Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
Ultrasound of cholecystitis
Samir Haffar M.D.
Assistant Professor of Gastroenterology
Ultrasound of cholecystitis
 Acute cholecystitis
 Complications of acute cholecystitis
 Chronic cholecystitis
 Acute cholecystitis
Causes of right upper quadrant pain
• Peptic ulcer disease
• Pancreatitis
• Hepatitis
• Appendicitis
• Hepatic congestion ...
Diagnostic standard for acute cholecystitis
Tokyo guidelines 2007
Hirota M et al. J Hepatobiliary Pancreat Surg 2007 ; 14 ...
Acute cholecystitis – HIDA scan
Higher accuracy than ultrasonography
Talley NJ et al. Practical gastroenterology & hepatol...
Sonographic findings in acute cholecystitis
• Impacted stone in cystic duct or GB neck
• Positive sonographic Murphy's sig...
Acute cholecystitis
Caused by gallstones in more than 90% of cases
Large obstructing stone within GB neck
Thick hypoechoic...
Negative sonographic Murphy’s sign
• Patients who received pain medicine or steroids
• Para or quadriplegic patients
• Pat...
Gallbladder wall thickening
• Generalized edematous states CHF – Renal failure
End-stage cirrhosis
Hypoalbuminemia
• Infla...
Diffuse gallbladder wall thickening
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
Three e...
Gallbladder wall thickening
Uniformly echogenic pattern
Echogenic thickening of the wall in chronic cholecystitis
McGahan ...
Gallbladder wall thickening
Central hypoechoic zone separated by two echogenic layers
Gallbladder wall thickening due to a...
Gallbladder wall thickening
Striated pattern
Rubens DJ. Ultrasound Clin 2007 ; 2 : 391 – 413.
Striated wall with alternati...
Gallbladder wall thickening
Rubens DJ et al.Ultrasound Clin 2007 ; 2 : 391 – 413.
Gallstones
Focal GB wall thickening (7 m...
Gallbladder wall thickening
Rubens DJ et al.Ultrasound Clin 2007 ; 2 : 391 – 413.
Focal pyelonephritis
Heterogeneous decre...
Pericholecystic fluid
Two specific patterns
Type I Thin anechoic crescent-shaped collection
adjacent to gallbladder wall
N...
Acute cholecystitis
Hyperemic GB wall
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
Color...
Acute acalculous cholecystitis (AAC)
5 – 15% of acute cholecystitis
• Critically ill patients Major surgery
Severe trauma
...
Acute acalculous cholecystitis (AAC)
Difficult to diagnose clinically & on imaging
Marked GB mural thickening
Hypoechoic r...
Hemorrhagic cholecystitis
Rare – Atherosclerosis – High mortality rate
Bennett GL et al. Radiol Clin N Am 2003 ; 41 : 1203...
Hemorrhagic cholecystitis
Differential diagnosis
• Blood in gallbladder Neoplasm
Aneurysms
Trauma
Anticoagulation
Ectopic ...
 Complications of acute cholecystitis
Complications of acute cholecystitis
• Suppurative cholecystitis (empyema)
• Gangrenous cholecystitis Up to 20%
• Emphysem...
Suppurative cholecystitis (Empyema)
Patients very ill with fever & acute pain
Fine echoes caused by pus in bile
Pericholec...
Gangrenous cholecystitis
No specific diagnostic US findings
• Striated thickening of GB wall
• Intraluminal membranes (5%)...
Gangrenous cholecystitis
Mucosal sloughing
Rubens D J. Ultrasound Clin 2007 ; 2 : 391 – 413.
Longitudinal US of gallbladde...
Emphysematous cholecystitis
Prompt surgical intervention required
• Organisms Clostridium welchii & Escherichia coli
• Cha...
Emphysematous cholecystitis
Associated with DM & atherosclerotic disease
Intraluminal & intramural gas bubbles
Debris with...
Emphysematous cholecystitis
Small amount of gas
Supine position
Presence of echoes anteriorly
Could be in the lumen or the...
Emphysematous cholecystitis
Large amount of gas
Absence of a normal gallbladder is a clue
Gas in GB completely obscures th...
Emphysematous cholecystitis
Abdominal radiography
Intraluminal & intramural gas bubbles
Bates J A. Abdominal Ultrasound: H...
Gallbladder perforation
5 – 10 % of patients with acute cholecystitis
Small defect in GB wall: not always seen
Deflation o...
GB perforation – Pericholecystic abscess
Rumack CM, Wilson SR, & Charboneau JW. Diagnostic Ultrasound.
Elsevier-Mosby, St....
 Chronic cholecystitis
Forms of chronic cholecystitis
• Traditional chronic cholecystitis
Thick gallbladder wall with gallstones
• Wall-Echo-Shad...
Chronic cholecystitis
Bates J A. Abdominal Ultrasound: How, Why and When.
Churchill Livingstone, Edinburg, UK, 2nd edition...
Wall-Echo-Shadow complex (WES)
Contracted gallbladder filled with stones
2 parallel arcuate hyperechoic lines
Separated by...
Porcelain gallbladder
Calcified wall with acoustic shadow
Mistaken for stone within GB lumen
No GB wall visible
Rumack CM,...
Porcelain gallbladder – Mild calcification
Rickes S et al. N Engl J Med, 2002 ; 346 : e4.
Computed tomography
Gallstones
C...
Porcelain gallbladder
Abdominal radiography
Xanthogranulomatous cholecystitis (XGC)
2% of cholecystectomy specimens
Compressed lumen
Multiple large mural nodules
sepa...
Thank You
Upcoming SlideShare
Loading in …5
×

Ultrasound of acute & chronic cholecystitis

  • Be the first to comment

Ultrasound of acute & chronic cholecystitis

  1. 1. Ultrasound of cholecystitis Samir Haffar M.D. Assistant Professor of Gastroenterology
  2. 2. Ultrasound of cholecystitis  Acute cholecystitis  Complications of acute cholecystitis  Chronic cholecystitis
  3. 3.  Acute cholecystitis
  4. 4. Causes of right upper quadrant pain • Peptic ulcer disease • Pancreatitis • Hepatitis • Appendicitis • Hepatic congestion from right-sided heart failure • Perihepatitis (Fitz-Hugh-Curtis syndrome) • Right lower lobe pneumonia • Right-sided pyelonephritis • Nephro-ureterolithiasis
  5. 5. Diagnostic standard for acute cholecystitis Tokyo guidelines 2007 Hirota M et al. J Hepatobiliary Pancreat Surg 2007 ; 14 : 78 – 82 . Three categories of diagnostic findings One criterion from each category must be fulfilled (1) Murphy sign or pain/tenderness in RUQ or RUQ mass (2) Fever, leukocytosis, or elevated CRP (3) Confirmation by US or HIDA scan
  6. 6. Acute cholecystitis – HIDA scan Higher accuracy than ultrasonography Talley NJ et al. Practical gastroenterology & hepatology: Liver & biliary disease. Wiley Blackwell, Oxford, UK, First edition, 2010. Tracer in GB Tracer in CBD Tracer in small bowel GB CBD Small bowel Normal HIDA scan Non-filling of GB Tracer in CBD Tracer in small bowel CBD Small bowel Acute cholecystitis
  7. 7. Sonographic findings in acute cholecystitis • Impacted stone in cystic duct or GB neck • Positive sonographic Murphy's sign • Thickening of GB wall (>3 mm) • Distention of GB lumen (> 4 cm) • Pericholecystic fluid collections (frequent) • Hyperemic GB wall on color Doppler (supportive test) None of above signs pathognomonic Combination of multiple signs make correct diagnosis Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.
  8. 8. Acute cholecystitis Caused by gallstones in more than 90% of cases Large obstructing stone within GB neck Thick hypoechoic gallbladder wall Positive sonographic Murphy sign Ralls PW et al. Gastroenterol Clin N Am 2002 ; 31 : 801–825.
  9. 9. Negative sonographic Murphy’s sign • Patients who received pain medicine or steroids • Para or quadriplegic patients • Patients not able to give reliable history or pain response • Denervated GB: DM – gangrenous cholecystitis • Gallbladder rupture Careful attention to clinical status important when assessing for sonographic Murphy’s sign Rubens DJ. Ultrasound Clin 2007 ; 2 : 391 – 413.
  10. 10. Gallbladder wall thickening • Generalized edematous states CHF – Renal failure End-stage cirrhosis Hypoalbuminemia • Inflammatory conditions Primary Acute cholecystitis Chronic cholecystitis Cholangitis Secondary Acute hepatitis Perforated DU Pancreatitis Diverticulitis/colitis • Neoplastic conditions Adenocarcinoma – Metastases • Miscellaneous Adenomyomatosis – Varices Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.
  11. 11. Diffuse gallbladder wall thickening McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008. Three echo patterns (not specific)  Uniformly echogenic pattern  Central hypoechoic zone & 2 peripheral echogenic layers  Striated pattern
  12. 12. Gallbladder wall thickening Uniformly echogenic pattern Echogenic thickening of the wall in chronic cholecystitis McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
  13. 13. Gallbladder wall thickening Central hypoechoic zone separated by two echogenic layers Gallbladder wall thickening due to ascites
  14. 14. Gallbladder wall thickening Striated pattern Rubens DJ. Ultrasound Clin 2007 ; 2 : 391 – 413. Striated wall with alternating echogenic & hypoechoic layers Striated wall in setting of acute cholecystitis: gangrenous cholecystitis Striated wall without evidence of acute cholecystitis: non specific
  15. 15. Gallbladder wall thickening Rubens DJ et al.Ultrasound Clin 2007 ; 2 : 391 – 413. Gallstones Focal GB wall thickening (7 mm) Free air with reverberation shadows Pericholecystic fluid (arrows) Free air (arrowheads) Extraluminal air (paired arrowheads) Peptic ulcer perforation
  16. 16. Gallbladder wall thickening Rubens DJ et al.Ultrasound Clin 2007 ; 2 : 391 – 413. Focal pyelonephritis Heterogeneous decreased attenuation area typical of focal pyelonephritis GB wall thickening 3-cm echogenic mass in lower pole of rt kidney
  17. 17. Pericholecystic fluid Two specific patterns Type I Thin anechoic crescent-shaped collection adjacent to gallbladder wall Nonspecific finding Type II Round or irregularly shaped collection with thick walls, septations, or internal debris Associated with GB perforation & abscess Teefey SA et al. J Ultrasound Med 1991 ; 10 : 603 – 6. Rubens DJ. Ultrasound Clin 2007 ; 2 : 391 – 413.
  18. 18. Acute cholecystitis Hyperemic GB wall McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008. Color Doppler sonography Increased vascularity in GB wall Supportive test
  19. 19. Acute acalculous cholecystitis (AAC) 5 – 15% of acute cholecystitis • Critically ill patients Major surgery Severe trauma Sepsis Total parenteral nutrition Diabetes Atherosclerotic disease HIV infection • Nonhospitalized patients Elderly male with atherosclerosis HIDA scan & sampling of luminal contents help to establish the diagnosis
  20. 20. Acute acalculous cholecystitis (AAC) Difficult to diagnose clinically & on imaging Marked GB mural thickening Hypoechoic regions within wall Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 – 287. Marked GB mural thickening with hypo & hyperenhancing areas
  21. 21. Hemorrhagic cholecystitis Rare – Atherosclerosis – High mortality rate Bennett GL et al. Radiol Clin N Am 2003 ; 41 : 1203 – 1216. Echogenic material with higher echogenicity than sludge Increased density of bile
  22. 22. Hemorrhagic cholecystitis Differential diagnosis • Blood in gallbladder Neoplasm Aneurysms Trauma Anticoagulation Ectopic pancreas Ectopic gastric mucosa • High-density bile Recently administered IV contrast Milk of calcium bile Bennett GL et al. Radiol Clin N Am 2003 ; 41 : 1203 – 1216.
  23. 23.  Complications of acute cholecystitis
  24. 24. Complications of acute cholecystitis • Suppurative cholecystitis (empyema) • Gangrenous cholecystitis Up to 20% • Emphysematous cholecystitis 1 % • Hemorrhagic cholecystitis Rare • Gallbladder perforation 5 – 10%
  25. 25. Suppurative cholecystitis (Empyema) Patients very ill with fever & acute pain Fine echoes caused by pus in bile Pericholecystic GB collection (leakage) US used to guide drainage before surgery Bates J A. Abdominal Ultrasound: How, why and when. Churchill Livingstone, Edinburg, UK, 2nd edition, 2004 Large GB full of pus & stones
  26. 26. Gangrenous cholecystitis No specific diagnostic US findings • Striated thickening of GB wall • Intraluminal membranes (5%) • Marked asymmetry of GB wall • Echogenic debris within GB • Pericholecystic fluid collections • US Murphy’s sign negative in 70% Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 – 287. Mucosal sloughing Echogenic debris within GB
  27. 27. Gangrenous cholecystitis Mucosal sloughing Rubens D J. Ultrasound Clin 2007 ; 2 : 391 – 413. Longitudinal US of gallbladder Intraluminal membranes associated gallbladder gangrene Stone impacted in gallbladder neck
  28. 28. Emphysematous cholecystitis Prompt surgical intervention required • Organisms Clostridium welchii & Escherichia coli • Characteristics Male preponderance (70%) Frequent occurrence in diabetic (50%) Lack of gallstones in up to one third Higher risk of gangrene & perforation • Three stages Stage 1: Gas in GB lumen Stage 2: Gas in GB wall Stage 3: Gas in pericholecystic tissues Bennett GL et al. Radiol Clin N Am 2003 ; 41 : 1203 – 1216. Appearance depends on amount of gas present
  29. 29. Emphysematous cholecystitis Associated with DM & atherosclerotic disease Intraluminal & intramural gas bubbles Debris within necrotic GB Higher sensitivity of CT for the diagnosis Diagnosis should be confirmed by abdominal radiography or CT Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 – 287.
  30. 30. Emphysematous cholecystitis Small amount of gas Supine position Presence of echoes anteriorly Could be in the lumen or the wall Rubens D J. Ultrasound Clin 2007 ; 2 : 391 – 413. Upright position Gas moves & breaks into bubbles Distinguishing it from calcium
  31. 31. Emphysematous cholecystitis Large amount of gas Absence of a normal gallbladder is a clue Gas in GB completely obscures the lumen (dirty shadow) Bates J A. Abdominal Ultrasound: How, Why and When. Churchill Livingstone, Edinburg, UK, 2nd edition, 2004 Location of GB fossa essential to avoid mistaking this for bowel gas
  32. 32. Emphysematous cholecystitis Abdominal radiography Intraluminal & intramural gas bubbles Bates J A. Abdominal Ultrasound: How, Why and When. Churchill Livingstone, Edinburg, UK, 2nd edition, 2004
  33. 33. Gallbladder perforation 5 – 10 % of patients with acute cholecystitis Small defect in GB wall: not always seen Deflation of the gallbladder Pericholecystic fluid collection Pericholecystic abscess Rumack CM, Wilson SR, & Charboneau JW. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, Missouri, USA, 3rd edition, 2005. Disruption of GB wall
  34. 34. GB perforation – Pericholecystic abscess Rumack CM, Wilson SR, & Charboneau JW. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, Missouri, USA, 3rd edition, 2005. Abscess (internal strands typical of abscess) Echogenic inflamed fat Small amount of ascites
  35. 35.  Chronic cholecystitis
  36. 36. Forms of chronic cholecystitis • Traditional chronic cholecystitis Thick gallbladder wall with gallstones • Wall-Echo-Shadow complex (WES) Double arc-shadow sign • Porcelain gallbladder High incidence of GB carcinoma (10 – 30%) • Xanthogranulomatous cholecystitis (XGC) Difficult to distinguish from adenomyomatosis & gallbladder carcinoma
  37. 37. Chronic cholecystitis Bates J A. Abdominal Ultrasound: How, Why and When. Churchill Livingstone, Edinburg, UK, 2nd edition, 2004 Thick gallbladder wall Small gallbladder stone with posterior AS Bouts of acute cholecystitis may complicate chronic cholecystitis
  38. 38. Wall-Echo-Shadow complex (WES) Contracted gallbladder filled with stones 2 parallel arcuate hyperechoic lines Separated by thin hypoechoic space Distal acoustic shadowing McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008. Differentiation from air or calcification in GB wall Normal GB wall not seen; only bright echo & AS seen
  39. 39. Porcelain gallbladder Calcified wall with acoustic shadow Mistaken for stone within GB lumen No GB wall visible Rumack CM, Wilson SR, & Charboneau JW. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, Missouri, USA, 3rd edition, 2005. Dense calcification in GB fundus
  40. 40. Porcelain gallbladder – Mild calcification Rickes S et al. N Engl J Med, 2002 ; 346 : e4. Computed tomography Gallstones Calcification of GB wall Ultrasonography Gallstones (one in cystic duct) leading to GB enlargement (5 cm) Calcification of GB wall
  41. 41. Porcelain gallbladder Abdominal radiography
  42. 42. Xanthogranulomatous cholecystitis (XGC) 2% of cholecystectomy specimens Compressed lumen Multiple large mural nodules separated by enhancing margins Stone not visualized Compressed lumen Multiple hypoechoic mural nodules Wall markedly thickened Adjacent stone Rubens D J. Ultrasound Clin 2007 ; 2 : 391 – 413.
  43. 43. Thank You

    Be the first to comment

    Login to see the comments

  • ElTahirMoeElFatih

    Aug. 5, 2020
  • MuhammadNajim1

    Sep. 2, 2020
  • RaghavReddy31

    Sep. 9, 2020
  • Safil

    Oct. 3, 2020
  • TishyaGaba

    Oct. 10, 2020
  • AmrithaPP

    Oct. 14, 2020
  • uraiwanruengwitayawong

    Nov. 8, 2020
  • OkekePaschal

    Nov. 10, 2020
  • princeoppsjohn

    Nov. 21, 2020
  • RuslMoayed

    Nov. 22, 2020
  • JasmeenAli

    Dec. 1, 2020
  • DayaRaj4

    Feb. 28, 2021
  • TahraAdam

    Mar. 28, 2021
  • ZaidRaza8

    Apr. 12, 2021
  • Mdahm1

    Apr. 15, 2021
  • RajaRaviTeja1

    Apr. 20, 2021
  • JuhiKumari54

    Apr. 25, 2021
  • alialjadiry

    May. 3, 2021
  • TrnTn59

    May. 6, 2021
  • ssuserfa18de

    Jun. 25, 2021

Views

Total views

55,586

On Slideshare

0

From embeds

0

Number of embeds

214

Actions

Downloads

191

Shares

0

Comments

0

Likes

183

×