Billiary/ gallbladder

Which ducts unite to form the common hepatic duct

right and left hepatic ducts

unites at the porta hepatis

which are parts of biliary system: Gallbladder, CBD, CD, PV, CHD

The portal vein is part of the venous system, not the biliary tree.

What is the correct sequence of bile flow from the liver to the duodenum?

Right/left hepatic ducts → common hepatic duct → cystic duct → common bile duct → ampulla of Vater → duodenum

In the porta hepatis (Mickey Mouse appearance), which structure lies anterior and lateral to the portal vein?

The common bile duct

hepatic artery lies anterior and medial

sphincter of Oddi does what functions

It controls the flow of bile into the duodenum.
The sphincter of Oddi surrounds the ampulla of Vater and regulates bile flow into the duodenum.

What two ducts come together to form the CBD

The cystic duct and CHD

At the porta hepatis, which structure is anterior and lateral to the portal vein?

CBD

Which of the following best describes the location of the gallbladder?

The gallbladder sits anterior to the right kidney, medial to the right lobe of the liver, in the main lobar fissure.

The fundus of the gallbladder normally projects:

The fundus often extends just beyond the liver margin and contacts the anterior abdominal wall at the 9th costal cartilage.

The cystic duct connects with what and has what valve?

The cystic duct connects with the common bile duct and has the Spiral Valve of Heister.

The common bile duct meets what duct and has what valve?

The common bile duct (CBD) joins the main pancreatic duct (duct of Wirsung) to form the ampulla of Vater, which opens into the second part of the duodenum under control of the sphincter of Oddi.

1⃣ “What is the normal diameter of the common bile duct in an adult?”

common bile duct in an adult is typically up to 6 mm. diameter goes up to 10mm when older.

3⃣ “Which of the following measurements would indicate a thickened gallbladder wall?”

Greater than 3mm

4⃣ “Hydrops of the gallbladder refers to:”

→ ✅ Gallbladder transverse diameter >4 cm due to bile or mucus distension.

→ ✅ Gallbladder transverse diameter >4 cm due to bile or mucus distension.

4mm

common measurement of CHD

less than or equal to 4mm

2⃣ “What feature within the cystic duct helps prevent kinking?”

The spiral valve of Heister.

3⃣ “Why is the cystic duct difficult to see sonographically?”

It is a long, narrow, and often tortuous structure, making it challenging to visualize during an ultrasound.

location of gallbladder

anterior to RT kidney and transverse colon

Posterior to abdominal wall

medial to RT love of liver

Lateral to duodenum

What are parts of gallbladder

Fundus, body, and neck

The three parts of the gallbladder, from distal to proximal, are:

fundus, body, and neck.

The gallbladder fundus typically contacts which structure?

Diaphragm

On ultrasound, the gallbladder neck is found:

Following the main lobar fissure from the right portal vein

What is the size of normal gallbladder- length, transverse, and wall thickness

Length: 7-10cm

Diameter: 2.5-4 cm

Wall thickness: less than/ equal to 3mm

2⃣ The normal gallbladder measures approximately:

C. 7–10 cm long and 2.5–4 cm wide

3⃣ A gallbladder that measures 11 cm long and 5 cm wide with a thin wall would be described as:

Answer: C (Hydrops = overdistended GB)

4⃣ The gallbladder wall should always be measured:

On the anterior wall where it’s perpendicular to the sound beam

A gallbladder wall thicker than 3 mm can be caused by all except

A. Acute cholecystitis
B. Hepatitis
C. Congestive heart failure
D. Portal hypertension
E. Fasting

Answer: E (fasting makes the GB distend, not thicken)

Phrygian Cap definition

A Phrygian cap is a variant anatomical shape of the gallbladder where the fundus is folded back on itself, resembling a hat, often found incidentally during imaging studies.

Septated Gallbladder

Thin internal partitions dividing the lumen partially or completely

Congenital/ due to inflammation

Usually benign

Septated gallbladder- sonographic appearance

Thin echogenic lines within lumen.

may lead to sludge formation

Stones are most likely to lodge in which gallbladder variation?

Hartmann's pouch or neck of the gallbladder.

A Phrygian cap is considered:

A normal anatomic variant

A gallbladder embedded within the liver tissue is termed:

Intrahepatic gallbladder

A 47-year-old female presents with right upper quadrant pain and nausea after fatty meals. Ultrasound shows a distended gallbladder with a single echogenic focus lodged near the gallbladder neck, producing posterior shadowing. Which normal variant best explains the typical location of the obstruction?

Hartmann's pouch

The description (“stone at neck with shadowing”) fits this perfectly.

“A patient with RUQ pain after eating greasy food and a positive Murphy’s sign most likely has which of the following?

Cholecystitis (acute)

Jaundice is a clinical sign that suggests involvement of which biliary structure?

Common Bile duct obstruction

Which symptom is most characteristic of biliary disease?

Severe abdominal pain RUQ after fatty meal

A patient presents with jaundice, dark urine, and pale stools. These findings most likely indicate:

obstructive jaundice due to bile duct obstruction.

A patient with painless jaundice and a palpable, distended gallbladder likely has:

Courvoisier's sign indicating pancreatic cancer.

Which symptom is least specific for biliary disease?
A. Nausea
B. Vomiting
C. RUQ tenderness
D. Shoulder pain
E. Lower abdominal cramping

E. Lower abdominal cramping is least specific for biliary disease but may occur due to other conditions.

What are the main functions of the gallbladder

Reservoir for bile, concentration of bile, ejection of bile, and regulation of bile flow

Does gallbladder make bile?

No, the liver produces bile, which is then stored in the gallbladder.

What does the gallbladder do to the bile

The gallbladder stores and concentrates bile, releasing it into the small intestine during digestion.

Absorbs water and electrolytes which makes it more concentrated

How does the gallbladder regulate bile flow

Coordinates with sphincter of Oddi to control the release of bile into the duodenum.

The primary function of the gallbladder is to

store and concentrate bile.

Which hormone stimulates gallbladder contraction after a fatty meal?

Cholecystokinin (CCK)

After cholecystectomy, which of the following occurs?

Gallbladder regenerates in 6 weeks

The mucosal folds that help concentrate bile in the gallbladder are called:

Honeycomb folds

Which statement about bile secretion is TRUE?
A. Bile production stops when the gallbladder is full.
B. Bile salts stimulate the liver to produce more bile.
C. The gallbladder produces bile salts.
D. Bile is secreted only during digestion.
E. Bile enters the stomach for fat digestion.

B. Bile salts stimulate the liver to produce more bile.

After cholecystectomy, bile:

continues to flow directly from the liver to the intestine as the gallbladder is no longer present to store it.

bile reaches the duodenum via CBD and enters the ampulla of vater then the dudenum.

After removal of the gallbladder, what happens to the sphincter of Oddi?

Loses tonus and remains focused. allows free flow of bile from liver to duodenum.

Following cholecystectomy, what is considered a normal diameter of the common bile duct?

Up to 8 mm in adults. or 10mm

A 65-year-old woman is post-cholecystectomy. Ultrasound shows a 9-mm CBD with no stones or obstruction. Her liver tests are normal, and she is asymptomatic. What should the sonographer conclude?

Normal — physiologic dilation after gallbladder removal

What is Sludge

Thickened bile

happens when bile stagnates

causes of sludge

Bile stasis

stones in cystic duct, tumor

critical illness

does sludge move?

yes, if something doesnt move think polyp or tumor

Is sludge reversable?

yes when underlying cause is resolved

On ultrasound, biliary sludge typically appears as:

Low-level echoes that layer and move with patient position

Which of the following may cause bile sludge formation? Select all that apply:
A. Prolonged fasting
B. Total parenteral nutrition (TPN)
C. Hyperdynamic gallbladder contraction
D. Cystic duct obstruction
E. Pregnancy

all except C

“Tumefactive sludge” refers to:

Mass-like clumps of sludge that may mimic tumors

Causes- intrinsic of gallbladder wall thickening

a.       Acute and Chronic Cholecystitis

b.       Gallbladder carcinoma

c.       Adenomyomatosis

d.       Grangrenous

e.       Gallbladder perforation

extrinsic causes of gallbladder wall thickening

a.       Hepatitis/ Cirrhosis

b.       Congestive Heart failure

c.       Hypoalbuminemia (low protein)

d.       Ascites

e.       Sepsis

f.        Portal hypertension

g.       Systemic disease

Normal variations of gallbladder

Phrygian Cap, Septate gallbladder, Hartmann’s pouch, partial or complete septation.

What measurement would the there be gallbladder wall thickening

>3mm

Gallbladder wall thickening greater than 3 mm is considered abnormal. Which of the following is an intrinsic cause?
A. Hepatitis
B. Cirrhosis
C. Acute cholecystitis
D. Congestive heart failure
E. Ascites

C. Acute cholecystitis

Diffuse gallbladder wall thickening without tenderness in a patient with ascites and low albumin most likely results from:

A. Acute cholecystitis
B. Hypoalbuminemia
C. Adenomyomatosis
D. Emphysematous cholecystitis
E. Carcinoma

B. Hypoalbuminemia

Which condition is least likely to cause gallbladder wall thickening?
A. Portal hypertension
B. Congestive heart failure
C. Prolonged fasting
D. Acute cholecystitis
E. Cirrhosis

Answer: C (Fasting distends the GB but doesn’t thicken the wall.)

On ultrasound, which feature best supports inflammatory wall thickening rather than systemic edema?
A. Absence of pericholecystic fluid
B. Positive Murphy’s sign and hyperemia
C. Smooth, symmetric wall layers
D. Normal bile ducts
E. Lack of stones

Answer: B (Positive Murphy's sign and hyperemia indicate inflammation.)

Which extrinsic cause produces GB wall thickening by increasing venous pressure?
A. Hepatitis
B. Congestive heart failure
C. Hypoalbuminemia
D. Cirrhosis
E. Sepsis

Answer: B (Congestive heart failure leads to increased venous pressure, causing gallbladder wall thickening.)

Which of the following is not a potential complication of acute cholecystitis?
A. Gangrenous cholecystitis
B. Emphysematous cholecystitis
C. Hydrops
D. Perforation
E. Phrygian cap

Answer: E (Phrygian cap is a variant anatomical shape, not a complication.)

The most common cause of gallbladder perforation is:

Gangrenous cholecystitis

The most common cause of acute cholecystitis is:

Gallstones lodged in the cystic duct or Hartmann’s pouch

Which of the following is the hallmark clinical sign of acute cholecystitis?
A. Courvoisier’s sign
B. Boas’ sign
C. Murphy’s sign
D. Cullen’s sign
E. Rovsing’s sign

C. Murphy’s sign

4⃣ Which lab pattern supports the diagnosis of acute cholecystitis?

Elevated white blood cell count, alkaline phosphatase, and bilirubin levels.

Which physiologic event initiates pain during a biliary attack in acute cholecystitis?

Gallbladder contraction against an obstructed cystic duct

A patient’s labs show marked leukocytosis, mild bilirubin elevation, and normal AST/ALT.

A patient’s labs show marked leukocytosis, mild bilirubin elevation, and normal AST/ALT.
What does this pattern suggest?
A. Acute cholecystitis without CBD obstruction
B. Viral hepatitis
C. Choledocholithiasis
D. Cirrhosis
E. Acute pancreatitis

Answer: A
Marked WBC ↑ = infection; mild bilirubin ↑ = partial obstruction; normal liver enzymes rule out hepatitis.

what is classic triad of acute cholecystitis

Distension, stone, murphy sign

Which of the following findings would indicate a complication of acute cholecystitis rather than the uncomplicated form?

Gas within the gallbladder wall

Which finding best differentiates chronic from acute cholecystitis?
A. Presence of gallstones
B. Wall thickening >3 mm
C. Pericholecystic fluid
D. Contracted gallbladder with negative Murphy’s sign
E. Distended gallbladder with hyperemia

D. Contracted gallbladder with negative Murphy’s sign. This finding is indicative of chronic cholecystitis.

A “packed bag” or “WES sign” is characteristic of

Wall- echo- shadow= wall of GB, Echo from stones, shadow posteriorly indicating gallbladder obstruction.

4⃣ Chronic cholecystitis most often results from:

repeated episodes of acute cholecystitis or prolonged irritation due to gallstones.

Which of the following is least characteristic of chronic cholecystitis?
A. Thick, fibrotic wall
B. Distended gallbladder
C. Gallstones
D. Negative Murphy’s sign
E. Normal WBC count

B. Distended gallbladder. This finding is typically associated with acute cholecystitis rather than chronic cholecystitis.

Ultrasound of chronic cholecystitis

small, thick, fibrotic GB with stones, negative Murphy’s sign

Gallstone in cystic duct (Hartmann’s pouch)

Gallbladder inflames (acute cholecystitis)

Gallstone in Common bile duct

Bile backs up, cannot drain into duodenum and bilirubin levels rise.

Jaundice

Gallstone in Ampulla of Vater (CBD+ pancreatic duct junction)

Bile and pancreatic blockage (pancreatitis) may lead to jaundice and abdominal pain.

Gallstones in gallbladder only (not obstructing ducts)

Bile may thicken or form stones but drains normally (asymptomatic)

Gallbladder torsion is most often seen in

Elderly women with a mobile gallbladder

The primary sonographic finding in torsion of the gallbladder is:
A. Small, contracted gallbladder with shadowing stones
B. Floating, massively distended gallbladder without stones
C. Non-shadowing echogenic foci within the lumen
D. Air in the wall with dirty shadowing
E. Dilated intrahepatic bile ducts only

B. Floating, massively distended gallbladder without stones

Torsion of the gallbladder differs from acute cholecystitis in that:
A. It usually involves multiple gallstones
B. It presents with painless jaundice
C. It occurs in elderly patients with a mobile gallbladder and no stones
D. It has no risk of necrosis
E. It can be treated with antibiotics alone

C. It occurs in elderly patients with a mobile gallbladder and no stones

The key difference between cholelithiasis and acute cholecystitis is:

Gallbladder wall thickening and positive Murphy’s sign

A patient has recurrent mild RUQ pain after fatty meals, multiple gallstones, and a contracted, thick-walled gallbladder with a negative Murphy’s sign. Which diagnosis best fits?
A. Acute cholecystitis
B. Chronic cholecystitis
C. Cholelithiasis only
D. Porcelain gallbladder
E. Adenomyomatosis

B. Chronic cholecystitis