usg in gall bladder pathologies

ROLE OF USG IN GB PATHOLOGIES

DrPratibha Malik

Moderator-Dr Revathi

Always look for cholecytectomy scar first

IndicationsNormal AnatomyPathogical FindingsGB

gallstonessludgecholecystitispolypsgallbladder cancer

Biliary tractBile duct stonesklatskin tumour

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CONTENTS

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INDICATIONS

Abdominal pain vomiting fever jaundice abnormal labs

(bilirubin transaminases)

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Technique and Preparation

Curvilinear probes 2-5 MHz

Views Subcostal sagittal intercostal sagittal coronal left lateral decubitus oblique views reverse trendelenberg

Indications Normal Anatomy Pathogical FindingsGB

gallstones sludge cholecystitis polyps gallbladder cancer

Biliary tract Bile duct stones klatskin tumour

Contents

NORMAL ANATOMY OF THE BILLIARY SYSTEM

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

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

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Mickey Mouse view of Portal Triad

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NORMAL VARIANTSPhrygian 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 lsquofoldedrsquo (the so-called Phrygian cap)

CONTENTS Indications Normal Anatomy Pathogical FindingsGB

Gallstones sludge cholecystitis polyps gallbladder cancer


Gold standard for diagnosis 3 sonographic criteria-

Echogenic focus Cast acoustic shadow Seek gravitational dependence

CHOLELITHIASIS

Cholelithiasis with posterior acoustic shadowing and normal GB wall thickness




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

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DD

ECHOGENIC LESIONS IN GALL BLADDER DD

MOBILE OR POSTERIOR SHADOWING

bullSTONESbullSLUDGE

FIXED

bullPOLYPbullADHESIVE STONEbullSLOW MOVING TUMEFACTIVE

SLUDGE




GB inflammation

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 (gt3mm) 4 Pericholecystic fluid

Other less specific imaging findings include gallbladder distension(gt4 cm) and sludge

99mTc-HIDA scintigraphy HIDA cholescintigraphy in acute cholecystitis will demonstrate

nonvisualization of the gallbladder

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

Sonographic Murphyrsquos sign

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Sonographic Murphyrsquos 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 pancreatitispeptic ulcer diseaseacute hepatitis

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 ldquocomet-tailrdquo 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

Gallbladder gangrenemucosal sloughing Longitudinalultrasound of a patient who had acute cholecystitissecondary to stone (arrow) impacted in thegallbladder neck Note the intraluminal membranes(arrowheads) that are associated with gangrene ofthe gallbladder

Chronic calculus cholecystitisUSG FINDINGS

Thickened echogenic wall Contracted GB Cholelithisis

Chronic calculus cholecystitis

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)

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

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

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

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 thegallbladder 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




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 4ndash7 of patients who undergo ultrasonography

GB POLYPS GB polyps are classified into 2 groups Neoplastic

Adenomas Adenocarcinomas

Nonneoplastic Cholesterol polyps Inflammatory polyps Adenomyomatosis

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

On CD demonstration of supplying vessel pathognomic of polyp

INCREASE RISK OF MALIGNANCY IN POLYP

Diameters gt 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




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

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

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

CA GB WITH LIVER INVASION

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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

FOCALADENOMYOMATOSISGALL BLADDER CANCER

DIFFUSE

ACUTE CHOLECYSTITISCHRONIC CHOLECYSTITISXANTHOGRANULOMATOUS

CHOLECYSTTISADENOMYOMATOSIS GB WALL EDEMAGB CANCER

OTHERS- ASCITISCHFHYPOALBUMINEMIA




BILIARY TRACT

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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 (eg mass) or stricture is detected measuring a CBD larger than 6-7 mm

2000 Am Coll of Gastroenterology

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Intrahepatic duct stones

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 01 to 07 of patients with cholelitiasis

Csendes classification of Mirizzi syndrome

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

COMPONENTS OF MS There must be 4 components for the syndrome to

occur1 Anatomy- placing the cystic duct parallel to the

common hepatic duct2 Impaction of a stone in the cystic dust or

gallbladder neck3 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

INTRAHEPATIC GALL STONES

INTRAHEPATIC VS EXTRAHEPATIC CALCULUS

bullCarolis disease is characterized by congenital segmental dilation of the intrahepatic bile ducts producing primary intrahepatic gallstonesbullSecondary intrahepatic gall stone formation occurs due to chronic obstruction of CBD and CHD

bullIts believed that most patients suffering a chronic illness have excessive amounts of gallstones in the liverbull Gallstones found in gallbladder tend to be hardened and relatively large while stones found in liver tends to be soft and noncalcifiedbullIntrahepatic Gallstones cause liver congestion and elevted liver enzymes

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 lithiasisSecondary intrahepatic stones related to ananatomical condition precipitating stasis or infection

TYPES OF INTRAHEPATIC CALCULUS

EXTRAHEPATIC CALCULUS

CALCULI IN THE DISTAL CBD




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

Risk factors Primary sclerosing cholangitis Choledochal cysts Parasitic infections Hepatolithiasis (also called Oriental

cholangiohepatitis) Toxin exposures Genetic Factors

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)

Figure Cholangiocarcinoma (A) Irregular mass at the porta causing biliary obstructionmdasha Klatskin tumour(B) MRI of the same patient confirming the mass at the porta

KLATSKIN TUMOUR

KLATSKIN TUMOUR

COLOUR DOPPLER TO LOOK FOR VASCULAR INVASION

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THICKENING OF BILE DUCT WALL

FOCAL STRICTURE

bullBACTERIAL CHOLANGITISbullCHOLANGIOCARCINOMAbullCHOLEDOCAL CYSTSbullMETASTASISbullBENIGN STRICTURE

NO STRICTURE

bullPOLYPOID CANCERbullSTONESbullPERIAMPULLARY CANCERbullSENILE CHANGEbullPOSTCHOLECYSTECTOMY

DILATATIONbullCHOLEDOCHAL CYSTbullASCARIASIS

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Pearls and Pitfalls The gallbladder is a mobile organ remember to change patient positioning andor 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 (eg 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

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Always look for cholecytectomy scar first

IndicationsNormal AnatomyPathogical FindingsGB

gallstonessludgecholecystitispolypsgallbladder cancer

Biliary tractBile duct stonesklatskin tumour

040823

CONTENTS

040823

INDICATIONS



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Contents






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CHOLELITHIASIS






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DD




FIXED


SLUDGE




GB inflammation











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GB POLYPS


























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DIFFUSE







BILIARY TRACT

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KLATSKIN TUMOUR

KLATSKIN TUMOUR


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FOCAL STRICTURE


NO STRICTURE



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INDICATIONS



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Contents






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CHOLELITHIASIS






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DD




FIXED


SLUDGE




GB inflammation











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GB POLYPS


























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DIFFUSE







BILIARY TRACT

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KLATSKIN TUMOUR

KLATSKIN TUMOUR


040823


FOCAL STRICTURE


NO STRICTURE



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Contents






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CHOLELITHIASIS






040823

040823

DD




FIXED


SLUDGE




GB inflammation











040823

























GB POLYPS


























040823




DIFFUSE







BILIARY TRACT

040823






040823




































KLATSKIN TUMOUR

KLATSKIN TUMOUR


040823


FOCAL STRICTURE


NO STRICTURE



040823








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Contents






040823

040823


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CHOLELITHIASIS






040823

040823

DD




FIXED


SLUDGE




GB inflammation











040823

























GB POLYPS


























040823




DIFFUSE







BILIARY TRACT

040823






040823




































KLATSKIN TUMOUR

KLATSKIN TUMOUR


040823


FOCAL STRICTURE


NO STRICTURE



040823








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040823

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CHOLELITHIASIS






040823

040823

DD




FIXED


SLUDGE




GB inflammation











040823

























GB POLYPS


























040823




DIFFUSE







BILIARY TRACT

040823






040823




































KLATSKIN TUMOUR

KLATSKIN TUMOUR


040823


FOCAL STRICTURE


NO STRICTURE



040823








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CHOLELITHIASIS






040823

040823

DD




FIXED


SLUDGE




GB inflammation











040823

























GB POLYPS


























040823




DIFFUSE







BILIARY TRACT

040823






040823




































KLATSKIN TUMOUR

KLATSKIN TUMOUR


040823


FOCAL STRICTURE


NO STRICTURE



040823








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040823

040823










CHOLELITHIASIS






040823

040823

DD




FIXED


SLUDGE




GB inflammation











040823

























GB POLYPS


























040823




DIFFUSE







BILIARY TRACT

040823






040823




































KLATSKIN TUMOUR

KLATSKIN TUMOUR


040823


FOCAL STRICTURE


NO STRICTURE



040823








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040823










CHOLELITHIASIS






040823

040823

DD




FIXED


SLUDGE




GB inflammation











040823

























GB POLYPS


























040823




DIFFUSE







BILIARY TRACT

040823






040823




































KLATSKIN TUMOUR

KLATSKIN TUMOUR


040823


FOCAL STRICTURE


NO STRICTURE



040823








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CHOLELITHIASIS






040823

040823

DD




FIXED


SLUDGE




GB inflammation











040823

























GB POLYPS


























040823




DIFFUSE







BILIARY TRACT

040823






040823




































KLATSKIN TUMOUR

KLATSKIN TUMOUR


040823


FOCAL STRICTURE


NO STRICTURE



040823








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040823

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DD




FIXED


SLUDGE




GB inflammation











040823

























GB POLYPS


























040823




DIFFUSE







BILIARY TRACT

040823






040823




































KLATSKIN TUMOUR

KLATSKIN TUMOUR


040823


FOCAL STRICTURE


NO STRICTURE



040823








Slide 1

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040823

DD




FIXED


SLUDGE




GB inflammation











040823

























GB POLYPS


























040823




DIFFUSE







BILIARY TRACT

040823






040823




































KLATSKIN TUMOUR

KLATSKIN TUMOUR


040823


FOCAL STRICTURE


NO STRICTURE



040823








Slide 1

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GB inflammation











040823

























GB POLYPS


























040823




DIFFUSE







BILIARY TRACT

040823






040823




































KLATSKIN TUMOUR

KLATSKIN TUMOUR


040823


FOCAL STRICTURE


NO STRICTURE



040823








Slide 1

Slide 2

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Slide 77











040823

























GB POLYPS


























040823




DIFFUSE







BILIARY TRACT

040823






040823




































KLATSKIN TUMOUR

KLATSKIN TUMOUR


040823


FOCAL STRICTURE


NO STRICTURE



040823








Slide 1

Slide 2

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GB POLYPS


























040823




DIFFUSE







BILIARY TRACT

040823






040823




































KLATSKIN TUMOUR

KLATSKIN TUMOUR


040823


FOCAL STRICTURE


NO STRICTURE



040823








Slide 1

Slide 2

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Slide 76

Slide 77





















040823




DIFFUSE







BILIARY TRACT

040823






040823




































KLATSKIN TUMOUR

KLATSKIN TUMOUR


040823


FOCAL STRICTURE


NO STRICTURE



040823








Slide 1

Slide 2

Slide 3

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BILIARY TRACT

040823






040823




































KLATSKIN TUMOUR

KLATSKIN TUMOUR


040823


FOCAL STRICTURE


NO STRICTURE



040823








Slide 1

Slide 2

Slide 3

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040823






040823




































KLATSKIN TUMOUR

KLATSKIN TUMOUR


040823


FOCAL STRICTURE


NO STRICTURE



040823








Slide 1

Slide 2

Slide 3

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Slide 10

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040823




































KLATSKIN TUMOUR

KLATSKIN TUMOUR


040823


FOCAL STRICTURE


NO STRICTURE



040823








Slide 1

Slide 2

Slide 3

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Slide 76

Slide 77



































KLATSKIN TUMOUR

KLATSKIN TUMOUR


040823


FOCAL STRICTURE


NO STRICTURE



040823








Slide 1

Slide 2

Slide 3

Slide 6

Slide 8

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Slide 10

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Slide 77

KLATSKIN TUMOUR


040823


FOCAL STRICTURE


NO STRICTURE



040823








Slide 1

Slide 2

Slide 3

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040823


FOCAL STRICTURE


NO STRICTURE



040823








Slide 1

Slide 2

Slide 3

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040823








Slide 1

Slide 2

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usg in gall bladder pathologies

Health & Medicine