Lecture 3: Gall bladder

Course: FRD3062 Medical Imaging Science and Methods 4

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(Advanced Ultrasound )Lecture : Topic 3
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Learning outcomes

• By the end of this topic you should be able to:

• describe the anatomy of the gallbladder
• demonstrate a detailed knowledge of sonographic technique for
gallbladder assessment
• describe the sonographic appearance of the normal gallbladder
• describe the sonographic appearances of common gallbladder
pathology

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Anatomy
• Pear shaped organ
• Located at inferior margin of
liver-gall bladder fossa
• Found under the liver in the
upper right region of the
abdomen

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Anatomy
• Fundus-variable position
• Body
• Neck-fixed to main
lobar fissure
• 10cm long, 2-5cm wide

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Anatomy
CYSTIC DUCT
– (Spiral Valves of Heister)-Prevent cystic duct from
overextending or collapsing

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Anatomy
• Wall - 3 layers
– Inner mucosa
– Middle fibromuscular
– Outer serous
• Many inward folds (rugae)
- Aids bile concentration

• Wall thickness ≤ 3mm

(when distended with bile)

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Physiology

• Bile, produced by liver, is concentrated in GB

• Bile - water 82%, bile acids 12%
– Remaining 6% cholesterol, bilirubin (bile pigment),
proteins, electrolytes, mucus

• Fasting – GB distends, wall stretched thin

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Physiology

• Sphincter of Oddi in duodenum controls bile excretion and

prevents GI fluids entering bile ducts

• Fats and amino acids - cholecystokinin (CCK) released

• CCK stimulates GB contraction and Sphincter of Oddi

relaxation

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Congenital Variations

• PHRYGIAN CAP
– 1-6%
– Fundus folded in on the body
– Beware pathology

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Congenital variants
Hartmann’s Pouch
• Outpouching near neck , common location for impaction of
stones

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Congenital Variations

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Equipment

• Variable depth and position - variable methods to visualise

– Curvilinear 7-4MHz, 5-2MHz

– Linear 9-4MHz, 13-4MHz

• Tissue Harmonic Imaging (THI) - fluid filled structures

Please Read more about (THI)

https://pubs.rsna.org/doi/full/10.1148/rg.2015140338
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Ultrasound Technique

• Intercostal and subcostal

• Image in multiple planes

– Supine
– LPO
– Decubitus
– Erect

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Ultrasound Appearance

• Anechoic
• Almost pear-shaped/oval structure in RUQ
• Wall well defined, regular, hyperechoic
– If contracted, walls will appear thicker and more
irregular
• Thickness ≤ 3mm measured in transverse plane in the axis
of the beam

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Ultrasound Appearance

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Ultrasound Appearance

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Ultrasound Appearance

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Ultrasound appearances
• JUNCTIONAL FOLD
– Commonly seen folds in neck
– Mistaken for polyps / calculi

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Ultrasound appearances

Phrygian Cap

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Ultrasound Appearance

• Fundus may be hard to see - shadow from nearby bowel

obscuring

• Landmarks - portal vein, main lobar fissure, right kidney

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Pathology

• Cholelithiasis (Gallstones)
– Mobile versus impacted
• Sludge
• Focal wall pathology
• Cholecystitis
• Adenomyomatosis
• Cancer of Gall Bladder

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 Pathology - Cholelithiasis

• The 5-F rule refers to risk factors for the development of

cholelithiasis
– Fair: more prevalent in the Caucasian population 1
– Fat: BMI >30
– Female
– Fertile: one or more children
– Forty: age ≥40
– Cholelithiasis can occur in young patients with a positive Family History;
in such cases, the ‘Familial' factor can substitute for the ‘Forty' factor

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Cholelithiasis or Gallstones are composed mainly of

• Cholesterol 80-90%
• Calcium bilirubinate (pigmented)
• Calcium carbonate

 Absorb and reflect ultrasound beam

 Prominent posterior Acoustic shadow

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Cholelithiasis

• Posterior shadowing depends on:

– Composition of stone
– Size*
– Beam width*
– Signal processing

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Cholelithiasis

• SIZE AND NUMBER

– Approximate number
– Largest size - ? Position
– Assess mobility vs impaction

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Cholelithiasis

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Cholelithiasis

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Cholelithiasis

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Cholelithiasis

• MOBILE VS. IMPACTED

– Most stones gravity dependent - drop from neck/body
to fundus when patient erect
– No movement if gallbladder is contracted

– Differentiate from polyp

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 Cholelithiasis
• If impacted galll bladder is :
– Permanently contracted or
– Full of fine low-level echoes or
– Distended due to mucocele

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Gallbladder Sludge
• Occurs when solutes in bile precipitate
• Calcium bilirubinate / cholesterol crystals
• Low to mid-level echoes
• No posterior shadowing (unless calculi also present)
• Viscous

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Gallbladder Sludge

Causes
• Bile stasis
– Prolonged fasting
– Critical illness
– Rapid weight loss

Complications
– Obstruction
– 5-15% develop gallstones
– cholecystitis

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Gallbladder Sludge

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Gall bladder sludge

• Sludge balls

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Focal lesions - polyps

• Common
• Usually asymptomatic
• Cholesterol - project into gallbladder lumen but do not cast
shadow
• On stalk or neck - usually fixed with movement unless on
long stalk
• Associated with carcinoma in older patients if over 1cm

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Focal - polyps
• Differentials
– Malignancy > 1cm
– Small non-shadowing stone
– Adenomyomatosis

• DDx stone - neck/stalk, non-mobile, no shadow

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Focal - Polyps

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Focal - Adenomyomatosis

• Non-inflammatory-benign condition
• Exaggeration of normal invaginations of the GB epithelium
• Rokitansky-Aschoff sinuses

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Adenomyomatosis

• Deposits of crystals in wall = comet tail artefact

• Often asymptomatic - biliary colic
• Usually benign but malignant transformation has been
reported (rare)

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Adenomyomatosis

ULTRASOUND
– Echogenic foci in wall with comet-tail artefact
– Diffuse/focal wall thickening

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Focal - Adenomyomatosis

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Carcinoma
• Associated with calculi and history of cholecystitis
• Risk factors:
– Large stones
– Polyps > 1cm
– Porcelain gallbladder
• Asymptomatic early - advanced at diagnosis

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Carcinoma

• 3 presentations
– Focal or diffuse wall thickening
– Intraluminal polypoid mass
– Infiltrative mass arising in GB fossa and invading liver

• Highly malignant - metastasizes to liver and portal nodes

• Poor prognosis

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Carcinoma

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Acute Cholecystitis

• 90% associated with gallstones

• Causes: friction of stones on wall/or trapped bile due to
obstruction
• Inner wall injured – bacteria flourishes

• Acute or chronic

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Acute Cholecystitis

• Typically RUQ tenderness

• Positive Sonographic Murphy’s
• Nausea, vomiting

• calculous cholecystitis (90-95%)

• acalculous cholecystitis (5-10%)

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Acute Cholecystitis

• Ultrasound assists in:

– Diagnosis of wall thickening - DDX acute or chronic
– Other signs of inflammation
– Presence of gallstones
– Assessing bile ducts
– Non biliary causes

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Acute Cholecystitis

ULTRASOUND FEATURES
– Wall thickening >3mm (fasting)diffuse or focal
– +/- striated appearance of alternating hypoechoic and hyperechoic
bands
– Peri-cholecystic fluid
– Sludge or stone(may be impacted in cystic duct or neck)
– Dilatation of GB > 4cm(mucocele)
– +ve sonographic Murphy’s sign
– Hyperaemic wall shown with color doppler

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Acute Cholecystitis

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Acute Cholecystitis
– Dilated GB +thickened wall

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Acute Cholecystitis

• ACALCULOUS
– Uncommon
– Typically patients with pre-existing illness or post
surgery
– Bile stasis leads to distention and decreased blood
flow to GB - predisposes to infection

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Acalculous Cholecystitis

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Acute Cholecystitis

• COMPLICATIONS
– Gangrenous(severe/prolonged>necrosis)
– Emphysematous(gas forming bacteria)
– Perforation >liver abscess
– Gallbladder empyema
• Cystic duct obstructed - infection
• Pus-filled lumen
• May need to drain prior to surgery - tube guidance

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Chronic Cholecystitis

• Usually associated with stones

• RUQ pain to lesser degree - recurring
• ULTRASOUND
– Wall fibrosed and irregularly thickened - hyperechoic
– GB shrunken and contracted - may not see lumen
around stones
– DDx vs acute =absence of other signs

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Chronic cholecystitis

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Cholecystitis - Pitfalls

• Many and varied, ensure:

– Fasting state
– Use different positions - calculi, gas
– Watch in real-time
– Different planes, accurate wall measurement
– Clinical signs
– Artefacts (positive and negative)

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SUMMARY

• describe the anatomy of the gallbladder

• demonstrate a detailed knowledge of sonographic
technique for gallbladder assessment
• describe the sonographic appearance of the normal
gallbladder
• describe the sonographic appearances of common
gallbladder pathology

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Readings

• Bates, JA 2011, Abdominal Ultrasound: How, Why and When,

3rd ed. Churchill Livingstone, Edinburgh.
• Rumack, CM Wilson, SR Charboneau, JW 2011, Diagnostic
Ultrasound Vol.1, 4th Ed. Mosby, St. Louis.

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