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Boling B, Solis A. Point-of-Care Ultrasonography in the Critical Care Setting: Abdominal POCUS. AACN Adv Crit Care 2023; 34:216-227. [PMID: 37644636 DOI: 10.4037/aacnacc2023298] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
Point-of-care ultrasonography is becoming standard practice for diagnosis and management of patients in the critical care setting. When using point-of-care ultrasonography for evaluation of the abdomen, most providers will immediately think of the Focused Assessment with Sonography for Trauma examination. However, there are a number of important abdominal applications for the nontrauma patient, including evaluation of the function of abdominal organs, differentiation of shock states, and identification of sources of sepsis. This article covers basic approaches to an abdominal point-of-care ultrasonography examination of the biliary tract, liver, kidneys, bladder, and appendix, as well as identification and management of intra-abdominal free fluid.
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Affiliation(s)
- Bryan Boling
- Bryan Boling is Nurse Practitioner, Department of Anesthesiology, Division of Critical Care Medicine, University of Kentucky, 531 Southbend Dr, Lexington, KY 40503 ; and Adjunct Faculty, Adult-Gerontology Acute Care Nurse Practitioner Program, Georgetown University, Washington, DC
| | - Abbye Solis
- Abbye Solis is Nurse Practitioner, Weinberg Surgical Intensive Care Unit, Johns Hopkins Hospital, Baltimore, Maryland; and Adjunct Faculty, Adult-Gerontology Acute Care Nurse Practitioner Program, Georgetown University, Washington, DC
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Vardar BU, Dupuis CS, Goldstein AJ, Vardar Z, Kim YH. Ultrasonographic evaluation of patients with abnormal liver function tests in the emergency department. Ultrasonography 2022; 41:243-262. [PMID: 35026887 PMCID: PMC8942730 DOI: 10.14366/usg.21152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 11/18/2021] [Indexed: 12/24/2022] Open
Abstract
Ultrasonography is often the initial modality used to evaluate patients found to have abnormal liver function tests (LFTs) in the emergency department. While an assessment for biliary ductal dilatation and obstruction remains one of the main questions to answer, radiologists should also be aware of the ultrasonographic appearance of other conditions that can cause abnormal LFTs. This may be crucial for the management and disposition of patients in the emergency department. This article reviews the ultrasonographic features of diseases that may cause abnormal LFTs.
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Affiliation(s)
| | - Carolyn S Dupuis
- Department of Radiology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Alan J Goldstein
- Department of Radiology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Zeynep Vardar
- Department of Radiology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Young H Kim
- Department of Radiology, University of Massachusetts Medical School, Worcester, MA, USA
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ACR Appropriateness Criteria® Acute Nonlocalized Abdominal Pain. J Am Coll Radiol 2018; 15:S217-S231. [DOI: 10.1016/j.jacr.2018.09.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 09/07/2018] [Indexed: 02/07/2023]
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Ratanaprasatporn L, Uyeda JW, Wortman JR, Richardson I, Sodickson AD. Multimodality Imaging, including Dual-Energy CT, in the Evaluation of Gallbladder Disease. Radiographics 2018; 38:75-89. [DOI: 10.1148/rg.2018170076] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Lisa Ratanaprasatporn
- From the Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115
| | - Jennifer W. Uyeda
- From the Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115
| | - Jeremy R. Wortman
- From the Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115
| | - Ian Richardson
- From the Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115
| | - Aaron D. Sodickson
- From the Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115
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Lahham S, Becker BA, Gari A, Bunch S, Alvarado M, Anderson CL, Viquez E, Spann SC, Fox JC. Utility of common bile duct measurement in ED point of care ultrasound: A prospective study. Am J Emerg Med 2017; 36:962-966. [PMID: 29162442 DOI: 10.1016/j.ajem.2017.10.064] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 10/19/2017] [Accepted: 10/24/2017] [Indexed: 12/07/2022] Open
Abstract
BACKGROUND Measurement of the common bile duct (CBD) is considered a fundamental component of biliary point-of-care ultrasound (POCUS), but can be technically challenging. OBJECTIVE The primary objective of this study was to determine whether CBD diameter contributes to the diagnosis of complicated biliary pathology in emergency department (ED) patients with normal laboratory values and no abnormal biliary POCUS findings aside from cholelithiasis. METHODS We performed a prospective, observational study of adult ED patients undergoing POCUS of the right upper quadrant (RUQ) and serum laboratory studies for suspected biliary pathology. The primary outcome was complicated biliary pathology occurring in the setting of normal laboratory values and a POCUS demonstrating the absence of gallbladder wall thickening (GWT), pericholecystic fluid (PCF) and sonographic Murphy's sign (SMS). The association between CBD dilation and complicated biliary pathology was assessed using logistic regression to control for other factors, including laboratory findings, cholelithiasis and other sonographic abnormalities. RESULTS A total of 158 patients were included in the study. 76 (48.1%) received non-biliary diagnoses and 82 (51.9%) were diagnosed with biliary pathology. Complicated biliary pathology was diagnosed in 39 patients. Sensitivity of CBD dilation for complicated biliary pathology was 23.7% and specificity was 77.9%. CONCLUSION Of patients diagnosed with biliary pathology, none had isolated CBD dilatation. In the absence of abnormal laboratory values and GWT, PCF or SMS on POCUS, obtaining a CBD measurement is unlikely to contribute to the evaluation of this patient population.
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Affiliation(s)
- Shadi Lahham
- University of California, Irvine, Department of Emergency Medicine, 333 The City Boulevard West Suite 640, Orange 92868, CA, USA.
| | - Brent A Becker
- York Hospital, Department of Emergency Medicine, York, PA, USA
| | - Abdulatif Gari
- University of California, Irvine, Department of Emergency Medicine, 333 The City Boulevard West Suite 640, Orange 92868, CA, USA
| | - Steven Bunch
- University of California, Irvine, Department of Emergency Medicine, 333 The City Boulevard West Suite 640, Orange 92868, CA, USA
| | - Maili Alvarado
- University of California, Irvine, Department of Emergency Medicine, 333 The City Boulevard West Suite 640, Orange 92868, CA, USA
| | - Craig L Anderson
- University of California, Irvine, Department of Emergency Medicine, 333 The City Boulevard West Suite 640, Orange 92868, CA, USA
| | - Eric Viquez
- University of California, Irvine, Department of Emergency Medicine, 333 The City Boulevard West Suite 640, Orange 92868, CA, USA
| | - Sophia C Spann
- University of California, Irvine, Department of Emergency Medicine, 333 The City Boulevard West Suite 640, Orange 92868, CA, USA
| | - John C Fox
- University of California, Irvine, Department of Emergency Medicine, 333 The City Boulevard West Suite 640, Orange 92868, CA, USA
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Mathur M, Singh J, Singh DP, Kaur N, Gupta S, Haq S. Imaging Evaluation of Enhancement Patterns of Flat Gall Bladder Wall Thickening and Its Correlation with Clinical and Histopathological Findings. J Clin Diagn Res 2017; 11:TC07-TC11. [PMID: 28571228 DOI: 10.7860/jcdr/2017/25472.9624] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 01/19/2017] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Gall bladder Wall Thickening (GWT) is caused by wide spectrum of diseases. Initially Ultrasound (USG) was used as imaging modality for screening of acute abdomen because of its high sensitivity and real time character. Now, Computed Tomography (CT) is used because of its high temporal and spatial resolution. AIM Evaluation of GWT and its enhancement patterns on contrast enhanced CT scan in a bid to differentiate benign from malignant causes and to correlate the imaging features with clinical and histopathological findings. MATERIALS AND METHODS It was a hospital based prospective study in which USG was done as an initial modality for screening and Multi Detector Computed Tomography (MDCT) scan was done later on for detailed evaluation of enhancement patterns of GWT. The study cases were then divided into five CT patterns according to enhancement patterns. The diagnostic performance of MDCT was compared with histopathological and serological findings. Relevant history, clinical examination and routine investigations were done. RESULTS The one layered pattern with a heterogeneously enhancing thick layered pattern (Type 1) was significantly associated with gall bladder cancer (p<0.001). The sensitivity and specificity of Type 1 enhancement pattern on CT for predicting the Gall Bladder (GB) malignancy were 90.476% and 97.43% respectively. The positive and negative predictive values were 95% and 95%, respectively. Focal wall thickening, irregular margin character and hepatic infiltration by GWT and lymphadenopathy were other findings that predict malignancy (p-value<0.05). CONCLUSION MDCT enhancement patterns of a thickened GB wall and associated findings were helpful in differentiating malignant GWT from benign GWT.
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Affiliation(s)
- Manoj Mathur
- Associate Professor, Department of Radiology, Government Medical College, Patiala, Punjab, India
| | - Jasvir Singh
- Junior Resident, Department of Radiology, Government Medical College, Patiala, Punjab, India
| | - Devinder Pal Singh
- Professor and Head, Department of Surgery, Government Medical College, Patiala, Punjab, India
| | - Navneet Kaur
- Associate Professor, Department of Pathology, Government Medical College, Patiala, Punjab, India
| | - Saryu Gupta
- Assistant Professor, Department of Radiology, Government Medical College, Patiala, Punjab, India
| | - Samrin Haq
- Junior Resident, Department of Radiology, Government Medical College, Patiala, Punjab, India
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Avegno J, Carlisle M. Evaluating the Patient with Right Upper Quadrant Abdominal Pain. Emerg Med Clin North Am 2016; 34:211-28. [DOI: 10.1016/j.emc.2015.12.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Tubay M, Zelasko S. Multimodality Imaging of the Gallbladder: Spectrum of Pathology and Associated Imaging Findings. CURRENT RADIOLOGY REPORTS 2016. [DOI: 10.1007/s40134-016-0148-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Mehta H. Abdominal Pain. CLINICAL PATHWAYS IN EMERGENCY MEDICINE 2016. [PMCID: PMC7121692 DOI: 10.1007/978-81-322-2710-6_26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Becker BA, Fields WA, Pfisterer L, Stuntz RM, Stahlman BA, Kochert EI. Extrabiliary Pathology Identified by Right Upper Quadrant Abdominal Ultrasound in Emergency Department Patients. J Emerg Med 2015; 50:92-8. [PMID: 26409669 DOI: 10.1016/j.jemermed.2015.07.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 06/22/2015] [Accepted: 07/25/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND The effectiveness of point of care (POC) right upper quadrant ultrasound (RUQ US) in the diagnosis of biliary disease has been well studied. Extrabiliary pathology that might remain undetected in the course of typical, focused POC RUQ US has not been directly examined. OBJECTIVES Our objective was to determine the prevalence and clinical significance of extrabiliary findings (EBFs) seen on radiology-performed, comprehensive RUQ US. METHODS We conducted a retrospective review of all adult patients undergoing radiology-performed RUQ US in the emergency department (ED) between January 2007 and April 2012. Ultrasound findings and contemporaneous laboratory values were collected. EBFs were identified and further classified by clinical significance. RESULTS A total of 1579 charts were included, demonstrating a total of 1030 EBFs, with 747 (47.3% [95% confidence interval {CI}, 44.8-49.8%]) patients demonstrating ≥ 1 EBF. Of these EBFs, 184 were classified as clinically significant (CSEBFs) and 150 (9.5% [95% CI, 8.1-11.0%]) patients had ≥ 1 CSEBF. A total of 50 unspecified masses were seen in 47 (3.0% [95% CI, 2.1-3.8%]) patients, with 8 (0.5%) representing a previously undiagnosed malignancy. CONCLUSION CSEBFs were seen in < 10% of ED patients undergoing comprehensive RUQ US. Nonspecific masses were seen in 3% of patients, but < 1% of patients were found to have a new malignancy.
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Affiliation(s)
- Brent A Becker
- Department of Emergency Medicine, Wellspan York Hospital, York, Pennsylvania
| | - William A Fields
- Department of Emergency Medicine, Wellspan York Hospital, York, Pennsylvania
| | - Lauren Pfisterer
- Department of Emergency Medicine, Memorial Hospital, York, Pennsylvania
| | - Robert M Stuntz
- Department of Emergency Medicine, Wellspan York Hospital, York, Pennsylvania
| | - Barbara A Stahlman
- Department of Emergency Medicine, Wellspan York Hospital, York, Pennsylvania
| | - Erik I Kochert
- Department of Emergency Medicine, Wellspan York Hospital, York, Pennsylvania
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Kuo DC, Rider AC, Estrada P, Kim D, Pillow MT. Acute Pancreatitis: What's the Score? J Emerg Med 2015; 48:762-70. [DOI: 10.1016/j.jemermed.2015.02.018] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 01/30/2015] [Accepted: 02/21/2015] [Indexed: 02/07/2023]
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Revzin MV, Scoutt L, Smitaman E, Israel GM. The gallbladder: uncommon gallbladder conditions and unusual presentations of the common gallbladder pathological processes. ACTA ACUST UNITED AC 2014; 40:385-99. [DOI: 10.1007/s00261-014-0203-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Becker BA, Chin E, Mervis E, Anderson CL, Oshita MH, Fox JC. Emergency biliary sonography: utility of common bile duct measurement in the diagnosis of cholecystitis and choledocholithiasis. J Emerg Med 2013; 46:54-60. [PMID: 24126067 DOI: 10.1016/j.jemermed.2013.03.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Revised: 03/07/2013] [Accepted: 03/15/2013] [Indexed: 12/07/2022]
Abstract
BACKGROUND Measurement of the common bile duct (CBD) has traditionally been considered an integral part of gallbladder sonography, but accurate identification of the CBD can be difficult for novice sonographers. OBJECTIVE To determine the prevalence of isolated sonographic CBD dilation in emergency department (ED) patients with cholecystitis or choledocholithiasis without laboratory abnormalities or other pathologic findings on biliary ultrasound. METHODS We conducted a retrospective chart review on two separate ED patient cohorts between June 2000 and June 2010. The first cohort comprised all ED patients undergoing a biliary ultrasound and subsequent cholecystectomy for presumed cholecystitis. The second cohort consisted of all ED patients receiving a biliary ultrasound who were ultimately diagnosed with choledocholithiasis. Ultrasound data and contemporaneous laboratory values were collected. Postoperative gallbladder pathology reports and endoscopic retrograde cholangiopancreatography (ERCP) reports were used as the criterion standard for final diagnosis. RESULTS Of 666 cases of cholecystitis, there were 251 (37.7%) with a dilated CBD > 6 mm and only 2 cases (0.3%; 95% confidence interval [CI] 0.0-0.7%) of isolated CBD dilation with an otherwise negative ultrasound and normal laboratory values. Of 111 cases of choledocholithiasis, there were 80 (72.0%) with a dilated CBD and only 1 case (0.9%; 95% CI 0.0-2.7%) with an otherwise negative ultrasound and normal laboratory values. CONCLUSION The prevalence of isolated sonographic CBD dilation in cholecystitis and choledocholithiasis is <1%. Omission of CBD measurement is unlikely to result in missed cholecystitis or choledocholithiasis in the setting of a routine ED evaluation with an otherwise normal ultrasound and normal laboratory values.
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Affiliation(s)
- Brent A Becker
- Department of Emergency Medicine, York Hospital (Wellspan Health), York, Pennsylvania
| | - Eric Chin
- Department of Emergency Medicine, San Antonio Uniformed Service Health Education Consortium, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Eric Mervis
- Department of Emergency Medicine, University of California, Irvine, Orange, California
| | - Craig L Anderson
- Department of Emergency Medicine, University of California, Irvine, Orange, California
| | - Masaru H Oshita
- Department of Emergency Medicine, Kaiser Permanente South Sacramento, Sacramento, California
| | - J Christian Fox
- Department of Emergency Medicine, University of California, Irvine, Orange, California
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A focus on acute cholecystitis and acute cholangitis. JOURNAL OF ACUTE DISEASE 2012. [DOI: 10.1016/s2221-6189(13)60019-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Barbosa ABR, Souza LRMFD, Pereira RS, D'Ippolito G. Espessamento parietal da vesícula biliar no exame ultrassonográfico: como interpretar? Radiol Bras 2011. [DOI: 10.1590/s0100-39842011000600010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
O objetivo desta revisão é fornecer auxílio na interpretação correta do espessamento das paredes da vesícula biliar e seus possíveis diagnósticos diferenciais. O espessamento da vesícula biliar é um achado frequente em exame de ultrassonografia e um tema de grande interesse, por ter sido considerado durante muito tempo como sinal específico de colecistite aguda, apesar de se reconhecer que ocorre em uma série de outras situações clínicas. A adequada caracterização e interpretação desse achado é de grande importância, pois o diagnóstico correto tem impacto direto no tratamento, que em alguns casos inclui intervenção cirúrgica. Neste artigo procuramos apresentar um conjunto de sinais ultrassonográficos que, associados ao quadro clínico e laboratorial do paciente, permitem restringir as alternativas diagnósticas e estabelecer, com maior precisão, a causa do espessamento parietal da vesícula biliar, através de uma avaliação racional dos dados obtidos.
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Privette TW, Carlisle MC, Palma JK. Emergencies of the Liver, Gallbladder, and Pancreas. Emerg Med Clin North Am 2011; 29:293-317, viii-ix. [DOI: 10.1016/j.emc.2011.01.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Gore RM, Thakrar KH, Newmark GM, Mehta UK, Berlin JW. Gallbladder imaging. Gastroenterol Clin North Am 2010; 39:265-87, ix. [PMID: 20478486 DOI: 10.1016/j.gtc.2010.02.009] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The treatment of gallbladder disease has been revolutionized by improvements in laparoscopic surgery as well as endoscopic and radiologic interventional techniques. Therapeutic success is dependent on accurate radiologic assessment of gallbladder pathology. This article describes recent technical advances in ultrasonography, multidetector computed tomography, magnetic resonance imaging, positron emission tomography, and scintigraphy, which have significantly improved the accuracy of noninvasive imaging of benign and malignant gallbladder disease. The imaging findings of common gallbladder disorders are presented, and the role of each of the imaging modalities is placed in perspective for optimizing patient management.
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Affiliation(s)
- Richard M Gore
- Department of Radiology, NorthShore University Health System, Evanston, IL 60201, USA.
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