4. Anatomy of the gallbladder
Sherlock S & Dooley J. Diseases of the liver and biliary system.
Blackwell Science, Oxford, UK, 11th edition, 2002.
5. Normal ultrasound of gallbladder
Minimum 6 hours of fasting
Subcostal or intercostal scanning
Supine â LLD â Prone â Erect
GB wall ⤠3 mm Anterior wall
Long-axis
Perpendicular
Transverse diameter < 4 cm
Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.
F
B
N
6. Gallbladder folds
Abraham D et al. Emergency medicine sonography: Pocket guide.
Jones & Bartlett Publishers, Boston, MA, USA, 1st edition, 2010.
Longitudinal view of gallbladder
Hartmanâs pouch
Phrygian cap
8. Acoustic shadow from a GB fold
Part of a fold within gallbladder producing an acoustic shadow
When only part of fold is visualized, it may mimic a polyp or a stone
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
9. Edge refraction shadow
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
Shadow near neck of GB on longitudinal section
Absence of visible stone at origin of shadow
Scanning in different positions
10. Proximal cystic duct
Longitudinal view of GB neck & proximal cystic duct
Serrated appearance of cystic duct secondary to valves of Heister
Occasionally identified on sonography
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
13. Congenital abnormalities of the gallbladder
⢠Agenesis of gallbladder Confirmation with other tests
⢠Anomalous GB location Abnormal locations
⢠Duplication of gallbladder One or two cystic ducts
⢠Septated gallbladder Honeycomb appearance
⢠Gallbladder diverticulum Any location in gallbladder
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
14. Congenital anomalies of the gallbladder
Yamada T et all. Textbook of gastroenterology.
Wiley-Blackwell, Oxford, UK, 5th edition, 2009.
Septated GBDuplicated GB Diverticulum
15. Agenesis of gallbladder
1 in 6,000 live births â fewer than 300 reported cases
Waller AH et al. Clin Gastroenterol Hepatol 2008 ; 6 : 38.
⢠First described by Lemery in 1701
⢠Failure of cystic bud to develop in fourth week of life
⢠Associated with chromosomal abnormalities
⢠Symptoms attributed to biliary dyskinesia
⢠US diagnosis: absence of gallbladder
⢠HIDA scan: acute cholecystitis
Diagnosis usually obtained after surgical exploration
16. Agenesis of gallbladder
Waller AH et al. Clin Gastroenterol Hepatol 2008 ; 6 : 38.
HIDA scan
Uptake by liver
Excretion into CBD & bowel
No visualization of gallbladder
MRI & MRCP
No visualization of normal or
ectopic GB
Normal biliary tree
17. Anomalous location of gallbladder
Rare â Reported only in isolated case reports
Most common locations
⢠Left side (posterior to left lobe)
⢠Intrahepatic
⢠Suprahepatic (right lobe & diaphragm)
⢠Retrohepatic (posterior to right lobe)
Intrahepatic GB
May preclude Lap surgery
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
18. Duplication of gallbladder
One in 3000 to 4000 GB
2 gallbladders adjacent to each other with 2 separate cystic ducts
After meals, both gallbladders showed normal emptying
www.ultrasound-images.com/gall-bladder.htm
19. Multi-septate gallbladder
Congenital origin â Very rare
⢠Entire GB or part of lumen
⢠Chambers communicate by orifices
⢠Isolated or coexist with other anomalies
⢠Symptoms of recurrent cholecystitis
⢠Multiple linear fine echogenic septations
Oriented horizontally or vertically
Kapoor V et al. J Ultrasound Med 2002 ; 21 : 677 â 680.
20. True diverticulum of gallbladder
Extreme rarity
Occurs anywhere in GB
Usually single
Varies greatly in size
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
22. US of gallbladder stone
Gold standard for diagnosis of cholelithasis
3 sonographic criteria
⢠Echogenic focus
⢠Cast acoustic shadow
⢠Seek gravitational dependence
Stones < 2 â 3 mm may be difficult to visualize
Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 â 287.
23. Shadow of gallbladder stone
* Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 â 287.
** Rubens DJ. Ultrasound Clin 2007 ; 2 : 391 â 413.
3 patterns of shadowing*
ď Clean shadow Solitary stone
ď Confluent shadowing Multiple small stones
ď Wall-Echo-Shadow (WES) GB filled with gallstones
** Soft pigment stones may not shadow
24. Confluent shadowing of GB stones
Multiple small stones gravel abut each other with confluent AS
Mural thickening of gallbladder
25. Acoustic shadow of a gallbladder stone
Time gain compensation
too high
Time gain compensation
is lower
Bates J A. Abdominal Ultrasound: How, why and when.
Churchill Livingstone, Edinburg, UK, 2nd edition, 2004
26. Stone smaller
than the beam
Shadowing of the stones
Shadow
Bates J A. Abdominal Ultrasound: How, why and when.
Churchill Livingstone, Edinburg, UK, 2nd edition, 2004
Stone occupies
width of the beam
Large stone
outside focal zone
Large stone
just out of beam
No shadow
27. Floating stones
Bates J A. Abdominal Ultrasound: How, Why and When.
Churchill Livingstone, Edinburg, UK, 2nd edition, 2004
Floating stones just below anterior gallbladder wall
28. Tissue harmonic imaging & gallstones
Longitudinal ultrasound
Normal gallbladder
Rubens D. Radiol Clin North Am 2004 ; 42 : 257 â 78.
Harmonic imaging
Multiple small stones
29. Correct & incorrect positions for prone scanning
Demonstrates gravitational dependence of stone
Correct: transducer as vertically as possible to image anterior GB wall
Incorrect: most dependent anterior part of GB not well examined
Hough DM et al. J Ultrasound Med 2000 ; 19 : 633 â 638.
30. Pitfalls in diagnosis of GB stone
Residue in bowel indenting posterior wall of GB
mimics gallstones
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
31. Dependent debris in the gallbladder
⢠Sludge
⢠Pseudosludge
⢠Blood
⢠Pus
⢠Milk of calcium bile
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
32. Biliary sludge
Prevalence unknown in general population
⢠Predisposing factors Pregnancy
Rapid weight loss & prolonged fasting
Long-term TPN
Ceftriaxone â Prolonged octreotide tt
Bone marrow transplantation
⢠Evolution (3 years) 50% resolve spontaneously
20% persist asymptomatically
5 â 15 % develop gallstones
10 â 15 % become symptomatic
⢠Complications Biliary colic, AAC, pancreatitis
33. Biliary sludge
Also known as biliary sand
Low-amplitude nonshadowing echoes in dependent portion of GB
Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 â 287.
Occasionally, sludge can be highly echogenic
34. Pseudosludge
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
Most commonly along posterior surface of gallbladder
Produced by âsidelobe artifactsâ
Disappear in different positions & when central portion of GB scanned
35. Aggregated sludge â Sludge ball
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
Change in appearance or disappearance on follow-up
Differentiates sludge ball from a stone or neoplasm
Nonshadowing mobile echogenic structures
36. Aggregated sludge â Tumefactive sludge
GB with tumor-like sludge
Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.
Potential mobility of sludge
Normal gallbladder wall
No vascularity detected on Doppler US
Follow-up
37. Biliary sludge
"hepatization" of gallbladder
Rumack CM, Wilson SR, & Charboneau JW. Diagnostic Ultrasound.
Elsevier-Mosby, St. Louis, Missouri, USA, 3rd edition, 2005.
GB entirely filled with sludge isoechoic to adjacent liver
Recognized by identifying normal GB wall
38. Blood in the gallbladder
Clinical history very useful for diagnosis
Sonographic findings
⢠Echogenic or mixed echogenicity
⢠Fluid with low-level internal echoes
⢠Retractile
⢠May be mobile
Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.
Angled edges of clot
Quite typical of blood clots
39. Milk of calcium bile (limey bile)
Diagnosis can be confirmed by abdominal radiography or CT
High-attenuation material within
dependent portion of GB
Highly echogenic material in
dependent portion of GB with AS
Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.
42. Causes of right upper quadrant pain
⢠Peptic ulcer disease
⢠Pancreatitis
⢠Hepatitis
⢠Appendicitis
⢠Hepatic congestion from right-sided heart failure
⢠Perihepatitis (Fitz-Hugh-Curtis syndrome)
⢠Right lower lobe pneumonia
⢠Right-sided pyelonephritis
⢠Nephro-ureterolithiasis
43. Diagnostic standard for acute cholecystitis
Tokyo guidelines 2007
Hirota M et al. J Hepatobiliary Pancreat Surg 2007 ; 14 : 78 â 82 .
Three categories of diagnostic findings
One criterion from each category must be fulfilled
(1) Murphy sign or pain/tenderness in RUQ or RUQ mass
(2) Fever, leukocytosis, or elevated CRP
(3) Confirmation by US or HIDA scan
44. Acute cholecystitis â HIDA scan
Higher accuracy than ultrasonography
Talley NJ et al. Practical gastroenterology & hepatology: Liver & biliary disease.
Wiley Blackwell, Oxford, UK, First edition, 2010.
Tracer in GB
Tracer in CBD
Tracer in small bowel
GB
CBD
Small
bowel
Normal HIDA scan
Non-filling of GB
Tracer in CBD
Tracer in small bowel
CBD
Small
bowel
Acute cholecystitis
45. Sonographic findings in acute cholecystitis
⢠Impacted stone in cystic duct or GB neck
⢠Positive sonographic Murphy's sign
⢠Thickening of GB wall (>3 mm)
⢠Distention of GB lumen (> 4 cm)
⢠Pericholecystic fluid collections (frequent)
⢠Hyperemic GB wall on color Doppler (supportive test)
None of above signs pathognomonic
Combination of multiple signs make correct diagnosis
Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.
46. Acute cholecystitis
Caused by gallstones in more than 90% of cases
Large obstructing stone within GB neck
Thick hypoechoic gallbladder wall
Positive sonographic Murphy sign
Ralls PW et al. Gastroenterol Clin N Am 2002 ; 31 : 801â825.
47. Negative sonographic Murphyâs sign
⢠Patients who received pain medicine or steroids
⢠Para or quadriplegic patients
⢠Patients not able to give reliable history or pain response
⢠Denervated GB: DM â gangrenous cholecystitis
⢠Gallbladder rupture
Careful attention to clinical status important
when assessing for sonographic Murphyâs sign
Rubens DJ. Ultrasound Clin 2007 ; 2 : 391 â 413.
48. Gallbladder wall thickening
⢠Generalized edematous states CHF â Renal failure
End-stage cirrhosis
Hypoalbuminemia
⢠Inflammatory conditions Primary Acute cholecystitis
Chronic cholecystitis
Cholangitis
Secondary Acute hepatitis
Perforated DU
Pancreatitis
Diverticulitis/colitis
⢠Neoplastic conditions Adenocarcinoma â Metastases
⢠Miscellaneous Adenomyomatosis â Varices
Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.
49. Diffuse gallbladder wall thickening
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
Three echo patterns (not specific)
ď Uniformly echogenic pattern
ď Central hypoechoic zone & 2 peripheral echogenic layers
ď Striated pattern
50. Gallbladder wall thickening
Uniformly echogenic pattern
Echogenic thickening of the wall in chronic cholecystitis
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
52. Gallbladder wall thickening
Striated pattern
Rubens DJ. Ultrasound Clin 2007 ; 2 : 391 â 413.
Striated wall with alternating echogenic & hypoechoic layers
Striated wall in setting of acute cholecystitis: gangrenous cholecystitis
Striated wall without evidence of acute cholecystitis: non specific
53. Gallbladder wall thickening
Rubens DJ et al.Ultrasound Clin 2007 ; 2 : 391 â 413.
Gallstones
Focal GB wall thickening (7 mm)
Free air with reverberation shadows
Pericholecystic fluid (arrows)
Free air (arrowheads)
Extraluminal air (paired arrowheads)
Peptic ulcer perforation
54. Gallbladder wall thickening
Rubens DJ et al.Ultrasound Clin 2007 ; 2 : 391 â 413.
Focal pyelonephritis
Heterogeneous decreased
attenuation area typical
of focal pyelonephritis
GB wall thickening 3-cm echogenic mass
in lower pole of rt kidney
55. Pericholecystic fluid
Two specific patterns
Type I Thin anechoic crescent-shaped collection
adjacent to gallbladder wall
Nonspecific finding
Type II Round or irregularly shaped collection with
thick walls, septations, or internal debris
Associated with GB perforation & abscess
Teefey SA et al. J Ultrasound Med 1991 ; 10 : 603 â 6.
Rubens DJ. Ultrasound Clin 2007 ; 2 : 391 â 413.
56. Acute cholecystitis
Hyperemic GB wall
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
Color Doppler sonography
Increased vascularity in GB wall
Supportive test
57. Acute acalculous cholecystitis (AAC)
5 â 15% of acute cholecystitis
⢠Critically ill patients Major surgery
Severe trauma
Sepsis
Total parenteral nutrition
Diabetes
Atherosclerotic disease
HIV infection
⢠Nonhospitalized patients Elderly male with atherosclerosis
HIDA scan & sampling of luminal contents
help to establish the diagnosis
58. Acute acalculous cholecystitis (AAC)
Difficult to diagnose clinically & on imaging
Marked GB mural thickening
Hypoechoic regions within wall
Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 â 287.
Marked GB mural thickening
with hypo & hyperenhancing areas
59. Complications of acute cholecystitis
⢠Suppurative cholecystitis (empyema)
⢠Gangrenous cholecystitis Up to 20%
⢠Emphysematous cholecystitis 1 %
⢠Hemorrhagic cholecystitis Rare
⢠Gallbladder perforation 5 â 10%
60. Suppurative cholecystitis (Empyema)
Patients very ill with fever & acute pain
Fine echoes caused by pus in bile
Pericholecystic GB collection (leakage)
US used to guide drainage before surgery
Bates J A. Abdominal Ultrasound: How, why and when.
Churchill Livingstone, Edinburg, UK, 2nd edition, 2004
Large GB full of pus & stones
61. Gangrenous cholecystitis
No specific diagnostic US findings
⢠Striated thickening of GB wall
⢠Intraluminal membranes (5%)
⢠Marked asymmetry of GB wall
⢠Echogenic debris within GB
⢠Pericholecystic fluid collections
⢠US Murphyâs sign negative in 70%
Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 â 287.
Mucosal sloughing
Echogenic debris within GB
62. Gangrenous cholecystitis
Mucosal sloughing
Rubens D J. Ultrasound Clin 2007 ; 2 : 391 â 413.
Longitudinal US of gallbladder
Intraluminal membranes associated gallbladder gangrene
Stone impacted in gallbladder neck
63. Emphysematous cholecystitis
Prompt surgical intervention required
⢠Organisms Clostridium welchii & Escherichia coli
⢠Characteristics Male preponderance (70%)
Frequent occurrence in diabetic (50%)
Lack of gallstones in up to one third
Higher risk of gangrene & perforation
⢠Three stages Stage 1: Gas in GB lumen
Stage 2: Gas in GB wall
Stage 3: Gas in pericholecystic tissues
Bennett GL et al. Radiol Clin N Am 2003 ; 41 : 1203 â 1216.
Appearance depends on amount of gas present
64. Emphysematous cholecystitis
Associated with DM & atherosclerotic disease
Intraluminal & intramural gas bubbles
Debris within necrotic GB
Higher sensitivity of CT
for the diagnosis
Diagnosis should be confirmed by abdominal radiography or CT
Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 â 287.
65. Emphysematous cholecystitis
Small amount of gas
Supine position
Presence of echoes anteriorly
Could be in the lumen or the wall
Rubens D J. Ultrasound Clin 2007 ; 2 : 391 â 413.
Upright position
Gas moves & breaks into bubbles
Distinguishing it from calcium
66. Emphysematous cholecystitis
Large amount of gas
Absence of a normal gallbladder is a clue
Gas in GB completely obscures the lumen (dirty shadow)
Bates J A. Abdominal Ultrasound: How, Why and When.
Churchill Livingstone, Edinburg, UK, 2nd edition, 2004
Location of GB fossa essential to avoid mistaking this for bowel gas
68. Gallbladder perforation
5 â 10 % of patients with acute cholecystitis
Small defect in GB wall: not always seen
Deflation of the gallbladder
Pericholecystic fluid collection
Pericholecystic abscess
Rumack CM, Wilson SR, & Charboneau JW. Diagnostic Ultrasound.
Elsevier-Mosby, St. Louis, Missouri, USA, 3rd edition, 2005.
Disruption of GB wall
69. GB perforation â Pericholecystic abscess
Rumack CM, Wilson SR, & Charboneau JW. Diagnostic Ultrasound.
Elsevier-Mosby, St. Louis, Missouri, USA, 3rd edition, 2005.
Abscess (internal strands typical of abscess)
Echogenic inflamed fat
Small amount of ascites
70. Hemorrhagic cholecystitis
Rare â Atherosclerosis â High mortality rate
Bennett GL et al. Radiol Clin N Am 2003 ; 41 : 1203 â 1216.
Echogenic material with higher
echogenicity than sludge
Increased density of bile
71. Hemorrhagic cholecystitis
Differential diagnosis
⢠Blood in gallbladder Neoplasm
Aneurysms
Trauma
Anticoagulation
Ectopic pancreas
Ectopic gastric mucosa
⢠High-density bile Recently administered IV contrast
Milk of calcium bile
Bennett GL et al. Radiol Clin N Am 2003 ; 41 : 1203 â 1216.
73. Forms of chronic cholecystitis
⢠Traditional chronic cholecystitis
Thick gallbladder wall with gallstones
⢠Wall-Echo-Shadow complex (WES)
Double arc-shadow sign
⢠Porcelain gallbladder
High incidence of GB carcinoma (10 â 30%)
⢠Xanthogranulomatous cholecystitis (XGC)
Difficult to distinguish from adenomyomatosis &
gallbladder carcinoma
74. Chronic cholecystitis
Bates J A. Abdominal Ultrasound: How, Why and When.
Churchill Livingstone, Edinburg, UK, 2nd edition, 2004
Thick gallbladder wall
Small gallbladder stone with posterior AS
Bouts of acute cholecystitis may complicate chronic cholecystitis
75. Wall-Echo-Shadow complex (WES)
Contracted gallbladder filled with stones
2 parallel arcuate hyperechoic lines
Separated by thin hypoechoic space
Distal acoustic shadowing
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
Differentiation from air or calcification in GB wall
Normal GB wall not seen; only bright echo & AS seen
76. Porcelain gallbladder
Calcified wall with acoustic shadow
Mistaken for stone within GB lumen
No GB wall visible
Rumack CM, Wilson SR, & Charboneau JW. Diagnostic Ultrasound.
Elsevier-Mosby, St. Louis, Missouri, USA, 3rd edition, 2005.
Dense calcification in GB fundus
77. Porcelain gallbladder â Mild calcification
Rickes S et al. N Engl J Med, 2002 ; 346 : e4.
Computed tomography
Gallstones
Calcification of GB wall
Ultrasonography
Gallstones (one in cystic duct)
leading to GB enlargement (5 cm)
Calcification of GB wall
81. Classification of gallbladder polyps
3 â 7% of subjects undergoing US
Gallahan WC et al. Gastroenterol Clin N Am 2010 ; 39 : 359 â 367.
Neoplastic
Adenomas (4%) 5 â 20 mm, solitary
Miscellaneous Leiomyomas, lipomas,
neurofibromas, carcinoids
Non-neoplastic
Cholesterol polyp (60%) < 10 mm
Adenomyomatosis (25%) Usually fundus
Inflammatory (10%) < 10 mm
82. Risk of malignancy in GB polyps
⢠Size Small polyp not necessarily benign
Sessile polyps ⤠10 mm quite aggressive
⼠10 mm suspicious
> 18 mm usually invasive malignancy
⢠Patient age > 50
⢠Concurrent gall stones
⢠Diagnosis of PSC
Talley NJ et al. Practical gastroenterology & hepatology: Liver & biliary disease.
Wiley Blackwell, Oxford, UK, First edition, 2010.
83. Cholesterol polyp & cholesterolosis
Lamina propria infiltrated with lipid-laden foamy macrophages
Cholesterol polyp
Cholesterolosis
â strawberry gallbladderâ
84. Cholesterol polyp & cholesterolosis
Cholesterol polyp
Cholesterolosis
â strawberry gallbladderâ
Johnson CD et al. Mayo Clinic gastrointestinal imaging review.
Mayo Clinic Scientific Press, Rochester, USA, 2005.
86. Gallbladder polyp
Any size
PSC
Cholelithiasis
Sessile
Lap surgery
Talley NJ et al. Practical gastroenterology & hepatology: Liver & biliary disease.
Wiley Blackwell, Oxford, UK, First edition, 2010.
> 18 mm
Staging &
Open surgery
< 10 mm
Symptoms
Yes
Imaging: US or EUS
Every 6 months
Non
10 â 18 mm
No consensus guidelines to guide treatment
Management should be individualized
87. Variable Score
Tumor maximum size (mm) Value in mm
EUS in gallbladder polyp
Retrospective study of 70 surgical cases - Multivariate analysis
Sadamoto Y et al. Endoscopy 2002 ; 34 : 959 â 965.
Scores ⼠12: neoplastic polyp
Sen: 78% â Sp: 83% â Accuracy: 83 %
Internal echo pattern
Heterogeneous
Homogeneous
4
0
Hyperechoic spotting
Single 1 â 5 mm hyperechoic spot
Multiple hyperechoic 1 â 3 mm spots
Presence: â 5
Absence: 0
88. EUS in gallbladder polyp
11 mm in diameter (11)
Homogenous (0)
Hyperechoic spots (â 5)
Cholesterol polyp GB adenoma
9 mm in diameter (9)
Heterogeneous (4)
Hyperechoic spots (0)
Sadamoto Y et al. Endoscopy 2002 ; 34 : 959 â 965.
Score: 6 Score: 13
89. Adenomyomatosis (Rokitansky-Aschoff sinuses)
8% of patients undergoing cholecystectomy
Fundic
Most frequent
Adenomyoma
Segmental
Hourglass
Diffuse
Excessive proliferation of surface epithelium
which can invaginate into muscularis
90. Diffuse adenomyomatosis of gallbladder
Thickened GB wall
Comet-tail artifacts in GB wall
ââComet-tailâ or ââring-downââ artifact
91. Diffuse adenomyomatosis of gallbladder
Thick gallbladder wall
Echogenic intramural foci
ââring-downââ artifacts
Multiple high signal intensity
structures within GB wall
âstring of pearlsâ appearance
Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 â 287.
92. Segmental adenomyomatosis
Rumack CM, Wilson SR, & Charboneau JW. Diagnostic Ultrasound.
Elsevier-Mosby, St. Louis, Missouri, USA, 3rd edition, 2005.
Masslike areas obliterating lumen
Cystic spaces suggest diagnosis
Multiple echogenic foci
Crystals in sinuses suggest dg
93. Fundal adenomyomatosis
Hypoechoic mass-like
Fundal adenomyoma
Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.
Thickened GB wall with small
Rokitansky-Aschoff sinus at fundus
95. US of gallbladder carcinoma
3 major patterns of presentation
Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 â 287.
⢠Polypoid GB mass
25% of carcinoma â > 1 cm â Broad based â Role of EUS
⢠Mural thickening
Least common â Focal or diffuse â Irregular
Most difficult to diagnose
⢠Gallbladder fossa mass
Most common â Replacing GB â Invading adjacent liver
96. Gallbladder carcinoma â Mural thickening
Marked mural thickening of the neck of gallbladder
Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 â 287.
97. Gallbladder carcinoma â Polypoid mass
Enhancing mass in GB fundus
Rubens DJ et al. Ultrasound Clin 2007 ; 2 : 391 â 413.
Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 â 287.
2-cm polypoid mass in GB fundus
Internal vascularity
Villous adenoma with foci of CIS
98. Gallbladder carcinoma â Gallbladder fossa mass
Mass occupying GB fossa
Coronal reformatted CT scan
Rubens DJ et al. Ultrasound Clin 2007 ; 2 : 391 â 413.
Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 â 287.
Immobile gallstones
Heterogeneous mass in GB fossa
Some vascularity on color Doppler
Color Doppler US
99. Malignant tumors of gallbladder
⢠Most frequent Adenocarcinoma
⢠Unusual histologic variants Papillary adenocarcinoma
Mucinous adenocarcinoma
Signet ring cellâtype
⢠Unusual malignancies Squamous cell carcinoma
Carcinosarcoma
Small cell carcinoma
Lymphoma
Metastasis
Kim MJ et al. AJR 2006 ; 187 : 473 â 480.
Radiologic findings overlap with ordinary GB carcinoma
100. Signet ring cell carcinoma of gallbladder
Kim MJ et al. AJR 2006 ; 187 : 473 â 480.
Target-like wall thickening of
gallbladder
Targetlike wall thickening of GB
Enhancement of gallbladder fundus
Massive necrotic LN along porta
hepatis & hepatoduodenal ligament
102. Volvulus of gallbladder
Mobile GB with long suspensory mesentery
⢠Rare acute entity
⢠Symptoms of acute cholecystitis
⢠Often seen in elderly females
⢠US findings:
Massively distended & inflamed GB
Unusual location of gallbladder
Unusual horizontal long axis in left to right direction
Rumack CM, Wilson SR, & Charboneau JW. Diagnostic Ultrasound.
Elsevier-Mosby, St. Louis, Missouri, USA, 3rd edition, 2005.
The gallbladder is a pear-shaped bag 9 cm long with a capacity of about 50 ml.The gallbladder is divided into the fundus, body, and neck, with the fundus being the most anterior, and often inferior, segment.In the region of the neck, there may be an infundibulum, called Hartmann's Pouch, which is a common location for impaction ofgallstones.Within the cystic duct and sometimes the gallbladder neck, small mucosal folds exist called the spiral valves of Heister; these are occasionally identified on sonography.
Normal gallbladder showing a thin fold.Normal gallbladder capacity: 30 to 50 mL
Serrated: Ů ŘłŮŮ â ٠شعشع - Ů ŮشاعŮValves of Heister areoccasionally identified on sonography.
Agenesis of gallbladder: 1 in 6,000 live births
72-year-old Hispanic woman had an 8-day history of right upper quadrant pain radiating to the right scapula.Ultrasonography revealed cholelithiasis, gallbladder wall thickening, and a dilated common bile duct.The patient had a laparoscopic cholecystectomy, which was promptly converted to open technique due to failure to identify gallbladder. Exploratory laparotomy was done with complete dissection and skeletonization of vascular and biliary structures, as well as pancreaticoduodenal areas. These maneuvers were unsuccessful in revealing a gallbladder. The common bile duct was identified and found to be dilated (20 mm). It was explored, and an intraoperativecholangiogram through a T-tube did not show cystic duct, gallbladder, or stones. A T-tube was placed at the time of surgery, and bilirubin subsequently returned to a normal level. The T-tube was removed 4 weeks later without sequelae.
hepatobiliaryiminodiacetic acid (HIDA) scan
Failure to migrate may lead to an intrahepatic, or partially intrahepatic, gallbladder, a rare but significant finding that may preclude laparoscopic surgery.Other reported ectopic sites include the gallbladder in the retroperitoneum posterior to the right kidney, lateral to the right lobeof the liver, within the falciform ligament, within the anterior abdominal wall, and in the lesser peritoneal sac.
Two cystic structures with septum of entire length of 2 cavitiesTwo cystic structures separated from each otherTriple & quadruple GB have also been reportedDefinitive diagnosis of double gallbladder requires demonstration, which is difficult sonographically, of two separate cystic ducts.
Harmonic imaging significantly improves visualization of small gallstonesThis type of ultrasound transmits the insonating US beam at a fundamental frequency, such as 2.5 or 3 MHz, and receives the returningechoes not only at the fundamental frequency but also at the second harmonic frequency that is twice the fundamental frequency creatingthe image with the higher harmonic frequency. By eliminating the fundamental frequency, this technique significantly reduces degradation of the image by noise, since lower frequencies easily can be filtered out. In addition, scattering of the US beam from fat in the anterior abdominal wall is diminished because the harmonic frequencies are generated after the beam enters the body. The narrower harmonic beam also has fewer side lobes, and therefore, improved lateral resolution and signal to noise ratio. Harmonic imaging increases the echogenicity of gallstones and strengthens their posterior shadows, permitting visualization of stones not seen with conventional grayscale ultrasound.
Gallbladder sludge is thick viscous bile that consists of cholesterol monohydrate crystals and calcium bilirubinate granules embedded in a gel matrix of mucus glycoproteins.It often develops in patients with prolonged fasting in intensive care units, trauma patients receiving total parenteral nutrition, and within 5 to 7 days of fasting in patients who have undergone gastrointestinal surgery. Sludge typically has a fluctuating course and may disappear and reappear over several months or years. Sludge may be an intermediate step in the formation of gallstones. Some 5 - 15% of patients with sludge will develop asymptomatic gallstones.
Aggregate: ŮŘŞŘŹŮ Řš - ŮŘŞŮŘŞŮBall: Ůع؊
Tumefactive: Ů ŘŘŻŘŤ Ůع٠اTumefactive sludge (arrowheads) appears as a polypoid mass within the gallbladder.
Milk of calcium bile or limey bile is an uncommon disorder characterized by puttylike, thickened bile composed of calcium carbonate. It is usually associated with cystic duct obstruction and chronic cholecystitis.Sonographically, milk of calcium bile demonstrates echogenic layering material with a flat or convex meniscus usually associated with acoustic shadowing. Occasionally a weak reverberation artifact may be produced. CT and plain radiographs show high-attenuation material layering within the gallbladder lumen.Diagnosis can be confirmed by abdominal radiography or CT.
HIDA (Hepatic Imino-Diacetic Acid) imagesRadionuclide cholescintigraphy with technetium Tc 99m-labelled iminodiacetic acid analogs (hepatobiliaryiminodiacetic acid scan) was first introduced in the late 1970s. The hepatic parenchymal uptake is observed within 1 minute, with peak activity occurring at 10 to 15 minutes. The bile ducts are usually visualized within 10 minute. The gallbladder should fill with isotope within 1 hour if the cystic duct is patent. If the gallbladder is not identified, delayed imaging up to 4 hours should be performed.Prompt biliary excretion of the isotope without visualization of the gallbladder is the hallmark of acute cholecystitis.False-positive results may occur in patients with abnormal bile flow because of hepatic parenchymal disease or a prolonged fast with a distended, sludge-filled gallbladder.Delayed gallbladder filling can be seen in the setting of chronic cholecystitis.
Positive sonographic Murphyâs sign and the presence of gallstones had a positive predictive value of 92% for the diagnosis of acute cholecystitis.Patients who have thickening of the gallbladder wall caused by etiologies other than acute cholecystitis, the gallbladder often is nondistended, implying a nonobstructive (non-biliary) cause of wall thickening.
The sonographic Murphyâs sign is defined as the presence of maximal tenderness elicited by direct pressure of the transducer over a sonographically localized gallbladder. The sonographic Murphyâs sign is different from surgical Murphyâs sign, which consists of arrest of inspiration caused by pain from an inflamed gallbladder when the examinerâs hand is placed on the patientâs subcostal right upper quadrant.
Striated:٠؎ءء â Ů ŮŮŮ - Ů Řزز
Identifying the presence of pericholecystic fluid is useful because it is highly specific for GB disease either:1- Acute cholecystitis2- Pericholecystic abscess3- GB perforation
AAC typically results from a gradual increase of bile viscosity because of prolonged stasis that leads to functional obstruction of cystic duct.The diagnosis of acalculouscholecystitis can be difficult to make as gallbladder distention, wall thickening, internal sludge, & pericholecystic fluid may all be present in critically ill patients without cholecystitis.Because no stones are present, the diagnosis is more difficult and may be delayed.The patients may be obtunded or receiving analgesics, reducing the sensitivity of Murphy's sign. It is the combination of the findings that suggests the diagnosis; the more signs present, the more the likelihood of cholecystitis. Nevertheless, cholescintigraphy or percutaneous sampling of the luminal contents should be used more liberally to aid in establishing the diagnosis.
Sonographic findings of AAC include:Gallbladder distention and sludgeMural thickening (other etiologies considered unlikely)Hypoechoic regions within the wallPericholecystic fluidDiffuse increased echogenicity within the gallbladder resulting from hemorrhage, pus, intraluminal membranesPositive sonographic Murphyâs sign (50%)
Emphysematous : ŮŮا؎Ů
Gangrenous cholecystitis is a major complication of acute cholecystitis and is associated with significantly increased morbidity and mortality, requiring emergency cholecystectomy. The pathologic features include hemorrhage, necrosis, and microabscesses within the wall of the gallbladder, mucosal ulcers as well as strands of fibrinousexudate, and purulent debris within the gallbladder. The incidence of gangrenous cholecystitis has been reported to be between 2% and 38% of all patients with acute cholecystitis. Perforation of the gallbladder can occur in up to 10% of cases of acute cholecystitis, frequently a sequela of gangrenous cholecystitis. Clinical findings are variable, and it is difficult to diagnose gangrenous cholecystitis clinically. The disorder has no specific diagnostic sonographic findings. However, in the clinical setting of acute cholecystitis, several sonographic features suggest gangrenous cholecystitis, including striated thickening of the wall, intraluminal membranes, marked asymmetry of the gallbladder wall causing focal irregularities or mass-like intraluminal protrusions from the wall, nonlayeringechogenic debris within the gallbladder, and loculatedpericholecystic fluid collections containing debris. Sonographic Murphyâs sign may be negative in up to 70% of patients with gangrenous cholecystitis, possibly because of denervation of the gallbladder wall by gangrenous changes.
First described in 1931 by Hegner. Emphysematous cholecystitis is definitively treated with cholecystectomy, although percutaneouscholecystostomy may be used as an initial temporizing procedure in critically ill patients.The overall mortality rate for patients with the emphysematous form of cholecystitis is 15%, compared with a rate of less than 4% in uncomplicated cases of acute cholecystitis.
Small amounts of gas appear as echogenic lines with posterior dirty shadowing or reverberation artifact (ringdown). Large amounts of gas can be more difficult to appreciate; the absence of a normal gallbladder is a clue.A bright echogenic line with posterior dirty shadowing is seen within the entire gallbladder fossa. Movement of gas bubbles is a helpful finding, and compression of the gallbladder fossa may precipitate this sign.
Small amounts of gas appear as echogenic lines with posterior dirty shadowing or reverberation artifact (ringdown). Large amounts of gas can be more difficult to appreciate; the absence of a normal gallbladder is a clue.A bright echogenic line with posterior dirty shadowing is seen within the entire gallbladder fossa. Movement of gas bubbles is a helpful finding, and compression of the gallbladder fossa may precipitate this sign.
Some 5% to 10% of patients with acute cholecystitis develop gallbladder perforation.It occurs most commonly in the setting of gangrenous cholecystitiswith other risk factors including gallstones, impaired vascular supply, infection, malignancy, and steroid use. The fundus of the gallbladder is the most common site of perforation because it has the most tenuous blood supply.The focus of perforation, seen as a small defect or rent in the wall of the gallbladder, is often, but not always, visible.Clues to perforation are the deflation of the gallbladder with loss of its normal gourdlike shape, and a pericholecystic fluid collection.The latter is often a small fluid collection about the wall defect, in distinction to the thin rim of fluid about the entire organ present in uncomplicated cholecystitis.The collection may have internal strands typical of abscesses elsewherePerforation of the gallbladder may extend into the adjacent liver parenchyma, forming an abscess collection. The presence of a cystic liver lesion about the gallbladder fossa should raise the possibility of a pericholecystic abscess.
This rare complication of acute cholecystitis results from hemorrhage secondary to mucosal ulceration and necrosis and has been reported in the presence and absence of gallstones. Atherosclerosis of the gallbladder wall is a major predisposing factor.Classically the patient presents with biliary colic, jaundice, and melena.Only occasionally does the patient experience a gastrointestinal bleed.At sonography, blood in the gallbladder appears as echogenic material within the lumen which higher echogenicity than sludge. This may form a dependent layer; however, blood clots may appear as clumps or masses adherent to the gallbladder wall.As the hemorrhage evolves, this may have a cystic appearance.Prompt diagnosis is essential because hemorrhagic cholecystitis is associated with a high mortality rate.
Wall-Echo-Shadow complex (WES) or Double arc-shadow signThe proximal hyperechoic arc represents the wall of the gallbladder. The distal hyperechoic arc represents the reflections from gallstonesThe hypoechoic space in between represents either a small sliver of bile between the wall of the gallbladder and the gallstones or a hypoechoic portion of the wall of the gallbladder.When air or calcification is present, the normal gallbladder wall is not seen; only the bright echo and the posterior shadowing are seen.
Its cause is unknown, but occurs inassociation with gallstone disease and may represent a form of chronic cholecystitis.The term derives from the brittle consistency of the gallbladder.The entire wall or only part of the wall of the gallbladder may be calcified.Patients often have few symptoms, and the diagnosis is often made by detecting a palpable right upper quadrant mass or finding typical calcifications on plain radiographs. Prophylactic cholecystectomy is advocated in these patients, even in the paucity of symptoms, because of the strikingly high incidence (11%â33%) of carcinoma of the gallbladder.Differential diagnosis includes gallstones and emphysematous cholecystitis. Because the calcifications occur in the wall of the gallbladder, the WES complex is absent
Rare form of chronic cholecystitis. Gallbladder wall is infiltrated by foamy histiocytes, lymphocytes, polymorphonuclear leukocytes, fibroblasts, and giant cells. The cause is probably similar to that of xanthogranulomatouspyelonephritis, which is a chronic infection associated with the formation of calculi. Gallstones are present in most patients with XGC.Presents sonographically as diffuse or focal thickening of the gallbladder wall, with mural nodularity. The hypoechoic nodules or bands within the thickened wall may be seen suggesting the diagnosis.Because the hepatic surface of the gallbladder lacks a serosal layer, the inflammatory process more easily extends to the adjacentliver, and the liverâgallbladder margin is frequently indistinct.
Gall-bladder polyps are usually asymptomatic but may cause biliary colic.Gall-bladder polyps are usually discovered incidentally by transabdominalultrasonography, because they are so commonly asymptomatic.The primary limitation of ultrasonography is its inability to distinguish benign from malignant polyps, particularly when there are concomitant gall stones within the gall bladder and when the polyp is > 10 mm in diameter.
Cholesterol polyps are more common in women, at least until age 60, and have no malignant potential.The mechanism of formation of cholesterol polyps is unknown and they are found in association with gall stones only in the minorityof patients.
For a polyp > 18 mm, open surgery is recommended: the polyp is highly likely to be a locally invasive malignancy, and should be staged preoperatively with CT or EUS.
Heterogeneousâ was defined as a gallbladder polyps pattern with mixed echogenicity not including hyperechoic spot(s).
Has been postulated to result from mechanical obstruction of the gallbladder (from stones, cystic duct kinking, or congenital septum), chronic inflammation, and anomalous pancreaticobiliaryductal union.The association of this disorder with clinical findings is controversial. More than 90% of cases are associated with gallstones, which may be responsible for biliary symptoms.There is also a higher frequency of gallbladder carcinoma in gallbladders with segmental adenomyomatosis than in those without segmental adenomyomatosis.The epithelium and muscular layers proliferate, and invagination of the epithelial-lined spaces into the gallbladder wall produce intramural diverticula, termed Rokitansky-Aschoff sinuses. These may accumulate bile, cholesterol crystals, or even stones.
On US examinations they may be anechoic if large enough and bile containing but more frequently are small and contain cholesterol, biliary sludge, or gallstones that create echogenic foci, often with ring-down or comet tail artifacts. If the diverticula and their associated artifacts are not present, nonspecific mural thickening indistinguishable from acute or chronic cholecystitis and gallbladder carcinoma may be present.
These foci are caused by the cholesterol crystals within RASs.String: ŘŽŮء â ŘłŮŮ - ŘبŮpearls: ŮؤŮؤ
In one sonographic series, half the patients with these early carcinomas had no protruding lesions, and fewer than one-third were identified preoperatively.