Gallbladder Pathology

Abdominal II

Clinical symptoms of gallbladder disease

fat intolerance or post-prandial pain

mid-epigastric pain

abdominal pain that radiates to the right shoulder

jaundice

chills and fever

nausea and vomiting

Sludge

thickened bile that occurs from stasis

Sludge is seen in patients who:

prolonged fasting

hyperalimentation therapy

GB obstruction

Sludge is ______ dependent and will ______ with patient position to the _____ border

gravity; move; posterior

Sludge on an ultrasound

low-level echoes layered in dependent part of the gallbladder

Sludge often turns into a _____

gall stone

NORMAL GB WALL THICKNESS

< 3 mm

MOST COMMON cause of acute cholecystitis

cholelithiasis (which leads to cystic duct obstruction)

Clinical signs of acute cholecystitis

acute RUQ pain

positive Murphy’s sign

fever

leukocytosis

Acute cholecystitis on ultrasound

increased color doppler flow

dilation of gallbladder (hydrops)

thickened wall

stones and sludge

pericholecystic fluid

“Halo sign” suggesting subserosal edema

If left untreated, acute cholecystitis can develop into:

emphysematous cholecystitis

gangrenous cholecystitis

Emphysematous cholecystitis

rare complication of acute cholecystitis associated with gas forming bacteria in the wall and lumen of the gallbladder

MORE COMMON demographic in which emphysematous cholecystitis occurs in

elderly men

diabetic patients

Emphysematous cholecystitis on ultrasound

if gas is present, prominent bright echo along the anterior wall

ring down or comet-tail artifact posterior to the echogenic structure

NO shadowing

Gangrenous cholecystitis

serious, painful complication of acute cholecystitis that may lead to a perforation (wall is rotting away)

on ultrasound, walls may be thickened and edematous, with focal areas of exudate, hemorrhage, and necrosis

Acalculous cholecystitis

acute inflammation with the absence of stones; uncommon

most likely caused by decreased blood flow through the cystic artery (plaque)

Acalculous cholecystitis on ultrasound

GB wall extremely thickened (>4-5 mm)

dilated GB

sludge

ascites

pericholecystic fluid

MORE COMMON to get torsion of the GB

rare condition with female prevalence; check blood flow!!!!!!

Torsion of the gallbladder can occur because of:

the way the mesentery stretches

MOST COMMON form of GB inflammation

chronic cholecystitis; results from multiple acute cholecystitis attacks

Clinical signs of chronic cholecystitis

RUQ pain - not as severe as acute cholecystitis

dull and irritating

Complications of a cholecystectomy

new or increasing pain

increased bile damage (dumping syndrome)

biliary leak or biloma formation

hemorrhage (decreasing hematocrit)

retained stone

WES

wall echo shadow

With cholelithiasis the GB wall ________ with bright _______ _________

thickens; posterior shadowing

MOST COMMON GB disease

cholelithiasis

Gallstones can consist of

small crystals or bile salts

cholesterol

Gallstone 5 F’s

fat

female

forty

fertile

fair-skinned

If you suspect a patient has stones;

put them in another position to prove that they move

Porcelain gallbladder

rare condition where there is a calcium incrustation of the GB wall

If you have a porcelain GB you are at risk for this;

GB cancer

Hyperplastic cholecystitis

two types: cholesterolosis and adenomyomatosis

represented by a variety of degenerative and proliferative changes

Cholesterolosis

condition where cholesterol is deposited within the lamina of the GB

Strawberry gallbladder

cholesterolosis

With cholesterol polyps:

there is usually muliple and they do not shadow

they grow off the wall - they WILL NOT move

small (<10 mm)

comet tail artifact may be present

MOST COMMON pseudotumor of the GB

cholesterolosis

Adenomyomatosis

hyperplastic change in the anterior gallbladder wall

papillomas may occur singly or in groups

Adenomyomatosis on ultrasound

soft tissue structure that arises from the gallbladder wall

does not move with change of patient position

comet-tail artifact

MOST COMMON benign GB tumor

adenoma

Adenomas appear as a ______ elevation, located in the _____ of the GB usually near the ______

flat; body; fundus

With an adenoma, if the GB wall is thickened adjacent to the adenoma;

malignancy should be suspected

Primary GB carcinoma is nearly always a rapidly _______ disease with mortality rate approaching ____%

progressive; 100

This is associated with gallbladder carcinoma in 80 to 90% of cases

cholelithiasis

Gallbladder carcinoma usually arises in the _____ and can infiltrate ______ or diffusely

body; locally

Along with gallbladder carcinoma, the _______ part of the liver is often invaded by the direct spread of the ______

adjacent; tumor

Metastatic cancer of the GB is usually a result of a ______ and is accompanied by ______ metastasis

melanoma; liver

MOST COMMON age for GB carcinoma

women age 60+

GB carcinoma symptoms

loss of appetite (anorexia)

fatty food intolerance

jaundice

belching

Gallbladder carcinoma on ultrasound

heterogeneous, solid mass

semisolid echo texture

wall abnormally thickened

double barrel shotgun sign

Choledochal cysts

group of diseases that manifests as congenital focal, or diffuse cystic dilation of the biliary tree

Why do choledochal cysts form?

possibly a result from pancreatic juices refluxing into the bile duct

irregular junction of the pancreatic duct into the distal common bile duct causing duct wall abnormality, weakness, and outpouching

String of pearls sign in the abdomen

choledochal cysts

Clinical signs of choledochal cysts

abdominal mass

pain

fever

jaundice

failure to thrive

Choledochal cysts may be associated with

gallstones

pancreatitis

cirrhosis

Caroli’s disease

communicating cavernous ectasia of intrahepatic ducts characterized by congenital segmental cystic dilation of major intrahepatic bile ducts

MOST COMMON type of choledochal cysts

Type V (Caroli’s disease)

Clinical signs of Caroli’s disease

cramp-like abdominal pain secondary to biliary stasis

ductal stones

hepatic fibrosis

Caroli’s disease on ultrasound

multiple cystic structures that converge toward the porta hepatis with absence of doppler signal

dilation of extrahepatic and CBD may be present

sludge or stones may be present

central dot sign

Caroli’s disease - dilated duct surrounding the hepatic artery and portal vein

CHD normal internal diameter

< 4mm

MOST COMMON cause of biliary obstruction

tumor

thrombus

Where to look when there is extrahepatic biliary obstruction

Pancreatic CA

choledocholithiasis

chronic pancreatitis with stricture

pancreas head (malignancy) or adenopathy

porta hepatis area

UNCOMMON CAUSE for extrahepatic biliary obstruction

Mirizzi syndrome

Mirizzi syndrome

results from an impacted stone in the cystic duct, which creates mechanical compression of the CHD

large stone should be visualized in the neck of the GB or cystic duct

Klatskin tumor

specific type of cholangiocarcinoma that can occur at the bifurcation of the CHD

nonunion of the right and left ducts

Stones tend to affect ________ ampulla which may lead to the stones entering the ________

Vater’s; duodenum

Clinical lab values of choledocholithiasis

direct bilirubin

alkaline phosphatase

leukocytosis

Hemobilia

caused by trauma secondary to a biliary procedure or liver biopsies

Clinical findings of hemobilia

pain

bleeding

jaundice

Pneumobilia

air in the biliary tree secondary to CBD stents, biliary intervention, or biliary-enteric anatomoses

Pneumobilia on ultrasound

bright echogenic linear structures that follow the portal triads

air bubble movement may be noted

Types of cholangitis

sclerosing

AIDS

acute obstructive suppurative

Causes of cholangitis

ductal strictures

parasitic and bacterial infections

stones and neoplasms

Cholangitis on ultrasound

CBD may show

smooth wall thickening

irregular wall thickening

** may be so thickened its difficult to visualize on ultrasound

Cholangiocarcinoma

neoplasm may arise from any portion of the biliary tree

typically adenocarcinoma arising from the epithelium of the bile ducts

Cholangiocarcinoma locations

intrahepatic (peripheral)

hilar (Klatskin’s)

distal

Clinical signs of cholangiocarcinoma

pruritus

jaundice

weight loss/anorexia

RUQ pain

biliary colic

Risk factors of cholangiocarcinoma

HX of primary sclerosing cholangitis

biliary stones

chronic inflammation

Where can tumors metastasize from to the CBD?

breast

colon

melanoma