clinical notes for students

1. CLINICAL
NOTES FOR MID
STUDENT
PRESENTED BY :
HAFIZA NOOR FATIMA
UNIVERSITY OF LAHORE
FROM BOOK :
REQUISITES

2. GALLBLADDER

3. Anatomy
• The gallbladder is a pear-shaped, hollow structure located
under the liver and on the right side of the abdomen.
• Its primary function is to store and concentrate bile, a yellow-
brown digestive enzyme produced by the liver.
• The gallbladder is part of the biliary tract.
• Is the long oval organ
• GB is used as a landmark for identifying the junction b/w the
left and the right lobes of the liver

4. • Size <_4cm in transverse
<10cm longitudinal
• Wall thickness <3mm
• Folds in the GB are present . Sometimes in the neck or in the
whole GB . When GB fundus folds itself it is called as phyrgian
cap

5. • Septations are rare and generally are thinner than folds . They
separate the GB into segments.

6. • Variations in the location of GB is rare
• Intrahepatic GB is mostly present. Mostly located immediately
above the interlobar fissure

7. Gallbladder duplication:
• Rare congenital anomaly
• May be partial or complete

8. Parts of gallbladder:

9. Technique
• Patients should breakfast 8 hrs after midnight before GB scan
to reduce upper abdominal bowel gas
• A recent meal makes the examination harder to perform and
interpret & decreases diagnostic sensitivity
• In supine position
• 3-5MHz transducer
• APPROACHES:
subcostal
intercostal

10. Subcostal approach:
• Deep inspiration
• Liver as a window
• Scan should obtained from a variety of positions such as:
left posterior oblique
left lateral decubitus
prone
upright
• GB neck is most imp place where stones are present

11. GALLSTONES

12. • Gallstones are stone-like objects that form in the gallbladder
or bile ducts.
• Gallstones can be tiny (the size of a grain of sand), or may be
as large as a golf ball.
• Depending on the symptoms, people who have gallstones may
not need treatment, or they may need to take medication or
have surgery to remove their gallbladder. If the stones are in
the bile ducts, they usually need to be removed by endoscopy.
• Majority are asymptomatic

13. On ultrasound:
• Mobile
• Echogenic
• Intraluminal structures
• Produce acoustic shadow
(Shadowing occurs b/c of the absorption of the ultrasound beam
by the stones)
Shdowing depends upon the size of the stones
Stones smaller than 3mm may not cast a detectable shadow
Shadowing is independent of the stone composition

14. • GB completely filled with stones is hard to recognized when it
is filled with bile
• There is an echogenic shadowing structure
• In the right upper quadrant
• Could be confused with a gas filled loop of bowel
• In most cases stones produce a clear shadow & gas produces a
dirty shadow
• When the density of bile is high in GB , stones may float.this
occurs when the specific gravity of bile is greater than th
specific gravity of stones, indicates that floating stones are
composed of cholesterol.
• Most common situation in which the specific gravity of the bile
inc is when IV contrast medium has been injected.

15. Wall Echo Shadow (WES)
• The wall-echo-shadow sign (also known as WES sign) is an
ultrasonographic finding within the gallbladder fossa referring
to the appearance of a "wall-echo-shadow"
• Consists of three arc shaped lines
1. Echogenic
representing pericolecystic fat
as well as the interface b/w the GB wall and the liver
2. Hypoechoic
represents GB wall
3. Echogenic
arising from the stones

17. POLYPS

18. • Small
• Soft tissue structures
• Are adherent to the GB wall
• Do not move or shadow

19. Cholesterolosis
• A condition in which triglycerides, cholesterol percursors &
cholesterols easters are deposited with In the lamina propria
of GB.
• Cause is unknown
• Not produce any chages in the appearance and thickness of
GB wall on ULT or other imaging tests
• Sometimes referred as strawberry GB b/c the mucosa bears a
resemblance to the surface of a strawberry

20. Cholesterol Polyps
• Most common type of GB polyps
• Gallbladder polyps are elevated lesions on the mucosal surface of
the gallbladder
• The vast majority are benign, but malignant entities are possible
• Attached to the wall by means of a slender stalk . This is referred to
as the ball on the wall sign
• Are usually 5mm or less & only rarely get bigger than 10mm
• Have no shadow
• Non mobile nature
• Other types of polyps are adenomas , papillomas , leiomyomas,
lipomas & neuromas
• These lesions are larger than C.polyps
• And are true neoplasms , are always solitary
• Larger polyps may have detectable blood flow on CD imaging

21. • Polypoid lesions of the GB wall that are 5mm or less require
no therapy
• Lesions are b/w 5 & 10mm should be mentioned to ensure
their stability
• If small polyps are multiple , they are cholesterol polyps and
can be ignored
• Lesions are larger than 10mm should be removed b/c of the
possibility of cancer

22. Adenomymatosis
• Form of hyperplastic cholecystoses
• Etiology is unknown
• Is characterized by mucosal hyperplasia & thickening of the
muscular layer of GB
• Mucosal herniation into the muscular layer are called
Rokitansky Aschoff sinuses and they frequently contains
cholesterol crystals
• Occurs equally in men and women

23. On ULT :
• Cholesterol crystals results in bright reflections & short comet
tail artifacts arising from the GB wall
• Adenomyomatosis may also appear as diffuse wall thickening,
focal segment annular thickening or localized mass
• When the diagnosis of adenomyomtosis is in doubt an oral
cholecystogram can be obtained b/c it may demonstrate the
Rokitansky Aschoff sinuses .

24. SLUDGE

25. • Sludge balls are almost always mobile
• Do not produce a shadow
• Are quite a bit larger than non shadowing stones
• Consists of calcium billurubinate granules & cholesterol
crystals
• Often in the setting of thick viscous bile
• Appears as a low to high level non shadowing reflectors in GB
• Found in the dependent portion of the GB
• May fill the entire GB lumen.

26. • May forms mass like aggregates called as sludge balls or
tumefactive sludge
• Sometimes non crystalline components of sludge may seen in
the non dependent part of the GB lumen . This should not be
confused with the GB stones
• Sludge have a very inhomogenous appearance with prominent
hypoechoic regions
• Color doppler imaging is also helpful
• Detection of flow excludes tumefactive sludge
• Lack of flow is not helpful b/c it can occur in hypovascular
tumors in addition to tumefactive sludge

27. ACUTE CHOLECYSTITIS

28. • Acute cholecystitis is an inflammation of the gallbladder
• AC occurs from the persistent obstruction of cystic duct or GB
neck by an impacted gallstone

29. • Cholecystitis can become very severe and in most cases
requires immediate medical attention.
• This condition can become chronic if it persists for a prolonged
period of time, or if you’re having recurring symptoms from
the inflammation.

30. On ULT
• Pericholecystic fluid
• Sloughed mucosal membranes
• Irregular striated intramural sonolucencies
• Wall disruption
• Wall ulceration
• Focal wall bulge
• Gallstones
• Wall thickening>_3mm
• GB enlargement
• Impacted stone
• Murphy’s sign

32. • Width of the GB is more imp than length
• Pericholecystic fluid is mostly present in the fundus
• Collections seen b/w liver & GB may refer to edema in the
areolar tissues

33. Acalculous cholecystitis
• Acute . C occurs in the absence of gallstones & referred as
acalculous . c
• Risk factors includes
ischemia
GB wall infection
chemical toxicity to GB wall
cystic duct obstruction
• It occurs in very sick patients like after major surgery, trauma
& extensive burns etc

34. Emphysematous Cholecystitis
• Emphysematous cholecystitis is a rare form of acute
cholecystitis where gallbladder wall necrosis causes gas
formation in the lumen or wall.
• Occurs in elderly men
• Caused by ischemia
• More common in diabetic patients
• Often not associated with gallstones
• The majority of patients are between 50 and 70 years of age

35. On ULT :
• Bright reflections from a non dependent portion of the GB
wall
• Dirty acoustic shadowing
• In many cases shows ring down artifact that is reliable sign of
gas

36. CARCINOMA

37. • GB cancer is the 5th most common gastrointestinal malignancy
• Probably occurs b/c of the chronic irritation of GB wall by
stones
• Vast majority of them is associated with gallstones
• Predominantly affects older persons with long-standing
cholecystolithiasis , and as such is most common in elderly
women (>60 years of age, F:M ratio = 4:1) 1,3

38. On ULT :
• Mass centered on GB fossa with associated stones
• Eccentric irregular wall thickening
• Bulky intraluminal polypoid mass
• Infiltration of adjacent liver or vessels
• Periportal & or peripancreatic lymphadenopathy
• Bile duct obstruction

39. GB Masses :
• Tumefactive sludge
• Inflammatory wall thickening
• Polyps
• Metstases
• Focal adenomyomatosis

40. Causes Of GB Masses:
Common
• Polyps
• Adenomyomatosis
• GB cancer
• Tumefactive sludge
Uncommon
• Metastases
• Chronic cholecystitis

41. GB WALL THICKENING

42. • The normal upper limit of GB wall is 3mm
• A large number of processes can result in thickened GB wall
• A large number of non biliary processes can also cause GB wall
thickening due to edema

43. CAUSES
Biliary
• Cholecystitis
• Adenomyomatosis
• Cancer
• AIDS cholengiopathy
• Sclerosing cholengitis
Non Biliary
• Hepatitis
• Pancreatitis
• Heart failure
• Hypoproteinemie
• Cirrhosis
• Portal hypertension
• Lymphatic obstruction

44. On ULT :
• Most non biliary causes of GB wall thickening produce
concentric thickening that may be uniform in echogenicity or
may have a regular or irregular layered appearance with both
hypo and echogenic components

45. PROCELAIN GB

46. • Extensive calcifications of GB produces a brittle bluish wall
that is called as procelain GB
• Associated with chronic GB inflammation
• 95% of the cases have gall stones

47. On ULT :
• When the GB wall is heavily calcified and the wall is diffusely
involved it will appear as echogenic arc with dens posterior
shadowing
• Less calcification will produce only partial shadowing so that
the back wall o the GB remains visble
• If WES is seen it is almost certainly a stone filled GB
• If ring down artifact is detected emphysematous cholecystitis
can be diagnosed

48. THE END