US 422 Abdomen Ultrasound II- Week 3

Gallbladder and Biliary System

What are common clinical symptoms of gallbladder disease?

(RUQ) abdominal pain, N/V, right shoulder pain, jaundice

What is sludge?

thickened bile

Sludge frequently occurs from _________________.

bile stasis

Common reasons for sludge:

prolonged fasting, hyperalimentation therapy, obstruction

What measurement is considered a thickened gallbladder wall?

< 3 mm

intrinsic causes of gallbladder wall thickening

cholecystitis, gallbladder perforation, sepsis, hyperplastic cholecystosis, carcinoma, AIDS cholangiography, sclerosing cholangitis

extrinsic causes of gallbladder wall thickening

hapatitis and cirrhosis, hypoalbuminemia, renal failure, right heart failure, ascites, multiple myeloma, portal node lymphatic obstruction

What is cholecystitis?

an inflammation of the gallbladder

different forms of cholecystitis:

acute or chronic, acalculous, emphysematous, gangrenous

What is the most common cause of acute cholecystitis?

gallstones

What is the clinical presentation of acute cholecystitis?

RUQ pain, positive Murphy’s sign, fever, leukocytosis, increased serum bilirubin and alkaline phosphate levels

What are complications of acute cholecystitis?

emphema, emphysematous or gangrenous cholecystitis, perforation

What are sonographic findings of cholecystitis?

• gallbladder wall thickening

• distended gallbladder lumen >4 cm

• gallstones

• positive Murphy’s sign

• increased color Doppler flow

• pericholecystic fluid collection

Emphysematous cholecystitis is rapidly progressive and fatal in ___% of patients.

15

Gangrenous cholecystitis is a serious, painful complication of acute cholecystitis that may lead to ___________________.

perforation

Gangrenous cholecystitis occurs after a prolonged infection, which causes the gallbladder to undergo ____________.

necrosis

With gangrenous cholecystitis, gallstones or fine gravel occur in what percentage of patients?

80% to 95%

The common echo feature of gangrene is the presence of diffuse medium to coarse ____________________________ filling the gallbladder lumen in the absence of bile duct obstruction.

echogenic densities

Acalculous cholecystitis is the acute inflammation of the gallbladder in the absence of _____________________.

cholelithiasis

Acalculous cholecystitis is most likely caused by decreased blood flow through the _______________.

cystic artery

Conditions that produce depressed motility may precede the development of _____________________.

acalculous cholecystitis

Torsion of the gallbladder is more often found in _______________________.

older women

Torsion of the gallbladder present typical of _____________________.

acute cholecystitis

Sonographic findings of gallbladder torsion.

inflammation and distention, cystic artery and cystic duct may be twisted

If the gallbladder becomes twisted more than 180 degrees, then a risk of _______________exists.

gangrene

What is the most common form of gallbladder inflammation?

chronic cholecystitis

Chronic cholecystitis is the result of:

numerous attacks of acute cholecystitis with subsequent fibrosis of the gallbladder wall

With chronic cholecystitis, patients may present with some ____________, but not the tenderness experienced with acute cholecystitis.

transient RUQ pain

What is the most common disease of the gallbladder?

cholelithiasis

What is cholelithiasis?

dingle, large gallstone or multiple tiny stones

______________ are the most dangerous because they can enter the bile ducts and obstruct the outflow of bile.

Tiny stones

What are the “five F’s” of cholelithiasis?

fat, female, forty, fertile, fair

What are other risk factors of cholelithiasis?

pregnancy, diabetes, oral contraceptive use, hemolytic diseases, diet-induced weight lodd, total parenteral nutrition

With cholelithiasis, patients may be asymptomatic until a stone lodges in the _______ or ______________.

cystic; common duct

RUQ pain with radiation to the shoulder after a high-fat meal is a typical presentation for

cholelithiasis

Porcelain gallbladder is a rare occurrence that is defined as:

calcium incrustation of the gallbladder wall

Porcelain gallbladder is associated with _____________ in the majority of patients.

gallstones

T/F Porcelain gallbladder occurs more often in older female patients.

true

What percent of porcelain gallbladder patients will develop cancer on the gallbladder wall?

25%

What are two types of hyperplastic cholecystits?

cholesterolosis and adenomyomatoasis

Hyperplastic cholecystits is represented by a variety of degenerative and proliferative changes of the gallbadder such as:

hyperconcentration, hyperexcitability, and hyperexcretion

What is cholesterolosis?

a condition in which cholesterol is deposited within the lamina propria of the gallbladder

Cholesterolosis is associated with cholesterol stones in ____ % to ____% of patients.

50; 70

Cholesterolosis is also referred to as a ____________.

strawberry gallbladder

What are polyps?

small, well-defined soft-tissue projections connected by the stalk to the gallbladder wall

A small percentage of patients with cholesterolosis will show _______________.

cholesterol polyps

What is adenomyomatosis?

a hyperplastic change in the gallbladder wall

With adenomyomatosis, ____________ may occur singly or in groups and may be scattered over a large part of the mucosal surface of the gallbladder.

papilomas

________________ of the gallbladder is rare and is nearly always a rapidly progressive disease with a mortality rate approaching 100%

Primary carcinoma

Gall bladder carcinoma is associated with cholelithiasis in approximately ____% to ____% of patients.

80; 90

Gallbladder carcinoma occurs most frequently in women _____ years of age.

> 60

Gallbladder carcinoma arises in the _____ of the gallbladder, or rarely in the cystic duct.

body

The tumor infiltrates the gallbladder locally or diffusely and causes a __________ and _________ of the wall.

thickening; rigidity

What are choledochal cysts?

congenital, focal, or diffuse cystic dilation of the biliary tree

T/F Choleduchal cysts are more common in men than women.

false

Choledochal cysts may be associated with:

gallstones, pancreatitis, cirrhosis

Symptoms of choledochal cysts include: abdmominal mass, pain, fever, jaundice

Choledochal cysts Type I

a fusiform dilation of the CBD

What is the most common type of choledochal cyst

Type I and IVa

Type I Choledochal cysts are associated with a ____________ between the distal bile duct and the pancreatic duct.

long common channel (> 20 mm)

Choledochal cysts Type II

true diverticuli of the bile ducts

Choledochal cysts Type III

confined to the intraduodenal portion of the CBD

Choledochal cysts Type IVa

intrahepatic and extrahepatic biliary dilations

Choledochal cysts Type IVb

confined to the extrahepatic biliary tree

Choledochal cysts Type V

classified as Caroli’s disease

What is Caroli’s Disease?

a rare congenital abnormality most likely inherited in an autosomal recessive fashion

Caroli’s Disease is most commonly found in the ________ or ____________ populatoin.

young adult; pediatric

Caroli’s disease symptoms include:

recurrent cramp-like upper abdominal pain, secondary to biliary stasis, ductal stones, cholangitis, hepatic fibrosis

Cystic disease of the kidney is strongly associated with _________________.

Caroli’s disease

What are the two types of Caroli’s disease?

• simple classic form

• more common form associated with periportal hepatic fibrosis

Differential diagnosis for Caroli’s disease:

polycystic liver disease

Caroli’s disease

The common hepatic duct has an internal diameter of ______mm. A duct diameter of ____mm is borderline, and __ mm requires further investigation.

<4; 5; 6

The CBD is considered borderline if it measures ___ mm. It is considered dilated if it is ___ mm.

>6; 10

The normal CBD should measure less than _____ mm.

3

The most common cause of biliary obstruction is the presence of a __________ or _________ within the ductal system.

tumor; thrombus

What three conditions cause the majority of biliary obstruction at the level of the distal duct and cause the extrahepatic duct to be entirely dilated?

pancreatic carcinoma, choledocholithiasis, chronic pancreatitis with stricture formation

Where does suprapancreatic obstruction originate?

between the pancreas and the porta hepatis

The most common cause for suprapancreatic obstruction is _______ or ___________ at this level.

malignancy; adenopathy

Porta hepatis obstruction is usually the result of a __________.

neoplasm

With patients with obstruction at the level of the porta hepatis, ultrasound will show ______________ ductal dilation and a normal _______________.

intrahepatic; common duct

With porta hepatic obstruction, _______ of the gallbladder may be present.

hydrops

What is cholangiocarcinoma?

a rare malignancy that originates within the larger bile ducts

What is a Klatskin tumor?

a specific type of cholangiocarcinoma that can occur at the bifurcation of the common hepatic duct, with involvement of both the central left and right ducts

What is the most suggestive sonographic feature that indicates cholangiocarcimona?

isolated intrahepatic duct dilation

Klatskin tumor

What is Mirizzi syndrome?

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

Patients with Mirizzi syndrome may present with _______________.

painful jaundice

On ultrasound, an intrahepatic ductal dilation is seen with a ________________ and a ______________ in the neck of the gallbladder or cystic duct.

normal-size common duct; large stone

What is primary choledocholithiasis?

the de novo formation of calcium stones in the bile duct

What diseas can the primary choledocholithiasis stones result from?

sclerosing cholangitis, Caroli’s disease, parasitic infections, chronic hemolytic diseases, prior biliary surgery

_________________ denotes the majority of stones in the common bile duct have migrated from the gallbladder.

Secondary choledocholithiasis

The main cause of hemobilia is _____________ secondary to percutaneous biliary procedures or liver biopsies.

biliary trauma

Other causes of hemobilia:

cholangitis, cholecystitis, vascular malformations, abdominal trauma, malignancies

hemobilia clinical findings:

pain, bleeding, jaundice

hemobilia sonographic appearance:

• depends on length of time the blood has been present

• acute hemorrhage will appear as fluid with low-level internal echoes

• look for blood clots that may move in the duct with extension into the gallbladder

What is pneumobilia?

air within the biliary tree secondary to biliary intervention, biliary-enteric anastomoses, or CBD stents

acute abdomen pneumobilia may be caused by:

• emphysemaotous cholecystitis

• inflammation from an impacted stone in the CBD

• prolonged acute cholecystitis, which may lead to erosion of the bowel

pneumobilia sonographic findings:

• air in the bile ducts appears as bright, echogenic linear structures that follow the portal triads

• posterior dirty shadow and reverberation artifact is seen

• movement of tiny air bubbles with a change in the patient’s position should be noted

What is cholangitis?

inflammation of the bile ducts