Adult male-RUQ abd pain.VSS/Afeb. WBC-16.8K. Obstructive pattern on hepatic panel with normal amylase/lipase. See thread. #POCUS #IMPOCUS #FOAMed #FOAMus #MedEd #ultrasound @grepmeded @NephroP @medpedshosp @PratsEM @cianmcdermott @HeyDrNik @jminardi21 @PittIMPOCUS @SonoStache

GB measurements: Length 10.1 cm, TRV width 4.0 cm, Wall thickness 3.1 mm. CBD: mid/distal- 5.1 mm. See GB sag video. Has large stone in neck. This was LLD position--stone remained impacted. Always scan in 2 positions when stone seen in neck in initial supine position.

GB TRV Sweep. Sludge also present.

Liver TRV sweep. Note presence of intrahepatic ductal dilatation. Always make this evaluation a part of your POCUS GB study. What is diagnosis? What is causing these lab/POCUS findings?

Doppler. Liver TRV. Dilated intrahepatic ducts.

Maybe patient has second gallstone that has passed into proximal CBD resulting in intrahepatic ductal dilatation but normal mid/distal CBD? Shouldn't be GB stone in neck causing this, right? Needs further evaluation prior to operative planning--MRCP or ERCP.

MRCP performed. Has Mirizzi's syndrome-Pt has extrinsic compression of biliary tree(can be CHD or CBD that is compressed) by the large gallstone. Rare condition and patients can present with RUQ pain, fever, jaundice

Want more info on Mirizzi's syndrome and review of POCUS GB-go to http://www.emsono.com . Will have a Breaking the Sound Barrier series monthly (free open access) of interesting case(s)posted here since Twitter limits video length.