Biliary Tree ( IMAGES ) Flashcards
Sagittal gallbladder and portal vein
Transverse gallbladder
Rolling gallstone.
The patient is in the supine position, and the gallstone is located within the neck
The patient then rolled into the left lateral decubitus position, and the gallstone (arrow) moves into the fundus of the gallbladder.
Cholelithiasis.
Multiple shadowing, echogenic mobile gallstones within a gallbladder
WES sign — gallbladder filled with stones
Sludge.
Sagittal image of the gallbladder demonstrates layering sludge
Sludge and stones.
Sagittal image of the gallbladder that contains both sludge and small, mobile, shadowing stones.
Sagittal image of a gallbladder demonstrating HEPATIZATION of a gallbladder that is filled with sludge and is consequently isoechoic to the liver
Gallbladder polyps.
Adenomyomatosis of the gallbladder
comet tail artifact (arrows) is produced by cholesterol crystals located in the Rokitansky-Aschoff sinuses of the anterior gallbladder wall
Acute cholecystitis.
Sagittal and transverse images of a patient with a positive Murphy sign
revealing a inflamed gallbladder containing gallstones and sludge, with a thickened gallbladder wall, and pericholechystis fluid (arrow)
Gallbladder perforation.
Longitudinal and transverse images
The defect seen on the anterior wall (arrows) is better demonstrated in the transverse Debris is also located within the gallbladder lumen
Emphysematous cholecystitis.
Longitudinal image of a gallbladder that contains air (arrows) within its anterior wall secondary to emphysematous cholecystitis
Champagne sign
Acalculous cholecystitis.
Longitudinal image of a gallbladder demonstrating a
striated, thickened wall.
Although the patient complained of a positive Murphy sign and fever, no gallstones were identified within the gallbladder.
Gallbladder carcinoma.
An irregular mass projects into the gallbladder lumen from a stalk (arrow)
Spectral Doppler shows arterial flow within the mass
Common bile duct. Longitudinal image of the common bile duct (calipers), hepatic artery (arrow), portal vein (PVn), and inferior vena cava (IVG).
Dilated intrahepatic duct.
Color Doppler image of a dilated intrahepatic duct (between calipers)
CHOLEDOCHOLITHIASIS
1. Echogenic foci within the bile duct that may or may not shadow
2. May have biliary dilatation but not always
Mirizzi syndrome.
It is a clinical condition in which the patient presents with jaundice, pain, and fever secondary to a lodged stone in the cystic duct with subsequent compression of the common duct and dilation of the EXTRAHEPATIC ducts
CHOLANGITIS
1. Biliary dilatation
2. Biliary sludge or pus
3. Choledocholithiasis
4. Bile duct wall thickening
PNEUMOBILIA
1. Echogenic linear structures within the ducts that produce ring-down artifacts and dirty shadowing
CHOLANGIOCARCINOMA
1. Dilated intrahepatic ducts that abruptly terminate at the level of the tumor
2. A solid mass may be noted within the liver or ducts
BILIARY ATRESIA
1. Absent biliary ducts
2. Triangular cord sign (avascular, echogenic, triangular or tubular structure anterior to the portal vein)
3. Sonographic signs of cirrhosis and portal hypertension
CHOLEDOCHAL CYST
1. Cystic mass in the area of the porta hepatis (separate from the gallbladder)
2. Biliary dilatation
CAROLI DISEASE
1. Segmental dilatation of the INTRAhepatic ducts
2. The patient may also have cystic renal disease
3. Central dot sign (echogenic dots in the nondependent part of the dilated duct)
Distention (hydrops) of the gallbladder may be found in patients who have been on intravenous fluids for several days or may be secondary to a mass or enlarged lymph nodes compressing the common bile duct.
Transverse and sagittal images of the common bile duct.
The transverse view shows Mickey Mouse sign ;
the portal triad with the portal vein posterior, the common duct anterior and lateral, and the hepatic artery anterior and medial. The sagittal view shows the common duct anterior to the main portal vein.
On this sagittal image, the hepatic artery (HA) is shown anterior to the common duct (CD). The portal vein (PV) is anterior to the inferior vena cava (IC). GB, Gallbladder.
The cystic duct is sometimes seen to arise from the neck of the gallbladder (arrows).
This coronal decubitus view shows the aorta (AO), inferior vena cava (IC), gallbladder (GB), portal vein (PV), and liver (L).
Acute cholecystitis
Swollen, edematous gallbladder was found in this middle-aged male with cirrhosis
Emphysematous cholecystitis.
If the gas is intraluminal, the sonographer should look for a prominent bright echo along the anterior wall with ring-down or comet-tail artifact directly posterior to the echogenic structure
Gangrenous cholecystitis.
The common echo features of gangrene are the presence of diffuse medium to coarse echogenic densities filling the gallbladder lumen in the absence of bile duct obstruction.
Acalculous cholecystitis with thickening of the gallbladder wall secondary to edema and inflammation.
45-year-old female with right-upper-quadrant pain and distention. The wall, echo, shadow (WES) sign was visualized and indicated that the gallbladder — Note the sharp posterior shadow.
The appearance is different from that of the porcelain gallbladder because the anterior wall is not as bright or echogenic.
Longitudinal and transverse scans of the gallbladder
(GB), with a layer of stones “floating” (arrows) along the thick bile layer of sludge (SI).
Porcelain gallbladder.
On sonography, a bright echogenic echo (arrow) is seen in the region of the gallbladder with shadowing posterior.
Carcinoma of the gallbladder may extend into the cystic duct either by direct extension of the tumor or by extrinsic compression by the involved lymph nodes.
A, Transverse scan of the liver shows dilated ducts with an inhomogeneous liver parenchyma.
B, Transverse scan of the inhomogeneous liver parenchyma.
C, Transverse scan of the dilated ducts within the liver.
Carcinoma of the gallbladder.
The most common sonographic appearance of the soft tissue mass is a heterogeneous solid or semisolid echo texture. The gallbladder wall is usually irregular and asymmetric and markedly abnormal and thickened.
Transverse and longitudinal scans of a young patient with a choledochal cyst (Ccy) in the right upper quadrant. IC, Inferior vena cava; L, liver; P, pancreas.
Choledochal cysts
appear as true cysts in the right upper quadrant with or without an apparent communication with the biliary system;
the cystic structure may contain internal sludge, stones, or solid neoplasm.
Caroli’s disease.
Multiple cystic structures in the area of the ductal system converge toward the porta hepatis;
masses may be localized or diffusely scattered cysts that communicate with the bile ducts.
Dilated common bile duct ( < 6 mm )
Inflammation of the pancreas may cause the common duct to dilate.
This patient had acute pancreatitis (P) and dilation of the common duct
A, Aorta; IC, inferior vena cava.
stone in the distal common duct.
Carcinoma of the head of the pancreas with obstruction of the common bile duct (CBD).
A 60-year-old female with a history of cholecystectomy several years previously. The patient was known to have had previous hepatic calculi and now has right-upper-quadrant pain.
Moderate diffuse dilation of the right and left INTRAhepatic ducts is present.
Echogenic ovoid structures seen in the distal right hepatic and left hepatic ducts represent calculi or sludge balls.
The intrahepatic duct was minimally dilated.
Choledocholithiasis.
Stones tend to become impacted in the distal portion of the INTRAhepatic duct of the ampulla of VATER and may project into the duodenum.
Gas in the right upper quadrant may cause shadowing in the area of the gallbladder
(GB, arrows).
Cholangitis.
The biliary tree is dilated and the common bile duct wall may show a smooth or irregular thickening
Ascariasis.
On sonography the sonographer may denote an enlarged duct with a moving “tube” or parallel echo-genic lines within the biliary ducts.
A & B, Intrahepatic cholangiocarcinoma.
A large heterogeneous or hypovascular solid hepatic mass may be seen with a variable texture that ranges from hypochoic to hyperechoic.
Biliary ductal dilation may also be associated with these obstructive masses.
C & D
KLATSKIN tumor is a specific type of cholangiocarcinoma that can occur at the bifurcation of the common hepatic duct, with involvement of both the central left and right duct. The most suggestive sonographic feature to indicate cholangiocarcinoma is isolated INTRAhepatic duct dilation
Distal cholangiocarcinoma on sonography shows a sclerosing tumor as nodular with focal irregular ducal constriction and wall thickening.
Metastases to the biliary tree.
A, Diffuse isoechoic metastases are seen throughout the liver parenchyma.
B, Irregular mass (arrow) protruding into the gallbladder lumen.
