Case:

A 38-year-old HIV positive male presented to the Emergency Department with three days of a Zoster form rash affecting T5-T10 on his right side. The patient was seen in the clinic earlier in the day and sent to the ED for admission. Review of symptoms was positive for three months of epigastric pain unrelated to food but worse with his HIV medications. Additionally, the patient noted seven days of chills, vomiting and diarrhea.

The patient's vital signs were BP 116/84, HR 84, RR12, and T 100.3°F, O2 sat 98% on room air. He was cachetic but in no apparent distress. Abdominal exam revealed a Zoster form rash from the right back to the right upper quadrant. Mild tenderness was noted in the epigastrium. Rectal exam was heme negative. The rest of the physical exam was unremarkable.

Limited ED bedside ultrasound (US) examination was performed as part of the physical exam to evaluate for biliary disease. The patient was placed left lateral decubitus position. The gallbladder and biliary tree were viewed in the longitudinal scanning plane beginning in the mid-clavicular line. The gallbladder was visualized and scanned in the both the long and short axis.

View Gallbladder wall thickening with sludge		View Dialated CBD with absence of Color Flow		View Fistula Flickering Video		View Leaking Fistulae Video

On the long axis and short views, the lumen contained sludge that slowly layered out in the dependent portion of the gallbladder. On the short axis view, the gallbladder wall was thickened and the common bile duct size was enlarged. On closer inspection, a suspected bowel to gall bladder fistulae was noted leaking contents into the gall bladder.

Discussion:

Biliary sludge is typically reported in cases of impaired gallbladder contractility, prolonged total parenteral nutrition, pregnancy, or fasting (1). On ultrasound, sludge usually has low amplitude, non-shadowing echoes in the most dependent portion of the gallbladder (2). Patients often have a fluctuating course, with frequent recurrence that often progress to gallstone formation.

AIDS cholangiopathy is a syndrome of biliary stricture and eventual obstruction resulting from infection with opportunistic organisms such as Cryptosporidium parvum, Microsporidium, Cytomegalovirus (CMV) and Cyclospora cayetanensis (3). Both lymphoma and Kaposi's sarcoma have also been implicated (4). Reported in 26 percent of AIDS patients before highly active antiretroviral therapy, the incidence of AIDS cholangiopathy has decreased. But even today, AIDS cholangiopathy may be the first infection in patients with CD4 counts less than 100/mm3.

Patients with AIDS cholangiopathy typically present with right upper, diarrhea, and prominent elevation of alkaline phosphatase (4) Fever and jaundice are less common, and diarrhea may be the first presenting complaint. Laparoscopic cholecystectomy is curative (5).

US has been reported to be more sensitive than CT for detecting gallbladder wall abnormalities and cholelithiasis (2) With limited training, emergency physicians achieve sensitivities of 86-96% and specificities of 78-97% for detecting gallstones (6). Compared to the radiologists, emergency physicians obtained greater sensitivity in detecting Murphy's sign in patients with cholecystitis (7).

Conclusion:

The patients CT scan demonstrated findings on limited ED US. Biliary sludge, gall bladder wall thickening, and an enlarged common bile duct were noted. Additionally, gas was noted in the lumen of the gall bladder but not in the biliary tree, suggesting an enteric to gall bladder fistulae. The patient was admitted to the HIV with general surgery on consult for next day cholecystectomy.

References:

1. Angelico M, Santis A, Capocaccia L. Biliary Sludge: A Critical Update. Journal of Clinical Gastroenterology 1990; 12(6):656-662.
2. Cosby K, Kendall J. Practical Guide to Emergency Ultrasound. Lippincott, 2006: 183-205.
3. Afdhal N. (June 14, 2005) Up To Date/AIDS Cholangiopathy. Retrieved March 18, 2008, from http://www.utdol.com/utd/store/index.do
4. Wilcox M, Monkemuller KE. Hepatobiliary Diseases in Patients with AIDS: Focus on AIDS Cholangiopathy and Gallbladder Disease. Digestive Diseases 1998; 16:205-213.
5. Yusuf T, Baron B. AIDS Cholangiopathy. Current Treatment Options in Gastroenterology 2004; 7(2):111-117.
6. Shah K, Wolfe RE. Hepatobiliary Ultrasound. Emergency Medicine Clinics of North America 2004; 22(3):661-673.
7. Kendall J, Shimp R. Performance and Interpretation of Focused Right Upper Quadrant Ultrasound by Emergency Physicians. Journal of Emergency Medicine 2001; 21(1):7-13.