Gallbladder reverse Flashcards
Pear shaped hollow organ
Lies on the visceral surface of the liver
Divided into neck/body/fundus
Neck is continuous with the cystic duct
Anatomy of the gallbladder
Size is variable,
but approx 7-10cm in length and 2.5-4cm in width
Gallbladder size
An increase in GB size is termed
Gallbladder Hydrops
in the neck keeps the cystic duct from kinking
Heister’s valves function
CYSTIC ARTERY
CYSTIC VEIN
gallbladder Vascular Supply
a branch of the right hepatic artery
CYSTIC ARTERY-
drains the blood directly into the portal vein
CYSTIC VEIN-
Lies intrahepatic and then migrates to the surface of the liver
Covered with a peritoneal layer on most of the surface. The rest of the gallbladder is covered with an adventicia tissue layer.
There is a potential space where these meet that can be an area where infection or inflammation can occur
If migration does not occur, the gallbladder can be termed ectopic
Gallbladder location
gallbladder not developed
still has biliary duct system
gallbladder agenesis
Stores bile produced by the liver can hold approx 50 ml
-Concentrates bile when the body is in a fasting state
gallbladder function
Bile is forced into the gallbladder due to an increased pressure within the CBD produced by the action of the sphincter of Oddi
How does the bile get into the gallbladder
As the stomach empties the food into the duodenum, the intestines secrete enzymes and bile salts that stimulate the gallbladder to contract and push the bile into the duodenum
Cholecystokinin hormone
How does bile get out of the gallbladder
There are folds within the mucous membrane of the wall that has a honeycomb appearance and unite with each other
How does the gallbladder concentrate bile
Consists of the right and left hepatic duct,
common hepatic duct,
common bile duct,
pear shaped gallbladder,
and cystic duct
Anatomy of the Bile Ducts
come from the right lobe of the liver in the Porta hepatis and unite to form the CHD
Right and left hepatic ducts
approx 4mm in diameter, joins the cystic duct(draining the gallbladder) and is now called the CBD
Common Hepatic Duct
by piercing into the wall of the duodenum where is joins the main pancreatic duct and together, they open into the duodenum through a small opening called the ampulla of Vater
CBD ends
lies lateral to the hepatic artery and anterior to the portal vein (left ear of Mickey Mouse)
CBD (prox portion) location
Normal measurement is
CBD measurement
approx 4 cm long,
connects the neck of the gallbladder to the CHD to form the CBD
normally not seen by ultrasound
Cystic Duct-
Termed cholecystectomy
The tone of the spincter of Oddi is lost, and bile is free to move into the duodenum at a fasting or non fasting state.
Normal size of the CBD is increased, and normal is < 10mm
Normally cannot see surgical clips by ultrasound
Physiology after removal of gallbladder
Bilobed gallbladder
Septated gallbladder
Phrygian cap
Hartmann pouch
Junctional fold
Normal variants of the Gallbladder
Hourglass appearance
Bilobed gallbladder
Appear as thin separations within the gallbladder
Septated gallbladder
Gallbladder fundus is folded onto itself
Phrygian cap
Outpouching of gallbladder neck
Hartmann pouch
Prominent fold located at the junction of the gallbladder neck
Junctional fold
¨Should not exceed 8-10 cm in length, and 5 cm in width
¨Transverse measurement is a better indicator of enlargement
¨Referred to as hydropic gallbladder
¨An enlarged often palpable on physical exam caused by a pancreatic head mass is termed Courvoisier gallbladder
¨Patients will have painless jaundice
Gallbladder enlargement
¨Cholelithiasis
¨Gallbladder sludge
¨Gallbladder polys
¨Adenomyomatosis
¨Acute cholecystitis
¨Acalculous cholecystitis
¨Gallbladder enlargement
¨Gallbladder carcinoma
Gallbladder Pathology
¨Obesity
¨Pregnancy
¨Increased parity
¨Gestational diabetes
¨Estrogen therapy
¨Oral contraceptive use
¨Rapid weight loss programs
¨Hemolytic disorder
¨Total parenteral nutrition (TPN)
Cholelithiasis Risk factors and predisposing conditions
¨Asymptomatic
¨Biliary colic
¨Abdominal pain after fatty meals
¨Epigastric pain
¨Nausea and vomiting
¨Pain that radiates to shoulders
Clinical findings of cholelithiasis
¨Echogenic, mobile, shadowing structure(s) within the lumen of the gallbladder
¨Stones that lodge within the cystic duct or neck of the gallbladder may not move
¨WES sign may be present (gallbladder completely filled with stones)
Sonographic findings of cholelithiasis
¨Echogenic, nonshadowing, and nonmobile masses that projects from the gallbladder wall into the gallbladder lumen
¨Also called adenoma
Sonographic findings of polyps
¨Asympomatic
¨Caused by a disturbance in cholesterol metabolism and accumulation of cholesterol within the wall of the gallbladder
¨May be single or multiple
¨Most measure less than 5mm
¨Benign
¨If these adenomas grow rapidly or >2cm, worrisome for gallbladder carcinoma
Clinical findings of polyps
¨Benign hyperplasia of the gallbladder
¨
¨Epithelium and muscular layers of the wall have tiny sinuses called Rokitansky-Aschoff sinuses. These contain cholesterol crystals that produce comet tail artifacts
¨
¨May be focal or diffuse
Adenomyomatosis
¨Sudden onset of gallbladder inflammation
¨Focal tenderness, caused by inflammation is termed a positive sonograghic Murphy’s sign
Acute Cholecystitis
¨RUQ tenderness
¨Epigastric or abdominal pain
¨Leukocytosis
¨Possible elevation in alkaline phosphatase, aminotransferase, and/or bilirubin
¨Fever
¨Pain that radiates to the shoulders
¨Nausea and vomitting
Clinical Findings of Acute Cholecystitis
¨Gallstones
¨Positive sonographic Murphy’s sign
¨Gallbladder wall thickening
¨Pericholecystic fluid
¨Sludge
Sonographic findings of Acute cholecystitis
local tenderness over the gallbladder with transducer pressure
Murphy’s sign
Chronic cholecystitis
Gangrenous cholecystitis
Emphysematous cholecystitis
(bacterial invasion within the gallbladder wall)
Gallbladder perforation
Sequela of Acute Cholecystitis
Nontender gallbladder/intolerance to fatty foods/belching
Gallstones
Possible gallbladder wall thickening
Chronic cholecystitis
Elevated symptoms of acute cholecystitis
Linear echogenic membranes within the lumen of the gallladder/striated gallbladder wall
Gangrenous cholecystitis
Elevated symptoms of acute cholecystitis
Diabetes
Gas within the gallbladder wall that leads to ring down artifact/gallstones may not be present
Emphysematous cholecystitis
(bacterial invasion within the gallbladder wall)
Elevated symptoms of acute cholecystitis
Small opening or tear in the gallbladder wall
Gallbladder perforation
¨Most common form of gallbladder inflammation
¨Results from numerous attacks of acute cholecystitis which causes fibrosis of the gallbladder wall
¨Clinically, patients have transient pain RUQ, but not a positive Murphys sign
¨Sonographically, contracted gallbladder filled with stones (WES) sign
Chronic cholecystitis
¨Presents with all the clinical and sonographic findings of cholecystitis except no gallstones are present
¨More commonly seen in children, recently hospitalized patitents , and those who are immunocompromised
¨Uncommon
¨Caused by decreased blood flow through the cystic artery
¨Can also be caused by extrinsic compression of the cystic duct by a mass or lymphadenopathy
Acalculous Cholecystitis
¨Rare
¨Seen mostly in elderly females
¨Associated with a mobile gallbladder with a long suspensory mesentery
¨Clinical symptoms mimic acute cholecystitis
¨
¨Sonographic findings massively inflamed and distended gallbladder, gangrene can develop
¨Treatment is surgical removal of GB
Torsion of the gallbladder
¨Results from the calcification of the gallbladder wall
¨Occurs mainly in older female patients
¨May appear sonographically similar to WES sign
¨Has been associated with the potential development of gallbladder carcinoma (25%)
Porcelain gallbladder
¨Rare, although most common cancer of the biliary tract
¨Caused by chronic irritation of the gallbladder wall by gallstones
¨Size > 2cm , suspicous for carcinoma vs poloyp
¨Color doppler can reveal vessels within the malignancy
¨Most common metastatic disease of the gallbladder is malignant melanoma
Gallbladder carcinoma
¨Weight loss
¨Right upper quadrant pain
¨Jaundice
¨Nausea and vomiting
¨Hepatomegaly
Clinical findings of gallbladder carcinoma
¨Nonmobile mass within the gallbladder lumen that measures >2cm
¨Gallstones seen in approx 90%
¨Diffuse or focal gallbladder wall thickening
¨Irregular mass that may completely fill the gallbladder fossa
¨Invasion of the mass into surrounding liver tissue
Sonographic findings of gallbladder carcinoma
¨Choledocholithiasis
¨Cholangitis
¨Pneumobilia/hemobilia
¨Cholangiocarcinoma
¨Ascariasis
Bile Duct Pathology
¨Primary – formation of stones in the bile duct resulting from a disease that leads to stasis or dilation of the ducts
¡Sclerosing cholangitis
¡Caroli’s disease
¡Parasitic infections
¡Chronic hemolytic diseases
¡Prior biliary surgery
Choledocholithiasis
¨Secondary
¡Stones found in the bile duct that has migrated down from the gallbladder
Choledocholithiasis
¨Inflammation of the biliary ducts
¨
5mm
Several types
Acute bacterial
AIDS
Pyogenic
Sclerosing
¡All of these have similar sonographic findings that include varying degrees of biliary dilatation, biliary sludge, and bile duct wall thickening
Cholangitis
Recent biliary surgery
Sequela of emphysematous cholecystitis
Hemobilia-blood within biliary tree due to percutaneous intervention (liver bx)
Symptoms of acute cholecystitis
Pneumobilia
Hemobilia
Dilated intrahepatic ducts that abruptly terminate at the level of the tumor
A solid mass may be noted within the liver or ducts
Cholangiocarcinoma
¨Congenital disorder
¨Found in younger adult or pediatric population
¨
¨Characterized by segmental diliation of the intrahepatic ducts
¨May appear segmental, saccular, or berry shaped
¨
¨Often seen in association with cystic renal disease and may precede the development of cholangiocarcinoma, a hepatic abscess, cholangitis and sepsis
Caroli disease
¨Biliary atresia and Choledochal Cyst
¡Congenital disease thought to be caused by a viral infection at birth, although some think it may be an inherited disorder
¡A narrowing or obliteration of all or a portion of the biliary tree
¡This leads infants to suffer from cirrhosis and portal hypertension
Pediatric pathology of the bile ducts
4 types
Most common being described as the cystic dilatation of the Common bile duct
Discovered in infancy or the first decade of life
Jaundice
Pain
Fever
Choledochal cyst
¨Cystic mass in the area of the porta hepatis (separate from the gallbladder)
¨Biliary dilatation
Sonographic findings of a choledochal cyst
¨Jaundice
¨Pruitis
¨Unexplained weight loss
¨Abdominal pain
¨Elevated bilirubin
¨Elevated alkaline phosphatase
Clinical findings of cholangiocarcinoma
¨Dilated intrahepatic ducts that abruptly terminate at the level of the tumor
¨A solid mass may be noted within the liver or ducts
¨Klatskin tumor- found at the junction of the left and right hepatic ducts
Sonographic findings of cholangiocarcinoma
