Fevers, Rigors and Jaundice

A 60yo patient presented to ED with 2/52 of fevers, rigors and 2/7 of jaundice. 

Nil appetite for the last 1/7

Nil nausea or vomiting

PHx GB Ca - cholecystectomy and pancreatoduodenectomy 2025

OE obs stable, afebrile.

Lax abdo. Mild RUQ tenderness. NIl guarding. 

Bloods: WCC 10, obstructive LFTs and bili 41.

RUQ liver US 

RUQ liver US (annotated)

Other examples of dilated intra-hepatic ducts

This patient didn't have normal anatomy due to previous surgery. But in other patients you can look for a dilated GB at the porta hepatis. If severely dilated, it will be the same calibre as the adjacent portal vein giving the impression of a double barrel shot sun. 

dilated CBD above the portal vein (with colour in PV) 

To get this view, scan at the R hypochondrium with the transducer saggital, probe marker to the patient's right shoulder. This will show the portal vein in transverse with the CBD and hepatic artery above (mickey mouse sign). 

Rotating clockwise will elongate the PV and the CBD.

This patient also had a couple of loops of dilated bowel (>6cm!) in the RUQ and a distended stomach in the LUQ. 

Normal small intestine is <3cm. Signs of SBO are dilated small intestine >3cm with contents rolling around in the lumen instead of moving forward (washing machining). 

Dilated loops of SI with washing machining (arrow)

Delayed presentations may show hypoechoic content which looks like faeces. 

dilated SI with faecalised content (eg hyperechoic gas is not normal in SI)

In this patient,  based on this US, and the clinical picture, antibiotics were started for ascending cholangitis and the patient was admitted to surgery. 

His CT showed a dilated SI and stomach.