USG in gall bladder pathologies

1. ROLE OF USG IN GB
PATHOLOGIES
Dr.Pratibha Malik
Moderator-
Dr. Revathi

2. Always look for cholecytectomy
scar first!!
Indications
Normal Anatomy
Pathogical Findings:GB
gallstones
sludge
cholecystitis
polyps
gallbladder cancer
Biliary tract
Bile duct stones
klatskin tumour
08/03/14
CONTENTS

3. 08/03/14
INDICATIONS
 Abdominal pain
 vomiting
 fever
 jaundice
 abnormal labs
(bilirubin,
transaminases)

4. 08/03/14
Technique and Preparation
Curvilinear probes :2-5
MHz
Views:
 Subcostal sagittal
 intercostal sagittal
 coronal
 left lateral decubitus
 oblique views
 reverse trendelenberg

5.  Indications
 Normal Anatomy
 Pathogical Findings:GB
 gallstones
 sludge
 cholecystitis
 polyps
 gallbladder cancer
 Biliary tract
 Bile duct stones
 klatskin tumour
Contents

6. NORMAL ANATOMY OF THE
BILLIARY SYSTEM

7. NORMAL APPERANCE OF GB
Normal Gallbladder is seen as a sonolucent pear shaped
structure with slim wall (2 mm or so). Best seen with overnight
fasting or at least 4-5 hours fasting. It is seen usually at the
inferior aspect of the liver right lobe.

8.  The main hepatic fissure appears as an echogenic
line that extends from the neck of the gallbladder to
the portal vein and serves as a landmark.
 The complex of the gallbladder, main hepatic fissure,
and portal vein (in the short-axis) has the
appearance of an exclamation point
08/03/14

9. 08/03/14

10. "Mickey Mouse" view of
Portal Triad
08/03/14

11. 08/03/14

12. NORMAL VARIANTS
Phrygian cap
Figure (A) A folded gallbladder is
difficult to examine with the patient
supine.
(B) Turning the patient, right side
raised, unfolds the gallbladder,
enabling the lumen to be satisfactorily
examined.
The gallbladder may be ‘folded’ (the so-
called Phrygian cap).

13. CONTENTS
 Indications
 Normal Anatomy
 Pathogical Findings:GB
 Gallstones
 sludge
 cholecystitis
 polyps
 gallbladder cancer
 Biliary tract
 Bile duct stones
 klatskin tumour

14. Gold standard for diagnosis:
3 sonographic criteria-
 Echogenic focus
 Cast acoustic shadow
 Seek gravitational dependence

15. CHOLELITHIASIS
Cholelithiasis with posterior acoustic shadowing and
normal GB wall thickness

16. CONTENTS
 Indications
 Normal Anatomy
 Pathogical Findings:GB
 gallstones
 sludge
 cholecystitis
 polyps
 gallbladder cancer
 Biliary tract
 Bile duct stones
 klatskin tumour

17. Sludge is identified on ultrasound as slightly hyperechoic material forming a
meniscus within the gallbladder lumen.
Sludge may be a precursor to gallstones and has been related to pathology
such as acute cholecystitis and acute pancreatitis
08/03/14

18. 08/03/14
DD
ECHOGENIC LESIONS
IN GALL BLADDER
DD
MOBILE OR POSTERIOR
SHADOWING
•STONES
•SLUDGE
FIXED
•POLYP
•ADHESIVE STONE
•SLOW MOVING TUMEFACTIVE
SLUDGE

19. CONTENTS
 Indications
 Normal Anatomy
 Pathogical Findings:GB
 gallstones
 sludge
 cholecystitis
 polyps
 gallbladder cancer
 Biliary tract
 Bile duct stones
 klatskin tumour

20. GB inflammation

21. CALCULUS CHOLECYSTITIS VS ACALCULUS
 Acute cholecystitis refers to the acute inflammation of the
gallbladder . It is the primary complication of cholelithiasis
 90 to 95% of cases are due to calculous obstruction of the gallbladder
neck or cystic duct.
 Most sensitive US finding :
1. Presence Of Cholelithiasis
2. Sonographic Murphy Sign.
3. Gallbladder Wall Thickening (>3mm)
4. Pericholecystic fluid.
 Other less specific imaging findings include gallbladder distension(>4
cm) and sludge.
99m
Tc-HIDA scintigraphy
 HIDA cholescintigraphy in acute cholecystitis will demonstrate
nonvisualization of the gallbladder.

22. Figure: Acute cholecystitis: (A) TS of an oedematous, thickened gallbladder wall
with a stone. (B) LS with a thickened wall (arrows). Stones and debris are present.
(C) and (D) TS and LS demonstrating pericholecystic fluid.

23. Sonographic Murphy’s sign
08/03/14
Sonographic Murphy’s sign is positive when the point of maximal tenderness is
identified in the right upper quadrant while the gallbladder is identified on the
ultrasound monitor.
Differential diagnosis of acute cholecystitis
choledocholithiasis
pancreatitis
peptic ulcer disease
acute hepatitis

24.  Complications
 gangrenous cholecystitis
 emphysematous cholecystitis
 gallbladder perforation
 pericholecystic abscess
 cholecystoenteric fistula
 liver abscess
 Gangrenous and emphysematous cholecystitis - serious complications of acute
cholecystitis that may be identified with ultrasound by the presence of air within
the gallbladder wall or lumen . Air on ultrasound is represented by “comet-
tail” artifacts.
 Gallbladder perforation may also be diagnosed by ultrasound. Findings of
perforation include significant amounts of pericholecystic fluid that may contain
echogenic material which may be walled off from the rest of the abdomen.

25. Gallbladder gangrene/mucosal sloughing. Longitudinal
ultrasound of a patient who had acute cholecystitis
secondary to stone (arrow) impacted in the
gallbladder neck. Note the intraluminal membranes
(arrowheads) that are associated with gangrene of
the gallbladder.

26. Chronic calculus cholecystitis
USG FINDINGS
 Thickened echogenic wall
 Contracted GB
 Cholelithisis

27. Chronic calculus cholecystitis

28.  When the gallbladder is entirely filled with stones, a wall echo shadow
(WES) sign is seen
 The WES triad is another sign of chronic cholecystitis; here the WES
stands for Wall (of the GB), Echo (of the calculus) and Shadow
(caused by the stones).

29. ACALCULUS CHOLECYSTITIS
 Acute acalculous cholecystitis (AAC) refers
development of cholecystitis either in a gallbladder without
gallstones or in a gallbladder with gallstones where the
stones are not the contribuatry factor to the development
of cholecystitis .
AETIOLOGY
 It usually occurs in critically ill or
 injured patients.

30. Figure :(A) Acalculous cholecystitis. The gallbladder wall is markedly thickened
and tender on scanning.
(B) Gravity-dependent sludge with a thick, oedematous wall. No stones were
present.

31. PORCELAIN GB
 A porcelain gallbladder refers to extensive calcium
encrustation of the gallbladder wall.
 The term porcelain gallbladder has been used to
emphasize the blue discoloration and brittle
consistency of the gallbladder wall at surgery
 Association between porcelain gallbladder and
gallbladder adenocarcinoma- 22-30 % .
 Cholecystectomy routinely performed when a
porcelain gallbladder is identified.

32. Porcelain gallbladder. (A) Sagittal imageof the gallbladder shows a densely
echogenic anterior wall (arrow) with a sharp shadow that obliterates the
gallbladder lumen and posterior wall. (B) Transverse ultrasound of the
gallbladder in the same patient. The anterior wall is bright, but, without enough
reflection or attenuation to eliminate visualization of the lumen and posterior wall
(arrow), which is also echogenic and casts a posterior acoustic shadow.

33. CONTENTS
 Indications
 Normal Anatomy
 Pathogical Findings:GB
 gallstones
 sludge
 cholecystitis
 polyps
 gallbladder cancer
 Biliary tract
 Bile duct stones
 klatskin tumour

34. GB POLYPS
 Gallbladder polyps are outgrowths of the gallbladder mucosal wall.
 Do not cast an acoustic shadow.
 Remain fixed on turning the patient ;so distinguishable from stones
 Majority are not neoplastic but are hyperplastic or represent lipid
deposits(cholesterolosis).
 Gallbladder (GB) polyps are incidentally detected in approximately
4%–7% of patients who undergo ultrasonography

35. GB POLYPS
GB polyps are classified into 2 groups:
Neoplastic
 Adenomas
 Adenocarcinomas
Nonneoplastic
 Cholesterol polyps
 Inflammatory polyps
 Adenomyomatosis

36. GB polyps are soft tissue masses attached to the wall of the gallbladder and
differentiated from gallstones by their lack of mobility and shadowing

37. On CD demonstration of supplying vessel
pathognomic of polyp.

38. INCREASE RISK OF MALIGNANCY IN
POLYP
 Diameters > 10 mm
 Sessile Polyps
 Single Polyps
 Polyps With Adjacent Wall Thickening Or Invasion
 Increased Patient Age
 Size Of At Least 10 mm Is The Most Well-established
predictor of malignancy

39. CONTENTS
 Indications
 Normal Anatomy
 Pathogical Findings:GB
 gallstones
 sludge
 cholecystitis
 polyps
 gallbladder cancer
 Biliary tract
 Bile duct stones
 klatskin tumour

40. CARCINOMA GB
 Gall bladder carcinoma is the most common biliary
tract cancer.
 Delayed presentation and early spread of tumor
make it one of the lethal tumors with poor prognosis.

41. RISK FACTOR FOR CA GB
 Gallstones
 History of chronic cholecystitis
 Porcelain gallbladder.
 Choledochal cysts,
 Anomalous pancreaticobiliary duct junctions
 Gallbladder polyps > 1 cm in size.
 Peak incidence in the 6th
-7th
decades of life
 3-5 times more predominant in females

42. USG FINDINGS IN CA GB
 A Mass Completely Occupying Or Replacing The Gallbladder
Lumen
 Focal Or Diffuse Asymmetric Gallbladder Wall Thickening
 An Intraluminal Polypoid Lesion.
 Invasion of adjacent liver parenchyma
 Hepatic metastasis
 Periportal/ peripancreatic lymphadenopathy
 Sonographically : Heterogeneous, Predominantly Hypoechoic
Tumor Fills Much Or All of the gallbladder lumen.

43. CA GB WITH LIVER INVASION

44. 08/03/14
The normal gallbladder wall measures less than 4 mm. the gallbladder wall is measured at the
most narrow point of the anterior wall in the short-axis. Care must be taken to not measure the
wall at an oblique angle
THICKENING OF GALL BLADDER
WALL
DD
FOCAL
ADENOMYOMATOSIS
GALL BLADDER CANCER
DIFFUSE
ACUTE CHOLECYSTITIS
CHRONIC CHOLECYSTITIS
XANTHOGRANULOMATOUS
CHOLECYSTTIS
ADENOMYOMATOSIS
GB WALL EDEMA
GB CANCER
OTHERS-
ASCITIS,CHF,HYPOALBUMINEMIA

46. CONTENTS
 Indications
 Normal Anatomy
 Pathogical Findings:GB
 gallstones
 sludge
 cholecystitis
 polyps
 gallbladder cancer
 Biliary tract
 Bile duct stones
 klatskin tumour

47. BILIARY TRACT

48. 08/03/14
BILE DUCTS
 Sonographically, the CBD appears as an anechoic tubular
structure in the main portal triad, anterior to and following the
course of the main portal vein
 Conventionally, the upper limit of normal for the common bile
duct as measured by ultrasound is considered to be 6 mm.
 Biliary duct obstruction: caused by stones, pancreatic
pathology (e.g. mass), or stricture is detected measuring a
CBD larger than 6-7 mm.
2000 Am. Coll. of Gastroenterology

49. 08/03/14
Intrahepatic duct stones

50. The Mirizzi Syndrome
 Form of obstructive jaundice-described by
Mirizzi.
 Caused by a stone or stones impacted in the
neck of the gallbladder or the cystic duct, such
that the common hepatic duct is narrowed.
 Rare complication of gallstones-occurs in about
0.1% to 0.7% of patients with cholelitiasis.

51. Csendes classification of
Mirizzi syndrome

52. Figure: Mirizzi syndrome: a large stone in the
neck of the gallbladder (arrow) is compressing the bile duct,
causing intrahepatic duct dilatation. The lower end of the CBD
remains normal in calibre.

53. COMPONENTS OF MS
There must be 4 components for the syndrome to occur:
1. Anatomy- placing the cystic duct parallel to the common
hepatic duct
2. Impaction of a stone in the cystic dust or gallbladder neck
3. Obstruction of the common hepatic duct from the stone
itself, or from the resultant inflammatory response
4. Intermittent or constant jaundice occasionally causing
cholangitis, and with longstanding obstruction, biliary
cirrhosis

54. INTRAHEPATIC GALL STONES

55. INTRAHEPATIC VS EXTRAHEPATIC CALCULUS
•Caroli's disease is characterized by congenital
segmental dilation of the intrahepatic bile ducts producing
primary intrahepatic gallstones.
•Secondary intrahepatic gall stone formation occurs due to
chronic obstruction of CBD and CHD
•It's believed that most patients suffering a chronic illness
have excessive amounts of gallstones in the liver.
• Gallstones found in gallbladder tend to be hardened and
relatively large while stones found in liver tends to be soft
and noncalcified
•Intrahepatic Gallstones cause liver congestion and elevted
liver enzymes

56. Primary intrahepatic stones exclusively involving the
intrahepatic biliary tree-related to chronic parasitic infestation of
the biliary tree- (ascariasis )
Mixed intrahepatic stone- Associated with extrahepatic lithiasis
Secondary intrahepatic stones related to ananatomical
condition precipitating stasis or infection
TYPES OF INTRAHEPATIC CALCULUS

57. EXTRAHEPATIC CALCULUS
CALCULI IN THE DISTAL CBD

58. CONTENTS
 Indications
 Normal Anatomy
 Pathogical Findings:GB
 gallstones
 sludge
 cholecystitis
 polyps
 gallbladder cancer
 Biliary tract
 Bile duct stones
 klatskin tumour

59. KLATSKIN TUMOUR
 A Klatskin tumour is a term that was traditionally given
to a hilar cholangiocarcinoma (occuring at the
bifurcation of the common hepatic duct).
Typically, these tumours are
 Small In Size
 Poorly Differentiated
 Exhibit Aggressive Biologic Behaviour
 And tend to obstruct the intrahepatic bile ducts
 25% of all cholangiocarcinoma

60. Risk factors :
 Primary sclerosing cholangitis
 Choledochal cysts
 Parasitic infections
 Hepatolithiasis (also called Oriental cholangiohepatitis)
 Toxin exposures
 Genetic Factors

61. ULTRASOUND FINDINGS
 Presence of a hilar mass with obstruction
 Increased echogenicity relative to surrounding
liver ~79%
 Reduced echogenicity ~ 19 %
 Mixed echogenicity ~ 2 %
 Segmental dilatation or nonunion of R and L ducts
 Polypoid intraluminal masses,
 Nodular smooth masses with mural thickening.
 Should do doppler, as this is helpful to assess
Vascular invasion (unresectable)

62. Figure : Cholangiocarcinoma. (A) Irregular mass at the porta,
causing biliary obstruction—a Klatskin tumour.
(B) MRI of the same patient, confirming the mass at the porta.
KLATSKIN TUMOUR

63. KLATSKIN TUMOUR
COLOUR DOPPLER TO LOOK FOR
VASCULAR INVASION

64. 08/03/14
THICKENING OF BILE DUCT WALL
FOCAL STRICTURE
•BACTERIAL CHOLANGITIS
•CHOLANGIOCARCINOMA
•CHOLEDOCAL CYSTS
•METASTASIS
•BENIGN STRICTURE
NO STRICTURE
•POLYPOID CANCER
•STONES
•PERIAMPULLARY CANCER
•SENILE CHANGE
•POSTCHOLECYSTECTOMY
DILATATION
•CHOLEDOCHAL CYST
•ASCARIASIS

65. 08/03/14
Pearls and Pitfalls
 The gallbladder is a mobile organ; remember to change patient positioning
and/or probe placement to find the organ of interest.
 Distinguish gallstones from polyps and septations or folds by always scanning
through the whole organ and in both longitudinal and transverse planes.
 During the biliary exam, use color Doppler to help distinguish nonvascular from
vascular structures.
 Ultrasound findings must be interpreted in the context of the clinical
presentation; findings suggestive of acute cholecystitis (e.g., gallstone or
thickened wall) may be present in patients in a nondiseased state.
 The common bile duct can be dilated in the absence of pathology in older
patients and postcholecystectomy patients.
 Measure the anterior wall of the gallbladder. The posterior wall may appear
artificially thickened because of acoustic enhancement or artifact from bowel
gas.