Gallbladder and Bile ducts Ultrasound

1. Gallbladder and bile
ducts ultrasound
Mousa Hadid MD
Radiology Residents
Emergency Ultrasound Department
Ibn Al-Nafis Hospital.

2. GALLBLADDER

3. CHAPTER OUTLINES
 ANATOMY
 ANATOMIC VARIANTS
 TECHNIQUE
 GALLSTONES
 SLUDGE
 POLYPS
 ACUTE CHOLECYSTITIS
 GALLBLADDER WALL THICKENING
 CARCINOMA&METASTASES
 PORCELAIN GALLBLADDER
 ADENOMYOMATOSIS

4. ANATOMY
 The gallbladder is a long oval-shaped
organ that is positioned beneath the liver
immediately adjacent to the interlobar
fissure.
 It is divided into a fundus, body, and neck.
 The fundus, is directed downward, forward,
and to the right.
 the body and neck are directed upward and
backward to the left.
 Blood supply :cystic artery from right
hepatic artery .
 Cystic vein portal vein ..
 small veins liver.

5. ANATOMIC VARIANTS
• Phrygian cap
• Septations
• junctional folds
Morphology
• ectopic gallbladder : most frequently intrahepatic
gallbladder
Location
• Duplications
• agenesis
Size&Number

9. Grayscale Doppler Duplex

10. TECHNIQUE
 Fast for 6 hours. No food or drink.
 Patient position : the gallbladder is best
viewed in the left lateral decubitus position.
However it can be viewed with the patient
supine and erect.
 Probe placement : subcostal view, intercostal
view
 important to visualize the entire gallbladder,
the gallbladder neck especially important,
because stones can be missed if the entire
neck is not visualized.

12. Characteristic Appearance
Location Inferior to interlobar fissure
Between left and right hemiliver
Size <4 cm transverse
<10 cm longitudinal
Wall thickness <3 mm
Lumen Anechoic
Characteristics of the Normal
Gallbladder

14. GALLSTONES
 Gallstones are present in up to 10% of the
population.
 The majority (60% to 80%) of gallstones are
asymptomatic (silent).
 The most common symptom of gallstones is biliary
colic.
 gallstones are radiopaque only in 15-20% of cases .
 Us findings: mobile, echogenic, intraluminal
structures that cast acoustic shadows.
 stones smaller than 3 mm may not cast a detectable
shadow use Doppler Twinkle artifact.

15. mixed cholesterol pigment
stones(brown&
black)
Percentage 80% 10% 10%
Location gallbladder Gallbladder Brown(bile
duct)
Black(gallbladd
er)
Composition 20-50%
(cholesterol )
+ca
bilirubinate
>50%
cholesterol
<20%
cholesterol
+
High bilirubin
Predisposing
factors
female, rapid
loss of
weight, obesit
y OCP TPN …
similar to
MIXED
BROWN(bacteri
al infection,
biliary stasis)
BLACK (chronic
hemolysis, liver
cirrhosis)

18. SLUDGE
 Sludge consists of calcium bilirubinate
granules and cholesterol crystals often in
the setting of thick, viscous bile.
 A portion of biliary sludge contains
comparatively large particles (1-3 mm)
called microliths, the formation of which is
an intermediate step in the formation of
gallstones (about 12.5%).
 Risk factors: TPN, rapid weight loss ,
pregnancy , dehydration
 US findings :low- to high-level,
nonshadowing echoes in the dependent
portion of the gallbladder.
 crystals can produce comet tail & twinkle
artifact .

21. POLYPS
 Gallbladder polyps are relatively frequent, seen in up
to 7%of the population.
 Pathology:
 Benign :: 95% of all polyps(cholesterol, adenoma,
inflammatory )
 Malignant : 5% of all polyps( adenocarcinoma)
 US findings: a non shadowing ingrowth into
gallbladder lumen
 small polyps adherent to the wall and smooth
 larger lesions tend to be pedunculated and granular
in outline
 Management : depends on polyp size .

22. Intraluminal Abnormalities in
the Gallbladder
Ultrasound
characteristics
Common uncommon
Shadowing and mobile Stones Nothing else
Nonshadowing and mobile Sludge Stones (<3 mm)
Nonshadowing and
nonmobile
Polyps Sludge

24. ACUTE CHOLECYSTITIS
 Divided into: calculous and acalculous
 Acute calculous cholecystitis: 90-95% of
cases are due to gallstones
 asymptomatic gallstones carry an annual
risk of: 2% biliary colic
0.2% acute cholecystitis
 Clinical presentation: Constant (ruq) pain>
6h,Nausea, vomiting, and fever
 Gangrenous Cholecystitis: advanced acute
cholecystitis, The fundus is the most
common area to perforate , Murphy’s sign is
less likely.

25. Sonographic Signs of Acute Cholecystitis
Gallstones
Wall thickening (≥3 mm)
Gallbladder enlargement
Pericholecystic fluid
impacted stone
Sonographic Murphy’s sign
Sonographic Signs of Gangrenous Cholecystitis
Pericholecystic fluid
Sloughed mucosal membranes
Wall disruption
Wall ulceration
Focal wall bulge

28. ACUTE CHOLECYSTITIS
 Acute acalculous choleystitis : 5-10 % , seen in ( TPN
, PPV , critically ill or injured patients.
 Emphysematous cholecystitis: male elderly people
with diabetes , Gas can develop in the gallbladder
wall and/or lumen.
 Us findings : bright reflections ( dirty shadow ) from a
nondependent portion of the gallbladder wall.

29. GALLBLADDER WALL
THICKENING
Biliary Nonbiliary
Cholecystitis Hepatitis
Adenomyomatosis Pancreatitis
Cancer Heart failure
Sclerosing cholangitis Hypoproteinemia
AIDS cholangiopathy Cirrhosis
Portal hypertension
Lymphatic obstruction
Mononucleosis

31. Gallbladder carcinoma
 overall uncommon
 90 % are Adenocarcinomas, and the
remained are SCC
 Risk factors :gallstones(70-90%) ,porcelain
gallbladder, gallbladder polyps > 1 cm,
chronic cholecystitis.
 usually asymptomatic until they reach an
incurable stage.
 METASTASES :Melanoma is the tumor most
likely to metastasize to the gallbladder and it
can simulate polyps

32. Sonographic Appearance of
Gallbladder Cancer
Mass centered on gallbladder fossa with
associated stones
Eccentric irregular wall thickening
Bulky intraluminal polypoid mass
Infiltration of adjacent liver or vessels
Periportal and/or peripancreatic
lymphadenopathy
Bile duct obstruction

33. Common uncommon
Polyps Metastases
Adenomyomatosis Chronic cholecystitis
Gallbladder cancer
Tumefactive sludge
Causes of Gallbladder Masses

35. PORCELAIN GALLBLADDER
 Refers to extensive calcium encrustation of
the gallbladder wall
 Patients are usually asymptomatic
 It is associated with chronic gallbladder
inflammation and 95% of the cases have
gallstones.
 association between porcelain gallbladder
and gallbladder adenocarcinoma : early
studies 22-30% , More recent studies 5-7%
 US findings :echogenic superficial GB wall
with dense posterior shadowing.

37. ADENOMYOMATOSIS
 characterized by mucosal hyperplasia and
thickening of the muscular layer of the
gallbladder.
 relatively common, found in ~9% of all
cholecystectomy specimens .
 It is most often an incidental finding and
usually requires no treatment
 Three morphological types : fundal ,
segmental ,generalized.
 US findings : wall thickening, Comet tail
artifacts produced by cholesterol crystals.

39. Biliary ducts

40. CHAPTER OUTLINES
 ANATOMY
 NORMAL ANATOMICAL VARIANTS
 ULTRASOUND EXAMINATION
TECHNIQUE
 BILIARY OBSTRUCTION
 CHOLEDOCHOLITHIASIS
 CHOLANGIOCARCINOMA
 BILE DUCT WALL THICKENING
 CYSTIC DISEASE
 MIRIZZI’S SYNDROME

41. ANATOMY
 BILE DUCTS are divided into : intrahepatic ،
extrahepatic

42.  COMMON BILE DUCT (CBD):
 7-11 cm long and usually <6 mm wide in diameter but
this can be dependent on a number of factors
including age and prior cholecystectomy.
 Consists of three parts : supraduodenal, reroduodenal,
pancreatic .
 CYSTIC DUCT:
 2-3 cm long
 2-3 cm diameter
 Insertion : right lateral , at middle third of CHD 52%
 PORTA HEPATIS :from anterior to posterior (DAVE
MNEMONIC):
 D: ducts (right and left hepatic duct branches)
 A: arteries (right and left hepatic artery branches)
 V: vein (portal vein)
 E: epiploic foramen (of Winslow)

44. NORMAL ANATOMIC
VARIANTS
 Replaced or accessory right hepatic artery :
runs between the
inferior vena cava and the portal vein and is
situated on the
right lateral aspect of the portal vein.
 Cystic duct insertion : three main variations
1. low cystic duct insertion: into the distal-third
of the CHD (~10%).
2. medial cystic duct insertion: into the left, not
the right, side of the CHD (~15%).
3. parallel cystic duct course: courses parallel to
the CHD for at least 2 cm.

45. US EXAMINATION TECHNIQUE
 The patient should be fasted.
 Probe placement:
 anterior (epigastric ) approach
 Right subcostal approach.
 Throughout a comprehensive investigation
the patient may need to be supine, erect or
left decubitus or LPO.
 Utilize inspiration/expiration and asking the
patient to 'puff their stomach out' like a
pregnant belly.
 CBD VS hepatic artery :

46. CBD VS Hepatic artery :

50. BILE DUCTS DILATATION
INTRAHEPATIC EXTRAHEPATIC INTRA&EXTRA HEPATIC
KLATSKIN TUOMR early
choledocholithiasi
s
pancreatic or ampullary mass
intrahepatic
choledocholithiasi
s
sphincter of Oddi
dyskinesia
choledocholithiasis
Recurrent
pyogenic
Cholangitis
choledochal cyst sclerosing cholangitis
Caroli disease pregnancy recurrent pyogenic cholangitis
chronic pancreatitis

51. ULTRASOUND FEATURES
INTRAHEPATIC EXTRAHEPATIC
 >2 mm diameter
 >40% of diameter of
adjacent portal vein
 Increased through
transmission
 Irregular, tortuous
walls
 Stellate configuration
centrally
 usually measured in
the proximal duct,
near the hepatic
artery
 diameter measured
from inner wall to
inner wall
>6 mm +1 mm per
decade above 60 years
of age
>10 mm post-
cholecystectomy

53. CHOLEDOCHOLITHIASIS
 Secondary stones: 85% of common duct
stones form in the gallbladder and migrate to
the bile ducts, most are cholesterol stones.
 Primary stones :(usually brown pigment
stones), which form in the bile ducts , one risk
factor for this is duodenal diverticulum.
 Most stones are located in the distal-most
portion of CBD.
 US FEATURES:
 visualization of stone(s):echogenic rounded focus ,
~20% of CBD stones will not shadow
 dilated bile duct.

54. US
• ABDOMINAL : sensitivity between 13-55%
• EUS : very high sensitivity and specificity.
CT
• Routine contrast-enhanced CT : moderately sensitive
65-88%
• Ct cholangiography sensitivity of 65-88%
ERCP MRCP
• MRCP: sensitivity (90-94%)
• ERCP : High sensitivity , diagnosis &treatment

56. BILE DUCT WALL THICKENING
 The bile duct walls are normally displayed as
single bright lines, which actually represent
the reflection between the wall and the bile
in the lumen.
 Duct wall thickening is seen as a hyperechoic
inner layer and a hypoechoic outer layer.

57. Causes of Bile Duct Wall Thickening
Sclerosing cholangitis
Common bile duct stones
Pancreatitis
Ascending cholangitis
AIDS cholangiopathy
Cholangiocarcinoma
Recurrent pyogenic cholangitis
Biliary stents
Intramural venous collaterals

60. CHOLANGIOCARCINOMA
 occurs most commonly at the bifurcation of the CHD,
with involvement of both the central left and right
duct (Klatskin tumors).
 pattern of growth,: focal stricture(most common),
intraluminal polypoid mass or ,diffuse sclerosing
pattern.
 Sonographic findings : a dilated duct that abruptly
terminates at the level of the tumor. A mass may or
may not be seen to explain the obstruction , When
detected, the tumor itself is usually poorly marginated
and is close to the same echogenicity as the liver
,Focal thickening of the bile duct wall.
 ultrasound-guided biopsies can be a valuable way of
obtaining a tissue diagnosis

61. Lesions at the ductal confluence
gallbladder carcinoma
hepatocellular cancer.
Pancreatic or ampullary cancer
Metastasis
lymphoma

64. CYSTIC DISEASE
 Although choledochal cysts are typically thought of as
pediatric lesions, they are occasionally first detected
during adulthood
 Classification schemes vary, (e.g. todani , komi).
 The most common is type 1, which is a fusiform
dilatation of the extrahepatic duct.
 The classic clinical triad : jaundice80% , palpable
mass50% , abdominal pain
 Caroli’s disease is characterized by multifocal saccular
dilatation of the intrahepatic bile ducts with sparing of
the extrahepatic ducts.
 complications of biliary stasis, including ductal stones
and obstruction, cholangitis, and liver abscesses. More
commonly it is associated with hepatic fibrosis.
 US: The central dot sign.

65. Differential Diagnosis of Choledochal Cyst
Duplication cyst of duodenum
Dilated cystic duct remnant
Omental or mesenteric cyst
Pancreatic pseudocyst
Right renal cyst
Hepatic cyst
Aneurysm/pseudoaneurysm

68. MIRIZZI’S SYNDROME
 Rare abnormality that consists of a common duct
obstruction caused by a gallstone in the cystic duct or
the gallbladder neck.
 The obstruction may be caused by the actual mass
effect of the stone or by an associated inflammatory
reaction in the hepatoduodenal ligament
 This is more likely to occur with a low-inserting cystic
duct that travels in a commons heath with the CD .
 Sonographic findings : suggest the diagnosis in the
setting dilated ducts if an extrinsic mass effect from a
shadowing stone is seen at the level of obstruction.
 ERCP is used for diagnosis & sometime stent
placement.

70. References
 The Requisites third edition
 Medscape
 Surgical recall 7th edition
 Radiopaedia .com
 Ultrasoundpaedia .com

71. Thank you
Any questions?