Mild intermittent right upper quadrant pain and jaundice.
The Gall Bladder
The gall bladder is more difficult to find when it is full of stones, and can often be mistaken for gas filled bowel.
The GB wall is usually evident and may have a little hypoechoic bile directly adjacent to it. Then the stones which abutt the wall are echogenic with posterior shadowing. Bowel tends to have a less obvious wall, does not have the hypoechoic bile, and the gas whilst it is echogenic then casts a dirty grey shadow rather than a clean black one.
The Common Bile Duct
Here the CBD is clearly seen in longitudinal section. Within the lumen are rounded echogenic opacities with posterior acoustic shadowing. This is choledocholithiasis.
Difficulty finding the gall bladder?
Has the patient had a cholecystectomy?
Has the patient just eaten (contracted gall bladder)?
Is the gall bladder filled with echogenic sludge / tumour / polyps / blood?
Is the gall bladder full of echogenic pus and debris with a thickened wall - cholecystits?
Is the gall bladder full of stones?
Is it a porcelain gall bladder?
Is there emphysematous cholecystitis?
Is the gall bladder is an unusual site?
Is the gall bladder congenitally absent?
Try the subcostal approach first, get the patient to take and hold deep breaths whilst exploring the inferior liver surface particularly between the caudate and right lobes of the liver. Do this in transverse and longitudinal approaches fanning as you explore. Lying the patient on their left side may bring the GB out from below the costal margin.
Next try a more lateral intercostal approach. At the level of the xiphisternum in the right midaxillary line place the probe longitudinally within the intercostal space. Direct the probe toward the left nipple and again fan the probe searching for the GB.
Another intercostal approach can be made again at the level of the xiphisternum, but this time in the right midclavicular line, with the probe oriented horizontally and directed directly down into the bed (assuming the patient is supine).