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ROLE OF USG IN GB
PATHOLOGIES
Dr.Pratibha Malik
Moderator-
Dr. Revathi
Always look for cholecytectomy
scar first!!
Indications
Normal Anatomy
Pathogical Findings:GB
gallstones
sludge
chol...
08/03/14
INDICATIONS
 Abdominal pain
 vomiting
 fever
 jaundice
 abnormal labs
(bilirubin,
transaminases)
08/03/14
Technique and Preparation
Curvilinear probes :2-5
MHz
Views:
 Subcostal sagittal
 intercostal sagittal
 corona...
 Indications
 Normal Anatomy
 Pathogical Findings:GB
 gallstones
 sludge
 cholecystitis
 polyps
 gallbladder cance...
NORMAL ANATOMY OF THE
BILLIARY SYSTEM
NORMAL APPERANCE OF GB
Normal Gallbladder is seen as a sonolucent pear shaped
structure with slim wall (2 mm or so). Best ...
  The main hepatic fissure appears as an echogenic
line that extends from the neck of the gallbladder to
the portal vein ...
08/03/14
"Mickey Mouse" view of
Portal Triad
08/03/14
08/03/14
NORMAL VARIANTS
Phrygian cap
Figure (A) A folded gallbladder is
difficult to examine with the patient
supine.
(B) Turning ...
CONTENTS
 Indications
 Normal Anatomy
 Pathogical Findings:GB
 Gallstones
 sludge
 cholecystitis
 polyps
 gallblad...
Gold standard for diagnosis:
3 sonographic criteria-
 Echogenic focus
 Cast acoustic shadow
 Seek gravitational depende...
CHOLELITHIASIS
Cholelithiasis with posterior acoustic shadowing and 
normal GB wall thickness
CONTENTS
 Indications
 Normal Anatomy
 Pathogical Findings:GB
 gallstones
 sludge
 cholecystitis
 polyps
 gallblad...
Sludge is identified on ultrasound as slightly hyperechoic material forming a
meniscus within the gallbladder lumen.
Sludg...
08/03/14
DD
ECHOGENIC LESIONS
IN GALL BLADDER
DD
MOBILE OR POSTERIOR
SHADOWING
•STONES
•SLUDGE
FIXED
•POLYP
•ADHESIVE STON...
CONTENTS
 Indications
 Normal Anatomy
 Pathogical Findings:GB
 gallstones
 sludge
 cholecystitis
 polyps
 gallblad...
GB inflammation
CALCULUS CHOLECYSTITIS VS ACALCULUS
 Acute cholecystitis refers to the acute inflammation of the
gallbladder . It is the ...
Figure: Acute cholecystitis: (A) TS of an oedematous, thickened gallbladder wall
with a stone. (B) LS with a thickened wal...
Sonographic Murphy’s sign
08/03/14
Sonographic Murphy’s sign is positive when the point of maximal tenderness is
identifie...
 Complications
 gangrenous cholecystitis
 emphysematous cholecystitis
 gallbladder perforation
 pericholecystic absce...
Gallbladder gangrene/mucosal sloughing. Longitudinal
ultrasound of a patient who had acute cholecystitis
secondary to ston...
Chronic calculus cholecystitis
USG FINDINGS
 Thickened echogenic wall
 Contracted GB
 Cholelithisis
Chronic calculus cholecystitis
 When the gallbladder is entirely filled with stones, a wall echo shadow
(WES) sign is seen
 The WES triad is another si...
ACALCULUS CHOLECYSTITIS
 Acute acalculous cholecystitis (AAC) refers
development of cholecystitis either in a gallbladder...
Figure :(A) Acalculous cholecystitis. The gallbladder wall is markedly thickened
and tender on scanning.
(B) Gravity-depen...
PORCELAIN GB
 A porcelain gallbladder refers to extensive calcium
encrustation of the gallbladder wall.
 The term porcel...
Porcelain gallbladder. (A) Sagittal imageof the gallbladder shows a densely
echogenic anterior wall (arrow) with a sharp s...
CONTENTS
 Indications
 Normal Anatomy
 Pathogical Findings:GB
 gallstones
 sludge
 cholecystitis
 polyps
 gallblad...
GB POLYPS
 Gallbladder polyps are outgrowths of the gallbladder mucosal wall.
 Do not cast an acoustic shadow.
 Remain ...
GB POLYPS
GB polyps are classified into 2 groups:
Neoplastic
 Adenomas
 Adenocarcinomas
Nonneoplastic
 Cholesterol poly...
GB polyps are soft tissue masses attached to the wall of the gallbladder and
differentiated from gallstones by their lack ...
On CD demonstration of supplying vessel
pathognomic of polyp.
INCREASE RISK OF MALIGNANCY IN
POLYP
 Diameters > 10 mm
 Sessile Polyps
 Single Polyps
 Polyps With Adjacent Wall Thic...
CONTENTS
 Indications
 Normal Anatomy
 Pathogical Findings:GB
 gallstones
 sludge
 cholecystitis
 polyps
 gallblad...
CARCINOMA GB
 Gall bladder carcinoma is the most common biliary
tract cancer.
 Delayed presentation and early spread of ...
RISK FACTOR FOR CA GB
 Gallstones
 History of chronic cholecystitis
 Porcelain gallbladder.
 Choledochal cysts,
 Anom...
USG FINDINGS IN CA GB
 A Mass Completely Occupying Or Replacing The Gallbladder
Lumen
 Focal Or Diffuse Asymmetric Gallb...
CA GB WITH LIVER INVASION
08/03/14
 The normal gallbladder wall measures less than 4 mm.  the gallbladder wall is measured at the
most narrow point ...
CONTENTS
 Indications
 Normal Anatomy
 Pathogical Findings:GB
 gallstones
 sludge
 cholecystitis
 polyps
 gallblad...
BILIARY TRACT
08/03/14
BILE DUCTS
 Sonographically, the CBD appears as an anechoic tubular
structure in the main portal triad, anterior...
08/03/14
Intrahepatic duct stones
The Mirizzi Syndrome
 Form of obstructive jaundice-described by
Mirizzi.
 Caused by a stone or stones impacted in the
ne...
Csendes classification of
Mirizzi syndrome
Figure: Mirizzi syndrome: a large stone in the
neck of the gallbladder (arrow) is compressing the bile duct,
causing intra...
COMPONENTS OF MS
There must be 4 components for the syndrome to occur:
1. Anatomy- placing the cystic duct parallel to the...
INTRAHEPATIC GALL STONES
INTRAHEPATIC VS EXTRAHEPATIC CALCULUS
•Caroli's disease is characterized by congenital
segmental dilation of the intrahepa...
Primary intrahepatic stones exclusively involving the
intrahepatic biliary tree-related to chronic parasitic infestation o...
EXTRAHEPATIC CALCULUS
CALCULI IN THE DISTAL CBD
CONTENTS
 Indications
 Normal Anatomy
 Pathogical Findings:GB
 gallstones
 sludge
 cholecystitis
 polyps
 gallblad...
KLATSKIN TUMOUR
 A Klatskin tumour is a term that was traditionally given
to a hilar cholangiocarcinoma (occuring at the
...
Risk factors :
 Primary sclerosing cholangitis
 Choledochal cysts
 Parasitic infections
 Hepatolithiasis (also called ...
ULTRASOUND FINDINGS
 Presence of a hilar mass with obstruction
 Increased echogenicity relative to surrounding
liver ~79...
Figure : Cholangiocarcinoma. (A) Irregular mass at the porta,
causing biliary obstruction—a Klatskin tumour.
(B) MRI of th...
KLATSKIN TUMOUR
COLOUR DOPPLER TO LOOK FOR
VASCULAR INVASION
08/03/14
THICKENING OF BILE DUCT WALL
FOCAL STRICTURE
•BACTERIAL CHOLANGITIS
•CHOLANGIOCARCINOMA
•CHOLEDOCAL CYSTS
•METAST...
08/03/14
Pearls and Pitfalls
 The gallbladder is a mobile organ; remember to change patient positioning
and/or probe plac...
USG in gall bladder pathologies
USG in gall bladder pathologies
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USG in gall bladder pathologies

  1. 1. ROLE OF USG IN GB PATHOLOGIES Dr.Pratibha Malik Moderator- Dr. Revathi
  2. 2. Always look for cholecytectomy scar first!! Indications Normal Anatomy Pathogical Findings:GB gallstones sludge cholecystitis polyps gallbladder cancer Biliary tract Bile duct stones klatskin tumour 08/03/14 CONTENTS
  3. 3. 08/03/14 INDICATIONS  Abdominal pain  vomiting  fever  jaundice  abnormal labs (bilirubin, transaminases)
  4. 4. 08/03/14 Technique and Preparation Curvilinear probes :2-5 MHz Views:  Subcostal sagittal  intercostal sagittal  coronal  left lateral decubitus  oblique views  reverse trendelenberg
  5. 5.  Indications  Normal Anatomy  Pathogical Findings:GB  gallstones  sludge  cholecystitis  polyps  gallbladder cancer  Biliary tract  Bile duct stones  klatskin tumour Contents
  6. 6. NORMAL ANATOMY OF THE BILLIARY SYSTEM
  7. 7. NORMAL APPERANCE OF GB Normal Gallbladder is seen as a sonolucent pear shaped structure with slim wall (2 mm or so). Best seen with overnight fasting or at least 4-5 hours fasting. It is seen usually at the inferior aspect of the liver right lobe.
  8. 8.   The main hepatic fissure appears as an echogenic line that extends from the neck of the gallbladder to the portal vein and serves as a landmark.  The complex of the gallbladder, main hepatic fissure, and portal vein (in the short-axis) has the appearance of an exclamation point 08/03/14
  9. 9. 08/03/14
  10. 10. "Mickey Mouse" view of Portal Triad 08/03/14
  11. 11. 08/03/14
  12. 12. NORMAL VARIANTS Phrygian cap Figure (A) A folded gallbladder is difficult to examine with the patient supine. (B) Turning the patient, right side raised, unfolds the gallbladder, enabling the lumen to be satisfactorily examined. The gallbladder may be ‘folded’ (the so- called Phrygian cap).
  13. 13. CONTENTS  Indications  Normal Anatomy  Pathogical Findings:GB  Gallstones  sludge  cholecystitis  polyps  gallbladder cancer  Biliary tract  Bile duct stones  klatskin tumour
  14. 14. Gold standard for diagnosis: 3 sonographic criteria-  Echogenic focus  Cast acoustic shadow  Seek gravitational dependence
  15. 15. CHOLELITHIASIS Cholelithiasis with posterior acoustic shadowing and  normal GB wall thickness
  16. 16. CONTENTS  Indications  Normal Anatomy  Pathogical Findings:GB  gallstones  sludge  cholecystitis  polyps  gallbladder cancer  Biliary tract  Bile duct stones  klatskin tumour
  17. 17. Sludge is identified on ultrasound as slightly hyperechoic material forming a meniscus within the gallbladder lumen. Sludge may be a precursor to gallstones and has been related to pathology such as acute cholecystitis and acute pancreatitis 08/03/14
  18. 18. 08/03/14 DD ECHOGENIC LESIONS IN GALL BLADDER DD MOBILE OR POSTERIOR SHADOWING •STONES •SLUDGE FIXED •POLYP •ADHESIVE STONE •SLOW MOVING TUMEFACTIVE SLUDGE
  19. 19. CONTENTS  Indications  Normal Anatomy  Pathogical Findings:GB  gallstones  sludge  cholecystitis  polyps  gallbladder cancer  Biliary tract  Bile duct stones  klatskin tumour
  20. 20. GB inflammation
  21. 21. CALCULUS CHOLECYSTITIS VS ACALCULUS  Acute cholecystitis refers to the acute inflammation of the gallbladder . It is the primary complication of cholelithiasis  90 to 95% of cases are due to calculous obstruction of the gallbladder neck or cystic duct.  Most sensitive US finding : 1. Presence Of Cholelithiasis 2. Sonographic Murphy Sign. 3. Gallbladder Wall Thickening (>3mm) 4. Pericholecystic fluid.  Other less specific imaging findings include gallbladder distension(>4 cm) and sludge. 99m Tc-HIDA scintigraphy  HIDA cholescintigraphy in acute cholecystitis will demonstrate nonvisualization of the gallbladder.
  22. 22. Figure: Acute cholecystitis: (A) TS of an oedematous, thickened gallbladder wall with a stone. (B) LS with a thickened wall (arrows). Stones and debris are present. (C) and (D) TS and LS demonstrating pericholecystic fluid.
  23. 23. Sonographic Murphy’s sign 08/03/14 Sonographic Murphy’s sign is positive when the point of maximal tenderness is identified in the right upper quadrant while the gallbladder is identified on the ultrasound monitor. Differential diagnosis of acute cholecystitis choledocholithiasis pancreatitis peptic ulcer disease acute hepatitis
  24. 24.  Complications  gangrenous cholecystitis  emphysematous cholecystitis  gallbladder perforation  pericholecystic abscess  cholecystoenteric fistula  liver abscess  Gangrenous and emphysematous cholecystitis - serious complications of acute cholecystitis that may be identified with ultrasound by the presence of air within the gallbladder wall or lumen . Air on ultrasound is represented by “comet- tail” artifacts.  Gallbladder perforation may also be diagnosed by ultrasound. Findings of perforation include significant amounts of pericholecystic fluid that may contain echogenic material which may be walled off from the rest of the abdomen.
  25. 25. Gallbladder gangrene/mucosal sloughing. Longitudinal ultrasound of a patient who had acute cholecystitis secondary to stone (arrow) impacted in the gallbladder neck. Note the intraluminal membranes (arrowheads) that are associated with gangrene of the gallbladder.
  26. 26. Chronic calculus cholecystitis USG FINDINGS  Thickened echogenic wall  Contracted GB  Cholelithisis
  27. 27. Chronic calculus cholecystitis
  28. 28.  When the gallbladder is entirely filled with stones, a wall echo shadow (WES) sign is seen  The WES triad is another sign of chronic cholecystitis; here the WES stands for Wall (of the GB), Echo (of the calculus) and Shadow (caused by the stones).
  29. 29. ACALCULUS CHOLECYSTITIS  Acute acalculous cholecystitis (AAC) refers development of cholecystitis either in a gallbladder without gallstones or in a gallbladder with gallstones where the stones are not the contribuatry factor to the development of cholecystitis . AETIOLOGY  It usually occurs in critically ill or  injured patients.
  30. 30. Figure :(A) Acalculous cholecystitis. The gallbladder wall is markedly thickened and tender on scanning. (B) Gravity-dependent sludge with a thick, oedematous wall. No stones were present.
  31. 31. PORCELAIN GB  A porcelain gallbladder refers to extensive calcium encrustation of the gallbladder wall.  The term porcelain gallbladder has been used to emphasize the blue discoloration and brittle consistency of the gallbladder wall at surgery  Association between porcelain gallbladder and gallbladder adenocarcinoma- 22-30 % .  Cholecystectomy routinely performed when a porcelain gallbladder is identified.
  32. 32. Porcelain gallbladder. (A) Sagittal imageof the gallbladder shows a densely echogenic anterior wall (arrow) with a sharp shadow that obliterates the gallbladder lumen and posterior wall. (B) Transverse ultrasound of the gallbladder in the same patient. The anterior wall is bright, but, without enough reflection or attenuation to eliminate visualization of the lumen and posterior wall (arrow), which is also echogenic and casts a posterior acoustic shadow.
  33. 33. CONTENTS  Indications  Normal Anatomy  Pathogical Findings:GB  gallstones  sludge  cholecystitis  polyps  gallbladder cancer  Biliary tract  Bile duct stones  klatskin tumour
  34. 34. GB POLYPS  Gallbladder polyps are outgrowths of the gallbladder mucosal wall.  Do not cast an acoustic shadow.  Remain fixed on turning the patient ;so distinguishable from stones  Majority are not neoplastic but are hyperplastic or represent lipid deposits(cholesterolosis).  Gallbladder (GB) polyps are incidentally detected in approximately 4%–7% of patients who undergo ultrasonography
  35. 35. GB POLYPS GB polyps are classified into 2 groups: Neoplastic  Adenomas  Adenocarcinomas Nonneoplastic  Cholesterol polyps  Inflammatory polyps  Adenomyomatosis
  36. 36. GB polyps are soft tissue masses attached to the wall of the gallbladder and differentiated from gallstones by their lack of mobility and shadowing
  37. 37. On CD demonstration of supplying vessel pathognomic of polyp.
  38. 38. INCREASE RISK OF MALIGNANCY IN POLYP  Diameters > 10 mm  Sessile Polyps  Single Polyps  Polyps With Adjacent Wall Thickening Or Invasion  Increased Patient Age  Size Of At Least 10 mm Is The Most Well-established predictor of malignancy
  39. 39. CONTENTS  Indications  Normal Anatomy  Pathogical Findings:GB  gallstones  sludge  cholecystitis  polyps  gallbladder cancer  Biliary tract  Bile duct stones  klatskin tumour
  40. 40. CARCINOMA GB  Gall bladder carcinoma is the most common biliary tract cancer.  Delayed presentation and early spread of tumor make it one of the lethal tumors with poor prognosis.
  41. 41. RISK FACTOR FOR CA GB  Gallstones  History of chronic cholecystitis  Porcelain gallbladder.  Choledochal cysts,  Anomalous pancreaticobiliary duct junctions  Gallbladder polyps > 1 cm in size.  Peak incidence in the 6th -7th decades of life  3-5 times more predominant in females
  42. 42. USG FINDINGS IN CA GB  A Mass Completely Occupying Or Replacing The Gallbladder Lumen  Focal Or Diffuse Asymmetric Gallbladder Wall Thickening  An Intraluminal Polypoid Lesion.  Invasion of adjacent liver parenchyma  Hepatic metastasis  Periportal/ peripancreatic lymphadenopathy  Sonographically : Heterogeneous, Predominantly Hypoechoic Tumor Fills Much Or All of the gallbladder lumen.
  43. 43. CA GB WITH LIVER INVASION
  44. 44. 08/03/14  The normal gallbladder wall measures less than 4 mm.  the gallbladder wall is measured at the most narrow point of the anterior wall in the short-axis.  Care must be taken to not measure the wall at an oblique angle THICKENING OF GALL BLADDER WALL DD FOCAL ADENOMYOMATOSIS GALL BLADDER CANCER DIFFUSE ACUTE CHOLECYSTITIS CHRONIC CHOLECYSTITIS XANTHOGRANULOMATOUS CHOLECYSTTIS ADENOMYOMATOSIS GB WALL EDEMA GB CANCER OTHERS- ASCITIS,CHF,HYPOALBUMINEMIA
  45. 45. CONTENTS  Indications  Normal Anatomy  Pathogical Findings:GB  gallstones  sludge  cholecystitis  polyps  gallbladder cancer  Biliary tract  Bile duct stones  klatskin tumour
  46. 46. BILIARY TRACT
  47. 47. 08/03/14 BILE DUCTS  Sonographically, the CBD appears as an anechoic tubular structure in the main portal triad, anterior to and following the course of the main portal vein  Conventionally, the upper limit of normal for the common bile duct as measured by ultrasound is considered to be 6 mm.  Biliary duct obstruction: caused by stones, pancreatic pathology (e.g. mass), or stricture is detected measuring a CBD larger than 6-7 mm. 2000 Am. Coll. of Gastroenterology
  48. 48. 08/03/14 Intrahepatic duct stones
  49. 49. The Mirizzi Syndrome  Form of obstructive jaundice-described by Mirizzi.  Caused by a stone or stones impacted in the neck of the gallbladder or the cystic duct, such that the common hepatic duct is narrowed.  Rare complication of gallstones-occurs in about 0.1% to 0.7% of patients with cholelitiasis.
  50. 50. Csendes classification of Mirizzi syndrome
  51. 51. Figure: Mirizzi syndrome: a large stone in the neck of the gallbladder (arrow) is compressing the bile duct, causing intrahepatic duct dilatation. The lower end of the CBD remains normal in calibre.
  52. 52. COMPONENTS OF MS There must be 4 components for the syndrome to occur: 1. Anatomy- placing the cystic duct parallel to the common hepatic duct 2. Impaction of a stone in the cystic dust or gallbladder neck 3. Obstruction of the common hepatic duct from the stone itself, or from the resultant inflammatory response 4. Intermittent or constant jaundice occasionally causing cholangitis, and with longstanding obstruction, biliary cirrhosis
  53. 53. INTRAHEPATIC GALL STONES
  54. 54. INTRAHEPATIC VS EXTRAHEPATIC CALCULUS •Caroli's disease is characterized by congenital segmental dilation of the intrahepatic bile ducts producing primary intrahepatic gallstones. •Secondary intrahepatic gall stone formation occurs due to chronic obstruction of CBD and CHD •It's believed that most patients suffering a chronic illness have excessive amounts of gallstones in the liver. • Gallstones found in gallbladder tend to be hardened and relatively large while stones found in liver tends to be soft and noncalcified •Intrahepatic Gallstones cause liver congestion and elevted liver enzymes
  55. 55. Primary intrahepatic stones exclusively involving the intrahepatic biliary tree-related to chronic parasitic infestation of the biliary tree- (ascariasis ) Mixed intrahepatic stone- Associated with extrahepatic lithiasis Secondary intrahepatic stones related to ananatomical condition precipitating stasis or infection TYPES OF INTRAHEPATIC CALCULUS
  56. 56. EXTRAHEPATIC CALCULUS CALCULI IN THE DISTAL CBD
  57. 57. CONTENTS  Indications  Normal Anatomy  Pathogical Findings:GB  gallstones  sludge  cholecystitis  polyps  gallbladder cancer  Biliary tract  Bile duct stones  klatskin tumour
  58. 58. KLATSKIN TUMOUR  A Klatskin tumour is a term that was traditionally given to a hilar cholangiocarcinoma (occuring at the bifurcation of the common hepatic duct). Typically, these tumours are  Small In Size  Poorly Differentiated  Exhibit Aggressive Biologic Behaviour  And tend to obstruct the intrahepatic bile ducts  25% of all cholangiocarcinoma
  59. 59. Risk factors :  Primary sclerosing cholangitis  Choledochal cysts  Parasitic infections  Hepatolithiasis (also called Oriental cholangiohepatitis)  Toxin exposures  Genetic Factors
  60. 60. ULTRASOUND FINDINGS  Presence of a hilar mass with obstruction  Increased echogenicity relative to surrounding liver ~79%  Reduced echogenicity ~ 19 %  Mixed echogenicity ~ 2 %   Segmental dilatation or nonunion of R and L ducts  Polypoid intraluminal masses,  Nodular smooth masses with mural thickening.  Should do doppler, as this is helpful to assess Vascular invasion (unresectable)
  61. 61. Figure : Cholangiocarcinoma. (A) Irregular mass at the porta, causing biliary obstruction—a Klatskin tumour. (B) MRI of the same patient, confirming the mass at the porta. KLATSKIN TUMOUR
  62. 62. KLATSKIN TUMOUR COLOUR DOPPLER TO LOOK FOR VASCULAR INVASION
  63. 63. 08/03/14 THICKENING OF BILE DUCT WALL FOCAL STRICTURE •BACTERIAL CHOLANGITIS •CHOLANGIOCARCINOMA •CHOLEDOCAL CYSTS •METASTASIS •BENIGN STRICTURE NO STRICTURE •POLYPOID CANCER •STONES •PERIAMPULLARY CANCER •SENILE CHANGE •POSTCHOLECYSTECTOMY DILATATION •CHOLEDOCHAL CYST •ASCARIASIS
  64. 64. 08/03/14 Pearls and Pitfalls  The gallbladder is a mobile organ; remember to change patient positioning and/or probe placement to find the organ of interest.  Distinguish gallstones from polyps and septations or folds by always scanning through the whole organ and in both longitudinal and transverse planes.  During the biliary exam, use color Doppler to help distinguish nonvascular from vascular structures.  Ultrasound findings must be interpreted in the context of the clinical presentation; findings suggestive of acute cholecystitis (e.g., gallstone or thickened wall) may be present in patients in a nondiseased state.  The common bile duct can be dilated in the absence of pathology in older patients and postcholecystectomy patients.  Measure the anterior wall of the gallbladder. The posterior wall may appear artificially thickened because of acoustic enhancement or artifact from bowel gas.
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USG in gall bladder pathologies

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