GALLBLADDER

the gallbladder stores what

bile

diameter of GB should be:

< 4cm

longitudinal of normal GB should be:

< 10cm

normal gb wall thickness should be:

< 3mm

cystic duct should be how long?

4 cm long

CHD DIAMETER

<4MM

CBD DIAMETER

6MM

• prolonged fasting, hyperalimentation therapy, or with obstruction of the gallbladder.

• May be asymptomatic

• Gravity dependent

• Prominent GB size

• Some gallbladders may be so packed with this

• Occasionally found in the common duct.

• slowly resettle as the patient changes their position

• abnormal finding because either a functional or a pathologic abnormality exists when calcium bilirubin or cholesterol precipitates in bile

• will not present with gallbladder wall thickening or internal vascularity

• may also be seen in combination with cholelithiasis, cholecystitis, and other biliary diseases.

Sludge

• increased Serum amylase / alkaline phosphatase

• positive Murphy sign

• fever

• leukocytosis

• found 3x more frequently in females than males over 50, but it has a similar incidence in higher age groups

• Abnormal LFTs

• gb wall >3mm

• Distended gallbladder lumen >4 cm

• Gallstones

• Pericholecystic fluid collection

Acute Cholecystitis

• Repeated episodes of acute cholecystitis

• ≥ Serum amylase

• Abnormal LFTs

• No significant tenderness

• Symptoms are often milder and may only occur during or after meals (due to gallbladder contraction).

Chronic Cholecystitis

is the most common form of gallbladder inflammation.

Chronic cholecystitis

# 1 Pt. c/o RUQ pain, this image looked the same in both supine and LLD positions. Name the pathology

Cholesterolosis showing multiple cholesterol polyps

1. Left Hepatic Vein      
2. Portal Vein       

3. Common Bile Duct    

4. Cystic Duct
5. Neck      

6. Body       

7.Fundus               

8. Inferior Vena Cava (IVC)

Septations within Gallbladder

HINT: FEVER, positive murphys sign

Acute cholecystitis

• Affects more elderly men ; 50% of patients are diabetic

Emphysematous Cholecystitis

all patterns of acute cholecystitis

• severe right upper quadrant pain, fever, leukocytosis, and elevated bilirubin and alkaline phosphatase

• severe and potentially life-threatening complication of acute cholecystitis

• result of prolonged infection leading to necrosis of the gallbladder. It is breakdown of the gb wall and the presence of exudates, hemorrhage, and necrotic tissue.

• may cause complications like pericholecystic abscesses or peritonitis.

• Gallstones or fine gravel occur in 80% to 95% of patients.

  This echogenic material has the following three characteristics

  • Does not cause shadowing

  • Is not gravity-dependent

  • Does not show a layering effect

Gangrenous Cholecystitis

• Is the acute inflammation of the gallbladder in the absence of cholelithiasis

• Is most likely caused by decreased blood flow through the cystic artery

• Conditions that produce depressed motility (e.g., trauma, burns, postoperative patients, HIV, etc.) may precede development

• Extrinsic compression of the cystic duct by a mass or lymphadenopathy may also cause this condition.

• Clinically, the patient has a positive Murphy’s sign.

Acalculous cholecystitis

• Single, large gallstone or multiple tiny stones

• Often asymptomatic

• Other factors include pregnancy, diabetes, oral contraceptives, hemolytic diseases, diet-induced weight loss, and total parenteral nutrition (TPN)

• After a fatty meal, the gallbladder contracts to release bile; if the outflow tract is blocked by gallstones, then pain results. RUQ Pain, nausea, and vomiting.

• The pain can last up to 6 hours

• Patients often fall under the category of the “five Fs”: fat, female, forty, fertile, and fair

  
  LAB WORK:

• AST/ALT MAY BE NORMAL

• Elevated bilirubin

• Acute Elevated amylase

• Elevated ALP

• Abnormal LFTs

Cholelithiasis

different patterns of cholelithiasis

what is this showing

Cholelithiasis w Floating Stones

• Rare occurrence - calcium incrustation of the gallbladder wall.

• often in older female patients over 60

• Associated with gallstones, a form of chronic cholecystitis

• Significance: 25% of these patients will develop cancer on the gallbladder wall.

• Bright echogenic echo is seen in the region of the gallbladder with posterior shadowing.

• The differential will include a packed bag or WES sign.

Porcelain Gallbladder

• Benign condition that involves a hyperplastic change in the gallbladder wall.

• Exaggeration of normal invaginations of the luminal epithelium (called Rokitansky-Aschoff sinuses)

• Cholesterol Crystals, Mucosal Hyperplasia, Muscular Thickening, Papillomas

• The lesion remains immobile

• No Acoustic Shadow

• Artifact: comet tail

Adenomyomatosis

what is another name for this ?

packed bag

phrygian cap

black: cystic duct

white: valves of heister

sigmoid gallbladder or junctional folds

HINT: NO FEVER

Cholelithiasis

sludge

Adenomyomatosis

artifact: comet tail

porcelain gallbladder

Adenocarcinoma

Cholelithiasis showing multiple small floating and

nonfloating gallstones

Choledochal Cyst

Wall Echo Shadow “WES” Sign

1. Portal Vein                          

2. Common Bile Duct

3. Gallbladder                         

Pathology: Choledocholithiasis

Caroli’s Disease

patterns of sludge

biliary diagram

arrow is pointing to?

CBD

hartmann’s pouch

double gallbladder

arrow: MLF

curved arrow: portal vein

arrow: CBD

curved arrow: CBD

arrow: HA

what doesnt catch color

Common Bile Duct doesn’t catch COLOR

Small echogenic Adenoma in GB

what plane is this and what is it showing

SAG - CBD

what plane is this?

transverse

what are the arrows pointing to?

cystic duct

On this sagittal image, the hepatic artery (HA) is shown anterior to the common duct (CD)

the most common cause of this occurs from persistent obstruction of the cystic duct or gallbladder neck by an impacted gallstone.

Acute Cholecystitis

is the most common disease of the gallbladder

Cholelithiasis

is the most common form of gallbladder inflammation.

Chronic cholecystitis

the most common pseudotumor of the gallbladder

Cholesterol polyps

rare and is nearly always a rapidly progressive disease, with a mortality rate approaching 100%.

associated with cholelithiasis in about 80% to 90% of cases

It is twice as common as cancer of the bile ducts and occurs most frequently in women 60 and older

the most common sonographic appearance of the soft tissue mass is a heterogeneous solid or semisolid echo texture.

Gallbladder Carcinoma

two types of Caroli disease: the simple classic form and the more common form associated with

periportal hepatic fibrosis.

The most common cause of biliary ductal system obstruction is the presence of a

tumor or thrombus within the ductal system

Most common cause is the presence of a tumor or thrombus within the ductal system.

Process may be found in the extrahepatic or intrahepatic ductal pathway.

Obstruction of biliary ductal system is diagnosed by ultrasound when the sonographer finds the presence of ductal dilation.

This finding is called “too many tubes” or “shotgun” sign when intrahepatic ducts are dilated.

Biliary Obstruction

the most common cause for this obstruction is malignancy or adenopathy at this level.

Suprapancreatic Obstruction

Intrahepatic duct stones are less common than

common bile duct stones.

This incidence is uncommon, and the frequency increases with age. The most common risk factor in the Western world is primary sclerosing cholangitis.

Cholangiocarcinoma:

Most cholangiocarcinomas are adenocarcinomas, followed by squamous carcinomas.

The tumors are further divided into subtypes: sclerosing, nodular, and papillary. Nodular sclerosing tumors are the most common.

second most common primary malignancy of the liver.

An increased incidence of this tumor has risen over the past two decades, secondary to an increasing number of patients with liver cirrhosis and hepatitis C infection.

Intrahepatic Cholangiocarcinoma.

the most common tumor sites that can spread to the biliary system are from the

breast, colon, or melanoma.

The most common primary malignancy of the gallbladder is

Adenocarcinoma

Distension (hydrops) of the gallbladder but showing what?

sludge with hydrops

• Rare, primarily congenital

• More common in women than in men (4:1)

• Higher incidence in infants than adults

• linked with gallstones, pancreatitis, or cirrhosis, cholangitis
  
  Symptoms

• Abdominal mass

• Pain

• Fever

• Jaundice

• increased BILIRUBIN

• Diagnosis may be confirmed with a nuclear medicine hepatobiliary scan

Type I is a fusiform dilation of the common bile duct is Most common, along with type Iva

Choledochal Cysts

• rare and primarily limited to cystadenoma and cystadenocarcinoma.

• frequently in middle-aged women whose clinical presentation includes abdominal pain or mass or jaundice or both (if the mass is near the porta hepatis).

Sonographic:

• Cystic mass with multiple septa and papillary excrescences

• Mass may show variations in this pattern and appear as unilocular, calcified, or multiple.

• Lesion may be associated with dilation of the intrahepatic ducts.

Differential: hemorrhagic cyst or infection, echinococcal cyst, abscess, or cystic metastasis.

Intrahepatic Biliary Neoplasms

• A very rare condition found more often in older women

• gallbladder twists along its long axis

• mobile gallbladder with a long suspensory mesentery

• symptoms resembling acute cholecystitis, such as severe right upper quadrant pain, fever, and nausea.

Sonographic:

• Gallbladder massively inflamed and distended

• Cystic artery and cystic duct may become twisted

• if twisted more than 180 degrees, then a risk of gangrene exists. Surgical intervention is the treatment.

Torsion of the Gallbladder

• Rare complication of acute cholecystitis

• Affects more elderly men ; 50% of patients are diabetic

• gas-forming bacteria in the gallbladder wall and lumen with extension into the biliary ducts

• bright echo with comet-tail artifact or the WES sign

• gallstones may not be present in 30% to 50% of patients

• higher risk of perforation, its a surgical emergency.

• fatal in 15% of patients

Emphysematous cholecystitis (showing ct scan too)

• Rare congenital abnormality most likely inherited in an autosomal recessive fashion.

• Communicating cavernous ectasia of the intrahepatic ducts characterized by congenital segmental saccular cystic dilation of major intrahepatic bile ducts.

• Found in the young adult or pediatric population;

• may be associated with renal disease or congenital hepatic fibrosis

symptoms

Recurrent cramplike upper abdominal pain, secondary to biliary stasis, ductal stones, cholangitis, and hepatic fibrosis.

Two types of Caroli’s disease

• Simple classic form

• More common form associated with periportal hepatic fibrosis

Caroli’s Disease (medullary sponge kidney) is strongly associated

Transverse and longitudinal scan of a young patient with a choledochal cyst (Ccy) in the right upper quadrant.

• Localized cystic dilation of the common bile duct

• Diverticulum from the common bile duct

• Invagination of the common bile duct into the duodenum

• Dilation of the entire common bile duct and the common hepatic duct

4 pics of Choledochal Cysts

what is this disease associated with…this is carolis disease

MEDULLARY SPONGE KIDNEY

another name for hilar cholangiocarcinoma

Klatskin tumor

• is uncommon cause for extrahepatic biliary obstruction as a result of an impacted stone in the cystic duct, which creates extrinsic mechanical compression of the common hepatic duct.

• Patient presents with painful jaundice.

Mirizzi Syndrome

Carcinoma of the head of the pancreas with obstruction of the common bile duct (CBD) is demonstrated

Dilated intrahepatic ducts secondary to a mass in the area of the porta hepatis.

• Stones within the common bile duct (CBD)

• Primary choledocholithiasis occurs when calcium stones form de novo. This can result from conditions that cause bile duct strictures or dilation, leading to bile stasis. Examples of diseases linked to primary choledocholithiasis include:

  • Sclerosing cholangitis

  • Caroli disease

  • Parasitic infections

  • Chronic hemolytic diseases

  • Prior biliary surgery

• Secondary choledocholithiasis involves stones migrating from the gallbladder into the common bile duct. This form is typically associated with calculous cholecystitis (gallbladder inflammation due to stones).

Symptoms

• Increased direct bilirubin

• Leukocytosis

• Increased alkaline phosphatase

• Abnormal liver enzymes

Choledocholithiasis

• May be identified as Oriental sclerosing cholangitis.

• Other forms include AIDS cholangitis and acute obstructive suppurative cholangitis.

• Patients have malaise and fever, followed by sweating and shivering, right upper quadrant pain, and jaundice.

• In severe cases, patient is lethargic, prostrate, and in shock.

• Laboratory values show leukocytosis and an elevation of serum alkaline phosphatase and bilirubin.

Cholangitis

• Disease is caused by the parasitic roundworm, Ascaris lumbricoides, which uses a fecal-oral route of transmission.

• The worms may be 20 to 30 cm long and 6 cm in diameter.

• The worms grow in the small bowel before entering the biliary tree through the ampulla of Vater.

• Cause acute biliary obstruction

• may be symptomatic or have biliary colic, pancreatitis, or biliary symptoms.

• 

Ascariasis

• the second most common primary malignancy of the liver

• Incidence of this tumor has risen, secondary to increasing number of patients with liver cirrhosis and hepatitis C infection.

• These tumors are often unresectable with a poor prognosis.

Intrahepatic Cholangiocarcinoma

• specific type of cholangiocarcinoma

• jaundice, pruritus, and elevated cholestatic liver parameters.

• Begins in the right or left bile duct and then extends into the proximal duct and distally into the common hepatic duct and contralateral bile ducts.

• Tumor may extend outside of the ducts to involve the adjacent portal vein and arteries.

• Chronic obstruction leads to atrophy of the involved lobe.

• Majority of patients die within 1 year of diagnosis

• isolated intrahepatic duct dilation.

Hilar Cholangiocarcinoma

• Is difficult to distinguish from hilar cholangiocarcinoma; progressive jaundice is seen in the majority of patients.

• Tumor mass may be sclerosing or polypoid.

• Tumor spread in the superior ductal system and extrahepatic area should be carefully evaluated.

• May extend into the adjacent lymph nodes.

Sonographic findings

• Sclerosing tumor is nodular with focal irregular ductal constriction and wall thickening.

• Has a hypoechoic and hypovascular appearance with poorly defined margins

Distal Cholangiocarcinoma

Metastases to the Biliary Tree 

Result from pancreatic juices refluxing into the bile duct because of an connection of the pancreatic duct into the distal common bile duct, causing duct wall abnormality, weakness, and outpouching of the ductal walls

Choledochal Cysts

• Benign neoplasms that have a lower premalignant potential compared to colonic adenomas.

• typically solitary lesions

• to be pedunculated, meaning they are attached by a stalk

• Smaller adenomas are generally homogeneously hyperechoic

• Larger adenomas tend to become more heterogeneous

Adenoma of GB

what is this showing?

Choledocholithiasis

what are these pics showing?

Cholesterol polyps

What is the most common benign tumor of the gallbladder?

Cholesterol polyps