POCUS Imaging and Case Report by Dr. Gangadeep Singh
Case:
22 year old female with no past medical history, not taking any medications, and no recent travel presents to the emergency department with right upper quadrant abdominal pain and pain in her right shoulder for the past 5 days. Patient also has nausea, but no vomiting, fevers, chills, chest pain, or shortness of breath.
Patient was well appearing, in no acute distress, with stable vital signs and no significant lab abnormalities. Specifically, patient’s CBC, LFT’s and Lipase were within normal limits. On physical exam, patient did not have any significant RUQ tenderness, and the rest of the abdominal exam was benign as well. No jaundice or scleral icterus was noted. RUQ POCUS was performed.
Formal RUQ Ultrasound was done:
Impression:
Complex septate cystic structure in the right hepatic lobe measuring 5.8 x 5.9 x 6.1 cm, which demonstrates no internal flow.
Differential Diagnosis includes:
Neoplasm
Hemorrhagic cyst
Parasitic (Echinococcal – travel and animal exposure history important!)
Hepatic abscess
Simple cyst
Unfortunately, this patient signed out AMA so the exact etiology of this finding is unknown. Patient planned to follow up with her primary care doctor.
Teaching Points:
- Not all RUQ pain is the gallbladder.
- If there is concern for abscess, CT has been shown to be more sensitive than ultrasound (95 vs 85% respectively).
- Hepatic cysts are at risk for causing biliary colic, obstructive jaundice, cholangitis, pancreatitis, as well as other hepatic and vascular complications due to their size. They may also rupture into the peritoneum.
- Simple Cysts (containing only fluid) are benign but cystic tumors (containing fluid and solid areas) can grow to become malignant over time.
- LFT’s are usually normal unless process is advanced.
- Ultimately, cysts large enough to cause symptoms, or that appear concerning by imaging or patient presentation, will require surgical resection or needle aspiration for both diagnosis and treatment.
References:
- Regev, Arie, and Rajender Reddy. “Diagnosis and Management of Cystic Lesions of the Liver.” UpToDate, 2018, www.uptodate.com/contents/diagnosis-and-management-of-cystic-
lesions-of-the- liver?search=hepatic%2Bcyst&source=search_result&selectedTitle=1~116&usage_type=default
&display_rank=1. - Tintinalli, Judith E., et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, Eighth Edition. McGraw-Hill Education, 2016.