PATHOLOGY OF GALLBLADDER AND

BILIARY SYSTEM
 ANATOMY
• Pear shaped
• 7-10cm long, 3cm broad.
• Located : fossa between Right and left
lobe
• 30-50 ml capacity.

• When Obstructed 300ml.

• Gallbladder wall : 2-3 mm

Part
• Fundus
• Body
• Infundibulum
• neck
VARIANT ANOMALIES

I. Normal
II. Phrygian cap
III. Bilobed
IV. Diverticulum
V. Hourglass
VI. Septated
CHOLECYSTITIS
 ACUTE CHOLECYSTITIS
acute inflammation of the gallbladder.
primary complication of cholelithiasis
Ultrasound
-Sonography murphy sign
-Cholelithiasis
-Gallbladder wall thickening → 3 mm
-Pericholecystic fluid
 CT Scan
Diagnostic criteria on CT as proposed by
Mirvis et al;
major criteria
- Gallstones
- thickened gallbladder wall
- pericholecystic fluid collection
- subserosal oedema
minor criteria
- gallbladder distention
- sludge
CHRONIC CHOLECYSTITIS
prolonged inflammatory condition that affects the gallbladder →
intermittent obstruction of the cystic duct or infundibulum, or dysmotility
Imaging → non specific → contracted/distended
 EMPHYSEMATOUS
CHOLECYSTITIS
form of acute cholecystitis where
gallbladder wall necrosis → gas
formation in the lumen or wall
USG
-Hyperechogenic reflectors with low-level
posterior shadowing and reverberation
artifact
-small, non-shadowing echogenic foci
rising up from the dependent portions →
(champagne sign)
CT Scan
-Most sensitive and specific
imaging modality
- Gas within the gallbladder lumen
or wall
 GALLBLADDER
EMPYEMA (SUPPURATIVE
CHOLECYSTITIS)
complication of cholecystitis → gallbladder
lumen is filled and distended by purulent
material (pus)
USG :
- + cholecystitis with added echogenic content
within the gallbladder lumen
CT :
- Cholecystitis with added high-attenuating
material (representing pus) within the distended
gallbladder lumen.
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 XANTHOGRANULOMATOUS
CHOLECYSTITIS
difficult to differentiate from malignancy
It is characterised by the presence of multiple
intramural nodules.

USG
-Gallbladder wall thickening → diffuse/focal
-Intramural hypoechoic nodules or bands
- Infiltrated the adjacent liver → focal
hypoechogenicity of hepatic parenchyma
- gallstone often present
CT Scan
-5-20 mm small intramural hypoattenuating
nodules
-poor/heterogeneous contrast enhancement
-features of local infiltration, or other
complications, such as perforation, abscess
formation or formation of fistulous tracts
 GALLSTONES
Type of gallstones
-Cholesterol
-Mixed
-Pigmented stones
Plain radiograph
-Radioopaque → 15-20%
-May be Laminated → radiopaque outline
with lucent centre
-may show a Mercedes-Benz sign
USG
-Hyperechoic focus within gallbladder lumen with
posterior acoustic shadowing
-gravity-dependant movement → rolling stone
sign
-colour Doppler → twinkling artifact
CT Scan
- hyperattenuating to bile
-Pure cholesterol stones →
hypoattenuating to bile
 POLYP GALLBLADDER
elevated lesions on the mucosal surface of
the gallbladder
Benign → 95%
Neoplastic polyps → > 10 mm
Malignant → > 20 mm
US :
-non-shadowing polypoid ingrowth into the
gallbladder lumen
-Immobile
CT Scan
-often unable to detect small gallbladder
polyps
-Larger polyp → soft tissue attenuation
projections into the lumen
-enhancement similar to that of the rest of
the gallbladder
 GALLBLADDER CARCINOMA
US findings
- Large mass-like lesion replacing the GB,
irregular/ill-defined margin with
heterogenous echotexture and predominant
hypoechoic
-Asymmetric GB wall thickening
-Hepatic invasion with loss of normal
echogenic GB wall dividing mass from live
CT Scan
-Massa replacing GB/Irregular focal/diffuse wall thickening/intraluminar polypoid
-Hypodense mass with irregular, peripheral enhancement on arterial phase
-Invades liver and porta hepatis
-Bulky porta hepatis/paraaortic adenopathy common
-Calcified gallstones or porcelain GB may be present
ADENOMYOMATOSIS OF
GALLBLADDER
hyperplastic cholecystosis of
the gallbladder wall
benign cause of diffuse or focal
gallbladder wall thickening,
USG :
-mural thickening (diffuse, focal, annular)
-Comet-tail artifact → Pathognomonic
CT Scan
-gallbladder wall thickening and
enhancement → non-specific
-Rosary sign → enhanced
proliferative mucosal
epithelium, with the intramural
diverticula surrounded by the
unenhanced hypertrophied
muscle coat of the gallbladder
BILE DUCT
 ANATOMY

• Cystic duct : 3-4 cm long

• Common hepatic duct : 3 cm long
• Common bile duct : 7-11 cm long,
6-8 mm in diameter
 CAROLI DISEASE
autosomal recessive disease
secondary to the ductal plate
malformation
associated with polycystic kidney
disease, medullary sponge kidney
and medullary cystic disease
hallmark → intrahepatic duct
dilatation → dilatation can be very
large and saccular
Central dot sign → portal vein that is surrounded by dilated bile ducts.
Complications :
- Intraductal stones
- Cholangitis and abscess
- Livercirrhosis
- Cholangiocarcinoma
CHOLEDOCHAL CYSTS
congenital dilatation of the extrahepatic bile duct → due to
an underlying anomalous pancreatico-biliary junction
the biliary and pancreatic duct join proximal to the sphincter
of Oddi → sphincter oddi contracts → pancreatic enzyme s
will flow into bile duct → dilatation
US → dilated cystic lesion that communicates with the bile
duct and is separate from GB
CT scan → samiliar to US
CHOLANGITIS inflammation of the bile
ducts.
 ASCENDING CHOLANGITIS
Form of cholangitis and acute bacterial infection of biliary tree
US :
-Thickening of walls of the bile ducts
-Biliary dilatation with calculi
-With/without pus → debris material within CBD
-Dilation of intrahepatic ± extrahepatic ducts with abrupt cut off at site of obstruction
-Bile duct wall thickening with hyperenhancement
-Intraductal purulent bile or pus: High density on CT
-Heterogeneous liver enhancement
 PRIMARY SCLEROSING CHOLANGITIS
uncommon inflammatory condition →
multiple strictures, liver damage, and
eventually cirrhosis.
USG :
-Changes of cirrhosis → Distorted biliary tract
and atrophy of the entire liver, except caudate
lobe (Hypertrophy)
-irregularity of bile duct calibre
-Brightly echogenic portal triads
CT Scan :
- Dilatation of intra and
extrahepatic ducts
- Abnormal thickening and
hyperenhancement of bile ducts
- Intrahepatic biliary calculi
- Cirrhotic liver with hypertrophy
of caudate lobe and atrophy of
peripheral liver → Central lover
higher attenuation
- Delayed phase → discrete mass
with enhancement with dilatation
of ducts / nodular bile duct wall
thickening
 RECURRENT PYOGENIC CHOLANGITIS
formation of pigment stones throughout
biliary tree → biliary strictures and
repeated bouts of cholangitis
IMAGING :
-Intrahepatic and extrahepatic biliary
dilatation
-Multilevel stricture with intraductal
pigmented calculi
-Left lobe > right lobe
 OBSTRUCTION
gallstones in the bile duct / stricture
Stricture
-Distal stricture → distal cholangiocarcinoma,
pancreatic carcinoma, or pancreatitis
-Stricture within the liver → gallbladder
carcinoma, PSC, AIDS cholangiopathy
-Anywhere within biliary system → Metastastic
 CHOLANGIOCARCINOMA
adenocarcinoma of the bile
duct) arises from the columnar
epithelium of the bile duct.
Intrahepatic : arise in the very
small Peripheral duct
 INTRAHEPATIC
Ariese in the very small peripheral
duct
Peripheral biliary dilatation
Casue retraction of liver capsule
Enhanced in delayed phase
 INTRADUCTAL
intrabiliary mass with biliary
dilatation peripheral to the mass.
 KLATSKIN TUMOR – HILAR
CHOLANGIOCARCINOMA
The most common site → at
or near the confluence of the
right and left hepatic ducts.
IMAGING :
-Duct dilatation
-Ill-defined mass
-Lobar atrophy
-Vascular invasion
CHOLANGIOCARCINOMA
malignant epithelial tumours arising from the biliary tree, excluding
the gallbladder or ampulla of Vater.
Location → Intrahepatic (10%) and extrahepatic (90%)
Growth pattern
-Mass forming intrahepatic → homogenous mass with intermediate
echogenicity with peripheral hypoechoic halo, irregular in outline with
capsular retraction
-Periductal infiltrating intrahepatic →narrowed/dilated calibre bile duct
without well-defined mass
-Intraductal → duct ectasia with/without visible mass, polypoid mass seen
→ Hyperechoic
CT Scan
-Mass-forming : hypodense homogenous (NC) and heterogenous minor peripheral
enhancement with gradual centripetal enhancement, capsular retraction, dilatation
bile ducts distal, lobar-segmental hepatic atrophy
-Periductal infiltrating →