Chapter 3: The Gallbladder (Penny)
Although most polyps have a stalk, the stalk may not always be seen, and thus they typically yield the ___________________ because the polyp appears to be a round object, like a ball, that is stuck to the gallbladder wall.
"ball-on-the-wall" sign
SONOGRAPHIC FINDINGS OF GALLBLADDER SLUDGE
1. A collection of low-level, nonshadowing, dependent echoes within the gallbladder lumen
CLINICAL FINDINGS OF ADENOMYOMATOSIS
1. Asymptomatic
CLINICAL FINDINGS OF POLYPS
1. Asymptomatic
CLINICAL FINDINGS OF GALLBLADDER SLUDGE
1. Asymptomatic 2. Any reason for biliary stasis (e.g., total parenteral nutrition, extended period of fasting)
CLINICAL FINDINGS OF CHOLELITHIASIS
1. Asymptomatic 2. Biliary colic 3. Abdominal pain after fatty meals 4. Epigastric pain 5. Nausea and vomiting 6. Pain that radiates to the shoulders
SONOGRAPHIC FINDINGS OF CHOLELITHIASIS
1. Echogenic, mobile, shadowing structure(s) within the lumen of the gallbladder 2. Stones that lodge within the cystic duct or neck of the gallbladder may not move 3. WES sign may be present (gallbladder completely filled with stones)
SONOGRAPHIC FINDINGS OF ADENOMYOMATOSIS
1. Focal or diffuse thickening of the gallbladder wall 2. Comet tail artifact that projects from the gallbladder wall into the lumen of the gallbladder
SONOGRAPHIC FINDINGS OF GANGRENOUS CHOLECYSTITIS AND GALLBLADDER PERFORATION
1. Gallstones (evaluate the neck and cystic duct for a possible lodged stone) 2. Loss of the sonographic Murphy sign 3. Gallbladder wall thickening with a possible perceptible wall tear 4. Focal wall necrosis, bulges of the gallbladder wall, sloughed membranes, and ulcerative craters 5. Gallbladder loses its typically shape 6. Pericholecystic fluid 7. Sludge
SONOGRAPHIC FINDINGS OF ACUTE CHOLECYSTITIS
1. Gallstones (evaluate the neck and cystic duct for a possible lodged stone) 2. Positive sonographic Murphy sign 3. Gallbladder wall thickening 4. Gallbladder enlargement 5. Pericholecystic fluid 6. Sludge
SONOGRAPHIC FINDINGS OF POLYPS
1. Hyperechoic, nonshadowing, and nonmobile mass that projects from the gallbladder wall into the gallbladder lumen
CLINICAL FINDINGS OF GANGRENOUS CHOLECYSTITIS AND GALLBLADDER PERFORATION
1. Right upper quadrant pain 2. Epigastric or abdominal pain 3. Leukocytosis 4. Possible elevation in ALP, ALT, GGT, and bilirubin (with obstruction) 5. Fever 6. Pain that radiates to the shoulders 7. Nausea and vomiting
CLINICAL FINDINGS OF ACUTE CHOLECYSTITIS
1. Right upper quadrant tenderness 2. Epigastric or abdominal pain 3. Leukocytosis 4. Possible elevation in ALP, ALT, GGT, and bilirubin (with obstruction) 5. Fever 6. Pain that radiates to the shoulders 7. Nausea and vomiting
A gallbladder sonogram should be performed after the patient has had nothing to eat for at least _ hours, although a period of _ hours is optimal
4; 8
The size of gallbladder is variable, although the normal ranges are said to be __ to _____ in length and no more than __ to ____ in diameter.
8 to 10 cm; 4 to 5 cm
Like cholesterolosis, it is a form of hyperplastic cholecystosis of the gallbladder
Adenomyomatosis
is literally interpreted as "the condition of glands within the muscle" of the gallbladder.
Adenomyomatosis
Causes of nonvisualization of the gallbladder
Cholecystectomy Gallbladder completely filled with stones (Wall-echo-shadow sign or WES sign) Postprandial Chronic cholecystitis (collapse and fibrosis of the gallbladder) Ectopic location Agenesis Hepatization of the gallbladder (caused by tumefactive sludge) Air-filled gallbladder or emphysematous cholecystitis
are the most common type of polyps
Cholesterol polyps
are the result of an accumulation of cholesterol and triglycerides within the gallbladder wall, thus causing an elevation in the gallbladder mucosal layer.
Cholesterol polyps
is a form of acute cholecystitis
Emphysematous Cholecystitis
Sources of focal gallbladder wall thickening
Gallbladder polyp Adenomyomatosis Gallbladder carcinoma Adhered gallstone
is a group of proliferative and degenerative gallbladder disorders, includes both adenomyomatosis and cholesterolosis.
Hyperplastic cholecystosis
is often associated with acute cholecystitis. Other laboratory findings may include an elevation in ___ and ___. ______ may also be elevated if obstruction to the ducts occurs.
Leukocytosis; ALP and ALT; Bilirubin
Besides right upper quadrant or epigastric pain, patients often complain of focal tenderness over the gallbladder with transducer pressure when the gallbladder is inflamed. This is termed a positive sonographic
Murphy sign
Risk factors and predisposing conditions for cholelithiasis
Obesity Pregnancy Increased parity Gestational diabetes Estrogen therapy Oral contraceptive use Rapid weight loss programs Hemolytic disorder Crohn disease Total parenteral nutrition
what is the most common variant in gallbladder shape?
Phrygian cap
Sources of diffuse gallbladder wall thickening
Postprandial Acute cholecystitis Chronic cholecystitis Adenomyomatosis Hepatic dysfunction (e.g., hepatitis, cirrhosis) Benign ascites Hypoalbuminemia AIDS cholangiopathy Congestive heart failure Gallbladder carcinoma
what are the tiny pockets located within the epithelium and muscular layers of the gallbladder wall called?
Rokitansky-Aschoff sinuses
may be found in patients who have coexisting gallstones or gallbladder carcinoma and in those suffering from jaundice, liver disease, hyperalimentation, or sepsis.
Sludge
what are the sonographic findings of sludge
a collection of low-level, nonshadowing, dependent echoes within the gallbladder lumen
what is cholecystokinin
a hormone released by the duodenum
Gangrenous cholecystitis can be a direct evolution of
acute cholecystitis
The presence of gallstones and a positive sonographic Murphy sign is a strong indicator of
acute cholecystitis
what is the sudden onset of gallbladder inflammation
acute cholecystitis
Hyperplastic cholecystosis also includes
adenomyomatosis
what is benign hyperplasia of the gallbladder?
adenomyomatosis
hen gallbladder disease is suspected, look for an elevation in
alkaline phosphatase (ALP), alanine aminotransferase (ALT), bilirubin, gamma-glu-tamyltransferase (GGT), and white blood cell count (WBC).
The normal gallbladder appears sonographically as an __________________ structure in the sagittal plane. A true transverse image of the gallbladder will typically yield an _________
anechoic, pear-shaped; anechoic circle
Gallstones have been also been found in
children, in newborns, and in the fetus
There are several causes of nonvisualization of the gallbladder, with the most obvious being a previous
cholecystectomy
As chyme leaves the stomach, the hormone _________________ is released by the duodenum, causing the gallbladder to contract.
cholecystokinin
Right upper quadrant sonography may be needed to further assess these patients for residual ___ or ___
choledocholithiasis or postoperative complications
Gallbladder polyps are often seen with cholesterolosis that results from the disturbance in ________ and accumulation of cholesterol typically within a focal region of the gallbladder wall
cholesterol metabolism
Gallstones typically consist of a mixture of
cholesterol, calcium bilirubinate, and calcium carbonate
Adenomyomatosis is associated with
comet tail artifact
Bile consequently flows from the gallbladder through the cystic duct and into the
common bile duct
what is the portion of the biliary tree that lies distal to the union of the cystic duct with the hepatic duct
common bile duct
blood supply to the gallbladder is via what?
cystic artery, a branch of the right hepatic artery
The neck is contiguous with the __________, which connects the gallbladder to the rest of the biliary system at the level of the _____________________
cystic duct; common hepatic duct
Emphysematous cholecystitis, most often discovered in
diabetic patients
Other positional and developmental anomalies of the gallbladder include
duplication, floating gallbladder, agenesis, and hypoplasia
One differential diagnosis of gangrenous cholecystitis is __________________________, also referred to as suppurative cholecystitis, in which the gallbladder is filled with purulent material, commonly referred to as pus.
empyema of the gallbladder
Moreover, patients who are _____________- the six Fs-have been shown to have higher incidence of gallstones
fat, female, fertile, flatulent, fair, and forty
Gallstones are more commonly seen in
female patients
Adenomyomatosis can be ______________ and is clinically silent and most often insignificant
focal or diffuse
In addition to the sonographic findings of acute cholecystitis, gangrenous cholecystitis includes
focal wall necrosis, bulges of the gallbladder wall, sloughed membranes, and ulcerative craters
The gallbladder wall, which can be _________ should measure no more than _____
focally or diffusely thickened; 3 mm
what is the most dependent portion of the gallbladder
fundus
Most polyps are benign and incidentally discovered. However, a rapidly growing polyp or large polyp is worrisome for
gallbladder carcinoma
what is a projection of tissue from the gallbladder wall that protrudes into the lumen of the gallbladder
gallbladder polyp
Patients who have undergone an extended period of fasting or are on total parenteral nutrition may have
gallbladder sludge
Although the occurrence is rare, the floating variant does have potential for twisting off of the blood supply, resulting in a condition termed ___ or ____, in which the patient will present with right upper quadrant pain.
gallbladder torsion or gallbladder volvulus
what is the most common cause of cholecystitis
gallstone that has become lodged in the cystic duct or neck of the gallbladder
The fundus is a common location for
gallstones to collect
Biliary stones that form within the gallbladder are called
gallstones, or cholelithiasis
what is it called when the gallbladder becomes necrotic and develops abscesses within its walls
gangrenous cholecystitis
pediatric patients who have _____, such as sickel cell diseas, and those with chrons disease have an increased risk for developing gallstones
hemolytic anemia
The gallbladder can also completely fill with tumefactive sludge, causing the gallbladder to appear isoechoic to the liver tissue, a condition referred to as
hepatization of the gallbladder
Cholesterolosis is considered a subset of __________________, and it may also cause a diffuse polypoid appearance of the gallbladder referred to as a strawberry gallbladder, although this is not distinct on imaging.
hyperplastic cholecystosis
describe the 3 layers of the gallbladder mucosal layer:
innermost layer
is the gallbladder intraperitoneal or retroperitoneal?
intraperitoneal
what is the normal size rangers for the gallbladder length? diameter? wall thickness?
length: 8-10cm diameter: no more than 5cm wall thickness: no more than 3mm
Cholesterol polyps tend to be small, measure
less than 10 mm
Although the location of the gallbladder relies on the position of the patient, a useful landmark to locate the gallbladder fossa is the
main lobar fissure
It is helpful in most situations to scan at the level of the ______ and ______ to find the gallbladder.
main lobar fissure and right portal vein
describe the 3 layers of the gallbladder fibromuscular layer:
middle layer
describe the 3 layers of the gallbladder
mucosal layer, fibromuscular layer, serosal layer
The mucosal layer consists of
multiple folds and rugae
The gallbladder ____ and ___ should be examined closely because these locations are common sites for gallstones to become lodged or to accumulate
neck and funds
The gallbladder has a
neck, body, and fundus
Most authors agree that a gallbladder that measures over 4 cm in transverse should evoke special scrutiny of the biliary tract for signs of
obstruction
describe the 3 layers of the gallbladder serosal layer:
outer layer
Pertoration, or rupture, of the gallbladder has a high mortality and morbidity rate secondary to
peritonitis
where is the gallbladder located?
posterior to the right lobe of the liver within the gallbladder fossa
what might be find in a patient who has had a recent cholecystectomy?
residual fluid located within the gallbladder fossa.
Cholelithiasis formation has been associated with many _____ and ____
risk factors and predisposing conditions
On varying the patient's position, polyps will neither
shadow nor move
what is most often associated with biliary stasis?
sludge (viscid bile)
what can result from tumefactive sludge?
sludge balls which will be mobile, but will not shadow
The twinkle artifact can be used to identify
small gallstones
This pear-shaped sac is used to ____ and _______ that is produced by the liver.
store and concentrate bile
what is the gallbladders function?
store and concentrate bile
Other sonographic findings include gallstones, pericholecystic fluid, sludge, and thickening of the gallbladder wall, which may contained pockets of edematous fluid creating a
striated appearance
what are some positions that the gallbladder can be evaluated in?
supine, LLD, upright, prone and any other position to demonstrate whether pathology is mobile or not Intercostal imaging should be employed, especially if midline visualization is obstructed by overlying bowel gas
It is important to note that tiny folds within the cystic duct, __________________, can also produce a posterior shadow, and therefore small gallstones may be suspected. Changing the patient position and altering scanning planes can often resolve this dilemma.
the spiral valves of Heister
what are Rokitansky-Aschoff sinuses made up of?
they contain cholesterol crystals that produce comet tail artifact
sludge that is thick and mimics an intraluminal gallbladder mass is known as ___.
tumefactive sludge
Small gallstones may become adhered to the gallbladder wall and may also not produce a ______________. The twinkle artifact-which occurs posterior to a strong, _____________________-may be used to differentiate an adhered, small gallstone from a gallbladder polyp
well-defined acoustic shadow; granular, and irregular surface like crystals, calculi, or calcifications
Although it may be difficult to diagnose sonographically, chronic infection of the gallbladder may also result in ____________________-that is characterized by asymmetrical gallbladder wall thickening and the other common sonographic findings of acute cholecystitis
xanthogranulomatous cholecystitis
