Gallbladder and Biliary system pathology

Biliary obstruction/jaundice

abnormal build-up of bilirubin cause by intrinsic/extrinsic blockage along the biliary tree

• most common cause of cholelithiasis (gallstones)

what are the three types of biliary obstruction/jaundice

1. hepatic: hepatic disease (viral hepatitis)

2. hemolytic: destructive rbc disease (sickle cell anemia)

3. surgical: obstructive pathology of biliary tree (choledocholithiasis: stone within bile duct)

biliary obstruction/jaundice: symp and predisposing factors

• jaundice, itchiness, comes and goes RUQ pain, dark urine, blood in stools

• pancreatic head cancer, cancer of ampula of vater

biliary obstruction/jaundice: sono

• CBD greater than 7mm

• double barrel sign/ too many tube signs

cholecystitis

inflammation of GB, caused by obstruction

what are the two types of cholecystitis

acute: acute inflammation and obstruction

• calculus= 90-95% obstruction due to gallstones

• acalculus= 5-10% parasitic/bacterial of gb wall causing infarction

chronic: recurring symptoms/episodes of inflammation, GB contracts over time

cholecystitis: symp

Epigastric pain, pain post-prandial (after eating there’s pain), positive murphy’s sign

cholecystitis: sono

dilation of gb, wall thickening, irregular wall

what are the 3 complications of cholecystitis?

1. emphysematous cholecystitis

2. gangrenous cholecystitis

3. GB perforation

Emphysematous cholecystitis

complication of acute cholecystitis, GB wall ischemia and infection

who: Elderly males, 50% diabetic

Emphysematous cholecystitis- symp

• Abnormal LFT’s, positive murphy’s sign

Emphysematous cholecystitis: sono

thickened GB wall, ring down (comet tail) artifact

Gangrenous cholecystitis

complication of acute cholecystitis, tissue loss due to decreased blood supply

Gangrenous cholecystitis- symp

Abnormal LFT’s

Gangrenous cholecystitis: sono

• focal areas of hemorrhage and necrosis

• complex

• wall striations

GB perforations

complication of acute cholecystitis

GB perforations: complications

• peritonitis

• biliary fistula

Mirizzi Syndrome

extrahepatic, gallstone impacted in the neck of the GB or cystic duct exerting pressure on the adjacent CHD causing obstruction

Mirizzi syndrome- complications

• cholecystocholedochal fistula (opening that connects between gb and hepatic duct or CBD)

mirizzi syndrome- symp

• pain, fever

• associated with edema + inflammation

mirizzi syndrome- sono

• segmental stenosis of CHD

• dilated duct above level of stone + normal duct below

Courvoisier GB

enlarged, caused by pancreatic adenocarcinoma

Courvoisier GB- symp

• epigastric pain, weight loss, and jaundice

Courvoisier GB- sono

dilated CBD, and pancreatic head mass

Cholangitis

infection and inflammation of biliary ducts caused by stone, results in wall thickening - compromises the lumen

Cholangitis- symp and who

fever, jaundice, RUQ pain

*who: associated with inflammatory bowel disease*

Sludge (biliary sand)

viscous bile

sludge- symp

asymptomatic

sludge- sono

low level, non shadowing, moves with patients position

sludge ball (tumefactive sludge)

aggregated mass of sludge (clumps together)

sludge ball- symp

asymptomatic

sludge ball- sono

• transient (eventually will go away and be reabsorbed)

• mimics inflammatory or neoplastic process

pseudo sludge

partial volume effect of liver + anechoic bile, artifact

pseudo sludge- symp

none

pseudo sludge- sono

absent in center, does not change with patients position

WES (wall echo shadow)

GB completely packed with stones

WES- symp

asymptomatic early on, Right shoulder, back pain

WES- sono

2 echoic lines w post shadowing

Hydrops of GB

abnormal dilation due to obstruction of cystic duct by stone. Bile is reabsorbed and GB is filled with mucocele

hydrops of gb- symp

• asymptomatic early on

• palp RUQ mass

hydrops of gb- sono

• non inflammed gb

• distended

Adenomyomatosis

• outpouching of mucosa

• stones may accumulate in diverticula

adenomyomatosis symp

asymptomatic

adenomyotosis- sono

• non mobile echogenic foci

• comet tail artifact

Choledocholithiasis general

stones within bile duct

• mc in distal cbd

choledocothlitasis symp and who

• Biliary colic (pain that comes in waves)

• jaundice

• increase direct bilirubin

who: Increases with age

choledocholithiasis general- sono

• echogenic structure in the extrahepatic duct (stone)

• ductal dilation

Primary Choledocholithiasis

stones form within the bile duct ( think: the duct made the stone itself)

primary choledocholithiasis- symp

• jaundice

• biliary colic

• chills/fever

primary choledocholithiasis- sono

• echogenic structure IN the extrahepatic duct

• may have no gallstones

• biliary tree is dilated

secondary choledocholithiasis

stones pass from the gallbladder via cystic duct

secondary choledocholithiasis- sym

• jaundice

• biliary colic

• chills/fever

secondary choledocholithiasis- sono

• echogenic structure in the extrahepatic duct

• biliary tree dilated

GB polyps general

benign GB wall growth

What are the two types of polyps

1- focal: single polyp attached to gb by stalk

2- diffuse: multiple polyps

GB polyps general- symp

asymptomatic, sometimes dull epigastric pain

GB polyps general- sono

• non mobile echogenic foci

• no shadowing

Cholesterolosis (strawberry GB)

lipids (fats) are deposited in the GB wall

• tiny yellow specks of cholesterol macrophages against red bile

cholesterolosis- symp

• asymptomatic

• dull epigastric pain

cholesterolosis- sono

• non mobile

• distributed unevenly, echo masses vary in size

Adenoma

benign neoplasm of GB (maybe precancerous)

adenoma- symp

asymptomatic, dull epigastric pain

adenoma- sono

• non mobile

• solitary

• *wall thickening near polyp*

GB carcinoma and who

rare malignant neoplasm, high incidence of porcelain gb

who: female > males, 50-80 years

gb carcinoma- sono

• irregular solid mass in/around the gb

Cholangiocarcinoma

cancer of biliary tree within CHD or CBD

how is cholangiocarcinoma classified by?

its location

• intrahepatic

• hilar-klatskin

• distal

cholangiocarcinoma- symp and who

• elevated bilirubin

who: MC japan/thailand

cholangiocarcinoma- risk factors

• chronic biliary stasis

• inflammation

• biliary infection

cholangiocarcinoma- sono

solid mass inside biliary duct

Klatskin’s tumor

cholangiocarcinoma in the junction of the right and left hepatic ducts

klatskin’s tumor- symp

• elevated bilirubin

klatskin’s tumor- sono

intrahepatic biliary dilation NOT extrahepatic

Porcelain gb

calcification of gb wall

porcelain gb- symp and who

• asymptomatic

• associated with gallstones and gallstone symptoms

who: females> male. MC > 60 years

porcelain gb- sono

thickly calcified gb wall with shadowing

empyema of the gb

pus inside the gb

empyema of the gb- symp

same as acute cholecystitis (…) and fever

empyema of the gb- sono

atypical bile echoes seen in the gb

• and thickened gb wall

caroli’s disease ( communicating cavernous dilation)

congenital abnormality, non obstructive biliary dilation

caroli’s disease- symp and who

• stone formation

• sepsis

• biliary stasis

who: men= women, by the age of 30

associated with congenital hepatic fibrosis

caroli’s disease- sono

beaded appearance, intrahepatic ducts appear segmental + irregular dilated

biliary atresia

absence of the extrahepatic biliary tree

• bile builds up in liver

biliary atresia- symp and who

• suspected in infants with jaundice and alcoholic stools

who: infants, associated with situs inversus

biliary atresia- sono

only two vessels seen in portal triad (portal v and hepatic a)

choledochal cyst

congenital anomaly, cystic dilation of CBD/biliary tree

choledochal cyst- symp and who

• asymptomatic

• triad: jaundice, RUQ pain, and RUQ mass

who: MC in 20s, asian females, 33% from japan

choledochal cyst- sono

anechoic mass separate from GB in porta hepatis

• absent blood flow in mass

• cystic duct may be entering mass

pneumobilia

air in biliary tree results from biliary enteric fistula (connection between biliary tract and GI

• commonly associated with interventional radiology procedure

pneumobilia - symp

• cause due to biliary enteric by-pass procedure : asymptomatic

• cause due to infection: RUQ pain, fever abd distention

pneumobilia- sono

• echogenic linear foci

• located within the intrahepatic biliary tree

• motion with patient position

• * ring down artifact *