Ch: 8 Gallbladder and Biliary System

Physiology: Functions of the Gallbladder

concentrates and stores bile, regulates biliary pressure, and contracts after eating

Physiology: what causes the gallbladder to contract

the secretion of CCK (cholecystokinin). could be after fatty food enters small intestine, or by IV CCK injections (for patients who are TPN (total parenteral nutrition))

Physiology: steps/process of bile do duodenum

food enters small intestine and CCK is secreted, the gb contracts and sphincter of Oddi relaxes. bile is released into the cystic duct, flows through the CBD, and enters the duodenum

Normal Variants/locations of the Gallbladder

mobile, ectopic (on the left, midline, transversely), in RLQ, partially or totally embedded in liver parenchyma, in abdominal wall or falciform ligament, in retroperitoneum, or above the liver

How common are Congenital Anomalies of the Gallbladder and when do they occur

They are rare and most occur between 4-12 gestational weeks

Congenital anomaly symptoms

the anomalies alone do not give rise to any characteristic symptoms but some defects do predispose to bile stasis (flow of bile is slowed or stopped) and attacks of cholecystitis

What is septate gallbladder and how is it found

Congenital anomaly. The gallbladder normally develops from cannulation of a blind sac (hepatic diverticulum), but septum forms if that is not complete.

it is often found incidentally

Septate gallbladder sonographic appearance

single septum appears as thin, linear echo

WHat can mimic septate gallbladder and how to differentiate

Simple junctional fold (gb is partially folded over itself) may mimic a septum. junctional fold will most likely shift when patient is rolled, unlike septate which will remain.

What is Biliary Atresia and where is it most commonly found

Congenital Anomaly. Destruction of extrahepatic biliary system and its the most common type of obstructive biliary disease in infants and young children

what percent of neonates have transient jaundice and when does it indicate serious abnormality, and where does it commonly come from

more that 50% have transient jaundice, but if a neonate has persistent or sudden onset jaundice after 1-2 weeks of life, that may indicate serious abnormality

Where does jaundice commonly come from in neonates

biliary atresia or neonatal hepatitis

What sex is biliary atresia commonly found

2x more common in males

What sex is neonatal hepatitis commonly found

4x more common in females

How can biliary atresia be repaired and its outcome

surgically with liver transplant or Kasai procedure (uses portion of small intestine as extrahepatic duct system).

outcome is better with early surgical intervention

Complications of untreated biliary atresia

cirrhosis, cholangitis (inflammation of intrahepatic ducts), portal HTN, failure of biliary drainage

2 sonographic indicators seem with biliary atresia

Portal HTN and small GB

What is/what causes a Choledochal Cyst

A congenital weakness of duct walls which results in cyst formation, or angulation of CBD causing partial obstruction leading to dilatation and cyst formation

Choledochal Cyst symptoms

Intermittent jaundice with colicky pain, failure to thrive, or palpable subhepatic mass displacing stomach or duodenum

What sex is Choledochal Cyst more common in

4x more common in females

Why is surgical management of Choledochal Cyst recommended

Due to increased incidence of malignant transformation

Choledochal Cyst sonographic appearance

localized cystic mass separate from GB in region of porta hepatis, and may be intrahepatic (adjacent to bile duct).

Must verify peristalsis to avoid mistaking fluid-filled bowel for a cyst (if there is movement, its most likely bowel appearing cystic)

What is biliary sludge

An acquired disease that represents precipitates (cholesterol depostis, calcium salts) formed in bile and settles in the gb.

Pathogenesis of biliary sludge

uncertain

Biliary sludge causes/associations and precursor for what

comes from stagnant bile, periods of prolonged fasting, total parenteral nutrition (TPN), pregnancy, or rapid weight loss.

May also be associated with other complications that can be a precursor for GB disease

Biliary sludge symptoms

Can produce pain bc gb is trying to contract with thick “mud like” material inside

Biliary sludge Sonographic appearance

homogeneous, non-shadowing echo pattern, often forms a fluid-fluid level that remains constant in sagittal and tranverse images, and a gb filled with sludge can be difficult to distinguish from adjacent liver parenchyma

What is fluid-fluid level

When sludge in gb has division of where anechoic fluid is and sludge area is by distinct line

What is Tumefactive sludge and why use color doppler

not layered sludge, has more mass appearance (sludge ball).

color doppler will help differentiate sludge ball from other pathologies/abnormalities bc sludge ball will be avascular

What is cholelithiasis and how common is it and what they contain

An acquired disease. gallstones, and they are very common. majority of calculi contain mixture of cholesterol, bilirubin, and calcium

Cholelithiasis size and quantity

size varies, could be small or large (small are more dangerous bc there easier to cause blockages)

they could be single or multiple

Cholelithiasis symptoms

Could be asymptomatic or experience RUQ pain, N/V, right shoulder or back pain

Cholelithiasis prevalence and risk factors

More prevalent in females.

most common risk factors are female, obesity, age, pregnancy, or diabetes but could also be from TPN, ethnicity, cirrhosis, or crohns disease

Cholelithiasis sonographic appearance

mobile, gravity dependent, echogenic with posterior enhancement, and small stone are typically multiple and described as gravel and mostly lay on posterior wall with shadowing

Non-mobile structures

polyps, impacted stones, or stones adherent to gb

Cholelithiasis: Wall-Echo-Shadow Triad (WES)

LOOK BACK AT SLIDES IDK

What is Acute Cholecystitis and what does it result from/in

An acquired disease with swelling/irritation of the gb.

up to 25% of cases result from impacted stones with gb neck or cystic duct.

may result in necrosis, ulceration, swelling, or edema.

Acute Cholecystitis symptoms

RUQ pain or palpable mass, positive murphy sign (pain with pressure), N/V, or abdominal distention, fever, and/or jaundice

Acute Cholecystitis lab values

can be non-specific. things to look for include leukocytosis (elevated WBC), hyperbilirubinemia, or elevated ALP

Acute Cholecystitis surgical intervention or what is done if surgery isn’t an option

leads to fewer complications. poor surgical candidates will receive IV antibiotics or gb drainage

What percent of Acute Cholecystitis cases resolve spontaneously

about 60%

Acute Cholecystitis Sonographic appearance

gb wall thickening, gallstones, pericholecystic fluid (fluid around gb), hydropic gb (distended gb filled with mucous, water, or fluid other than bile from prolonged blockage of cystic duct)

color doppler detects hyperemia

Complications of Cholecystitis

empyema (build up of pus in/around gb), gallbladder perforation (tear in gb wall and bile leaks into peritoneal cavity and cause biloma), or gangrenous (from necrosis or infection) or Emphysematous cholecystitis (gas buildup)

What is Acute Acalculous Cholecystitis and where is it commonly found

An acquired disease. its acute cholecystitis with no gallstones present. common in ICU patients

What is Acute Acalculous Cholecystitis a result of

stagnant bile and vascular changes. stagnant bile leads to overdistension of gb and vascular changes may lead to thrombosis of vessels supplying gb.

Acute Acalculous Cholecystitis causes

long term TPN, trauma, or surgery

Acute Acalculous Cholecystitis Symptoms

May be non specific but typically could experience RUQ pain, positive murphy sign, N/V, abdominal distention, or fever.

The difficulty diagnosing yields high morbidity and mortality

Acute Acalculous Cholecystitis sonographic appearance

GB distended, thickened wall, internal debris or sludge, pericholecystic fluid and/or edema

What is Chronic Cholecystitis and Associated Conditions and what to patients tend to have intolerance to

An acquired disease of recurrent inflammatory changes in GB secondary to infection, obstruction, or metabolic disorders. this is often associated with stones, and patients tend to have intolerance to fatty foods

Chronic inflammation of GB wall results in what

thickening and fibrosis (tough/hardened wall which is harder to contract)

Chronic Cholecystitis and Associated Conditions clinical clues

N/V, RUQ pain, or jaundice

Chronic Cholecystitis and Associated Conditions Sonographic clues

look for gallstones, evenly thickened walls, smaller GB, and decreased response to CCK

What is porcelain gallbladder and where is comes from and what it can cause

occurs when all parts of GB wall is calcified. It is a rare manifestation of chronic cholecystitis and is associated with high incidence of GB carcinoma

Porcelain gallbladder sonographic appearance

Single echogenic line representing calcified wall. All parts of the wall may be calcified and could have posterior shadowing that would obscure the GB

What measurement is considered thickening of Gallbladder wall

>3mm

Intrinsic causes of gallbladder wall thickening

Something within the GB or a condition of the GB that causes thickened wall.

Acute cholecystitis, Chronic cholecystitis, Gangrenous cholecystitis, Emphysematous cholecystitis, Adenomyomatosis, Polyp, Gallbladder carcinoma: primary or metastatic, or Gallbladder torsion

Extrinsic causes of gallbladder wall thickening

Non-GB related issue that may have side effects/complications that result in wall thickening.

Right-sided heart failure, Alcoholic liver disease, Hepatitis, AIDS, Sepsis, Hypoalbuminemia, Renal failure, Ascites (benign), Multiple myeloma, Portal node lymphatic obstruction, Systemic venous hypertension, or Gallbladder wall varices

Physiologic causes of gallbladder wall thickening

contracted gallbladder after eating

What is Cholestasis and Pregnancy relevance

Acquired disease where flow of bile from the liver is reduced or blocked. intrahepatic cholestasis occurs in 2nd+3rd trimester and resolves after delivery

What can the mother present with, with Cholestasis

pruritus (itchy skin), elevated ALP, serum transaminase (ALT), and bile acid

Severity/risks of cholestasis for mother and baby

for the mother, its a benign condition

the fetus is at risk for prematurity (delivered prematurely), dysrhythmia (irregular heartbeat), distress, or intrauterine death

What is a Gallbladder Polyp

Acquired benign neoplasm that is a fix, non-mobile mass extending from GB mucosa (inner lining)

What is gallbladder polyp caused by

chronic inflammation, hyperplasia of GB wall, or lipid deposits

What can present as a polyp

early stages of GB cancer

When should polyps be removed

When they are >1cm because they are suggestive of malignancy

Gallbladder polyp symptoms and associations

They are typically found incidentally and asymptomatic. there are no associations with age, gender, obesity, etc.

Gallbladder polyp sonographic appearance

Echogenic small masses along the GB wall

How common is Gallbladder Carcinoma and who is effects

it is an acquired malignant neoplasm and its rare and affects women >72 years old

Gallbladder carcinoma risk factors

Chronic cholecystitis, cholelithiasis (approx. 95% of cases), rapidly growing polyps, or porcelain gallbladder (approx. 25% of cases)

Survival rate of Gallbladder carcinoma

5 year survival rate is <5%

Early stages of gallbladder carcinoma detectability and signs/symptoms

difficult to detect and patients may be asymptomatic or present with symptoms similar to cholecystitis. no lab value variances to assist early diagnosis

Late stages of gallbladder carcinoma findings

jaundice, malaise, and weight loss. by this point, cancer has grown/spread.

Gallbladder carcinoma sonographic appearance

Look for irregular shaped mass that replaces GB (GB looks filled with mass like structure), irregular wall thickening, direct invasion into liver, or gallstones surrounded by echogenic mass.

color doppler will demonstrate internal vascularity

Most common tumor to metastasize to GB

Melanoma

Metastasis to Gallbladder prognosis and association

has a poor prognosis and is not associated with cholelithiasis, which differs from primary GB cancer

Metastasis of Gallbladder sonographic appearance

asymmetric wall thickening and solitary or multiple masses in GB

Metastasis of Gallbladder treatment

cholecystectomy