Biliary/GB Pathology

Thickened bile (precipitation) consisting of cholesterol, calcium bilirubinate, and mucus that accumulates in the gallbladder

GB sludge

GB Slude etiology.

bile stasis

abnormal bile composition

Possible clinical implications of GB sludge.

May (not) lead to gallstones or cholecystitis.

No issues when isolated.

Predisposing factors of GB sludge.

1. pregnancy

2. cholecystitis

3. NL patients

4. IV therapy

5. Alcoholics

6. Impaired CCK or nerve innervations

7. Extrahepatic duct obstruction

8. Decreased GB contractility

9. Delayed gastric emptying

Sonographic features of GB sludge.

1. non-shadowing

2. low amplitude echoes

3. gravity dependent

4. layering effect

5. moves slowly

6. may form sludge balls (tumefactive sludge)

7. mimic neoplasm, blood, or pus

An echogenic, non-shadowing, round mass that does not layer and has slow mobility.

tumefactive sludge (ball)

Echogenic material in GB with peristaltic movement that disappears after several seconds.

Pseudo-sludge from adjacent bowel gas

How would you differentiate a sludge ball from a tumor or polyp?

a true sludge ball will show no flow with color doppler on, while a tumor or poly may show bascularity

Formation of stones within GB lumen, composed primarily of cholesterol, bile pigments, and calcium salts; most common GB disease

cholelithiasis (GB stones)

Cholelithiasis etiology.

Abnormal bile composition

Bile stasis

Infection

Predisposing factors to cholelithiasis.

female

forty

fat

fertile

flatulent

If duct obstruction/inflammation is present in cholelithiasis, what lab values are elevated?

↑ Alkaline phosphatase (ALP)

↑ Bilirubin

↑ AST/ALT

Signs and symptoms of cholelithiasis.

RUQ pain (biliary colic), may radiate to the right shoulder or scapula

Pain 1-2 hours after fatty meals

N/V

Food intolerance (esp. greasy/fatty foods)

May be asymptomatic

Sonographic features of cholelithiasis.

Hyperechoic

Posterior shadowing

Gravity dependent

WES sign if contracted around a large stone(s)

Very small stones that move rapidly relative to gravity; may cause faint shadowing

gravel stones

A contracted GB filled with large gallstones showing a thin hyperechoic line -> anechoic line -> hyperechoic line (stone surface) -> posterior shadowing.

WES sign

Low-calcium or high-cholesterol stones with poor shadowing; appear to float slightly in bile and are less dense

floating stones

When a stone becomes embedded in the neck og the GB, have the patient cough to dislodge it. This scenario is called a...

common false negative

Why are GB stones (cholelithiasis) clinically significant?

A. predispose to cancer

B. associated with cholecystitis and choledochal cystitis

C. causes obstructive jaundice

Treatment methods for cholelithiasis.

Low fat diet

Cholecystectomy

Medication to dissolve stones

Inflammation of the GB wall; can be caused by cystic duct obstruction from a gallstone

acute cholecystitis can also be without a stone (acalculous)

How many cases of acute cholecystitis are associated with gallstones?

95%

Lab results in acute cholecystitis

Same as stones

↑ White Blood Cells

Signs and symptoms of acute cholecystitis.

Same as stones

Fever/leukocytosis

Jaundice (if CBD is obstructed)

+ Murphy sign

Palpable RUQ mass

Sonographic appearance of acute cholecystitis.

NL GB but abnormal lab tests

Thickened walls

Abnormal AP

+ Murphy sign

Halo sign w/ pericholic fluid

Etiology of acalculous acute cholecystitis.

Men

Stagnant bile causing ischemia and inflammation

People with acalculous acute cholecystitis are prone to what?

necrosis and perforation

Factors that predispose to acalculous acute cholecystitis.

Sepsis

Trauma or burns

Shock

Dehydration

Massive transfusions

Prolonged fasting

Postsurgical complications

Crohn's disease

Hemolytic disorders

Etiology of Calculous Acute Cholecystitis (most common)

obstruction from stones

Which type of acute cholecystitis is being described:

Thick, edematous wall (halo sign), no stones visualized, pericholecystic fluid, hyperemic wall

acalculous acute cholecystitis

Which type of acute cholecystitis is being described:

elevated WBC and ALP tests, NL-sized GB, thin wall, mobile gallstone, + murphy sign

early acute cholecystitis

Name the following described complication of acute cholecystitis:

pus-filled GB

empyema

Name the following described complication of acute cholecystitis:

GB breaks down (necrosis) and results in no pain due to nerve damage.

gangrenous GB

Name the following described complication of acute cholecystitis:

localized/focal bacterial infection of the GB

abscess formation

Describe the sonographic appearance of a GB with an abscess.

enlarged

hypoechoic

inhomogenous

complex

irregular

thickened walls

Name the following described complication of acute cholecystitis:

gas-producing bacteria in wall/lumen that float to the top and cause a dirty shadow ("champagne sign")

emphysematous GB

Name the following described complication of acute cholecystitis:

A tear in the GB wall -> bile leakage in peritoneum

perforation/rupture GB

Name the following described complication of acute cholecystitis:

rare; GB twists on blood supply

GB torsion

What diagnosis may also mimic an enlarged GB wall?

1. pancreatitis

2. cholangitis

3. hepatitis