Gallbladder and Biliary Tract Disease. Cholelithiasis.
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Transcript of Gallbladder and Biliary Tract Disease. Cholelithiasis.
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