Figure 6.

A 61-year-old male presented with abdominal pain, fever, rigors, and jaundice. Abdominal examination revealed tenderness and guarding in the right upper quadrant. The patient had no leukocytosis and his bilirubin was high (60 μmol/L). Serum amylase was normal. Point-of-care ultrasound examination (a) showed the presence of gall stones (white arrow) with a shadow (arrow heads), thickened wall of the gall bladder, normal diameter of the common bile duct (5 mm), and a normal pancreas. Magnetic resonance cholangiopancreaticography (b) showed a suspected filling defect in the distal end of the common bile duct (white arrow) with no significant dilatation. There was diffuse thickening of the wall of the gallbladder associated with multiple small gall stones. Laparoscopic cholecystectomy confirmed the presence of acute cholecystitis. The intraoperative cholangiogram was normal. (Point-of-care ultrasound study was performed by Professor Fikri Abu-Zidan)