Gallbladder and Biliary System

what does the biliary system consist of?

consists of GB and associated (intrahepatic/extrahepatic) ducts

• right and left hepatic ducts

• common hepatic duct (CHD)

• cystic duct

• common bile duct (CBD)

CHD is the _____ portion of the biliary tree

proximal

CBD is the _____ portion of the biliary tree

distal

where is the GB “housed” or positioned?

GB fossa (indentation) on posteroinferior portion of RLL

what is the fossa closely related to?

main lobar fissure

anatomy of biliary tree

what organ stores bile?

gallbladder

bile

• GB bile is more concentrated than hepatic bile due to rugae (inward folds) which helps to absorb water and secrete mucus

• composed of mostly water and bile acids and other things like cholesterol, bilirubin, proteins, electrolytes, and mucus

what are the major components of bile secreted by the liver?

cholesterol and bilirubin

bilious emesis

throw up that has bile (green); may indicate biliary obstruction

what does the GB aid in?

digestion

GB digestive process

1. liver produce bile

2. bile travels through biliary ducts (through right and left hepatic ducts which forms CHD)

3. GB stores bile

4. fatty meal triggers release of CCK from duodenum

5. bile is released

6. sphincter of Oddi opens —> bile drains freely into duodenum

CCK

• short for cholecystokinin

• hormone secreted into blood from small intestine

• stimulates contraction of GB and pancreatic secretion of enzymes

SONO: gallbladder

• anechoic, pear-shaped structure

• bright echogenic walls

• GB wall <3 mm

  • measured from outer-to-outer

** if patient has cholecystitis or ascites, GB wall mey thick

SONO: ducts

• anechoic

• 2 echogenic walls

SONO: CHD

around 4 mm at RHV and RPV

SONO: CBD

dilated +1 mm per decade at MPV

** if patient has cholecystectomy, CBD my be enlarged

portal triad consists of what?

• portal vein (head)

• duct (right ear)

• hepatic artery (left ear)

Heister’s valve

• aka spiral valve of Heister

• tiny valves found within cystic duct

GB parts and info

• parts: neck (superior portion), body, and fundus (inferior portion; close to bowel)

• around 9 cm from neck to fundus

• GB >12 cm is considered hydrops

• holds up to 40 mL of bile

• supplied by cystic artery

what supplies the GB?

cystic artery

Courvoisier sign

indicates an extrahepatic mass compressing CBD —> GB hydrops

left hepatic artery (LHA)

supplies LLL and caudate lobe

right hepatic artery (RHA)

supplies RLL and branches into cystic artery

indications for imaging the GB

• RUQ pain

• positive Murphy sign on physical exam

• pain radiating to right shoulder

• jaundice or abnormal LFTs

• loss of appetite

• n/v

• intolerance to fatty foods or dairy products

scanning techniques and protocol for imaging GB

• curvilinear probe

• patient NPO for 6-8 hours

• breathing technique!! (full inspiration)

• image in SAG and TRANS (to show neck, body, and fundus)

• is there a + Murphy’s sign?

  • place transducer over GB and press

• image CBD with and without color to include MPV

• LLD/LLO to confirm mobility of abnormalities

normal variants

• Hartmann's pouch

• Phrygian cap

• junctional fold

• septations

• agenesis

Hartmann’s pouch

• aka infundibulum

• outpouching near GB neck

• small part of GB that lies near cystic duct where stones may collect

what is another name for Hartmann’s pouch?

infundibulum

phrygian cap

folding of GB fundus

junctional fold

fold at neck and body of GB

septations

• internal division(s) of GB—hyperechoic line

• goes all the way across

  • if not then it is likely a fold

• associated with cholelithiasis

agenesis

• congenital abnormality

• failure of GB to develop

GB sludge

• aka thickened bile

• results from bile stasis

• gravity dependent; slowly resettled upon LLD/LLO repositioning

• can cause stone formation, biliary colic (abdominal pain), acalculous cholecystitis, and pancreatitis

• SONO: non-shadowing, low-level internal echoes (echogenic)

sludge ball

• aka tumefactive sludge

• clumping of sludge

??

floating sludge

layering sludge

??

sludge ball

• larger than gallstone

• mobile; no shadowing

what should a normal GB wall thickness be?

less than 3 mm

causes of thickened GB wall

biliary

• cholecystitis

• GB carcinoma

• adenomyomatosis

• sclerosing cholangitis

• hyperplastic cholecystosis

non-biliary

• hepatitis

• cirrhosis

• ascites

cholecystitis

• inflammation of GB

• several forms:

  • acute

  • chronic

  • acalculous

  • emphysematous

  • gangrenous

acute cholecystitis

• MC cause is from gallstones in cystic duct or neck of GB

• MC in females over age of 50

• s/s: + Murphy’s sign, fever

SONO: acute cholecystitis

• + Murphy’s sign

• irregular wall > 3 mm

• gallstones usually present

• wall edema

• hyperemia due to inflammation

• pericholecystic fluid may be present

??

acute cholecystitis

• irregular, thickened wall

??

acute cholecystitis

• thickened GB wall

• pericholecystic fluid in anterior GB

• ?FF in posterior GB

chronic cholecystitis

• recurrent attacks of acute cholecystitis with fibrosis of GB wall

• s/s: neg. Murphy’s; RUQ pain but no tenderness

• SONO:

  • neg. Murphy’s sign

  • contraction of GB

  • stones

  • WES sign

acalculous cholecystitis

• uncommon

• due to decreased cystic artery flow

• inflammation of GB wall in absence of stone

• SONO:

  • + Murphy’s sign

  • wall > 4-5 mm

  • sludge within

emphysematous cholecystitis

• rare complication of acute cholecystitis

• MC in older men and diabetic patients

• gas forming bacteria in the GB wall with extension into ducts

• Surgical emergency—susceptible to perforation

SONO: emphysematous cholecystitis

• bright echoes along anterior GB wall with “ring down” or “comet tail” artifact

• gallstones may not be present

??

emphysematous cholecystitis

• “ring down” artifact

gangrenous cholecystitis

• necrotic GB due to prolonged infection

• s/s: painful

• SONO: thickened irregular edematous wall; pericholecystic abscess; perforations; echogenic densities that fill the lumen of the GB that has:

  • no shadow

  • not gravity dependent

  • no layering effect due to increased viscosity of the bile

??

gangrenous cholecystitis

cholecystectomy

removal of GB —>

• sphincter of Oddi loses tonus

• bile flows freely into duodenum (biloma)

• extrahepatic bile ducts dilate, up to 1 cm

what are some post complications of cholecystectomy?

• biloma

• stones

• abscess

??

biloma

comet-tail artifact

hyperechoic shadow with tapering “tail”

reverberation artifact

hyperechoic ladder-like lines

??

reverberation artifact

• shown in anterior GB

cholelithiasis

• aka gallstones

• MC disease of GB

• any size and quantity; tiny stones are most dangerous (can get stuck in infundibulum)

• reposition patient to note mobility

what are the risk factors for cholelithiasis?

five F’s (risk factors)

1. fat

2. female

3. forty +

4. fertile

5. fair

SONO: cholelithiasis

• twinkle artifact

• posterior shadow (due to refraction, impedance, intensity of the sound beam, and stone(s) size)

• WES (wall echo shadow)

  • indicative of a stone-filled GB (GB is a packed)

  • 3 arched-shaped line

  • shadow posterior to 3rd line

??

cholelithiasis

• calcified stones with posterior shadowing

??

cholelithiasis

• WES sign

??

cholelithiasis

• WES sign

??

twinkle artifact from stones

??

twinkle artifact from stone

??

floating stones along sludge layer

??

cholelithiasis

• tiny stones along sludge layer + ascites

polyp

• small, well-defined soft tissue projection adhering to GB wall

• SONO:

  • non-shadowing

  • non-mobile

??

porcelain gallbladder

• calcium incrustation of GB wall

• rare occurrence

• associated with gallstones

• MC in elderly female

• increased risk of GB carcinoma

• differential dx: WES sign

SONO: porcelain gallbladder

• bright echogenic echo in region of GB with posterior shadowing

• GB wall thickly calcified with shadowing

• Calcification may not include entire GB wall

??

porcelain gallbladder

hyperplastic cholecystosis

• overgrowth of GB wall —> degenerative and proliferative changes of GB

• 2 types: cholesterolosis and adenomyomatosis

cholesterolosis

• aka strawberry gallbladder

• mucosa resembles surface of a strawberry due to deposit of cholesterol in the lamina propria of the GB

• some patients may have cholesterol polyps

• SONO:

  • small, ovoid, well-defined soft tissue projections

  • no shadowing

  • fixed to wall

??

cholesterolosis

??

cholesterolosis

adenomyomatosis

• cholesterol crystals that settle within the Rokitansky-Aschoff sinuses of GB wall

• mucosal hyperplasia (thickening of muscular layer of GB wall); papillomas occur

• SONO: thickening of wall with internal cystic spaces

• echogenic foci on wall with “comet tail” artifact

??

adenomyomatosis

??

adenomyomatosis

adenoma

• benign neoplasms of GB

• SONO:

  • solitary

  • homogeneously hyperechoic

  • thickening of wall adjacent to adenoma indicative of malignancy

gallbladder carcinoma

• primary carcinoma is rare but have a mortality rate of 100%

• high association with cholelithiasis (in 80%-90% of cases)

• MC in women older than 60 y/o

• tumor arises in GB body

• GB tumor is usually columnar cell adenocarcinoma

SONO: gallbladder carcinoma

• heterogeneous or semi-solid soft tissue mass centered in the GB

• thickened and irregular wall

• adjacent liver heterogeneous due to invasion

• dilated biliary ducts (“bil-dil”)

??

gallbladder carcinoma

• heterogeneous mass in GB

• adjacent heterogeneous liver

??

gallbladder carcinoma

• GB mass —> “bil-dil”

choledochal cysts

• rare

• congenital, focal, or diffuse dilation of biliary tree

• MC in females with increased incidence in infants

• Todani and colleagues classify into 5 types (depending on location)

• Type 1 is MC

• associated with gallstones, pancreatitis, or cirrhosis

s/s of choledochal cysts

• abdominal mass

• pain

• fever

• s/s: jaundice, abdominal mass, pain, fever, jaundice

SONO: choledochal cysts

• cystic dilation of biliary tree

• appear as true cysts in the RUQ

what is another name for Type 5 choledochal cyst?

Caroli’s disease

Type 5 choledochal cysts

• aka Caroli’s disease

• congenital and rare, seen as intrahepatic duct dilation

s/s: Caroli’s disease

• pain

• cholangitis

• medullary sponge kidney

• hepatic fibrosis

• renal failure

SONO: Caroli’s disease

• multiple cystic structures in the track of ducts (in the area of the ductal system) that converge at portal hepatitis

• “Central dot” sign = dilated duct surrounding the adjacent HA and PV

  • one Mickey ear is bigger than the other

??

Type 5 choledochal cysts (Caroli’s disease)

??

Type 5 choledochal cysts (Caroli’s disease)

biliary ductal dilatation

• “bil-dil” is ductal dilation due to obstruction

SONO: “bil-dil”

• “shot gun” barrel appearance

• parallel to the PVs

• intrahepatic ducts >2mm

• extrahepatic dilation occurs before intra

??

biliary ductal dilatation (“bil-dil”)

choledocholithiasis

• stones in the duct

• primary choledocholithiasis

Starts from thBiliary Obstructione formation of calcium stones in the bile duct

Secondary choledocholithiasis

Indicates that the majority of stone in the duct have migrated (to duct) from GB

biliary obstruction

• MC cause is the presence of tumor or thrombus in the ductal system

• locations of obstruction:*

  • intrapancreatic obstruction

  • suprapancreatic obstruction

  • porta hepatic obstruction

intrapancreatic obstruction

• extrahepatic duct completely dilated

• three primary causes:

1. pancreatic carcinoma

2. choledocholithiasis

3. chronic pancreatitis with stricture formation