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...
Thank You
Upcoming SlideShare
Loading in...5
×

Ultrasound of the gallbladder

51,037

Published on

Full description of gallbladder pathology by ultrasound

Published in: Health & Medicine, Business
2 Comments
71 Likes
Statistics
Notes
No Downloads
Views
Total Views
51,037
On Slideshare
0
From Embeds
0
Number of Embeds
4
Actions
Shares
0
Downloads
363
Comments
2
Likes
71
Embeds 0
No embeds

No notes for slide
  • 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
  • Phrygian : الفريجي أحد أبناء فريجيا القديمة بآسيا الوسطىcap : قلنسوة غطاء الرأس
  • Serrated: مسنن – مشرشر - منشاريValves 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: يتجمع - يتكتلBall: كرة
  • Tumefactive: محدث ورماTumefactive 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 Murphy’s 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 Murphy’s sign is defined as the presence of maximal tenderness elicited by direct pressure of the transducer over a sonographically localized gallbladder. The sonographic Murphy’s sign is different from surgical Murphy’s sign, which consists of arrest of inspiration caused by pain from an inflamed gallbladder when the examiner’s hand is placed on the patient’s subcostal right upper quadrant.
  • Striated:مخطط – مقلم - محزز
  • 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 Murphy’s sign (50%)
  • Emphysematous : نفاخي
  • 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 Murphy’s 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%–33%) 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 liver–gallbladder 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.
  • Heterogeneous” 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: خيط – سلك - حبلpearls: لؤلؤ
  • In one sonographic series, half the patients with these early carcinomas had no protruding lesions, and fewer than one-third were identified preoperatively.
  • Transcript of "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

    ×