If there is an impacted stone and a sonographic Murphey's the patient should come in.

40yo male came into ED with severe RUQ pain 2 hours duration. Similar previous episodes, nil US, but this time the pain had woken him from sleep.
RUQ tender, but no guarding. 
He was afebrile with normal obs
WCC normal, normal LFTs and lipase. 

​ED US revealed: not dilated, a thick walled GB with a several mobile stones but one stone impacted in the neck of the GB

Gb long. hyper echoic stone near the neck. The GB wall is thick and has a hypo echoic middle layer which could be GB wall oedema.

On sitting the patient up, the larger stones fall to the funds, but the stones at the neck remain (impacted)
The patient also had a positive sonographic murphey's.

The patient was admitted to EGS and scanned by radiology in the morning. The subsequent scan showed a severely dilated GB with perforation. 


Without US, this patient may have been dc home...