Is that gastritis?

41yo male presented with severe chest pain radiating to the back. 10/10 initially. Settled with morphine. 

Obs normal post analgesia but tachycardic and hypertensive on arrival.

Examination was unremarkable. CXR NAD. CTA chest was done to exclude dissection given his dramatic presentation and hx of pain radiating to back. 

He was sent home post normal CT with LMO FU for gastroscopy and H Pylori testing. 

He presented the next day with ongoing pain. Pain was unrelenting. There was now nausea and 2 episodes of vomiting. WCC was 15 with a neutrophilia. LFTs and lipase normal. 

Given the vomiting, I palpated his abdomen: epigastric tenderness nil guarding. Aha! time for US!!

This is what I found in the R hypogastrium:

US of R hypogastrium. Tranducer perperndicular to R costal margin. Probe marker to head

The GB wall thickness was 8mm (normal </= 3mm). He also had probe tenderness. 

So this is the classic sonographic signs for cholecystitis: gall stones and probe tenderness. Together they have about 90% sensitivity for cholecystitis.  

Other features of cholecytitis on US are dilated GB (>10cm long and >5cm wide) and pericholcystic fluid. 

The patient had his GB removed and it showed signs of cholecystitis with no perforation, So remember to US patients with CP/ epigastric pain. They may not have guarding and you may find cholecystitis. 

For info on how to image the GB at the bedside click on the button below:

For info on acute cholecystitis click on the button below: