GI 3 - Biliary pathology

Most normal biliary anomalies (3)

• Low insertion of cystic duct

• Aberrant right posterior duct

• Long common channel (pancreaticobiliary maljunction)

Name variant and the importance

Low insertion av cystic duct. Surgery needs to take extra care not to ligate common bile duct (choledochus / CBD)

Name variant and importance

Aberrant right posterior duct. Important to know if potential donor has this, as both right hepatic ducts require seperate anastomoses in recipient.

Name variant, the proper definition of the variant and assosiated conditions.

Long common channel (pancreaticobiliary maljunction). Defined as common duct >15 mm. Associated with choledochal cyst, biliary stricture and increase risk of biliary cancer.

What is the pathology and its risk factors?

Gallbladder stones. RF: female, obesity, pregnancy, middle-ages, diabetes.

Important differentials with ECHOGENIC FOCI in gallbladder lumen/wall?

• Stones - shadowing, mobile.

• Sludge - non-shadowing, mobile.

• Polyp - non-shadowing. immobile.

• Hyperplastic cholecystosis - multiple polyps

• Porcelain gallebladder - Calcification in gallbladder wall, causes shadowing.

• Nearby bowel - Bowel wall and “dirty” shadowing.

Name findings and diagnosis

Acute calculous cholecystis. Gallbladder wall thickening (>3 mm), hydrops, pericholecystic fluid and echogenic fat. Hyperemia in gallbladder wall mayb be present.

Calculous cholecystitis, name pathomechanism

Obstructing stone in infundibulum or d. cysticus →increased pressure in gallbladder → infection or inflammation

Name complications to acute cholecystitis

Emphysematous cholecystitis, gangernous/necrotizing cholecystitis, perforasion.

Name findings and suspected pathology

Inflammed gallbladder with no sure stones. Imaging suggests acalculous cholecystitis.

Which patients are at risk for acalculous cholecystitis and what is the suspected pathomechanism

Very sick pts, with certain exceptions (eg EBV). In general, pt with long stays at ICU, parenteral nutrition, trauma, sepsis. Suspected mechanism is biliary statis and hypoperfusion.

Name finding and diagnosis

Inflamed gallbladder with hyperechoic foci in gallbladder wall suspect of air. Sludge in lumen. Suspected diagnosis is emphysematous gallbladder

Etiology of emohysematous cholecystitis and at-risk patients.

Rare. Usually due to infection with gas-forming bacteria. Elderly diabetics are at risk.

What are imaging findings and what do you suspect

Distended inflamed gallebladder with irregular attenuation in gallbladder wall. Findings consistent with gangernous cholecystitis.

Pathomechanism of gangernous cholecystitis.

Increas intraluminal pressyre → ichemia in gallbladder wall→ necrosis → perforasjon end-point

List findings and diagnosis

Defect in gallbladder wall and free fluid. Findings consistent with gallbladder perforation with resultant biliary peritonitis.

Complication of SUBacute perforasion

Pericholecystic - or liverabscess.

Complication of CHRONIC perforasion

Cholecystoenteric fistula. Here a pt with gallebladder cancer

Name findings. What is a normal pitfall?

Image shows big stone, regognized by positive WES-triad (wall-echogenicity-shadow). Can be mistaken with porcelain gallbladder or air in lumen

Pathomechanism behind porcelain gallbladder

Chronic cholecystitis (chronic irritasion → supersaturated bile or recurrent biliary obstructions). Controversial assosiation with gallbladder carcinoma.

Name finding and pathology

Hyperechoic along gallbladder wall with some shadowing. This was a porcelain gallbadder. Porselensgalleblære. Can be difficult to differentiate from emfysematous gallbladder. No WES-triad so large stone unlikely.
Almost every pt with porcelain gallbladder have stones.

Diff.diagnosis in HYPERECHOGENICITY gallbladder wall

• Porcelain gallbladder

• Packet with stones / BIG stones (WES-triade)

• Emphysematous cholecystitis (intramural gass with “dirty shadowing”)

• Adjacent bowel (bowell wall with “dirty shadowing”)

Define Courvoisier gallbladder

Dilated gallbladder due to obstruction from malignant tumor. NO INFLAMMATION.
Can be due to obstructed cystic duct og CBD, last one may lead to dilated intrahepatic biliary tree.

Define hyperplastic cholecystosis

Non-neoplastic proliferation disordser resulting in deposition of holesterol-laden kke-neoplastis proliferasjonsforstyrrelser som et resultat av deposit av kolesterol-fylte makrophages in gallbladder wall. Primariliy composed of adenomyomatosis og cholesterolosis Some include polyps in these groups, if cholesterol based.

List findings and suspected diagnosis

Echogenic foci in gallbladder wall with “comet tail” artefact. Findings consistent with adenomyomatose.

Name MRI sequence and findings

T2 with fat suppression. Focal changes in fundus of gallbladder with high T2 signal. “Pearl necklace sign” - distribution, fitting with adenomyomatosis.

Mechanism of adenomyomatosis

Cholesterol deposits in mural Rokitansky-Aschoff sinuses in gallbladder wall. Can be diffuse or focal, typically in fundus if the latter. Focal findings might be difficult to differentiate from malignancy

Name findings and diagnosis

Hyperechoic structure seemingly adherrant to gallbladder wall. Findings consistent with polyp.

What are gallbladder polyps

Most of them benign cholesterol polyps, which are a part of hyperplastic cholecystosis.
RARELY may an individual polyp be a pre-malignant adenoma (<5%), there are the reason for controlls.

Name ris factors for malignancy in regards to gallbladder polyp

6 S-es:

• Size. >10 mm OR fast growth rate. CHOLECYSTEKTOMI!!

• Single. Singular is more suspect for malignancy

• Sessile (aka. broad based). Broad based polyp is suspicious of malignancy. Pedunculated polyps are usually benign.

• Stones. Gallbladder stones increase risk of (chronic) inflammation, and therefore malignancy.

• PSC. Increased risk of malignancy, and some are removed in these pt even if <10 mm.

• Sixty og above in age, increased risk of malignancy.

How often are the polyps controlled in Norway and the EU

Norge: If <10 mm, we controll these x1/year in 3 years. After 3rd controll, follow up ends.

EU: Imaging

How often are the polyps controlled in USA

Differenisal in diffuse thikening of gallbladder wall (>3 mm)

• Fluid overload/edema: Cirrhosis, heart failure, protein-wasting nephropathy.

• Inflammation, infection: Cholecystitis, hepatitis pankreatitis

• Infiltrating diseases: gallbladder cancer, metastases (rare)

• Post-prandial

Differenisal in focal thikening of gallbladder wall

• Hyperplastic cholecystosis: adenomyomatose, kolesterol polypper

• Vaskular: Varices:

• Neoplastic disease: Adenom-polypper, gallbladder cancer, adjacent liver cancer, metastasis (rare)

Differential in intraluminal contents WITHOUT shadowing

• Tumefactive sludge: mobile

• Blood/pus: mobile

• Polyp: immobile

• Cancer: immobile

Differential in increased echogenicity of gallbladder wall.

• Porcelain gallbladder

• Packed with stones (WES-triad)

• Emfysematous cholecystitis

MRCP primarily uses which sequences

T2. Fast-spin echo, incl with breathing techniques. May supply with contrast enhanced T1 sequence with fat saturation.

Choledocal cysts

Caroli disease

Choledocholithiasis

Mirizzi syndome

Pneumobilia

Biliary ductal dilation

Ascending cholangitis

PSC

PSC

PBC

AIDS cholangiopathy

Recurrent pyogenic cholangitis

Biliary cystadenoma / cystadenocarcinoma

Cholangiocarcinoma

Gallbladder carcinoma

Gallbladder metastases