Case presentation

A woman aged 44 years with a history of endometrial adenocarcinoma, for which she had a total abdominal hysterectomy and bilateral salpingo-oopherectomy, presents to the ED with 2 days of intermittent right-sided abdominal pain radiating to the epigastrium and right flank. The pain is exacerbated by eating fatty foods. Of note, patient reported intermittent right lower quadrant abdominal pain to an outpatient provider 3 months prior, and a CT was ordered to evaluate for cancer recurrence. The CT scan was performed 1 week prior to this ED visit and showed no acute pathology in the abdomen or pelvis, including an unremarkable gallbladder.

On initial evaluation, the patient is non-toxic appearing, with vital signs of temperature 36.8°C (98.2°F), pulse 76 beats/min, BP 143/101 mm Hg, RR 16 breaths/min and oxygen saturation of 100% on room air. The patient’s cardiovascular and pulmonary exams are unremarkable. Examination of the abdomen reveals right-sided abdominal tenderness to palpation without rebound, guarding or costovertebral angle tenderness. Basic laboratory tests reveal aspartate transaminase 199 (reference range 10–41 U/L), alanine transaminase 137 (reference range 7–35 U/L) and alkaline phosphatase 102 (reference range 42–98 U/L), and a right upper quadrant (RUQ) point-of-care ultrasound (POCUS) was performed.

What are the indications for performing RUQ POCUS?

Common indications for RUQ POCUS include abdominal pain, right-sided flank pain, jaundice and some cases of sepsis.1 2 The primary application of ED RUQ POCUS is to assess for the presence of gallstones as well as for evidence of acute cholecystitis, as biliary pathology is a common cause of abdominal pain presentations to the ED.1 3 For our patient, the differential diagnosis included hepatobiliary pathology, pyelonephritis, pancreatitis, appendicitis, nephrolithiasis, acute coronary syndrome and pulmonary embolus.

Which transducer is best suited for performing RUQ POCUS?

The curvilinear transducer, a low frequency probe with a large surface area, is preferred for its greater tissue penetration.

What views should be obtained when assessing the RUQ?

The first step in RUQ POCUS is to identify the gallbladder. Multiple approaches can …