Gallbladder Ultrasound

Shagufta Batool
Gallstones:
Gallstones are composed primarily of cholesterol (75%) and pigment
(25%). The majority (60% to 80%) of gallstones are asymptomatic
(silent). Surgery is seldom performed on silent stones because they
become symptomatic at a rate of only 2% per year. Approximately 30%
of patients with gallstones will have only a single episode of pain.
Appearance:
A gallbladder completely filled with stones is harder to recognize than
when it is filled with a combination of bile and stones. All that is
apparent is an echogenic shadowing structure in the RUQ that could be
confused with a gas-filled loop of bowel. If an identifiable gallbladder is
seen elsewhere, then the problem is solved. If not, the character of the
shadow is important.
A, Typical small stone with distinct clean acoustic shadow
Large stone. Note that the superficial surface of the stone is seen but absorption of the sound precludes
visualization of the deeper aspect of the stone
Differential diagnosis:
The major differential considerations for gallstones are
• Gallbladder polyps
• Sludge balls.
Sludge:
Biliary sludge is a mixture of particulate solids that have precipitated
from bile. Cholesterol crystals often in the setting of thick, viscous bile.
Sonographic appearance:
Typically homogeneous, sludge may have a very inhomogeneous
appearance with prominent hypoechoic regions. The lack of shadowing
distinguishes the different forms of sludge from gallstones, and mobility
distinguishes sludge from polyps and tumors.
Typical echogenic sludge layering in the dependent portion of the gallbladder lumen. Two stones are also
present
Polyps:
Cholesterolosis is a condition in which triglycerides, cholesterol
precursors, and cholesterol esters are deposited within the lamina
propria of the gallbladder.
Sonographic signs:
Cholesterol polyps are by far the most common type of gallbladder
polyp They are not true neoplasms but rather enlarged papillary fronds
filled with lipids and are attached to the wall by a slender stalk.
Sonographic signs:
The stalk is rarely seen, and so they typically appear as a spherically
shaped mass that is adjacent to the wall but barely attached to the
wall. This is referred to as the ball-on-the-wall sign. In rare instances, it
is possible to see the polyp move slightly on the stalk
Managmment:
Cholesterol polyps are usually 5 mm or less in size and only rarely get
bigger than 10 mm. They can be distinguished from gallbladder stones
by their lack of a shadow and non mobile nature.
Less than 5mm no further evaluation
5 to 10 mm should be monitored further
Larger than 10 mm should be removed surgically .
Longitudinal upright view shows a small (<5 mm) nonshadowing polypoid defect along the
nondependent portion of the GB typical of a cholesterol polyp.
Unusual case showing the stalk of a cholesterol polyp
Oblique view shows a stone in the dependent portion and a non shadowing polypoid-filling defect in the
nondependent portion. This is slightly larger than expected for a typical cholesterol polyp but demonstrates
the typical ball-on-the-wall sign
Longitudinal view shows wall thickening (5.7 mm) and a stone impacted in the neck of the gallbladder (arrow)
Longitudinal view shows wall thickening, sludge, stones, and a small collection of pericholecystic fluid
(arrowhead) near the gallbladder fundus.
Longitudinal view shows wall thickening, sludge, stone, and a collection of pericholecystic fluid near the
gallbladder fundus
Thick GB wall with intramural ulcerations (arrows).
Thick GB wall with intramural ulcerations
Carcinoma:
Gallbladder cancer is the fifth most common gastrointestinal
malignancy. It probably occurs because of chronic irritation of the
gallbladder wall. Gallstones larger than 3 cm have a tenfold increased
risk of cancer by stones.
Sonographic Appearance:
The most common sonographic appearance for gallbladder cancer is a
soft-tissue mass centered in the gallbladder fossa that completely or
partially obliterates the lumen. Identification of gallstones within the
mass can help to confirm that the mass originates in the gallbladder
rather than in the adjacent organs.
Approximately 15% to 30% of gallbladder cancers appear as focal or
diffuse with gallbladder wall thickening The least common form of
gallbladder cancer is a polypoid intraluminal mass. This form is almost
always larger than a centimeter (usually much larger). Size is therefore
a good way to distinguish cancer from gallbladder polyps. Gallbladder
cancers tend to be sessile, whereas polyps are usually very
pedunculated.
showing a homogeneous hypoechoic mass (cursors) obliterating the gallbladder lumen and
engulfing a gallstone.
E, Focal thickening (cursors) of the neck of the gallbladder.
Focal thickening of the anterior wall with invasion of the liver
Large polypoid mass (cursors) in the gallbladder fundus
Lobulated sessile polypoid mass (cursors) arising from the gallbladder wall.
Longitudinal view shows a focal area of gallbladder wall thickening (cursors) due to cancer, as well as
multiple stones.
Metastatic disease:
In addition to gallbladder cancer and polyps, metastatic disease to the
gallbladder is a rare cause of polypoid masses. Melanoma is the tumor
most likely to metastasize to the gallbladder and it can simulate polyps.
Therefore benign-appearing polyps should be viewed with suspicion in
patients with a history of melanoma.
Disease in the liver, lymph nodes, bowel, or peritoneum will accompany
gallbladder metastases. Lung cancer also can metastasize widely to
many organs, including the gallbladder.
Longitudnal view shows a mass later by CT scan it was
revealed it was primary from the lungs
Adenomyomatosis:
Adenomyomatosis is characterized by mucosal hyperplasia and
thickening of the muscular layer of the gallbladder. Mucosal herniations
into the muscular layer are called Rokitansky-Aschoff sinuses and are
the key pathological finding in adenomyomatosis. They are not related
to gallstones.
Sonographic signs:
Sonographically, the cholesterol crystals deposited in the Rokitansky-
Aschoff sinuses result in bright reflections and short comet-tail artifacts
arising from the gallbladder wall. The comet-tail artifact is the most
common and obvious finding in adenomyomatosis and is almost
exclusively seen along the near wall of the gallbladder. This artifact is
only seen in anechoic background. Rarely, large Rokitansky-Aschoff
sinuses will be resolved as cystic or hypoechoic spaces in the
gallbladder Wall.
Porcelain Gallbladder:
Extensive calcification of the gallbladder produces a brittle bluish wall
that has led to the term porcelain gallbladder. It is associated with
chronic gallbladder inflammation and 95% of the cases have gallstones.
The clinical significance of porcelain gallbladder has traditionally been
thought to be an increased risk of gallbladder carcinoma.
Sonographic appearences:
• When the GB IS diffusely involved with stones, it will appear as an
echogenic arc with dense posterior shadowing. Less extensive
calcification will produce only partial shadowing so that the back wall
of the gallbladder remains visible. In early cases, only segments of the
gallbladder wall may be affected. Cancers that develop in a porcelan
gallbladder have the same sonographic appearance as other cancers.
Longitudinal view of the GB shows an echogenic superficial wall with shadowing of the deep GB wall in the
region of the fundus but sound penetration and visualization of the back wall in the body of the GB (arrows)
Choledocholithiasis

Choledocholithiasis is the presence of a gallstone in the common bile

duct.
• abdominal pain in the right upper or middle upper abdomen
• fever
• jaundice (yellowing of the skin and eyes)
• loss of appetite
• nausea and vomiting
• clay-colored stools
Choledochal cyst :
A choledochal cyst is a congenital anomaly of the duct (tube) that
transports bile from the liver to the gall bladder and small intestine
when there is an abnormality at the intersection between the bile duct
and pancreatic duct. This abnormal connection forces pancreatic juice
to flow backwa.rd into the bile duct and may cause cysts to form
Thank you!