Biliary Pathologies

Question 1

Diffuse wall thickening

Answer 1

Definition/Description: wall thickening throughout the gallbladder
Characteristics: wall thicker than 3mm
Sonographic findings and their USA: the gb wall should be measured when the transducer is perpendicular to the anterior gb wall, usually in the transverse plane, measured from outer to outer margins, the wall can be hypervascular with color on.

Question 2

Jaundice

Answer 2

Definition/Description: The presence of bile in the tissues.
Signs and symptoms: Yellowing of the skin and whites of the eyes.
Lab Values: Elevated bilirubin.
Sonographic findings and their USA: Varies by underlying cause. Jaundice is a symptom of various causes of gallbladder obstruction. On U/S, there may be an echogenic stone with shadowing blocking the bile duct and/or the CBD may be dilated.

Question 3

Sludge

Answer 3

Definition/Description: It is thickened bile that occurs from bile stasis. Sludge is a mixture of particulate matter and mucous that forms in the bile.
Causes/Associated with: This is seen in patients with prolonged fasting or hyperalimentation therapy and with obstruction of the gallbladder.
Signs and symptoms: It may be asymptomatic or cause abdomen pain, nausea, and vomiting especially after a fatty meal.
Sonographic findings and their USA: It will have low level internal echoes layering in dependent part of the gallbladder and will change with patient position.

Question 4

Cholelithiasis

Answer 4

Definition/Description: The most common disease of the gallbladder; it could be described as a single large gallstone
or up to many small ones.
Causes/Associated with: The Five F’s (Fat -female-forty-fertile-fair)
Signs and symptoms: May be asymptomatic or RUQ pain with radiant shoulder pain after a fatty meal
Lab Values: Check bilirubin levels; Acute increase amylase; Abnormal LFTs
Sonographic findings and their USA: Dilated GB thick wall;
Hyperechoic intraluminal echoes with posterior shadowing;
WES sign; Gravity-dependent calcifications in GB

Question 5

Acute cholecystitis

Answer 5

Definition/Description: Inflammation of the gallbladder in acute form.
Signs and symptoms: RUQ pain with positive Murphy’s sign, and fever.
Lab Values: Elevated serum amylase levels with abnormal LFT’s. Leukocytosis, increased serum bilirubin, and increased alkaline phosphatase levels.
Sonographic findings and their USA: Gallbladder will be dilated (>4cm) and rounded with thick (>3mm) and irregular walls. Gallstones may be seen as echogenic areas. Pericholecystic fluid may also be present. Patient will have a positive Murphy’s sign. Increased color Doppler flow may be visualized surrounding gallbladder wall. Impacted stone may be seen in cystic duct or Hartmann’s pouch.

Question 6

Chronic cholecystitis

Answer 6

Definition/Description: Most common form of gallbladder inflammation.
Characteristics: Becomes chronic with multiple attacks of gallstones and inflammation.
Signs and symptoms: Patients may have transient RUQ pain, or biliary colic but not having much tenderness like acute cholecystitis does. Patients will have gallbladder thickening and cholelithiasis.
Sonographic findings and their USA: Gallstones in the gallbladder frequently found. Gallbladder is contracted and coarse wall thickening. The WES sign is shown with a packed bag of stones.

Question 7

Emphysematous cholecystitis

Answer 7

Definition/Description: It is a gas forming bacteria in the gallbladder wall and lumen with extension into the biliary ducts.
Signs and symptoms: Symptoms include RUQ pain (that may radiate to the back) and a fever. Nausea and vomiting occur in some cases as well.
Lab Values: Abnormal LFT’s.
Sonographic findings and their USA: There will be a bright echogenic in the gallbladder with ring down or comet tail artifact. It may appear as WES. The sonographic appearance will depend on the amount of gas.

Question 8

Gangrenous cholecystitis

Answer 8

Definition/Description: A serious painful complication of acute cholecystitis that may lead to perforation.
Lab Values: Abnormal LFTs
Sonographic findings and their USA: Medium to coarse echogenic densities that fill GB lumen in absence of duct obstruction; No shadow; Not gravity dependent; Does not layer

Question 9

Empyema of the gallbladder

Answer 9

Definition/Description: uncommon complication of cholecystitis when the gallbladder lumen fills with pus.
Signs and symptoms: Symptoms similar to acute uncomplicated cholecystitis (fever, chills, RUQ pain); signs of sepsis may or may not be present.
Lab Values: Abnormal LFT’s and elevated WBC’s
Sonographic findings and their USA: Sonographic features of cholecystitis with added echogenic content within the gallbladder lumen.

Question 10

Gallbladder perforation

Answer 10

Definition/Description: Medical condition where the gall bladder leaks or bursts.
Signs and symptoms: Nausea/vomiting, sharp RUQ pain, jaundice, fever
Lab Values: Elevated WBC’s
Sonographic findings and their USA: USA includes pericholecystic fluid collection with layering of the gallbladder wall. Other signs may include: “Hole sign” which is direct visualization of the perforation, color Doppler may show flow between GB lumen and pericholecystic abscess, and calculi may be detected within the perihepatic collection.

Question 11

Acalculous cholecystitis

Answer 11

Definition/Description: Uncommon condition of acute inflammation of the gallbladder in the absence of cholelithiasis.
Signs and symptoms: Positive Murphy’s sign.
Lab Values: Elevated serum amylase level and abnormal LFTs
Sonographic findings and their USA: Dilated gallbladder with extremely thickened (> 4-5 mm) and irregular walls (edema). Possibly echogenic sludge. Pericholecystic fluid within ascites or subserosal edema. Positive Murphy’s sign.

Question 12

Milk of calcium bile (limy bile)

Answer 12

Definition/Description: presence of a viscous substance in the dependent parts of the gallbladder and/or bile ducts, almost entirely composed of calcium carbonate, and therefore highly radiopaque.
Characteristics: Thick, paste-like substance within the gallbladder; rarely migrates to distal biliary ducts.
Signs and symptoms: RUQ pain and jaundice
Lab Values: Elevated bilirubin and ALP
Sonographic findings and their USA: USA is comparable to sludge- both have presence of a hyperechoic and heterogeneous substance dependently in the gallbladder.

Question 13

Gallbladder polyps

Answer 13

Definition/Description: ​Lesions that project from the gallbladder wall into the gallbladder interior are called gallbladder polyps; classified as benign or malignant
Signs and symptoms: many patients are asymptomatic; some people do suffer from nausea, vomiting, and occasional RUQ pain
Lab Values: only about 13% have elevated LFTs
Sonographic findings and their USA: ​The polyps appear as fixed, hyperechoic material protruding into the lumen of the gallbladder, with or without an acoustic shadow. A cholesterol polyp shows as a mass with similar echogenicity to the gallbladder wall and with no shadow cone.

Question 14

Porcelain gallbladder

Answer 14

Definition/Description: Rare occurrence that is defined as calcium incrustation of the gallbladder wall
Signs and symptoms: Patient is generally asymptomatic, generally is found when a mass is found on physical examination
Lab Values: LFT, CBC, or amylase or lipase tests
Sonographic findings and their USA: Bright echogenic echo is seen in the region of the gallbladder with posterior shadowing, differential will include WES sign or packed bag

Question 15

Hydrops of the gallbladder

Answer 15

Definition/Description: Dilation of the gallbladder is known as hydrops
Characteristics: Gallbladder measures larger than 4 cm in diameter or greater than 10 cm in length
Signs and symptoms: Abdominal pain with palpable gall bladder without any signs of infection. In an asymptomatic
patient, it likely is related to fasting.
Lab Values: LFT, CBC, or amylase or lipase tests
Sonographic findings and their USA: Gallbladder is enlarged, there may be a stone (or something else) obstructing a duct.

Question 16

Cholesterolosis

Answer 16

Definition/Description: Cholesterol is deposited within the lamina propria of the gallbladder.
Characteristics: Often called “strawberry gallbladder” because mucosa resembles the surface of strawberry. This condition is localized or diffuse and associated with cholelithiasis.
Signs and symptoms: Asymptomatic until it develops complications, such as cholelithiasis.
Lab Values: Unspecific. An elevated bilirubin or alkaline phosphate level generally indicates advanced or obstructive biliary tract disease.
Sonographic findings and their USA: USA of cholesterolosis is very definitive in its appearance. The polyps can be visualized as brightly echogenic non-mobile masses, with a
reverberation artifact. These masses appear without shadowing, and there no gallbladder wall thickening is detected.

Question 17

Gallbladder carcinoma

Answer 17

Definition/Description: Carcinoma of the gallbladder is the most common cancer of the biliary tract, and most tumors
appear in the gallbladder fundus.
Signs and symptoms: Nonspecific in the early stages, may mimic benign gallbladder disease, patients may present
with weight-loss, anorexia, RUQ pain, jaundice, nausea and vomiting, and hepatomegaly
Lab Values: CA 19-9 may be significantly elevated with gallbladder cancer. Liver function tests: Elevated
ALP and bilirubin levels are often found with more advanced disease. CBC: Anemia may be an indicator of more advanced disease
Sonographic findings and their USA: Inhomogeneous, polypoid lesion with irregular margins; localized wall thickening, a mass that replaces the gallbladder, calcification of the gallbladder wall, polyps greater than 10 mm in size suggest malignancy, associated gallstones as well as metastatic lesions within the liver, ascites, and intraductal biliary dilation may be visualized. Color Doppler imaging may be used to differentiate biliary sludge, which is avascular from hypoechoic mass, which would show flow.

Question 18

Adenomyomatosis

Answer 18

Definition/Description: It is a hyperplastic change in the gallbladder wall in which the mucosa overgrows, thickens the muscular wall, and forms intramural diverticula or sinus
tracts.
Sonographic findings and their USA: Papillomas may occur singularly or in groups and may be scattered across the gallbladder. They will not move with position changes and
they create comet tail artifact.

Question 19

Biliary obstruction

Answer 19

Definition/Description: A blockage of the biliary system. (Bile ducts and gall bladder)
Signs and symptoms: Obstructive jaundice, possibly RUQ pain
Lab Values: Elevated bilirubin, Elevated ALP, elevated WBC’s when infection present
Sonographic findings and their USA: Biliary ducts dilated; “shotgun sign” or “too many tubes” when intrahepatic ducts are dilated; Possible echogenic foci within ducts representing obstruction.

Question 20

Common duct measurements

Answer 20

Characteristics: Intrahepatic ducts run parallel to hepatic veins. Intrahepatic ducts / CHD has internal diameter of less than 4 mm;
CBD diameter less than 6 mm;
Cystic duct length about 4 cm.

Sonographic findings and their USA: Ducts are hypoechoic to anechoic vessel structures with no flow on color Doppler.

Question 21

Dilated intrahepatic ducts

Answer 21

Definition/Description: Increase in diameter beyond normal limits of intrahepatic ducts.
Characteristics: Intrahepatic duct diameter greater than 4 mm. Duct diameter 5mm= borderline, 6mm= requires further investigation; CBD= 6mm is borderline and greater than 10mm is dilated.
Signs and symptoms: May cause jaundice and RUQ pain, depending on cause.
Lab Values: Elevated bilirubin and ALP, depending on cause.
Sonographic findings and their USA: Ducts are hypoechoic to anechoic vessels; diameter of vessel will be greater than normal.

Question 22

Choledocholithiasis

Answer 22

Definition/Description: The presence of gallstones in the bile duct
Signs and symptoms: Abdominal pain; Fever; Jaundice
Lab Values: Increased direct bilirubin; Abnormal liver enzymes; Leukocytosis; Increased alkaline phosphatase
Sonographic findings and their USA: Echogenic structure in extrahepatic duct; Dilated biliary tree

Question 23

Mirizzi syndrome

Answer 23

Definition/Description: Obstruction of cystic duct, which creates extrinsic mechanical compression of the common hepatic duct.
Signs and symptoms: Painful jaundice
Lab Values: Elevated bilirubin and ALP
Sonographic findings and their USA: Intrahepatic ductal dilation with a normal-size common duct and a large stone in the neck of the gallbladder or cystic duct.

Question 24

Cholangiocarcinoma/ Klatskin tumor (Bile duct carcinoma)

Answer 24

Definition/Description: Aka bile duct carcinoma and Klatskin tumor. Rare malignant disease that most commonly occurs in the perihilar region.
Signs and symptoms: Patients show jaundice, pruritis, and elevated cholestatic liver parameters.
Lab Values: Increased bilirubin level, abnormal liver function tests, and carcinoembriogenic antigen (CEA) and Carbohydrate antigen 19-9 (CA19-9) level indicate that patients may have bile duct cancer.
Sonographic findings and their USA: Tumor is shown as hypoechoic and hypovascular with poorly defined margins. The sclerosing tumor is nodular with focal irregular ductal
constriction and wall thickening.

Question 25

Cholangitis (primary sclerosing cholangitis)

Answer 25

Definition/Description: Inflammation of the bile ducts
Signs and symptoms: Malaise, fever, sweating and shivering, RUQ pain, jaundice; in severe cases the patient is in shock and is lethargic
Lab Values: Elevated lab values show leukocytosis, serum alkaline phosphatase and bilirubin
Sonographic findings and their USA: Biliary tree is dilated and common bile duct wall may show smooth or irregular thickening, there may be choledocholithiasis with sludge, the ductal wall may be so thickened it may be hard to recognize, stones are usually lodged in the distal common bile duct or must be mobile to cause intermittent obstruction

Question 26

Biliary atresia

Answer 26

Definition/Description: Narrowing or underdevelopment of the biliary ductal system.
Signs and symptoms: Persistent jaundice, acholic stools, dark urine, and distended abdomen from hepatomegaly.
Lab Values: Abnormal liver enzyme tests.
Sonographic findings and their USA: Liver may be normal or enlarged with either normal or increased echogenicity of liver parenchyma causing decreased visualization of the peripheral portal venous vasculature. Small triangular structure may be seen superior to the porta hepatis, which is a hypoplastic remnant of the biliary structure.

Question 27

Pneumobilia

Answer 27

Definition/Description: Air within the biliary tree secondary to biliary intervention, biliary-enteric anastomoses, or common bile duct stents
Signs and symptoms: Fever, abdominal pain, loss of appetite
Lab Values: LFT, CBC, or amylase or lipase tests
Sonographic findings and their USA: Bright echogenic linear structures that follow the portal triads, posterior dirty shadow and reverberating artifact is seen, sonographer should look for the movement of tiny air bubbles with movement of the patient

Question 28

Choledochal cyst

Answer 28

Definition/Description: Unusual, diverse group of diseases that may manifest as congenital, focal, or diffuse cystic dilation of the biliary tree.
Signs and symptoms: Jaundice; Pain; Fever; mass
Lab Values: Possibly increased bilirubin
Sonographic findings and their USA: True cysts in RUQ with or without communication with biliary system

Question 29

Caroli’s disease

Answer 29

Definition/Description: Rare congenital abnormality that is most likely inherited in an autosomal recessive fashion
Characteristics: Found in young adults or pediatric population
Signs and symptoms: Recurrent cramp like upper abdominal pain secondary to biliary stasis, ductal stones, cholangitis, hepatic fibrosis
Lab Values: Usually reference bilirubin levels, CBC may indicate cholangitis, transaminase levels may be slightly elevated, creatinine and BUN should be obtained to detect associated renal disease
Sonographic findings and their USA: Multiple cystic structures in the area of the ductal system converge toward the porta hepatis, may be seen as localized or diffusely scattered cysts that communicate with the bile ducts, ducts may show beaded appearance, sludge or calculi may reside in the dilated ducts, ectasia (dilation) of the extrahepatic and common bile ducts may be present