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Gallbladder Disease and Normal Variants

Common Clinical Findings

Eva Tutone BS,RDMS,RVT Duke University Hospital

Gallbladder Anatomy Right lobe of Liver Three sections : Fundus, Body, Neck Cystic duct connects gallbladder to common bile duct Hartmann’s Pouch…common place for Gallstones!

Gallbladder Anatomy

Gallbladder Function Bile storage Concentration of bile Release into small intestine Fat emulsification

Anatomical Variants Abnormal Positioning Agenesis Duplication Phrygian Cap Micro gallbladder Multiseptate

Abnormal Position Very rare to be in left lobe. About 1 case per year in population imaged Detached gallbladder or Ectopic positioning

Suprahepatic GB in right lobe of liver

Agenesis of Gallbladder Very rare condition Often asymptomatic if only anomaly Sometimes seen with other internal malformations such as : genitourinary renal reproductive

Agenesis

Gallbladder duplication No increased chance of malignancies or stones Can be bilobed, incomplete gallbladder with common cystic duct Complete duplication with separate cystic ducts that lead to hepatic duct Complete duplication with common cystic duct entering to hepatic duct

Gallbladder duplication

Gallbladder Duplication

Phrygian Cap Most common variant Fold in the fundus No pathological significance and asymptomatic

Phrygian Cap

Micro Gallbladder Usually less than 2-3 cm long and .5-1.5cm wide Often thick walled Due to Cystic Fibrosis

Micro Gallbladder due to Cystic Fibrosis

Multiseptate Common finding 3-10 communicating compartments of columnar epithelium Can cause immobility of bile leading to sludge and stones

Multiseptate Gallbladder

Cholecystitis Acute Chronic Porcelain Gallbladder

Acute Cholecystitis Inflammation of the gallbladder Primary complication of cholelithiasis Most common cause of RUQ pain Sonographic Murphy’s sign Wall thickness >3mm Pericholecystic fluid

Increased wall thickness in case of calculus cholecystitis

Pericholecystic fluid

Chronic Cholecystitis Prolonged inflammatory condition Seen with cholelithiasis Wall thickening Gallbladder contracted or distended Pericholecystic inflammation is absent

Chronic Cholecystitis

Porcelain Gallbladder Calcifying cholecystitis

Extensive calcium encrustation of wall of gallbladder Asymptomatic

Porcelain Gallbladder

Non-tumor Gallbladder findings Adenomyomatosis Cholesterolosis Cholelithiasis Hydrops Cholesterol deposits in Gallbladder wall

Adenomyomatosis Hyperplastic cholecystosis-focal wall thickening. Also used to describe cholesterolosis Cholesterol crystals form in the Rokitansky-Aschoff sinuses Asymptomatic although associated with biliary stasis, gallstones and pancreatitis

Adenomyomatosis

Cholesterolosis Unrelated to atherosclerosis Triglycerides and cholesterol esters are deposited in the lamina of GB wall Lipid deposits are visible Strawberry Gallbladder

Cholesterolosis

Strawberry Gallbladder

Cholelithiasis Gallstones or cholelith Can be asymptomatic for years The 4 F’s Fat, Forty, Fertile, and Female Leading cause of Cholecystitis if stone blocks duct Stones form when bile is saturated with cholesterol or bilirubin Often managed by waiting for them to pass naturally If thought to be causing RUQ pain, nausea, and vomiting then cholecystectomy can be performed

Gallstone with shadow!

Multiple stones

WES Sign Wall-Echo-Shadow Causes include one large stone or multiple stones taking up entire gallbladder Triad-GB wall, echo from stones beneath wall, posterior shadow from stones

WES sign

Hydrops in Gallbladder Accumulation of fluid (bile, water) from cystic duct blockage Gallbladder tends to be very large greater than 9cm Main causes are stones but tumors can also cause this

Hydrops

Benign Tumor Findings Cholesterol Polyp Inflammatory Polyp

Cholesterol Polyp Lesions of mucosal surface of GB Non-shadowing polyploidy growth Majority are benign 95% Malignant 5% (Adenocarcinoma 95%) Greater than 50% are cholesterol polyps Most are less than 10mm with majority less than 5mm Size greater than 10mm increases malignancy rate 37-88%

Multiple Polyps

So many polyps!

Inflammatory Polyps Rare variant of benign polyp Difficult to differentiate from carcinoma if over 10mm Tend to be vascular in nature with stalk

Polyp with color flow

Malignant Gallbladder Tumor

Adenocarcinoma

Adenocarcinoma Most common cancer of gallbladder (90%) Can affect patients with chronic cholecystolithiasis Often asymptomatic in early treatable stages Patient will present with jaundice in late stage due to tumor involvement of bile ducts Extension into liver and small bowel

Adenocarcinoma

Gangrenous Gallbladder Can be caused by acute cholecystitis rare 10% become gangrenous A gallstone blocking duct leads to inflammation of wall and thus cutting off blood supply Gangrene can look like septations in GB

Gangrenous cholecystitis with membrane

A Bit about the Bile Ducts!

Choledocholithiasis One or more stones in the common bile duct. Pain can be similar to cholecystitis Can block passage of bile to duodenum Cholecystectomy or ERCP to remove stone

Choledocholithiasis

Choledochal Cyst Congenital dilation of biliary tree Rare finding and 60% are found before age 10 Can cause abdominal pain and jaundice if bile is backed up into cyst When scanning look for any blockage that might cause the cystic structure.

Choledochal Cyst

QUESTIONS???

References Jon W. Meilstrup (1994). Imaging Atlas of the Normal Gallbladder and Its Variants. Boca Raton: CRC Press. p. 4. Dhulkotia, A; Kumar, S; Kabra, V; Shukla, HS (1 March 2002). "Aberrant gallbladder situated beneath the left lobe of liver". HPB: Official Journal of The International Hepato Pancreato Biliary Association 4 (1): 39–42. Strasberg, SM (26 June 2008). "Clinical practice. Acute calculous cholecystitis". The New England Journal of Medicine 358 (26): 2804–11. Abbruzzese JL, Willett C. Gastrointestinal oncology. Oxford University Press, USA. (2004) ISBN:0195133722.

Greenberger N.J., Paumgartner G (2012). Chapter 311. Diseases of the Gallbladder and Bile Ducts. In Longo D.L., Fauci A.S., Kasper D.L., Hauser S.L., Jameson J, Loscalzo J (Eds), 'Harrison's Principles of Internal Medicine, 18e.Retrieved November 08, 2014 fromhttp://accessmedicine.mhmedical.com.ucsf.idm.oclc.org/content.aspx?bookid=331&Sectionid=40727107 Altun E, Semelka RC, Elias J et-al. Acute cholecystitis: MR findings and differentiation from chronic cholecystitis. Radiology. 2007;244 (1): 174-83. doi:10.1148/radiol.2441060920 - Pubmed citation Smith EA, Dillman JR, Elsayes KM et-al. Cross-sectional imaging of acute and chronic gallbladder inflammatory disease. AJR Am J Roentgenol. 2009;192 (1): 188-96. Kane RA, Jacobs R, Katz J et-al. Porcelain gallbladder: ultrasound and CT appearance. Radiology. 1984;152 (1): 137-41