Bedside ultrasound in an internal medicine department. Why?

A 74-year-old woman was admitted to the emergency department of her local hospital for fever and vomiting occurred three days before. There was no dyspnoea, but the patient was experiencing left shoulder pain with radiation to her left arm. Her past medical history included the endoscopic excision of a rectal polyp followed by transanal endoscopic microsurgery. Her labs showed neutrophilic leukocytosis (WBC 24000/mcl) and mild hypokalaemia; BNP levels were 428 pg/ml and blood troponin was 4,31 ng/ml. ECG changes such as ST-segment deviation or T-wave inversion were not observed: the patient was thus admitted to the internal medicine department with the diagnosis of Acute Coronary Syndrome. On her first day of hospital stay, the patients body temperature reached 38,5°C, inflammatory markers were elevated (RCP >25 mg/dl), while serial blood samples showed decreasing troponin levels and stenocardic pain was absent. However, the patient was experiencing pain in her right upper quadrant, where a mass of taut-elastic consistency could be palpated and Murphys sign was clearly positive; the abdomen was soft, but tender. The cardiothoracic examination was within normal limits, even though a chest X-ray revealed a consolidation at the superior right pulmonary lobe; the cardiac silhouette was not enlarged. A bedside abdominal ultrasound was performed, showing gallbladder hydrops and a double railway appearance of the gallbladders walls as an evidence of acute cholecystitis; luminal biliary sludge and intrahepatic bile duct dilatation were documented too. In order to check the hypothesis of Acute Coronary Syndrome, the patient underwent a thoracic ultrasound, which excluded signs of hypokinesia; EF, cardiac chambers size and diastolic function (assessed with Tissue Doppler Imaging) were within normal limits; there was no pleural effusion. At the ECG monitoring, ST-segment, T-waves and ventricular repolarization appeared normal. In the case of a suspected myocardial dysfunction supported by a severe sepsis, a broad-spectrum antibiotic therapy was set. The requested confirmatory diagnosis of acute cholecystitis (imaging ultrasound) was assessed by the radiologist on call (public holiday) by means of a further abdominal ultrasound and the surgical consult suggested the need for an urgent cholecystectomy. The patient was thus admitted to the surgery department and immediately underwent surgery for cholecystectomy. The macro- and microscopic histology report confirmed the diagnosis of acute gangrenous cholecystitis. This is an exemplary case to illustrate the utility of bedside ultrasound in internal medicine: in this specific contest, the whole diagnostic process took place in an internal medicine department on a public holiday and bedside ultrasound proved to be a valuable help in rebutting the first hypothesis (Acute Coronary Syndrome), confirming the most likely scenario of sepsis with myocardial dysfunction and early hepatic dysfunction (total bilirubin: 1,82 mg/dl, coagulation, renal function and SpO2 within normal limits; SOFA SCORE: 1) as a consequence of acute gangrenous cholecystitis.