Gallbladder Flashcards
CBD measure
CHD measure
CBD turns into CHD when…
< or = 6 mm
< or = 4 mm
It passes the hepatic artery
GB location
GB fossa, main lobar fissure
Kazaam view
Right shoulder to left hip
What is a Phrygian Cap
Fold at GB fundus
What is Hartmann’s pouch / Junctional parenchymal fold
Fold at GB neck
Gallbladder
Teardrop / pear shape
Stores bile. Contracts under colicystickinine
7-10 cm L, 2.5 cm W
GB wall < 3 mm
Fundus body neck
Capacity 50 ml bike storage.
CBD
Cystic duct + common hepatic duct = common bile duct
CBD < 6 mm
CHD < 4 mm
CBD lat/rt to hep artery, ant to the right of portal vein
CBD post/lat to panc head.
Valves of Heister
Spiral folds of mucosa in cystic duct
Arterial and Venous supply to GB
Cystic artery (branch of rt hepatic), and cystic vein (drains into portal)
Bile made mostly of
Bilirubin
Bilirubin
Direct/obstructive jaundice/conjugated bile, water soluble/surgical jaundice
Indirect bile/non obstructive/unconjugated/ water insoluble/medical jaundice
Serum direct bilirubin inc with obstruction.
Sludge aka echogenic bile
Assoc
US findings
Inspissated bile made of pigment granules & cholesterol crystals
Assos w. obstruction, cholecystitis, TPN, gallstones
Non shadowing low level echoes. Moves slowly.
GB hepatization
Sludge completely fills GB. Looks isoechoic to liver.
Tumefactive sludge
Sludge with tumor like appearance
What is cholelithiasis?
Predisposing factors?
Cause
Symptoms
US findings
Complications
Gallstones. Most common GB disease. Affects 20 million Americans
5 F’s, biliary infection, ETOH cirrhosis, anemia, TPN, ileal disease, estrogen, bypass surgery, obesity, pregnancy, diabetes, hypercholesterolemia, IV nutrition, OCP, rapid wt loss from diet, white, Hispanic.
Abnl bile composition, bile stasis (not contracting with IV nutrition), infection
Asymptomatic, RUQ pain, n/v, belching, chest pain, pain with fatty meal, pain radiating to right shoulder or epigastrium.
Echogenic foci, shadowing, mobile, dependent, WES sign when contracted.
Obstruction, cholecystitis, assoc w. GB cancer
5 F’s
Female Fat Forty Fertile Flatulent Fair
What are the steps of formation of a gallstone?
Saturation, nucleation, growth.
What is a gallstone made of?
Bilirubin, cholesterol, calcium
What is the WES sign?
Seen in patients with gallstones when the GB is contracted. Wall echo shadow
What is cholecystitis?
GB inflammation. 1/3 pt with stones will have cholecystitis.
Acute cholecystitis
95% with stones, usually stone obstructs cystic duct. Obstructs cystic drainage and gb wall inflames
Murphy’s sign, gallstones, diffuse wall thickening, gb dilatation, sludge
MC cause is stone in neck or cystic duct
Inc alk phos, alt, ast, wbc, bilirubin
Wall thickening > 3 mm, stones, halo w. edema (pericholecystic fluid), distended GB
Emphysematous cholecystitis
Infection with gas forming bacteria in GB wall. May not have stones.
Sudden progressive RUQ pain, fever, inc wbc.
Intraluminal and intramural gas. Reverb comet tail.
Gangrenous cholecystitis
Serious complication of acute cholecystitis. Wall hemorrhage. Necrosis.
Diffuse pain
Thickened striated wall, intraluminal echoes, taut GB, ff around GB, stones
Perforation
Complication of acute, usually in fundus, from cystic duct obstruction, GB distends and causes necrosis.
Stones, infection, diabetes, trauma, cancer, drugs
FF, abscess, wall thick, perforation,
Acalculous cholecystitis
Usually males. No stones.
Burn patients, sepsis, prolonged TPN, dehydrated, congenital biliary anomalies, prolonged fasting, pancreatic reflux, hemolysis
Thick GB wall, ff, murphy’s sign, GB wall edema, pericholecystic fluid
Chronic cholecystitis
90% with stones, enlg, thick wall, contracted GB, WES sign,
Fatty food intolerance, n/v, RUQ pain, epigastric pain, pain radiating to scapula
Alk Phos, AST, ALT, Bilirubin w. Jaundice, Amylase
Bouveret’s Syndrome
Fistula between duodenum and GB causing obstruction. Air can get to biliary tract & obstruct.
Mirizzi Syndrome
Large stone impacted in cystic duct. presses on common hep duct & causes pressure necrosis & erosion in duct wall.
IHDD, large stone in cystic duct. Normal size CBD
Empyema
Pus in GB, bacterial inflamed GB assoc w. acute cholecystitis. Lumen filled with exudate mainly pus.
Inc fever, chills, WBC
Complex appearance.
Porcelain GB
Various amount of calcifications of GB wall, rare,
females > 60 yrs.
assoc w. stone 95%, GB cancer
Asymptomatic, may be palpable
Hyperplastic cholecytosis
Benign proliferation of GB wall
Adenomyomatosis, cholesterolosis
Cholesterolosis
Strawberry GB, cholesterol polyps in wall
Stones, females
Polyps, focal areas w. comet tail artifact in wall
Adenomyomatosis
Comet tail/ v shaped reverb artifact in GB wall. Overgrowth of wall epithelium. Diffuse, focal, or segmental.
Females, > 40yrs
Wall thickening, intramural comet tail
GB carcinoma
Rare, adenocarcinoma is most common 80%
Lobular mass that fills lumen, liver mets, periaortic lymph nodes, bile duct obstruction
Females, > 60yrs, stones
Asymptomatic, late dx, loss of appetite, n/v, fatty food intolerance
Localized wall thickening, hetero polypoid lesion w. Irregular borders, cauliflower or broccoli appearance.
intrahepatic ducal dilatation, mets, ascites, color flow to tumor, porcelain GB
Poor prognosis
Caroli’s Disease
Rare, saccular dilatation of ducts
Assoc with infantile polycystic kidney disease & congenital hepatic fibrosis
Choledocholithiasis
Stones in ducts
Cholangitis
Inflamed bile ducts. Bacterial or parasitic. Fever chills fatigue RUQ pain jaundice
Dilated ducts 3-4mm, thick duct walls, extrahepatic ducts with stones, gallstones, large palp gb
Ascariasis
Parasitic roundworm grows in sm bowel and enters Ampulla of Vater. Poor sanitation areas.
Cholangiocarcinoma
Cancer of biliary tree. Assoc with primary sclerosing cholangitis. Adenocarcinoma most common.
- Intrahepatic
- Hilar
- Distal
Duct mass with irregular shadowing. Hepatomegaly. Intrahepatic ductal dilatation.
Klatskin Tumor
Bile duct cancer at hepatic duct bifurcation. Hilar. IHDD without extrahepatic ductal dilatation. Non Union of right and left hepatic ducts. Small solid mass at liver hilum. Death in months.
Mets to GB
Melanoma (mc), breast, colon
GB duplication
2 GB
Biliary atresia
Total absence of biliary tree or small GB. Persistent jaundice
Absent or small GB < 1.5 cm, hepatosplenomegaly, ascites
Choledochal cyst
Congenital cystic fusiform dilatation of cbd.
Cyst adj to GB.
Biliary Rhabdomyosarcoma
Rare soft tissue tumor, 1-5 years old. Arises in biliary tract and caused obstruction. Lobulated mass at hilum. Dilated ducts.
Hydropic GB
GB dramatically enlarged without wall thickening due to total obstruction of cystic duct
Asymptomatic, palp RUQ mass. Obstructing stone noted in an enlarged non tender gb.
What artifact can cause smudgy echoes?
Reverberation, side lobes, slice thickness artifact.
GB prep
8-12 hours NPO
GB thickening can be due to
Inflammation, hepatic dysfunction, congestive heart failure, GB wall varices, cholecystitis, ascites, hypoalbuminemia, acute hepatitis, adenomyomatosis, cancer, contracted normal gallbladder
Post prandial GB appearance
Contraction of GB with diffuse wall thickening
Murphy’s sign
Tenderness in GB
Dilated, nontender GB, look in…
Head of pancreas for a mass
Complication of acute cholecystitis, look for
Pancreatitis, GB perforation, gangrenous cholecystitis, emphysematous cholecystitis
Severe RUQ pain, n/v, thick GB wall, stones, adj complex fluid. This suggests.
Acute cholecystitis complicated by GB perforation
Male diabetic severe epigastric pain radiating to back, vomit, chills, fever. Large GB with nondependent hyperechoic foci associated with ring down artifacts. This suggests.
Emphysematous cholecystitis
Hypervascularity associated with acute cholecystitis is best evaluated with color Doppler on…
The cystic artery
Shadow at both edges of trvs GB due to
Refraction artifact/edge shadowing
Irregular mass within GB lumen with hypervascularity and stones. Suggests.
GB carcinoma
Rokitansky-Aschoff sinuses
Associated with adenomyomatosis.
Small mucosal herniation into muscular layer of GB. Diverticuliti in wall.
Appear cystic if filled with bile. Appear echogenic with v shaped reverb if filled with cholesterol.
Best way to image intrahepatic biliary system
Intrahepatic portal veins
Pneumobilia
Hemobilia
Air in biliary tract; echogenic foci in biliary tree with shadow and reverb comet tail, commonly seen in liver hilum. MC seen after endoscopic retrograde cholangiopancreatogram.
Blood in biliary tract
Courvoiser GB
GB distention without wall thickening due to obstructive neoplasm distal to the cystic duct.
Junctional fold
Incomplete wall appearing between the body and neck. Most common GB variant.
Difference between dilated bile ducts and hepatic veins.
Dilated bile ducts have irregular tortuous walls, bile ducts have no color flow
Which position helps see cbd?
Right posterior oblique
Most accurate test for acute cholecystitis?
Cholescintigraphy
Administering cholecystokinin will
Contract the GB if normal
CHD is located
Anterior to the hepatic artery and portal vein
Stone impacted in distal cbd. Evaluate for
Pancreatitis
Courvoiser GB
Enlg GB due to extrinsic cause (panc cancer)
Fatty meal
Bile duct dilates if obstructed and dec in size if not
MC cause of bile duct obstruction and labs elevated
Gallstones, panc cancer
Elevated serum alkaline phosphate and conjugated direct bilirubin
3 extrahepatic bile ducts
CHD, cystic duct, CBD
3 intrahepatic bile ducts
Right hepatic duct, left hepatic duct, Intrahepatic biliary radicals
Causes of enlarged gallbladder
Prolonged fasting Obstructed cystic duct (hydrops) Obstructed CBD Courvoiser GB (panc cancer) Intravenous hyperalinentation Diabetes Postvagotomy
Solid mass in GB evaluate
Liver for mets
