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Ultrasound of the gallbladderSamir Haffar M.D.Assistant Professor of Gastroenterology
Ultrasound of the gallbladder Normal GB ultrasound Congenital abnormalities GB stones & sludge Acute cholecystitis & i...
 Normal GB ultrasound
Anatomy of the gallbladderSherlock S & Dooley J. Diseases of the liver and biliary system.Blackwell Science, Oxford, UK, 1...
Normal ultrasound of gallbladderMinimum 6 hours of fastingSubcostal or intercostal scanningSupine – LLD – Prone – ErectGB ...
Gallbladder foldsAbraham D et al. Emergency medicine sonography: Pocket guide.Jones & Bartlett Publishers, Boston, MA, USA...
Gallbladder foldsPhrygian cap (fundus over body)Fold between neck & bodySigmoid GB (multiple folds)
Acoustic shadow from a GB foldPart of a fold within gallbladder producing an acoustic shadowWhen only part of fold is visu...
Edge refraction shadowMcGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.Shadow near neck of GB...
Proximal cystic ductLongitudinal view of GB neck & proximal cystic ductSerrated appearance of cystic duct secondary to val...
Distal cystic ductNormal distal cystic duct entering the CBD posteriorlyParulekar SG. Ultrasound Quarterly 2002 ; 18 : 187...
 Congenital abnormalities
Congenital abnormalities of the gallbladder• Agenesis of gallbladder Confirmation with other tests• Anomalous GB location ...
Congenital anomalies of the gallbladderYamada T et all. Textbook of gastroenterology.Wiley-Blackwell, Oxford, UK, 5th edit...
Agenesis of gallbladder1 in 6,000 live births – fewer than 300 reported casesWaller AH et al. Clin Gastroenterol Hepatol 2...
Agenesis of gallbladderWaller AH et al. Clin Gastroenterol Hepatol 2008 ; 6 : 38.HIDA scanUptake by liverExcretion into CB...
Anomalous location of gallbladderRare – Reported only in isolated case reportsMost common locations• Left side (posterior ...
Duplication of gallbladderOne in 3000 to 4000 GB2 gallbladders adjacent to each other with 2 separate cystic ductsAfter me...
Multi-septate gallbladderCongenital origin – Very rare• Entire GB or part of lumen• Chambers communicate by orifices• Isol...
True diverticulum of gallbladderExtreme rarityOccurs anywhere in GBUsually singleVaries greatly in sizeMcGahan J et al. Di...
 Gallbladder stones & sludge
US of gallbladder stoneGold standard for diagnosis of cholelithasis3 sonographic criteria• Echogenic focus• Cast acoustic ...
Shadow of gallbladder stone* Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 – 287.** Rubens DJ. Ultrasound Clin 20...
Confluent shadowing of GB stonesMultiple small stones gravel abut each other with confluent ASMural thickening of gallblad...
Acoustic shadow of a gallbladder stoneTime gain compensationtoo highTime gain compensationis lowerBates J A. Abdominal Ult...
Stone smallerthan the beamShadowing of the stonesShadowBates J A. Abdominal Ultrasound: How, why and when.Churchill Living...
Floating stonesBates J A. Abdominal Ultrasound: How, Why and When.Churchill Livingstone, Edinburg, UK, 2nd edition, 2004Fl...
Tissue harmonic imaging & gallstonesLongitudinal ultrasoundNormal gallbladderRubens D. Radiol Clin North Am 2004 ; 42 : 25...
Correct & incorrect positions for prone scanningDemonstrates gravitational dependence of stoneCorrect: transducer as verti...
Pitfalls in diagnosis of GB stoneResidue in bowel indenting posterior wall of GBmimics gallstonesMcGahan J et al. Diagnost...
Dependent debris in the gallbladder• Sludge• Pseudosludge• Blood• Pus• Milk of calcium bileMcGahan J et al. Diagnostic ult...
Biliary sludgePrevalence unknown in general population• Predisposing factors PregnancyRapid weight loss & prolonged fastin...
Biliary sludgeAlso known as biliary sandLow-amplitude nonshadowing echoes in dependent portion of GBGore RM et al. Gastroe...
PseudosludgeMcGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.Most commonly along posterior su...
Aggregated sludge – Sludge ballMcGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.Change in app...
Aggregated sludge – Tumefactive sludgeGB with tumor-like sludgeRumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St....
Biliary sludge"hepatization" of gallbladderRumack CM, Wilson SR, & Charboneau JW. Diagnostic Ultrasound.Elsevier-Mosby, St...
Blood in the gallbladderClinical history very useful for diagnosisSonographic findings• Echogenic or mixed echogenicity• F...
Milk of calcium bile (limey bile)Diagnosis can be confirmed by abdominal radiography or CTHigh-attenuation material within...
Milk of calcium bile (limey bile)Abdominal radiography
 Acute cholecystitis & its complications
Causes of right upper quadrant pain• Peptic ulcer disease• Pancreatitis• Hepatitis• Appendicitis• Hepatic congestion from ...
Diagnostic standard for acute cholecystitisTokyo guidelines 2007Hirota M et al. J Hepatobiliary Pancreat Surg 2007 ; 14 : ...
Acute cholecystitis – HIDA scanHigher accuracy than ultrasonographyTalley NJ et al. Practical gastroenterology & hepatolog...
Sonographic findings in acute cholecystitis• Impacted stone in cystic duct or GB neck• Positive sonographic Murphys sign• ...
Acute cholecystitisCaused by gallstones in more than 90% of casesLarge obstructing stone within GB neckThick hypoechoic ga...
Negative sonographic Murphy’s sign• Patients who received pain medicine or steroids• Para or quadriplegic patients• Patien...
Gallbladder wall thickening• Generalized edematous states CHF – Renal failureEnd-stage cirrhosisHypoalbuminemia• Inflammat...
Diffuse gallbladder wall thickeningMcGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.Three ech...
Gallbladder wall thickeningUniformly echogenic patternEchogenic thickening of the wall in chronic cholecystitisMcGahan J e...
Gallbladder wall thickeningCentral hypoechoic zone separated by two echogenic layersGallbladder wall thickening due to asc...
Gallbladder wall thickeningStriated patternRubens DJ. Ultrasound Clin 2007 ; 2 : 391 – 413.Striated wall with alternating ...
Gallbladder wall thickeningRubens DJ et al.Ultrasound Clin 2007 ; 2 : 391 – 413.GallstonesFocal GB wall thickening (7 mm)F...
Gallbladder wall thickeningRubens DJ et al.Ultrasound Clin 2007 ; 2 : 391 – 413.Focal pyelonephritisHeterogeneous decrease...
Pericholecystic fluidTwo specific patternsType I Thin anechoic crescent-shaped collectionadjacent to gallbladder wallNonsp...
Acute cholecystitisHyperemic GB wallMcGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.Color Do...
Acute acalculous cholecystitis (AAC)5 – 15% of acute cholecystitis• Critically ill patients Major surgerySevere traumaSeps...
Acute acalculous cholecystitis (AAC)Difficult to diagnose clinically & on imagingMarked GB mural thickeningHypoechoic regi...
Complications of acute cholecystitis• Suppurative cholecystitis (empyema)• Gangrenous cholecystitis Up to 20%• Emphysemato...
Suppurative cholecystitis (Empyema)Patients very ill with fever & acute painFine echoes caused by pus in bilePericholecyst...
Gangrenous cholecystitisNo specific diagnostic US findings• Striated thickening of GB wall• Intraluminal membranes (5%)• M...
Gangrenous cholecystitisMucosal sloughingRubens D J. Ultrasound Clin 2007 ; 2 : 391 – 413.Longitudinal US of gallbladderIn...
Emphysematous cholecystitisPrompt surgical intervention required• Organisms Clostridium welchii & Escherichia coli• Charac...
Emphysematous cholecystitisAssociated with DM & atherosclerotic diseaseIntraluminal & intramural gas bubblesDebris within ...
Emphysematous cholecystitisSmall amount of gasSupine positionPresence of echoes anteriorlyCould be in the lumen or the wal...
Emphysematous cholecystitisLarge amount of gasAbsence of a normal gallbladder is a clueGas in GB completely obscures the l...
Emphysematous cholecystitisAbdominal radiographyIntraluminal & intramural gas bubblesBates J A. Abdominal Ultrasound: How,...
Gallbladder perforation5 – 10 % of patients with acute cholecystitisSmall defect in GB wall: not always seenDeflation of t...
GB perforation – Pericholecystic abscessRumack CM, Wilson SR, & Charboneau JW. Diagnostic Ultrasound.Elsevier-Mosby, St. L...
Hemorrhagic cholecystitisRare – Atherosclerosis – High mortality rateBennett GL et al. Radiol Clin N Am 2003 ; 41 : 1203 –...
Hemorrhagic cholecystitisDifferential diagnosis• Blood in gallbladder NeoplasmAneurysmsTraumaAnticoagulationEctopic pancre...
 Chronic cholecystitis
Forms of chronic cholecystitis• Traditional chronic cholecystitisThick gallbladder wall with gallstones• Wall-Echo-Shadow ...
Chronic cholecystitisBates J A. Abdominal Ultrasound: How, Why and When.Churchill Livingstone, Edinburg, UK, 2nd edition, ...
Wall-Echo-Shadow complex (WES)Contracted gallbladder filled with stones2 parallel arcuate hyperechoic linesSeparated by th...
Porcelain gallbladderCalcified wall with acoustic shadowMistaken for stone within GB lumenNo GB wall visibleRumack CM, Wil...
Porcelain gallbladder – Mild calcificationRickes S et al. N Engl J Med, 2002 ; 346 : e4.Computed tomographyGallstonesCalci...
Porcelain gallbladderAbdominal radiography
Xanthogranulomatous cholecystitis (XGC)2% of cholecystectomy specimensCompressed lumenMultiple large mural nodulesseparate...
 GB polyps & adenomyomatosis
Classification of gallbladder polyps3 – 7% of subjects undergoing USGallahan WC et al. Gastroenterol Clin N Am 2010 ; 39 :...
Risk of malignancy in GB polyps• Size Small polyp not necessarily benignSessile polyps ≤ 10 mm quite aggressive≥ 10 mm sus...
Cholesterol polyp & cholesterolosisLamina propria infiltrated with lipid-laden foamy macrophagesCholesterol polypCholester...
Cholesterol polyp & cholesterolosisCholesterol polypCholesterolosis“ strawberry gallbladder”Johnson CD et al. Mayo Clinic ...
Gallbladder polypsGallahan WC et al. Gastroenterol Clin N Am 2010 ; 39 : 359 – 367.Sessile polypPedunculated polyp
Gallbladder polypAny sizePSCCholelithiasisSessileLap surgeryTalley NJ et al. Practical gastroenterology & hepatology: Live...
Variable ScoreTumor maximum size (mm) Value in mmEUS in gallbladder polypRetrospective study of 70 surgical cases - Multiv...
EUS in gallbladder polyp11 mm in diameter (11)Homogenous (0)Hyperechoic spots (– 5)Cholesterol polyp GB adenoma9 mm in dia...
Adenomyomatosis (Rokitansky-Aschoff sinuses)8% of patients undergoing cholecystectomyFundicMost frequentAdenomyomaSegmenta...
Diffuse adenomyomatosis of gallbladderThickened GB wallComet-tail artifacts in GB wall„„Comet-tail” or „„ring-down‟‟ artif...
Diffuse adenomyomatosis of gallbladderThick gallbladder wallEchogenic intramural foci„„ring-down‟‟ artifactsMultiple high ...
Segmental adenomyomatosisRumack CM, Wilson SR, & Charboneau JW. Diagnostic Ultrasound.Elsevier-Mosby, St. Louis, Missouri,...
Fundal adenomyomatosisHypoechoic mass-likeFundal adenomyomaRumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Lou...
 Gallbladder carcinoma
US of gallbladder carcinoma3 major patterns of presentationGore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 – 287.• ...
Gallbladder carcinoma – Mural thickeningMarked mural thickening of the neck of gallbladderGore RM et al. Gastroenterol Cli...
Gallbladder carcinoma – Polypoid massEnhancing mass in GB fundusRubens DJ et al. Ultrasound Clin 2007 ; 2 : 391 – 413.Gore...
Gallbladder carcinoma – Gallbladder fossa massMass occupying GB fossaCoronal reformatted CT scanRubens DJ et al. Ultrasoun...
Malignant tumors of gallbladder• Most frequent Adenocarcinoma• Unusual histologic variants Papillary adenocarcinomaMucinou...
Signet ring cell carcinoma of gallbladderKim MJ et al. AJR 2006 ; 187 : 473 – 480.Target-like wall thickening ofgallbladde...
 Miscellaneous: volvulus – nonvisualization
Volvulus of gallbladderMobile GB with long suspensory mesentery• Rare acute entity• Symptoms of acute cholecystitis• Often...
Volvulus of gallbladder
Nonvisualization of gallbladder• Previous cholecystectomy• Chronic cholecystitis• Contracted GB: postprandial – cystic fib...
Micro-gallbladder in cystic fibrosisBates J A. Abdominal Ultrasound: How, Why and When.Churchill Livingstone, Edinburg, UK...
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Ultrasound of the gallbladder

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Full description of gallbladder pathology by ultrasound

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Ultrasound of the gallbladder

  1. 1. Ultrasound of the gallbladderSamir Haffar M.D.Assistant Professor of Gastroenterology
  2. 2. Ultrasound of the gallbladder Normal GB ultrasound Congenital abnormalities GB stones & sludge Acute cholecystitis & its complications Chronic cholecystitis Polyps & adenomyomatosis GB carcinoma Miscellaneous: volvulus – nonvisualization
  3. 3.  Normal GB ultrasound
  4. 4. Anatomy of the gallbladderSherlock S & Dooley J. Diseases of the liver and biliary system.Blackwell Science, Oxford, UK, 11th edition, 2002.
  5. 5. Normal ultrasound of gallbladderMinimum 6 hours of fastingSubcostal or intercostal scanningSupine – LLD – Prone – ErectGB wall ≤ 3 mm Anterior wallLong-axisPerpendicularTransverse diameter < 4 cmRumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.FBN
  6. 6. Gallbladder foldsAbraham D et al. Emergency medicine sonography: Pocket guide.Jones & Bartlett Publishers, Boston, MA, USA, 1st edition, 2010.Longitudinal view of gallbladderHartman’s pouchPhrygian cap
  7. 7. Gallbladder foldsPhrygian cap (fundus over body)Fold between neck & bodySigmoid GB (multiple folds)
  8. 8. Acoustic shadow from a GB foldPart of a fold within gallbladder producing an acoustic shadowWhen only part of fold is visualized, it may mimic a polyp or a stoneMcGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
  9. 9. Edge refraction shadowMcGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.Shadow near neck of GB on longitudinal sectionAbsence of visible stone at origin of shadowScanning in different positions
  10. 10. Proximal cystic ductLongitudinal view of GB neck & proximal cystic ductSerrated appearance of cystic duct secondary to valves of HeisterOccasionally identified on sonographyMcGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
  11. 11. Distal cystic ductNormal distal cystic duct entering the CBD posteriorlyParulekar SG. Ultrasound Quarterly 2002 ; 18 : 187 – 202.
  12. 12.  Congenital abnormalities
  13. 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 gallbladderMcGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
  14. 14. Congenital anomalies of the gallbladderYamada T et all. Textbook of gastroenterology.Wiley-Blackwell, Oxford, UK, 5th edition, 2009.Septated GBDuplicated GB Diverticulum
  15. 15. Agenesis of gallbladder1 in 6,000 live births – fewer than 300 reported casesWaller 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 cholecystitisDiagnosis usually obtained after surgical exploration
  16. 16. Agenesis of gallbladderWaller AH et al. Clin Gastroenterol Hepatol 2008 ; 6 : 38.HIDA scanUptake by liverExcretion into CBD & bowelNo visualization of gallbladderMRI & MRCPNo visualization of normal orectopic GBNormal biliary tree
  17. 17. Anomalous location of gallbladderRare – Reported only in isolated case reportsMost common locations• Left side (posterior to left lobe)• Intrahepatic• Suprahepatic (right lobe & diaphragm)• Retrohepatic (posterior to right lobe)Intrahepatic GBMay preclude Lap surgeryMcGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
  18. 18. Duplication of gallbladderOne in 3000 to 4000 GB2 gallbladders adjacent to each other with 2 separate cystic ductsAfter meals, both gallbladders showed normal emptyingwww.ultrasound-images.com/gall-bladder.htm
  19. 19. Multi-septate gallbladderCongenital origin – 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 septationsOriented horizontally or verticallyKapoor V et al. J Ultrasound Med 2002 ; 21 : 677 – 680.
  20. 20. True diverticulum of gallbladderExtreme rarityOccurs anywhere in GBUsually singleVaries greatly in sizeMcGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
  21. 21.  Gallbladder stones & sludge
  22. 22. US of gallbladder stoneGold standard for diagnosis of cholelithasis3 sonographic criteria• Echogenic focus• Cast acoustic shadow• Seek gravitational dependenceStones < 2 – 3 mm may be difficult to visualizeGore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 – 287.
  23. 23. Shadow of gallbladder stone* Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 – 287.** Rubens DJ. Ultrasound Clin 2007 ; 2 : 391 – 413.3 patterns of shadowing* Clean shadow Solitary stone Confluent shadowing Multiple small stones Wall-Echo-Shadow (WES) GB filled with gallstones** Soft pigment stones may not shadow
  24. 24. Confluent shadowing of GB stonesMultiple small stones gravel abut each other with confluent ASMural thickening of gallbladder
  25. 25. Acoustic shadow of a gallbladder stoneTime gain compensationtoo highTime gain compensationis lowerBates J A. Abdominal Ultrasound: How, why and when.Churchill Livingstone, Edinburg, UK, 2nd edition, 2004
  26. 26. Stone smallerthan the beamShadowing of the stonesShadowBates J A. Abdominal Ultrasound: How, why and when.Churchill Livingstone, Edinburg, UK, 2nd edition, 2004Stone occupieswidth of the beamLarge stoneoutside focal zoneLarge stonejust out of beamNo shadow
  27. 27. Floating stonesBates J A. Abdominal Ultrasound: How, Why and When.Churchill Livingstone, Edinburg, UK, 2nd edition, 2004Floating stones just below anterior gallbladder wall
  28. 28. Tissue harmonic imaging & gallstonesLongitudinal ultrasoundNormal gallbladderRubens D. Radiol Clin North Am 2004 ; 42 : 257 – 78.Harmonic imagingMultiple small stones
  29. 29. Correct & incorrect positions for prone scanningDemonstrates gravitational dependence of stoneCorrect: transducer as vertically as possible to image anterior GB wallIncorrect: most dependent anterior part of GB not well examinedHough DM et al. J Ultrasound Med 2000 ; 19 : 633 – 638.
  30. 30. Pitfalls in diagnosis of GB stoneResidue in bowel indenting posterior wall of GBmimics gallstonesMcGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
  31. 31. Dependent debris in the gallbladder• Sludge• Pseudosludge• Blood• Pus• Milk of calcium bileMcGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
  32. 32. Biliary sludgePrevalence unknown in general population• Predisposing factors PregnancyRapid weight loss & prolonged fastingLong-term TPNCeftriaxone – Prolonged octreotide ttBone marrow transplantation• Evolution (3 years) 50% resolve spontaneously20% persist asymptomatically5 – 15 % develop gallstones10 – 15 % become symptomatic• Complications Biliary colic, AAC, pancreatitis
  33. 33. Biliary sludgeAlso known as biliary sandLow-amplitude nonshadowing echoes in dependent portion of GBGore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 – 287.Occasionally, sludge can be highly echogenic
  34. 34. PseudosludgeMcGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.Most commonly along posterior surface of gallbladderProduced by “sidelobe artifacts”Disappear in different positions & when central portion of GB scanned
  35. 35. Aggregated sludge – Sludge ballMcGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.Change in appearance or disappearance on follow-upDifferentiates sludge ball from a stone or neoplasmNonshadowing mobile echogenic structures
  36. 36. Aggregated sludge – Tumefactive sludgeGB with tumor-like sludgeRumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.Potential mobility of sludgeNormal gallbladder wallNo vascularity detected on Doppler USFollow-up
  37. 37. Biliary sludge"hepatization" of gallbladderRumack CM, Wilson SR, & Charboneau JW. Diagnostic Ultrasound.Elsevier-Mosby, St. Louis, Missouri, USA, 3rd edition, 2005.GB entirely filled with sludge isoechoic to adjacent liverRecognized by identifying normal GB wall
  38. 38. Blood in the gallbladderClinical history very useful for diagnosisSonographic findings• Echogenic or mixed echogenicity• Fluid with low-level internal echoes• Retractile• May be mobileRumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.Angled edges of clotQuite typical of blood clots
  39. 39. Milk of calcium bile (limey bile)Diagnosis can be confirmed by abdominal radiography or CTHigh-attenuation material withindependent portion of GBHighly echogenic material independent portion of GB with ASRumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.
  40. 40. Milk of calcium bile (limey bile)Abdominal radiography
  41. 41.  Acute cholecystitis & its complications
  42. 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. 43. Diagnostic standard for acute cholecystitisTokyo guidelines 2007Hirota M et al. J Hepatobiliary Pancreat Surg 2007 ; 14 : 78 – 82 .Three categories of diagnostic findingsOne 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. 44. Acute cholecystitis – HIDA scanHigher accuracy than ultrasonographyTalley NJ et al. Practical gastroenterology & hepatology: Liver & biliary disease.Wiley Blackwell, Oxford, UK, First edition, 2010.Tracer in GBTracer in CBDTracer in small bowelGBCBDSmallbowelNormal HIDA scanNon-filling of GBTracer in CBDTracer in small bowelCBDSmallbowelAcute cholecystitis
  45. 45. Sonographic findings in acute cholecystitis• Impacted stone in cystic duct or GB neck• Positive sonographic Murphys 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 pathognomonicCombination of multiple signs make correct diagnosisRumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.
  46. 46. Acute cholecystitisCaused by gallstones in more than 90% of casesLarge obstructing stone within GB neckThick hypoechoic gallbladder wallPositive sonographic Murphy signRalls PW et al. Gastroenterol Clin N Am 2002 ; 31 : 801–825.
  47. 47. Negative sonographic Murphy’s 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 – gangrenous cholecystitis• Gallbladder ruptureCareful attention to clinical status importantwhen assessing for sonographic Murphy‟s signRubens DJ. Ultrasound Clin 2007 ; 2 : 391 – 413.
  48. 48. Gallbladder wall thickening• Generalized edematous states CHF – Renal failureEnd-stage cirrhosisHypoalbuminemia• Inflammatory conditions Primary Acute cholecystitisChronic cholecystitisCholangitisSecondary Acute hepatitisPerforated DUPancreatitisDiverticulitis/colitis• Neoplastic conditions Adenocarcinoma – Metastases• Miscellaneous Adenomyomatosis – VaricesRumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.
  49. 49. Diffuse gallbladder wall thickeningMcGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.Three echo patterns (not specific) Uniformly echogenic pattern Central hypoechoic zone & 2 peripheral echogenic layers Striated pattern
  50. 50. Gallbladder wall thickeningUniformly echogenic patternEchogenic thickening of the wall in chronic cholecystitisMcGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
  51. 51. Gallbladder wall thickeningCentral hypoechoic zone separated by two echogenic layersGallbladder wall thickening due to ascites
  52. 52. Gallbladder wall thickeningStriated patternRubens DJ. Ultrasound Clin 2007 ; 2 : 391 – 413.Striated wall with alternating echogenic & hypoechoic layersStriated wall in setting of acute cholecystitis: gangrenous cholecystitisStriated wall without evidence of acute cholecystitis: non specific
  53. 53. Gallbladder wall thickeningRubens DJ et al.Ultrasound Clin 2007 ; 2 : 391 – 413.GallstonesFocal GB wall thickening (7 mm)Free air with reverberation shadowsPericholecystic fluid (arrows)Free air (arrowheads)Extraluminal air (paired arrowheads)Peptic ulcer perforation
  54. 54. Gallbladder wall thickeningRubens DJ et al.Ultrasound Clin 2007 ; 2 : 391 – 413.Focal pyelonephritisHeterogeneous decreasedattenuation area typicalof focal pyelonephritisGB wall thickening 3-cm echogenic massin lower pole of rt kidney
  55. 55. Pericholecystic fluidTwo specific patternsType I Thin anechoic crescent-shaped collectionadjacent to gallbladder wallNonspecific findingType II Round or irregularly shaped collection withthick walls, septations, or internal debrisAssociated with GB perforation & abscessTeefey SA et al. J Ultrasound Med 1991 ; 10 : 603 – 6.Rubens DJ. Ultrasound Clin 2007 ; 2 : 391 – 413.
  56. 56. Acute cholecystitisHyperemic GB wallMcGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.Color Doppler sonographyIncreased vascularity in GB wallSupportive test
  57. 57. Acute acalculous cholecystitis (AAC)5 – 15% of acute cholecystitis• Critically ill patients Major surgerySevere traumaSepsisTotal parenteral nutritionDiabetesAtherosclerotic diseaseHIV infection• Nonhospitalized patients Elderly male with atherosclerosisHIDA scan & sampling of luminal contentshelp to establish the diagnosis
  58. 58. Acute acalculous cholecystitis (AAC)Difficult to diagnose clinically & on imagingMarked GB mural thickeningHypoechoic regions within wallGore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 – 287.Marked GB mural thickeningwith hypo & hyperenhancing areas
  59. 59. Complications of acute cholecystitis• Suppurative cholecystitis (empyema)• Gangrenous cholecystitis Up to 20%• Emphysematous cholecystitis 1 %• Hemorrhagic cholecystitis Rare• Gallbladder perforation 5 – 10%
  60. 60. Suppurative cholecystitis (Empyema)Patients very ill with fever & acute painFine echoes caused by pus in bilePericholecystic GB collection (leakage)US used to guide drainage before surgeryBates J A. Abdominal Ultrasound: How, why and when.Churchill Livingstone, Edinburg, UK, 2nd edition, 2004Large GB full of pus & stones
  61. 61. Gangrenous cholecystitisNo 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 Murphy’s sign negative in 70%Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 – 287.Mucosal sloughingEchogenic debris within GB
  62. 62. Gangrenous cholecystitisMucosal sloughingRubens D J. Ultrasound Clin 2007 ; 2 : 391 – 413.Longitudinal US of gallbladderIntraluminal membranes associated gallbladder gangreneStone impacted in gallbladder neck
  63. 63. Emphysematous cholecystitisPrompt surgical intervention required• Organisms Clostridium welchii & Escherichia coli• Characteristics Male preponderance (70%)Frequent occurrence in diabetic (50%)Lack of gallstones in up to one thirdHigher risk of gangrene & perforation• Three stages Stage 1: Gas in GB lumenStage 2: Gas in GB wallStage 3: Gas in pericholecystic tissuesBennett GL et al. Radiol Clin N Am 2003 ; 41 : 1203 – 1216.Appearance depends on amount of gas present
  64. 64. Emphysematous cholecystitisAssociated with DM & atherosclerotic diseaseIntraluminal & intramural gas bubblesDebris within necrotic GBHigher sensitivity of CTfor the diagnosisDiagnosis should be confirmed by abdominal radiography or CTGore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 – 287.
  65. 65. Emphysematous cholecystitisSmall amount of gasSupine positionPresence of echoes anteriorlyCould be in the lumen or the wallRubens D J. Ultrasound Clin 2007 ; 2 : 391 – 413.Upright positionGas moves & breaks into bubblesDistinguishing it from calcium
  66. 66. Emphysematous cholecystitisLarge amount of gasAbsence of a normal gallbladder is a clueGas in GB completely obscures the lumen (dirty shadow)Bates J A. Abdominal Ultrasound: How, Why and When.Churchill Livingstone, Edinburg, UK, 2nd edition, 2004Location of GB fossa essential to avoid mistaking this for bowel gas
  67. 67. Emphysematous cholecystitisAbdominal radiographyIntraluminal & intramural gas bubblesBates J A. Abdominal Ultrasound: How, Why and When.Churchill Livingstone, Edinburg, UK, 2nd edition, 2004
  68. 68. Gallbladder perforation5 – 10 % of patients with acute cholecystitisSmall defect in GB wall: not always seenDeflation of the gallbladderPericholecystic fluid collectionPericholecystic abscessRumack CM, Wilson SR, & Charboneau JW. Diagnostic Ultrasound.Elsevier-Mosby, St. Louis, Missouri, USA, 3rd edition, 2005.Disruption of GB wall
  69. 69. GB perforation – Pericholecystic abscessRumack CM, Wilson SR, & Charboneau JW. Diagnostic Ultrasound.Elsevier-Mosby, St. Louis, Missouri, USA, 3rd edition, 2005.Abscess (internal strands typical of abscess)Echogenic inflamed fatSmall amount of ascites
  70. 70. Hemorrhagic cholecystitisRare – Atherosclerosis – High mortality rateBennett GL et al. Radiol Clin N Am 2003 ; 41 : 1203 – 1216.Echogenic material with higherechogenicity than sludgeIncreased density of bile
  71. 71. Hemorrhagic cholecystitisDifferential diagnosis• Blood in gallbladder NeoplasmAneurysmsTraumaAnticoagulationEctopic pancreasEctopic gastric mucosa• High-density bile Recently administered IV contrastMilk of calcium bileBennett GL et al. Radiol Clin N Am 2003 ; 41 : 1203 – 1216.
  72. 72.  Chronic cholecystitis
  73. 73. Forms of chronic cholecystitis• Traditional chronic cholecystitisThick gallbladder wall with gallstones• Wall-Echo-Shadow complex (WES)Double arc-shadow sign• Porcelain gallbladderHigh incidence of GB carcinoma (10 – 30%)• Xanthogranulomatous cholecystitis (XGC)Difficult to distinguish from adenomyomatosis &gallbladder carcinoma
  74. 74. Chronic cholecystitisBates J A. Abdominal Ultrasound: How, Why and When.Churchill Livingstone, Edinburg, UK, 2nd edition, 2004Thick gallbladder wallSmall gallbladder stone with posterior ASBouts of acute cholecystitis may complicate chronic cholecystitis
  75. 75. Wall-Echo-Shadow complex (WES)Contracted gallbladder filled with stones2 parallel arcuate hyperechoic linesSeparated by thin hypoechoic spaceDistal acoustic shadowingMcGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.Differentiation from air or calcification in GB wallNormal GB wall not seen; only bright echo & AS seen
  76. 76. Porcelain gallbladderCalcified wall with acoustic shadowMistaken for stone within GB lumenNo GB wall visibleRumack CM, Wilson SR, & Charboneau JW. Diagnostic Ultrasound.Elsevier-Mosby, St. Louis, Missouri, USA, 3rd edition, 2005.Dense calcification in GB fundus
  77. 77. Porcelain gallbladder – Mild calcificationRickes S et al. N Engl J Med, 2002 ; 346 : e4.Computed tomographyGallstonesCalcification of GB wallUltrasonographyGallstones (one in cystic duct)leading to GB enlargement (5 cm)Calcification of GB wall
  78. 78. Porcelain gallbladderAbdominal radiography
  79. 79. Xanthogranulomatous cholecystitis (XGC)2% of cholecystectomy specimensCompressed lumenMultiple large mural nodulesseparated by enhancing marginsStone not visualizedCompressed lumenMultiple hypoechoic mural nodulesWall markedly thickenedAdjacent stoneRubens D J. Ultrasound Clin 2007 ; 2 : 391 – 413.
  80. 80.  GB polyps & adenomyomatosis
  81. 81. Classification of gallbladder polyps3 – 7% of subjects undergoing USGallahan WC et al. Gastroenterol Clin N Am 2010 ; 39 : 359 – 367.NeoplasticAdenomas (4%) 5 – 20 mm, solitaryMiscellaneous Leiomyomas, lipomas,neurofibromas, carcinoidsNon-neoplasticCholesterol polyp (60%) < 10 mmAdenomyomatosis (25%) Usually fundusInflammatory (10%) < 10 mm
  82. 82. Risk of malignancy in GB polyps• Size Small polyp not necessarily benignSessile polyps ≤ 10 mm quite aggressive≥ 10 mm suspicious> 18 mm usually invasive malignancy• Patient age > 50• Concurrent gall stones• Diagnosis of PSCTalley NJ et al. Practical gastroenterology & hepatology: Liver & biliary disease.Wiley Blackwell, Oxford, UK, First edition, 2010.
  83. 83. Cholesterol polyp & cholesterolosisLamina propria infiltrated with lipid-laden foamy macrophagesCholesterol polypCholesterolosis“ strawberry gallbladder”
  84. 84. Cholesterol polyp & cholesterolosisCholesterol polypCholesterolosis“ strawberry gallbladder”Johnson CD et al. Mayo Clinic gastrointestinal imaging review.Mayo Clinic Scientific Press, Rochester, USA, 2005.
  85. 85. Gallbladder polypsGallahan WC et al. Gastroenterol Clin N Am 2010 ; 39 : 359 – 367.Sessile polypPedunculated polyp
  86. 86. Gallbladder polypAny sizePSCCholelithiasisSessileLap surgeryTalley NJ et al. Practical gastroenterology & hepatology: Liver & biliary disease.Wiley Blackwell, Oxford, UK, First edition, 2010.> 18 mmStaging &Open surgery< 10 mmSymptomsYesImaging: US or EUSEvery 6 monthsNon10 – 18 mmNo consensus guidelines to guide treatmentManagement should be individualized
  87. 87. Variable ScoreTumor maximum size (mm) Value in mmEUS in gallbladder polypRetrospective study of 70 surgical cases - Multivariate analysisSadamoto Y et al. Endoscopy 2002 ; 34 : 959 – 965.Scores ≥ 12: neoplastic polypSen: 78% – Sp: 83% – Accuracy: 83 %Internal echo patternHeterogeneousHomogeneous40Hyperechoic spottingSingle 1 – 5 mm hyperechoic spotMultiple hyperechoic 1 – 3 mm spotsPresence: – 5Absence: 0
  88. 88. EUS in gallbladder polyp11 mm in diameter (11)Homogenous (0)Hyperechoic spots (– 5)Cholesterol polyp GB adenoma9 mm in diameter (9)Heterogeneous (4)Hyperechoic spots (0)Sadamoto Y et al. Endoscopy 2002 ; 34 : 959 – 965.Score: 6 Score: 13
  89. 89. Adenomyomatosis (Rokitansky-Aschoff sinuses)8% of patients undergoing cholecystectomyFundicMost frequentAdenomyomaSegmentalHourglassDiffuseExcessive proliferation of surface epitheliumwhich can invaginate into muscularis
  90. 90. Diffuse adenomyomatosis of gallbladderThickened GB wallComet-tail artifacts in GB wall„„Comet-tail” or „„ring-down‟‟ artifact
  91. 91. Diffuse adenomyomatosis of gallbladderThick gallbladder wallEchogenic intramural foci„„ring-down‟‟ artifactsMultiple high signal intensitystructures within GB wall“string of pearls” appearanceGore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 – 287.
  92. 92. Segmental adenomyomatosisRumack CM, Wilson SR, & Charboneau JW. Diagnostic Ultrasound.Elsevier-Mosby, St. Louis, Missouri, USA, 3rd edition, 2005.Masslike areas obliterating lumenCystic spaces suggest diagnosisMultiple echogenic fociCrystals in sinuses suggest dg
  93. 93. Fundal adenomyomatosisHypoechoic mass-likeFundal adenomyomaRumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.Thickened GB wall with smallRokitansky-Aschoff sinus at fundus
  94. 94.  Gallbladder carcinoma
  95. 95. US of gallbladder carcinoma3 major patterns of presentationGore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 – 287.• Polypoid GB mass25% of carcinoma – > 1 cm – Broad based – Role of EUS• Mural thickeningLeast common – Focal or diffuse – IrregularMost difficult to diagnose• Gallbladder fossa massMost common – Replacing GB – Invading adjacent liver
  96. 96. Gallbladder carcinoma – Mural thickeningMarked mural thickening of the neck of gallbladderGore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 – 287.
  97. 97. Gallbladder carcinoma – Polypoid massEnhancing mass in GB fundusRubens DJ et al. Ultrasound Clin 2007 ; 2 : 391 – 413.Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 – 287.2-cm polypoid mass in GB fundusInternal vascularityVillous adenoma with foci of CIS
  98. 98. Gallbladder carcinoma – Gallbladder fossa massMass occupying GB fossaCoronal reformatted CT scanRubens DJ et al. Ultrasound Clin 2007 ; 2 : 391 – 413.Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 – 287.Immobile gallstonesHeterogeneous mass in GB fossaSome vascularity on color DopplerColor Doppler US
  99. 99. Malignant tumors of gallbladder• Most frequent Adenocarcinoma• Unusual histologic variants Papillary adenocarcinomaMucinous adenocarcinomaSignet ring cell–type• Unusual malignancies Squamous cell carcinomaCarcinosarcomaSmall cell carcinomaLymphomaMetastasisKim MJ et al. AJR 2006 ; 187 : 473 – 480.Radiologic findings overlap with ordinary GB carcinoma
  100. 100. Signet ring cell carcinoma of gallbladderKim MJ et al. AJR 2006 ; 187 : 473 – 480.Target-like wall thickening ofgallbladderTargetlike wall thickening of GBEnhancement of gallbladder fundusMassive necrotic LN along portahepatis & hepatoduodenal ligament
  101. 101.  Miscellaneous: volvulus – nonvisualization
  102. 102. Volvulus of gallbladderMobile GB with long suspensory mesentery• Rare acute entity• Symptoms of acute cholecystitis• Often seen in elderly females• US findings:Massively distended & inflamed GBUnusual location of gallbladderUnusual horizontal long axis in left to right directionRumack CM, Wilson SR, & Charboneau JW. Diagnostic Ultrasound.Elsevier-Mosby, St. Louis, Missouri, USA, 3rd edition, 2005.
  103. 103. Volvulus of gallbladder
  104. 104. Nonvisualization of gallbladder• Previous cholecystectomy• Chronic cholecystitis• Contracted GB: postprandial – cystic fibrosis• Porcelain gallbladder with shadowing• Air-filled GB or emphysematous cholecystitis• Agenesis of gallbladder• Ectopic location• Tumefactive sludge• GB carcinoma completely filling gallbladderRumack CM, Wilson SR, & Charboneau JW. Diagnostic ultrasound.Elsevier-Mosby, St. Louis, Missouri, USA, 3rd edition, 2005.
  105. 105. Micro-gallbladder in cystic fibrosisBates J A. Abdominal Ultrasound: How, Why and When.Churchill Livingstone, Edinburg, UK, 2nd edition, 2004
  106. 106. Thank You

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