Implications of Ultrasound Mismatch: A Novel Case Report of Discrepancy between Bedside Versus Formal Biliary Ultrasound

Ultrasound (US) is the gold standard imaging modality utilized to diagnose biliary disease. Point of care (POC) US in the emergency department (ED) can and has played an integral role in assessing patients for biliary disease to accelerate care. We report a case where bedside US in the ED was used as an important aspect of the patient's initial work up. Our case involves a 29 year-old female who presented to the emergency department with skin jaundice and sclera icterus. The patient had a history of liver transplant for hepatoblastoma at age 22 months, and was advised to come to the ED when her primary care physician noticed elevated liver enzymes on a routine lab check. When presenting to the emergency department, the patient denied any abdominal pain or nausea, but was experiencing dark colored urine and tan colored stools. Due to the suspicious nature of the patient's symptoms and history of present illness, a POC US in the ED was done which demonstrated a dilated common bile duct (CBD) secondary to visible stone, however the follow up complete abdominal ultrasound in the radiology suite subsequently was negative for pathology. Ultimately the patient received a magnetic resonance cholangiopancreatography (MRCP), demonstrated a gallstone in the common bile duct and reaffirmed the findings on POC US. The gallstone was removed and the patient received a revision of her hepaticojunostomy. This case demonstrates pathology recognized by the POC US performed in the ED, that was absent on radiology US, suggesting a transient and dynamic change in the gallstone's positioning within the duct.