Ultrasound of the Gall Bladder and Biliary Tree

Question 1

Position of the gall bladder

Answer 1

Position of the gall bladder
May be:- Intrahepatic Suprahepatic Retrohepatic Left - sided

Question 2

Gall bladder
Size
Shape
Wall / mucosa
Contents
Normal Variants.

Answer 2

Pear shaped sac attached to extra hepatic bile ducts by cystic ducts. Up to 10cm long and 3cm wide. Mucosal lining smooth except at the neck and the cystic duct where it forms folds that are arranged spirally- valves of Heister.

Normal variants:
Septated,fundus folded back on itself(Phrygian cap), diverticula, positional variations(retrohepatic,suprahepatic,intrahepatic, left sided, absent(rare 0.05%) or double(0.025).

Question 3

Gall bladder – wall/mucosa structure

Answer 3

Mucosal lining should be mainly smooth
At the neck of the gall bladder spiral folds form the valves of Heister
Wall thickness measurement up to
3 mm (anteriorly)

Question 4

Gall bladder – normal variants

Answer 4

Septated
Phrygian cap
Positional variants
Absence (0.05%)
Double (0.025%)

Question 5

Bile ducts structure and variations

Answer 5

Same pattern of distribution as HAs.
Rt and Lt hepatic ducts 3mm.
Unite outside the liver to form CHD 7mm
Joined by cystic duct to form CBD.
CBD passes behind duodenum and pancreas then unites with pancreatic duct in a common dilated terminal ampulla of Vater and enters the duodenum 8-10cm from pylorus-may vary.

VARIATIONS
Rt and Lt fail to unite-double hepatic duct.
Cystic duct may be absent or join at a different point.
CBD and pancreatic duct may open separately.
Choledocal cysts and bile duct cysts may be present.

Question 6

Preparation for abdomen ultrasound

Answer 6

6 hour starve
ID check
Full explanation
Informed consent
Optimise settings
After exam explain where and how to get the results.

Question 7

Technique for abdomen ultrasound

Answer 7

3.5 – 5 MHz probe
System
Sequential scanning
Arrested inspiration/valsalva
Sagittal scans from midline → RT

Identify long axis of GB.
Longitudinal and transverse scans
CD – Scan at right angles to LCM then trace back to head of pancreas
Patient position – supine and LPO.

Question 8

Images required from the abdomen ultrasound

Answer 8

Long axis of the gall bladder
Transverse section of the gall bladder
Common duct (with measurement) at the Porta Hepatis
Images to demonstrate pathology.

Question 9

Pathology of the gall bladder and biliary tree

Answer 9

Gall bladder – cholelithiasis - polyps - cholecystitis - biliary sludge
Biliary obstruction
Non obstructive biliary dilatation
Cholangitis
Air in the biliary tree

Question 10

Cholelithiasis overview

Answer 10

Gallstones
10% in developed countries. 2/3rds asymptomatic.
1 mm – 13lb 14 oz 80 yr old Dec 1952
1 – 23,530 85 yr old 1987
Increased incidence if you have Crohn’s disease, Diabetes, Pancreatic disease, Sickle cell disease and Cystic fibrosis.
Severe RUQ pain.
Can lead to gallstone Ileus.
Should cause shadowing can be difficult to distinguish between bowel – particularly if the GB is full of stones.
Don’t always shadow (if stone smaller than beam width or outside the focal zone)
Move with gravity.

Question 11

Gall bladder polyp overview

Answer 11

Incidental finding. Relatively common. Don’t move. Generally don’t shadow. May progress to malignant change.

Question 12

Cholecystitis overview

Answer 12

Inflammation of the gallbladder

Acute cholecystitis is really a clinical diagnosis. Usually age 30 – 60. Female > male.
Pyrexia, pain, occ mild jaundice.
No specific signs but look for:
Halo sign – echo poor rim of oedema
Positive Murphy’s sign
Gallstones – particularly neck or cystic duct
GB with thick wall after fasting
Large rounded GB

Chronic cholecystitis
Usually associated with gallstones
GB may be small or occasionally distended
Thick walled
Fatty intolerance
Liver biochemistry can be altered

Question 13

What is Biliary sludge

Answer 13

Small particles of calcium carbonate granules and cholesterol salts
May get sludge balls
Can be a precursor to gallstones
Due to biliary stasis
fasting, pathological obstruction, total parenteral nutrition.

Question 14

Carcinoma of the GB
Adenomyomatosis
Porcelain GB
Mucocoele of the GB
Cholesterolosis
Biliary Ascaris

Answer 14

make cards on these

Question 15

What is intrinsic Choledocholithiasis

Answer 15

Stones in the bile duct, Biliary obstruction

Question 16

Cholangiocarcinoma overview

Answer 16

Bile duct cancer is a rare disease in which malignant (cancer) cells form in the bile ducts
Male > female. Age 50 – 60 yrs. Occur anywhere between lower end of CBD to liver.
Jaundice
Klatskin tumours – confluence of Rt and lt hep ducts at porta hepatis.
Generally poor prognosis

Question 17

Choledochal cyst

Answer 17

Congenital cystic dilatation of the extrahepatic bile ducts.

Question 18

What do the types of Biliary obstruction
Intrinsic
Extrinsic mean?

Answer 18

Intrinsic
Stricture
Ca Ampulla of Vater
Biliary Atresia

Extrinsic
Ca Head of
Pancreas
Acute Pancreatitis
Enlarged lymph nodes at the Porta Hepatis

Question 19

Non-obstructive biliary dilatation
Primary sclerosing cholangitis overview

Answer 19

Chronic inflammation and bile duct fibrosis. Progressive obstructive jaundice.
Male > Female. 25 – 40 years. Associated with inflammatory bowel disease. 60% of patients with PSC have ulcerative colitis.
Increased risk of cholangiocarcinoma.
Large ducts – segmental dilatation due to fibrous strictures.
Medium ducts – fibrosed and echogenic.

Question 20

Non-obstructive biliary dilatation
Caroli’s disease

Answer 20

Congenital saccular dilatation of intrahepatic bile ducts. Multiple cyst like areas within the liver tissue – communicate with each other.