous phase imaging. There was no evidence of extrahepatic disease. CT-guided biopsy of one of these lesions showed replacement of liver parenchyma by a proliferation of large cells with intracytoplasmic lumina, some containing red blood cells (Figure C, high-magnification photomicrograph; stain, hematoxylin and eosin), which were strongly reactive for CD31 immunostain (Figure D, high-magnification photomicrograph). Immunostains for renal cell carcinoma were nonreactive. The patient complained of mild right upper quadrant pain and was otherwise unremarkable. What is the diagnosis? Look on page 978 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Epithelioid hemangioendothelioma (EHE) is a rare neoplasm of vascular origin described in 1982,1Weiss S.W. Enzinger F.M. Epithelioid hemangioendothelioma: a vascular tumor often mistaken for a carcinoma.Cancer. 1982; 50: 970-981Crossref PubMed Scopus (1107) Google Scholar which can present in the liver as well as soft tissues, bone, and brain, arising from a medium sized or large vein. It has low incidence in the general population <0.1 per 100,0002Hertl M. Cosimi A.B. Liver transplantation for malignancy.Oncologist. 2005; 10: 269-281Crossref PubMed Scopus (107) Google Scholar and is more common in females (61%).3Lau K. Massad M. Pollak C. et al.Clinical patterns and outcome in epithelioid hemangioendothelioma with or without pulmonary involvement: insights from an internet registry in the study of a rare cancer.Chest. 2011; 140: 1312-1318Abstract Full Text Full Text PDF PubMed Scopus (140) Google Scholar Hepatic EHE usually presents as multiple tumors (EHE nodular type) ranging in size from 0.2 to 14 cm that, in late-stage disease, may coalesce to form a large infiltrative mass present in the periphery (EHE diffuse type).1Weiss S.W. Enzinger F.M. Epithelioid hemangioendothelioma: a vascular tumor often mistaken for a carcinoma.Cancer. 1982; 50: 970-981Crossref PubMed Scopus (1107) Google Scholar The radiologic appearance of multiple hepatic lesions is often nonspecific and suggestive of metastatic disease or infectious etiology. However, the “targetoid” appearance of EHE lesions on MRI suggests this diagnosis. Histologically, the EHE is composed of multiple, atypical, “epithelioid” endothelial cells with prominent cytoplasmic vacuolization, suggestive of primitive lumen formation embedded within a fibrous–myxoid stroma and replacing the hepatic parenchyma (Figure C). The tumor cells are strongly reactive for vascular markers (CD31 and CD34). A disease-defining genetic alteration was identified as a chromosomal translocation in the t(1;3)(p36;q25), which was present in virtually all cases tested and is a useful diagnostic tool in evaluation of this diagnostically challenging neoplasm. Hepatic EHE is classified as tumor of “borderline” biologic potential and clinical outcome is unpredictable. Metastatic disease at the time of diagnosis does not necessarily correspond with reduced survival; some cases show long-term survival of up to 73% at 5 years,3Lau K. Massad M. Pollak C. et al.Clinical patterns and outcome in epithelioid hemangioendothelioma with or without pulmonary involvement: insights from an internet registry in the study of a rare cancer.Chest. 2011; 140: 1312-1318Abstract Full Text Full Text PDF PubMed Scopus (140) Google Scholar despite extensive disease presence. Treatment is challenging owing to the rarity of the disease, which precludes large-scale trials. Surgical resection and chemotherapeutic agents are offered in some cases and disease recurrence after orthotopic liver transplantation has been reported. In our case, chemotherapy was unsuccessful and the patient refused transplantation. She is alive with disease.

Abdominal ultrasound versus hepato-imino diacetic acid scan in diagnosing acute cholecystitis—what is the real benefit?

BackgroundAcute cholecystitis is one of the most common surgical problems, yet substantial debate remains over the utility of simple examination, abdominal ultrasound (AUS), or advanced imaging such as hepato-imino diacetic acid (HIDA) scan to support the diagnosis. Materials and methodsThe preoperative diagnostic workup of patients who underwent cholecystectomy with histologically confirmed acute cholecystitis was reviewed to calculate the sensitivity of AUS, HIDA scan, or both. In addition, the sensitivity of the commonly described ultrasonographic findings was assessed. ResultsFrom 2010 through 2012, 406 patients among 9087 reviewed charts presented to the emergency department with acute upper abdominal pain and met inclusion criteria. 32.5% (N = 132) of patients underwent AUS only, 11.3% (N = 46) underwent HIDA scan only, and 56.2% (N = 228) had both studies performed for workup. 52.7% (N = 214) of patients had histopathologically confirmed acute cholecystitis. The sensitivities of AUS, HIDA, and AUS combined with HIDA for acute cholecystitis were 73.3% (95% confidence interval [CI] = 66.3%–79.5%), 91.7% (95% CI = 86.2%–95.5%), and 97.7% (95% CI = 93.4%–99.5%), respectively. Although of limited sensitivity, AUS findings of sonographic Murphy sign, gallbladder distension, and gallbladder wall thickening were associated with a diagnosis of acute cholecystitis. ConclusionsThe sensitivity of AUS for diagnosing acute cholecystitis in patients with acute upper abdominal pain is limited. The addition of a HIDA scan in the diagnostic workup significantly improves sensitivity and can add valuable information in the appropriate clinical setting.