Gallbladder and Biliary Gallbladder and Biliary Tract DiseaseTract Disease

CholelithiasisCholelithiasis

CholelithiasisCholelithiasis

Cholelithiasis is the pathologic state of stones or

calculi within the gallbladder lumen.

A common digestive disorder worldwide:

• 20 million Americans have gallstones

• 700,000 cholecystectomys performed annually in the U.S.

• Most common gastrointestinal disorder requiring

hospitalization

CholelithiasisCholelithiasis

Most gallstones are composed primarily of bile (80%); remainder are composed of a mixture of bile components

Each type of stone has a particular pathophysiology and specific set of risk factors that alter the equilibrium and

solubility of the components of bile.

Cholesterol stones Pigment stones

CholelithiasisCholelithiasisAsymptomatic gallstone patients develop complications at an

annual rate of 1-2%.

In symptomatic patients, the complication rate increases to 3%.

Manifestations of cholelithiasisManifestations of cholelithiasis::• Many persons are asymptomaticMany persons are asymptomatic

• Early symptoms are epigastic fullness after meals or mild

distress

• Biliary colicBiliary colic (if stone is blocking cystic or common bile duct):

steady pain in epigastric or RUQ of abdomen lasting up to 5

hours with nausea and vomiting

• Jaundice may occur if there is obstruction of common bile duct

CholelithiasisCholelithiasis

Sonography is the procedure of choice for identifying Sonography is the procedure of choice for identifying gallstonesgallstones.

• Current high-resolution, real-time ultrasound (US) can identify gallstones as small as 2 mm, with a sensitivity greater than 95%.sensitivity greater than 95%.

• The technique is rapid, noninvasive, can be performed at the bedside, and does not involve ionizing radiation.

Ultrasonic Criteria for CholelithiasisUltrasonic Criteria for Cholelithiasis

• Intraluminal brightly echogenic structure

• Stones > 3mm will produce an acoustic shadow

• Stones will usually seek gravitational dependency

CholelithiasisCholelithiasisUltrasound

Ultrasound image obtained with a 3,5-MHz transducer demonstrates the multiple stones in the gallbladder with typical acoustic shadows.

CholelithiasisCholelithiasisUltrasound

Ultrasound image obtained with a 3,5-MHz transducer demonstrates a stone in the gallbladder with typical acoustic shadow.

NORMAL GALLBLADER

CholelithiasisCholelithiasisUltrasound

Ultrasound image demonstrates multiple shadowing stones.

CholelithiasisCholelithiasisUltrasound

Image PatternsImage Patterns::• Stones with shadowing• Stones without shadowing• Gravel• GB filled with stones• Floating stones as fluid level in bile• Adherent Gallstones• Dilation of common bile duct

CholelithiasisCholelithiasisUltrasound

Ultrasound image obtained with a 3-MHz transducer demonstrates pyramidal nonshadowing stones.

CholelithiasisCholelithiasisUltrasound

Wall-echo shadow sign indicates a stone-filled gallbladder.

CholelithiasisCholelithiasisUltrasound

Layer of gravel with shadowing

CholelithiasisCholelithiasis

Limitations of Techniques: Limitations of Techniques:

• US: False negatives may occur with small stones in the presence

of biliary sludge. The technique is operator-dependent. Inadequate

visualization of the gallbladder may occur in obese or contracted

patients, or in patients with abdominal wounds.

• Radiographs: Only 15-20%Only 15-20% of stones are visible on plain

radiographs.

• CT: Only 74-79%Only 74-79% of gallstones are identified in patients with CT.

CT is not a screening tool for uncomplicated cholelithiasis.

• MRI: MRI is not a screening tool. Stones may be incidental findings

on abdominal MRI.

CholelithiasisCholelithiasis• Only 15-20%Only 15-20% of stones are

visible on plain abdominal film.

CholelithiasisCholelithiasisCT Findings

CT demonstrates a layer of calcific-dense material in the gallbladder that may be gravel or milk of calcium bile

Noncontrast CT demonstrates a typical, laminated, calcified gallstone.

ERCP findings in cholelithiasis

CholelithiasisCholelithiasis

Gallbladder and CBD stones

Acute cholecystitisAcute cholecystitis

Manifestations of acute cholecystitisManifestations of acute cholecystitis• Episode of biliary colic involving RUQ pain radiating to

back, right scapula, or shoulder; the pain may be aggravated by movement, or deep breathing and may last 12 – 18 hours

• Anorexia, nausea, and vomiting• Fever with chillsFever with chills

Sonographic features of AC include the following:

• CalculiCalculi in the GB in more than 90% of patients.• Anterior GB-wall thickness of more than 3 mmmore than 3 mm • Positive Murphy signPositive Murphy sign (pain on compression of the GB with the

ultrasound probe) • Pericholecystic fluidPericholecystic fluid in severe cases (sign of actual or

impending perforation) • Acalculous cholecystitis: Five percent of cases are not

associated with gallstones. • Increased transverse GB diameter >4-5 cm>4-5 cm• GB distension: About 93% of patients with a GB volume of

greater than 70 mL have AC. • Loss of definition of GB margins

Acute cholecystitisAcute cholecystitis

Ultrasound

Acute cholecystitisAcute cholecystitis

Ultrasound image demonstrates: thickening of the gallbladder wall.

Ultrasound

Ultrasound image demonstrates:

a calculus at the neck of the gallbladder with acoustic shadowing and thickening of the gallbladder wall.

Gallbladder is slightly enlarged

Acute cholecystitisAcute cholecystitis

Ultrasound

Acute cholecystitisAcute cholecystitis

Ultrasound image demonstrates: thickening of the gallbladder wall and loss of definition of GB margins.

Acute nongangrenous cholecystitis.

CT scan shows pericholecystic fluid

CT Findings

Acute cholecystitisAcute cholecystitis

From: CT Findings in Acute Gangrenous Cholecystitis G. L. Bennett et al. AJR 2002; 178:275-281

Complications of cholecystitisComplications of cholecystitis

• Chronic cholecystitisChronic cholecystitis occurs after repeated attacks of acute cholecystitis; often asymptomatic

• Empyema:Empyema: collection of infected fluid within gallbladder

• GangrenGangrenous cholecystitis ous cholecystitis with perforation leading to peritonitis or abscess formation

• PancreatitisPancreatitis, liver damage, intestinal obstruction

Complications are more common in patients with small, multiple stones.

Acute cholecystitisAcute cholecystitis

Ultrasound

Transverse and longitudinal scans demonstrate a complex echo pattern in the area of the gallbladder and pericholecystic fluid - acute gangrenous cholecystitis.

Acute cholecystitisAcute cholecystitis

CT Findings

Acute cholecystitisAcute cholecystitis

Acute gangrenous cholecystitis.

CT scan with IV contrast material shows intraluminal linear densities corresponding to intraluminal membranes.

Note lack of contrast enhancement of gallbladder wall and pericholecystic inflammation.

renal cyst

From: CT Findings in Acute Gangrenous Cholecystitis G. L. Bennett et al. AJR 2002; 178:275-281

Ultrasound

Acute cholecystitisAcute cholecystitis

Acute gangrenous cholecystitis.

Sonography demonstrates an anechoic fluid mass situated in the wall of the gallbladder.

Sonograms shows marked laminated sonolucent thickening of the gallbladder wall, with the lumen of the gallbladder full of sludge.

Gallbladder is enlarged

Acute cholecystitisAcute cholecystitisCT Findings

Acute gangrenous cholecystitis. CT scan with IV contrast material shows air in gallbladder lumen.

From: CT Findings in Acute Gangrenous Cholecystitis G. L. Bennett et al. AJR 2002; 178:275-281

Acute cholecystitisAcute cholecystitisCT Findings

From: CT Findings in Acute Gangrenous Cholecystitis G. L. Bennett et al. AJR 2002; 178:275-281

Acute gangrenous cholecystitis.

CT scan shows loculated fluid attenuation abnormality adjacent to gallbladder, consistent with abscess (a). Defect in gallbladder wall is shown (perforation). White arrow shows pericholecystic inflammation (leading to peritonitis).

Abscess

Gallbladder SludgeGallbladder Sludge

The term biliary sludgebiliary sludge refers to a characteristic ultrasound

picture of movable, low-amplitude echoes that layer in the

most dependent part of the gallbladder and are not

associated with acoustic shadowing.

Sludge is composed of cholesterol crystals, calcium

bilirubinate granules, and mucin glycoprotein suspended

in bile and forms in an environment that combines a high

mucus concentration, dysmotility, and stasis.

The cholesterol and calcium bilirubinate crystals in biliary

sludge can lead to gallstone formationcan lead to gallstone formation.

Ultrasound

Longitudinal scan through the gallbladder shows layering of sludge in the gallbladder lumen.

Gallbladder SludgeGallbladder Sludge

Sludge can appear, disappear, and

reappear, its formation is a

dynamic, reversible process

This longitudinal view of the gallbladder, as imaged from the gastric antrum,

reveals dependent echogenic sludge.

Ultrasound

Gallbladder SludgeGallbladder Sludge

Clinical association with:• hyperalimentation, • hemolysis, • fasting, • pregnancy, • post-op state, • cirrhosis

Differentiate from: • hematobilia, • biliary tract tumors, • purulent bile

Gallbladder polypsGallbladder polyps

• It is estimated that as many as 4% of gallbladders examined

by ultrasound will have evidence of polyp formation.

• The 95% of all gallbladder polyps do not give rise to cancer.

They consist of cholesterol, muscle tissue or inflammatory

tissue.

• The minority are adenomatous polyps, which can progress

to cancer.

• It is believed that the risk of cancer in an adenomatous

gallbladder polyp is related to its size, with those larger than larger than

1 cm1 cm being at high risk.

Findings: Ultrasound scans demonstrate a small gallbladder with diffusely thickened wall and adjacent fixed small soft tissue polyps. There was no biliary ductal dilatation or shadowing echogenic stones within the gallbladder.

Chronic cholecystitis with gallbladder polyps

Gallbladder polypsGallbladder polyps

Porcelain GallbladderPorcelain GallbladderExtensive calcium

encrustation of the gallbladder wall variably has been termed calcified gallbladdercalcified gallbladder, calcifying

cholecystitis, or cholecystopathia chronica

calcarea.

Most porcelain gallbladders (90%) are associated with

gallstones.

The term porcelain gallbladder has been used to emphasize the blue discoloration and brittle consistency of the gallbladder wall at surgery.

Porcelain GallbladderPorcelain GallbladderPatients are usually asymptomatic, and porcelain gallbladder is found incidentally on plain abdominal radiographs, sonograms, or CT images.

Porcelain GallbladderPorcelain Gallbladder

Porcelain gallbladder is uncommon, and

recognizing the clinical and imaging

characteristics of the disease is important because of the high the high frequency (22%) of frequency (22%) of adenocarcinomaadenocarcinoma in

porcelain gallbladder

Image from an upper gastrointestinal series demonstrates a porcelain gallbladder