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DMS 204 Ch 11 Gallbladder & Biliary System

Terms in this set (81)

Is the gallbladder intra or extra peritoneal?
Intraperitoneal
What is the normal length of the gallbladder? What is the normal wall thickness?
7-10cm
3mm wall thickness
What are the spiral valves called in the cystic duct?
Heister's Valves (spiral)
What is the size of the cystic duct?
2-6cm in length
What does the cystic duct join into?
Cystic duct flow goes both ways. Joins with common hepatic duct to form CBD.
Describe the Common Bile Duct
Runs from the Cystic Duct to (posterior) head of pancreas. Joins w/ main pancreatic duct.
Goes through the muscular sphincter of ODDI & enters duodenum through the Ampulla of Vater.
What is a normal diameter for the Common Bile Duct?
Up to 6mm
The cystic artery is a branch of what?
The RIGHT Hepatic Artery
What does the Cystic Vein drain into?
Into the Portal Vein
Name some Gallbladder Variants.
•Hartmann's Pouch: Fold of gallbladder located between the body and neck. (Most common variant)

•Phyrgian Cap: Fold of the fundus. Partial or Complete

Septations

•Duplication
Name the functions of the biliary tree.
1)Concentrate and store bile produced in liver

2)Regulate bile flow
•Increased pressure in CBD causes gallbladder to distend
•Gallbladder contracts in the presence of cholecystokinin

3)Fasting State:
•Increased pressure in CBD causes bile to flow into GB
•Bile concentrates in GB
•Little bile flow to duodenum
•Sphincter of Oddi tightens
• Closes ampulla of Vater

4)Eating
•GB stimulated to contract by cholecystokinin
•Sphincter relaxes
•Ampulla opens
•Bile pours into the duodenum

5)A While After Eating:
•Stomach empties
•GB relaxes
•Sphincter tightens
•Bile flow decreases
•Bile forced into GB
What laboratory test gives information of Severity of bodily infection?
WBC count
(Leukocyte count)
If WBC count is increased, what could that indicate?
•Acute Cholecystitis
•Chronic Cholecystitis
•Injury to bile ducts
•Retained bile duct stones
If Direct (Serum) Bilirubin is elevated, what could that indicate?
•Choledoholithiasis (highest)
•Injury to bile ducts
•Carcinoma of gallbladder
•Retained bile duct stones
If Serum Alkaline Phosphatase is elevated, what could that indicate?
•Markedly increase with GB obstruction
•Usually indicative of obstruction
•Post-hepatic jaundice
Name some symptoms of Gallbladder Disease
1) Pain in RUQ:(Most classic symptom- Especially after a fatty meal)
2) Positive Murphy's sign (pressure placed on GB from transducer on skin= pain)
3) Nausea
4) Vomiting
5) White stools (acholic stools)
6) Obstruction
7) Intolerance of fatty foods/dairy products
8) Right shoulder pain
9) Chest pain
10) Fever
11) Jaundice: (Yellowish discoloration of the skin & sclerae)
What are you looking for sonographically when it comes to the gallbladder?
1) NPO for 8 to 12 hours
2) seen w/ Anechoic fluid filling a pear shaped structure
3) Located inferior & medial to the RT lobe of the liver.
4) Strong back wall
5) Anterior to RT Kidney
6) Lateral to pancreas and duodenum
7) Variety of kinks and folds may be noticed
What is the normal size of the gallbladder? (Length, Width & wall thickness)
• < 10 cm in longitudinal
•< 4cm in transverse
•Wall
< 3mm
T/F: Normal intrahepatic ducts are visualized sonographically.
FALSE
What duct is seen in the posterior aspect of the pancreatic head?
CBD
What is the normal intra luminal diameter for the 1)
1) Common Hepatic Duct:
< 4mm

2) Common Bile Duct:
< 6mm for those under 60 years

Add 1 mm for each additional decade

Up to 10 mm normal after cholecystectomy
What are some sonographic pitfalls & ways around them when imaging the gallbladder.
1) Limited visualization in supine position
=Use intercostal approach
=Sit patient up a bit
=Use sector transducer

2) Too many echoes along anterior wall
=Slide down and to the right on patient, increase distance between transducer and gallbladder

3) Can't get stones/sludge to move in LLD position
=Have patient sit up or stand to encourage movement
Name some benign conditions of the gallbladder:
•Cholelithiasis
•Sludge
•Cholecystitis
•Hydropic Gallbladder
•Porcelain Gallbladder
•Adenoma
•Adenomyomatosis
•Cholesterolosis
Name some Malignant Conditions of the Gallbladder:
•Primary carcinoma of the gallbladder
•Metastatic disease of the gallbladder
Name some Benign Conditions of the Biliary Tree:
•Biliary dilation
•Choledocholithiasis
•Cholangitis
•Ascariasis
•Hemo/pneumobilia
Name a Malignant Conditions of the Biliary Tree:
•Klatskin's tumor
What is the Most common disease of the gallbladder?
Cholelithiasis
•Single or multiple stones
•Range in size from very tiny to large
•Very tiny stones are the most dangerous due to increase risk of entering the bile ducts and obstructing flow
Name some Risk Factors for Cholelithiasis:
•Fat
•Female
•Forty
•Fertile
•Fair

Other factors leading to gallstones include:
•Pregnancy
•Diabetes
•BCP
•Hemolytic disease
•Diet-induced weight loss
What are some clinical findings for cholithiasis?
•Asymptomatic
•RUQ pain radiating to the shoulder
•Especially after fatty meal
•Epigastric pain
•Nausea and vomiting
What do gallstones look like sonographically?
•Hyperechoic intraluminal echoes
•Posterior shadowing
•Stones < 3 mm may not produce a shadow
•WES sign: (Wall, echo, shadow)
•Gravity dependent calcification in gallbladder
What is Mirrizzi Syndrome?
Mechanical obstruction of common hepatic duct (so, stone stuck (impacted) in cystic duct puts pressure or inflames the duct & closes off common Hepatic Duct.

so... nothing going in or out of GB (bec. of stone in cystic duct). Also, nothing getting OUT of liver bec. Hepatic Duct is the route out of the liver. Hepatic duct gets dilated.
What do you see clinically with Mirrizzi Syndrome?
•Jaundice
•Recurrent cholangitis (inflammation of bile ducts)
•Formation of biliary fistula
•Cholangitic cirrhosis
*White stools (acholic stools)
What do you see sonographically with Mirrizzi Syndrome?
Dilated intrahepatic ducts (normally cannot see these)
Normal common bile duct
What are some causes for non-visualization of the GB?
Patient is not fasting
Prior cholecystectomy
Gallbladder is contracted around stones (WES sign)
Hepatization of gallbladder (same echogenicity of the liver)
Congenitally absent gallbladder
What should you do to identify a GB that is difficult to find?
Identify Main Lobar Fissure
Try to identify Portal Vein
What is the name for thickened, echogenic bile?
SLUDGE
When do you visualize sludge?
Commonly seen with patients with extrahepatic biliary obstruction (after cystic duct joins bile duct).
Seen w/ acute or chronic cholecystitis
Seen w/ long term fasting (from biliary stasis)
Has a strong correlation w/ gallstones
Commonly seen in patients post-surgery and with pregnancy.
If sludge is associated with pain in RUQ, is it more likely to form gallstones?
YES.
Though sludge is mostly asymptomatic and of no consequence.
How does Sludge look sonographically?
-Non-shadowing echoes - low to medium level gray
-Gravity dependent - layered in dependent portion of GB ("dependent" = closest to table)
-Fluid-fluid level
-Tumefactive sludge may mimic a mass (sludge sticks together mimicking a mass and can roll when turning patient.) = tumefactive sludge ball
What is the most common cause of ACUTE Cholecystitis.
Caused by impacted stone in the cystic duct.
What are the clinical findings for ACUTE Cholecystitis?
More common in women
Acute RUQ pain
Positive Murphy's sign
Fever
Leukocytosis - Increased WBC's
What does ACUTE Cholecystitis look like sonographically?
Dilation and rounding of GB
Commonly presents with gallstones
+ Murphy's sign with probe pressure
Thickened, heterogeneous GB wall
Pericholecystitic fluid
What are some Complications that happen with ACUTE Cholecystitis?
-Pericholecystic abscess
-Emphysematous cholecystitis (air in GB)
-Gangrenous cholecystitis (eating through wall)
-Perforation of gallbladder
-Ascending cholangitis
-Liver abscess
*NOTE: person can become septic from bile in the body outside of GB
What is a rare complication of ACUTE cholecystitis and associated with the presence of gas-forming bacteria in the GB wall & lumen and can be a surgical emergency if it progresses into gangrenous GB with perforation?
Emphysematous Cholecystitis
(50% of patients are diabetic)
What does Emphysematous Cholecystitis look like sonographically?
Bright echo in area of GB
Ring down or comet tail
WES appearance (but not TRUE WES sign)
May simulate WES seen with stones due to gas
Fuzzy shadow ("Dirty shadow")
What does Gangrenous Cholecystitis look like sonographically?
Thickened gallbladder wall
May shown evidence of necrosis or hemorrhage
Gallbladder contents can pass out of gallbladder (if perforated)
Sloughed inner wall of gallbladder
It makes blood septic because bile ate through GB wall.
What is Acalculous Cholecystitis?
RARE; Inflammation of GB WITHOUT stones.
Believed to be caused by reduced bile flow to GB by cystic duct or by compression of cystic duct.
What kind of findings, clinically-speaking, do you see with Acalculous Cholecystitis?
(similar findings in Acute Cholecystitis):
-Acute RUQ pain
-Fever
-Leukocytosis
-More common in WOMEN
-Abnormal Liver Function Tests (LFT's)
-Increased Amylase
-Positive Murphy's Sign
What does Acalculous Cholecystitis look like sonographically?
Dilation of GB
Thickened GB wall / edema
Sludge
Pericholecystitic fluid
NO STONES!!!
What is the most common inflammation of the GB?
CHRONIC Cholecystitis.
Results from several attacks of acute cholecystitis
Causes fibrosis of GB wall
How does one present with CHRONIC Cholecystitis?
RUQ pain (*but not as severe as in ACUTE Cholecystitis.)
What ailment would someone have if they have a contracted GB that doesn't respond postprandially (bec wall is so fibrotic that it can't expand), a chronically thick GB wall, calculi and a WES sign?
CHRONIC Cholecystitis
(GB prob won't expand much more with fasting)
What is it called when trapped bile is reabsorbed and the GB is filled with clear, mucinous secretion derived from the GB wall. The GB distends from total obstruction of Cystic Duct.
Hydropic Gallbladder (Hydrops = edema)
What does one see clinically with a Hydropic Gallbladder?
Palpable RUQ mass
Epigastric pain
Nausea/vomiting
What does a Hydropic Gallbladder look like sonographically?
GB >10 cm in length
Thin, tense walls
What is a rare condition where the GB wall is incrusted with calcium?
Porcelain GB
Usually occurs in association with gallstones
25% of patient with porcelain gallbladder develop carcinoma of the gallbladder
Female predominance
Under the age of 60
What does Porcelain GB look like sonographically?
Stones - 90%
Wall is thickened
Wall is calcified with shadowing
Similar appearance as WES (but shadowing coming from calcified wall itself, not from stones!)
What are Adenomas of the GB?
Benign epithelial tumor
Usually asymptomatic
What do Adenomas in the GB look like sonographically?
Small, polypoid masses protruding into gallbladder lumen
No acoustic shadowing
Not gravity dependent
Usually located at fundus
What is a hyperplastic change to the surface epithelium of gallbladder wall where the diverticulum of inner mucosal layer going into or through the muscular wall?
Adenomyomatosis

Rokitansky-Aschoff sinuses ("keyhole" outpouches/sinuses)
Usually asymptomatic, but may present with RUQ pain
More common in women
What does Adenomyomatosis look like sonographically in the GB?
"Keyhole" outpouches/sinuses
Distorted gallbladder shape
Areas of wall thickening (inner wall gets overgrown)
Cholesterol gets trapped in sinuses and when soundbeam hits the sinus, it rickoshets & creates "Ring down" or "comet tail" artifact

NOTE: stones do NOT create ring-down. it's the outpouches... stones create shadowing instead.
Describe Diffuse, Segmental and Focal Adenomyomatosis.
1) Diffuse - entire gallbladder
2) Segmental - circumferential at proximal, mid or distal 1/3 of gallbladder
3) Focal - confined almost exclusively to the fundus
What makes the ring-down effect with Adenomyomatosis?
Ring-down created by sound bouncing back and forth within the outpouches. The US machine falsely plots echoes deeper than they actually are bec. of physics of sound.
What is the condition of cholesterol deposits within the GB called?
Cholestrolosis
More commonly seen in women
Usually asymptomatic
What are the 2 types of Cholestrolosis?
1) Strawberry Gallbladder: when cholesterol deposits towards outer wall like strawberry seeds on a strawberry (NOT seen in ultrasound)
2) Cholesterol Polyps (polyps in GB- CAN see in ultrasound.)
What does Cholestrolosis look like sonographically?
Projections from wall, usually < 10 mm
Do not shadow
Remain fixed with patient movement
What is the most common type of cancer in the biliary system?
Primary Carcinoma of GB
70-80% are adenocarcinomas (glandular in origin)
Who does primary carcinoma usually affect?
White females, in 60's and 70's.
Gallstones present in 65-95% of cases (suggesting inflammatory etiology)
Rapidly progressive disease with morality rate of nearly 100%
What are the clinical symptoms of Primary Carcinoma of the GB?
Frequently asymptomatic until advanced
Loss of appetite, nausea, vomiting
Fatty food intolerance
Jaundice- (not usually seen until infiltration into major biliary ducts and liver bed, has occurred- bec of inability to process bilirubin)
RUQ pain
Mass
What does Primary Carcinoma of GB look like sonographically?
Localized thickened GB wall
Polypoid lesions with irregular borders
Loss of usual smooth outline of GB
Solid mass filling the gallbladder
Infiltrating mass with GB wall markedly thickened
Fungating mass (invasive mass) growing into GB, inside wall (intraluminal) & possibly extending out of GB structure)
irregular contour of GB wall
HEPATIZATION of GB
Look for COLOR flow to mass. RI will be LOW
Metastatic disease of GB normally comes from what primary sites?
1) Melanoma - common (skin)
2) Pancreas
3) Stomach
4) Bile ducts
NOTE: GI metastatic disease reaches the GB through direct invasion, while lung, kidney, esophagus, and melanoma reach GB through blood stream
What is the sonographic appearance of Metastatic Disease of GB?
Focal thickening of the gb wall
Intraluminal mass without shadowing with sonographically normal gb wall
Cholelithiasis usually absent
What is the NORMAL wall thickness for the Gallbladder?
<3mm
What are the INTRINSIC reasons for thicker than normal GB wall?
Cholecystitis
Adenomyomatosis
Polyps
Gallbladder carcinoma
What are the EXTRINSIC reasons for thicker than normal GB wall?
Hepatitis/cirrhosis
AIDS
Renal failure
Ascites
Portal node lymphatic obstruction
What creates the "shotgun" sign within the liver?
Dilated biliary ducts (1 is Portal Vein 2nd is branch of bile duct)
Can be seen INTRAHEPATIC and EXTRAHEPATIC.

(EXTRAHEPATIC normal is seen first):
A) Primary areas of obstruction (extrahepatic)
1) Intrapancreatic
2) Pancreatic cancinoma
3) Choledocholithasis
4) Chronic pancreatitis

B) Suprapancreatic
Originates between the pancreas and the porta hepatis.
Head of pancreas, intrapancreatic duct and pancreatic duct are normal

C) Porta Hepatis
Usually due to neoplasm
Intrahepatic ductal dilation with normal CBD
What happens when eating a fatty meal w/ regard to GB size (normally and abnormally)?
Normal: duct decreases in size after fatty meal
Abnormal: duct remains the same or increases in size after a meal (bec of obstruction. Also increase in size due to stimulation of cholecystokinin.)
What is Choledocholithiasis?
Stones in the bile ducts
(can pass into ducts from GB and obstruct bile ducts)
What are some clinical findings to choledocholithiais?
(Usu asymptomatic until obstruction occurs)
RUQ pain
Jaundice
Cholangitis
Elevated Bilirubin (direct)
Elevated Alkaline Phosphatase
What does choledocholithiasis look like sonographically
Stones can be seen surrounded by bile in duct.
Watch for area of sudden tapering of dilated duct, search for shadowing at this point.
What is Cholangitis?
Inflammation/ Infection of the bile ducts
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