Gallbladders Gone WILD

Have you thought about your New Year’s resolutions yet? Will 2025 finally be the year you commit to the gym? Did you splurge on that expensive new gym membership? The truth about resolutions is that most of them fail. In fact, one study from the University of Bristol found that 88% of individuals who set New Year’s resolutions fail to achieve them ¹. And the #1 reason? Setting unrealistic or overly ambitious goals.

Let’s keep it real this year.

How about committing to becoming an even better ER doctor for your patients in 2025? Specifically, by improving your bedside diagnostic skills with PoCUS.

But how? When? And at what cost?!

• Its Free.
• You can start today
• It only takes 5 minutes – just read through our ultrasound blogposts! 
• Then, while you’re on shift – engage deliberate practice.
• By the end of 2025, you won’t just have sharpened your PoCUS skills—you’ll have elevated your diagnostic precision and the care you provide to patients.

Ok, lets dive into some Gallbladder stuff.

Gallbladder PoCUS can be challenging. No matter where you place the probe, it often feels like you’re missing the target. Why? Unlike other GI organs, the gallbladder isn’t fixed to the body wall—it can vary significantly in its RUQ position.²

To improve your success, remember the 3 Ps: Positioning, Placement, and Positives:

1. Positioning
   • Supine Position: Start with the patient completely supine. Consider having them flex their knees to relax the abdominal muscles
   • Left lateral decubitus position: Brings the gallbladder closer to midline and helps displace bowel gas
   • Coach breathing: An inspiratory hold can be key, especially when bowel gas obscures the view. It pushes the liver and gallbladder out from the thoracic cage, improving visualization. 
2. Placement
   • Standard Approach
     • Place the probe vertically in the mid-epigastrum below the xiphoid process. 
     • With a slight heel-toe motion, slide the probe along the costal margin until you locate the gallbladder, often near the mid-axillary line.
   • Troubleshooting tips:
     • Coach the patient to do an inspiratory hold to bring the gallbladder out from under the ribs
     • If still unsuccessful, try the novel ‘X-7 Intercostal Approach’. ³
       • Find the xiphoid process (X marks the spot)
       • Move 7 cm laterally over the ribs
       • Place your curvilinear probe vertically between the ribs
       • Approximately 70% of the time, this approach will locate it
3. Positives
   • When diagnosing acute cholecystitis, look for gallstones along with a secondary finding. (*Note: This applies to 95% of cases caused by cholelithiasis. Acalculous cholecystitis is more nuanced and should be considered in patients on TPN or with prolonged fasting.)
   • Gallstones
     • Hyperechoic structures that produce sharp posterior shadowing:

• • • Secondary Findings: 
      • Sonographic Murphy’s Sign: Maximal tenderness when the probe applies pressure directly over the visualized gallbladder 
      • Gallbladder thickness >3mm (see the image on the right, above)
      • Pericholecystic fluid: A subtle layer of black fluid surrounding the gallbladder wall (first image above)
      • Impacted stone: immobile stone in the gallbladder neck. Reposition the patient (eg: supine to left lateral decubitus) to assess mobility. 

Accuracy of Findings 

• Gallstones + Sonographic Murphy’s sign: 92% PPV for acute cholecystitis ⁴
• No gallstones + no sonographic Murphy’s sign: 95% NPV for acute cholecystitis ⁴
• Overall ER PoCUS Accuracy: ⁵
  • Sensitivity: 89.8%
  • Specificity: 88%

Clinical Integration

Refer to the proposed TOH gallbladder pathway below to guide management based on your bedside findings:

Test your skills!

Try our Gallbladder PoCUS quiz to help solidify your diagnostic capabilities. 

Don’t forget about our PoCUS Symposium

How many people can say they’ve gone on a Valentines date with an Olympic athlete? You can spend Valentine’s Day with the legendary Dr. Paul Pageau and other PoCUS faculty stars! This is the final announcement, as we’re nearing capacity for our limited spots. Register today for the Ottawa POCUS Symposium on February 14, 2025!