Hepatobiliary Ultrasound:Anatomy, Technique, Pathology

Laleh Gharahbaghian, MD FAAEMAssociate Director, EM Ultrasound

Co-Director, EM Ultrasound FellowshipStanford University Medical Center

Seric Cusick, MD RDMSDirector of Emergency Ultrasound

Fellowship Director, Emergency UltrasoundUniversity of California, Davis

Objectives• Review anatomy and landmarks

• Scanning Technique: Gallbladder Evaluation

• Transducer choice, orientation

• Scanning: transverse and longitudinal views

• Measurements: GB, anterior GB wall, CBD

• GB Pathology

• Liver Pathology

• Pitfalls and ‘Tricks of the Trade’

RUQ: Normal Anatomy

• Liver: used as acoustic window; ducts and vessels

• Biliary ducts: CBD

• Bowel: duodenum

• Kidney: retroperitoneal (posterior)

• GB: mobile, folds, contracts, anatomical variations

• General Location

• RUQ

• Subcostal

• Lies within fossa

• Posterior wall approximates duodenumNOTE: The gallbladder does not lie within a standard anatomic plane, and

may be found in many different projectionsTherefore, the long and short axis of the gallbladder may not lie within the

longitudinal and transverse planes of the body

Emergency Ultrasound:Gallbladder Location

RUQ: Abnormal GB: Normal Anatomy

• GB length: 7-10cm; width 2-3cm

• Anterior GB wall: <4mm, linear echo

• CBD: <7mm, above portal vein

• Main Lobar Fissure (MLF): between GB and portal vein

Anterior GB wall

MLF

Technique• Patient Position:

Supine or Left lateral decubitus

• Transducer: Curved, low frequency probe

• Indicator to patient’s right and then toward patient’s head (transverse / longitudinal view)

• Start at Xiphoid process and travel laterally along subcostal margin, flattening probe

• Once find GB: “fan” through it in two orthogonal planes

Technique

• Poor quality image: gas

• Left lateral decubitus

• Thin patients: GB can be elongated, anterior, lower in abdomen

• flatten probe along abdomen

• Obese patients: GB can be higher in abdomen

• X minus 7 approach

LongitudinalTransverse

xyphoid process7cm

Transverse LongitudinalAnatomical Variants

GB fold(s)

Pathology: Gallstones

• Echogenic

• Shadow

• Mobile

• Single or multiple

• Varying sizes

Pathology: Gallstones

• WES sign

• W - wall

• E - Echo

• S - Shadow

• = contracted GB full of stones

WES sign

Pathology: Cholecystitis

• Pericholecystic fluid

• Thickened GB wall

• Sonographic Murphy’s

• CBD Dilatation

FINDINGS:

Sludge

Pathology: Thick GB wall• HTN

• renal disease

• multiple myeloma

• adenomyomatosis

• Tumors

• CHF

• hepatitis

• ascites

• alcoholic liver disease

• hypoproteinemia

• hypoalbuminemia

• pericholecystic

CHOLECYSTITISMain etiology:

Normal

Abnormal

Pathology: Biliary Ducts

• Biliary ducts provide information regarding obstruction

• Common Bile Duct: located above portal vein

• follow MLF to CBD

• Tip: Use Color Doppler box to differentiate biliary ducts from hepatic vessels

longitudinal

Dilated Biliary

Ducts

Portal

Finding the CBD...

Finding the CBD..... Dilated Biliary Ducts

Pitfalls

• Mistaking Duodenum with GB

• Mistaking GB fold for stone/mass

• Gas Scatter - put patient in LLD

• WES sign - not knowing what you see when you see it

Tricks of the Trade: Scanning Tips

• Obtaining window - small liver, gas scatter, anterior GB can result in difficult visualization

• patient positioning, flattening probe

• System controls - adjust Gain, Depth to maximize image quality

When you can’t find the Gallbladder.....

• Left Lateral Decubitus position

• Try between the ribs (X minus 7)

• Try RUQ of FAST view (transducer at midaxillary line; indicator toward head)

• move probe anteriorly

• kidney leaves view, GB comes into view

Other things you may see...

Liver abscess

Other things you may see...

Liver cysts

Other things you may see...

TIPS

free fluid

Other things you may see...

Liver cancer

Summary

• Point-of-care ultrasound of the hepatobiliary system may aid in the care of emergency department patients

• Evaluation for gallstones and secondary features of cholecystitis may be facilitated by sonographic techniques and the appreciation of key pitfalls

References• Blaivas M, Harwood RA, Lambert MJ. Decreasing length of stay with emergency ultrasound examination of the

gallbladder. Acad Emerg Med. Oct 1999;6(10):1020-1023.

• Bree RL. Further observations on the usefulness of the sonographic Murphy sign in the evaluation of suspected

acute cholecystitis. J Clin Ultrasound. Mar-Apr 1995;23(3):169-172.

• Durston W, Carl ML, Guerra W, et al. Comparison of quality and cost-effectiveness in the evaluation of

symptomatic cholelithiasis with different approaches to ultrasound availability in the ED. Am J Emerg Med. Jul

2001;19(4):260-269.

• Gaspari RJ, Dickman E, Blehar D. Learning curve of bedside ultrasound of the gallbladder. J Emerg Med. Jul

2009;37(1):51-56.

• Jang T, Aubin C, Naunheim R. Minimum training for right upper quadrant ultrasonography. Am J Emerg Med. Oct

2004;22(6):439-443.

• Kendall JL, Shimp RJ. Performance and interpretation of focused right upper quadrant ultrasound by emergency

physicians. J Emerg Med. Jul 2001;21(1):7-13.

• Miller AH, Pepe PE, Brockman CR, Delaney KA. ED ultrasound in hepatobiliary disease. J Emerg Med. Jan

2006;30(1):69-74.

• Ralls PW, Colletti PM, Lapin SA, et al. Real-time sonography in suspected acute cholecystitis. Prospective

evaluation of primary and secondary signs. Radiology. Jun 1985;155(3):767-771.

• Ralls PW, Halls J, Lapin SA, Quinn MF, Morris UL, Boswell W. Prospective evaluation of the sonographic Murphy

sign in suspected acute cholecystitis. J Clin Ultrasound. Mar 1982;10(3):113-115.

• Rosen CL, Brown DF, Chang Y, et al. Ultrasonography by emergency physicians in patients with suspected

cholecystitis. Am J Emerg Med. Jan 2001;19(1):32-36.

• Scruggs W, Fox JC, Potts B, et al. Accuracy of ED Bedside Ultrasound for Identification of gallstones: retrospective

analysis of 575 studies. West J Emerg Med. Jan 2008;9(1):1-5.

• Shea JA, Berlin JA, Escarce JJ, et al. Revised estimates of diagnostic test sensitivity and specificity in suspected

biliary tract disease. Arch Intern Med. Nov 28 1994;154(22):2573-2581.

• Summers SM, Scruggs W, Menchine MD, et al. A Prospective Evaluation of Emergency Department Bedside

Ultrasonography for the Detection of Acute Cholecystitis. Ann Emerg Med. Feb 4.