drains bile from the liver and stores it in the gallbladder to be realeased later during digestion
What is the function of the gallbladder?
serves as a reservoir storing bile produced by the liver
How much bile can the gallbladder store?
50 mL capacity
When does the gallbladder fill?
during fasting
What hormone produced by the stomach stimulates the gallbladder to contract releasing the bile?
CCK- Cholecystokinin
Where is bile produced?
liver
What is the composition of bile?
water
bile salts
bilirubin (a bile pigment)
cholesterol
electrolytes
1. Rt hepatic duct
2. Lt hepatic duct
3. Common hepatic duct
4. Cystic duct
5. Common bile duct
6. Distal CBD
1. Liver
2. Intrahepatic ducts
3. Rt & Lt hepatic ducts
4. Common hepatic duct
5. Common bile duct
6. Gallstones
7. Pancreatic duct
8. Pancreas
9. Duodenum
What are the 3 portions of the gallbladder?
fundus
body
neck
What is the normal size of the gallbladder?
length 7-10 cm
transverse 3 cm
wall thickness < 3 mm
What are the folds along the inner border of the gallbladder?
Rokitansky-Aschoff sinuses
What helps prevent kinking of the duct in the neck of the gallbladder?
Heister's Valves
What is the outpouching called located near the junction of the cystic duct and the gallbladder neck?
Hartmann's Pouch or infundibulum
1. Heister's Valve
2. GB Neck
3. Hartmann's Pouch
4. Cystic Duct
5. GB Body
6. GB Fundus
The gallbladder is between what lobes of the liver?
Rt & Lt lobes
Where is the gallbladder located when the patient is supine?
When the patient is on their left side?
along the inferior border of the Rt lobe of the liver
midline
The gallbladder is typically located on the inferoposterior surface of the liver and can be _______ or ________.
extrahepatic or intrahepatic
What is the boundary between the right & left lobes of the liver; seen as a hyperechoic line on the sagittal image extending from the portal vein to the neck of the gallbladder?
Main Lobar Fissure
1. Portal Vein
2. Main Lobar Fissure
3. Gallbladder
Where are junctional folds typically located?
near the gallbladder neck
What is it called when a junctional fold occurs at the fundus?
Phrygian Cap
Name 4 gallbladder variants.
1. junctional fold
2. Phrygian cap
3. pear shaped
4. oval
Name 4 congenital gallbladder variants.
1. septations
2. bilobed
3. duplication
4. absence or agenesis (rare)
Phrygian cap
Septation & duplicated GB
Bile is the principle route of execretion for what 4 things?
1. bilirubin
2. cholesterol
3. steroids
4. drugs & other toxins
What are the tiny spiral valves found within the cystic duct called?
Heister's Valves
The lumen of the cystic duct contains ______ folds.
mucosal
What is the normal diameter of the common bile duct?
up to 6mm
What is name of the area where the common bile duct and the pancreatic duct merge?
Ampulla of Vater aka hepatopancreatic duct
What is the name of the small muscle that guards the ampulla of vater?
sphincter of oddi
What structures comprise the portal (hepatic) triad?
common bile duct
hepatic artery
portal vein
What is the name given to the portal triad when viewed sonographically in transverse?
mickey mouse sign
1. common bile duct
2. hepatic artery
3. portal vein
What is the normal sonographic appearance of the gallbladder?
anechoic lumen
thin well-defined walls
How long should the patient be NPO for examining the gallbladder?
8-12 hours
How should the patient be positioned for examining the gallbladder?
supine or decubitus
T/F
You should always scan the patient in 2 positions when imaging the gallbladder.
true
1. Hepatic artery
2. GB Neck
3. Portal Vein
4. IVC
1. common hepatic duct
2. portal vein
3. diaphragm
4. IVC
1. Portal Vein
2. IVC
3. Right Renal Artery
What is the disease process called where pancreatic juices reflux into the common bile duct causing focal or diffuse dilation?
Choledochal cysts
T/F
Choledochal cysts occur more frequently in infants, women, and people of East Asia.
True
What are the symptoms of choledochal cysts?
intermittent jaundice
palpable RUQ mass
colicky pain
What are the sonographic findings associated with choledochal cysts?
cyst in the portal hepatis
dilated CBD
Which type of choledochal cyst occurs 80% of the time, is associated with an abnormally long duct, and has a fusiform dilatation of the CBD?
Type 1
Which type of choledochal cyst is very rare and has a true diverticulum of the CBD?
Type 2
Which type of choledochal cyst is confined to a intraduodenal portion of the CBD (choledochoceles)?
Type 3
Which type of choledochal cyst involves multiple dilatations of the intra & extrahepatic biliary tract and is associated with an abnormally long duct?
Type 4 A
Which type of choledochal cyst involves multiple dilations with the extrahepatic biliary tract ONLY?
Type 4 B
What pathology is a rare congenital disorder with malformation of the intrahepatic biliary tree causing biliary stasis?
Caroli's Disease
Biliary stasis caused from Caroli's disease can cause what 3 pathologies?
stone formation
cholangitis
sepsis
What are the two types of Caroli's disease?
simple, classic form
periportal hepatic fibrosis (most common)
Which type of Caroli's disease is most common?
periportal hepatic fibrosis
What is the sonographic appearance of Caroli's disease?
saccular dilation of the intrahepatic ducts
converge toward portal hepatis
appears as many cysts
What causes ductal dilation/obstruction?
choledocholithiasis
masses
Which type of choledocholithiasis is cause by etiologic factors often related to disease causing strictures or dilation of the bile ducts leading to stasis?
Primary
Sclerosing cholangitis, Caroli’s disease, sickle cell disease, prior biliary surgery are all causes of which type of choledocholithiasis?
primary choledocholithiasis
Which type of choledocholithiasis is caused by migration of stones from the GB into the CBD?
secondary choledocholithiasis
What are the clinical symptoms associated with choledocholithiasis?
painless jaundice or
painful jaundice - acute obstruction or infection of the biliary tree
Why are choledocholithiasis difficult to diagnose?
because of limited visualization of the CBD due to bowel gas
What is the sonographic appearance of choledocholithiasis?
round echogenic foci
posterior shadowing
choledocholithiasis
What is the name of the pathology where the biliary tract hemorrhages due to trauma, inflammation, cholelithiasis, vascular disease, or neoplasm?
Hemobilia
What is the name of the pathology where air is found within the biliary tree?
pneumobilia
Inflammation of the bile ducts.
Cholangitis
50% of patients with Sclerosing cholangitis will also have what pathology?
ulcerative colitis
What is the sonographic appearance of cholangitis?
walls- smooth or irregular thickening of the intrahepatic ducts
sludge
hepatic abcess
What is the most common disease of the GB?
cholelithiasis aka gallstones
Gallstones are formed by precipitated crystals of _______ or _______.
bile salts or cholesterol
What is the sonographic appearance of cholelithiasis?
rounded
multiple or single
large or small
mobile or non-mobile
highly reflective echo in GB
posterior acoustic shadowing
Cholelithiasis aka Gallstones
Name the 5 F's for most common patients with cholelithiasis.
fat
female
forty
fertile (women of child bearing age)
fair (fair complected)
and 6 fertilized! (oh snap what now!)
Diabetes melitus is also a cause
What is the name of the sonographic sign when the GB is completely packed with stones you only see the anterior border?
Wall echo shadowing (WES sign)
What should you always do to the patient when checking for gallstones?
check for mobility (move the patient into a LLD)
What lab values are associated with cholelithiasis?
Bilirubin
Amylase
Abnormal LFT's (liver function tests)
Gallstones
Gallstones
excessive bile accumulation in the tissues resulting in yellowing in the skin and whites of the eyes
jaundice
What are 2 other names for sludge?
biliary sand or microlithiasis
low-level echoes found along the posterior margin of the gallbladder; move with change in position
sludge
Name given when sludge has a liver echotexture.
Hepatization
Why is it important to watch the gain settings when viewing the gallbladder?
if the GB is not anechoic in appearance it can look like sludge
sludge
Acute cholecystitis is associated 90-95% with what patient pathology?
cholelithiasis
Which GB pathology is caused by persistent obstruction of the GB neck or cystic duct resulting in inflammation of the GB wall?
Acute Cholecystitis
What is the name of the sign when the probe is pressed directly over the GB causing maximum pain?
Murphy's Sign
What lab values would you find in a patient with acute cholecystitis?
increased serum amylase
abnormal liver function test
What are the sonographic findings of acute cholecystitis?
dilation of the GB
Murphy's sign
thick wall
stones
pericholecystic fluid
What is the name of the fluid that results from extended inflammation along the hepatoduodenal ligament into the main lobar fissure resting adjacent to the GB?
Pericholecystic fluid
What lab test is associated with Chronic cholecystitis?
abnormal LFT's
What is the sonographic findings associated with chronic cholecystitis?
coarse GB wall thickening
contracted GB
WES sign
no Murphy's sign
What is the pathology with an acute inflammation of the gallbladder in the absence of gallstones?
Acalculous Cholecystitis
What additional study is used to diagnose acalculous cholecystitis?
Nuc Med study with CCK stimulation
What are the sonographic signs of Acalculous cholecystitis?
thick GB wall
sludge
pericholecystic fluid
What rare pathology involves infection of the GB with a gas forming bacteria which fills the lumen of the GB wall with gas?
Emphysematous cholecystitis
Emphysematous cholecystitis is fatal in what percent of patients?
15%
What pathlogy is a complication of acute cholecystitis; it can lead to perforation, ulcerations, pericholecystic fluid, or peritonitis?
Gangrenous cholecystitis
Gangrenous cholecystitis
What is the sonographic appearance of GB perforation?
deflation of GB
pericholecystic fluid
abscess
GB perforation
What is the rare GB pathology defined as calcium incrustation of the GB wall?
Porcelain GB
What is Porcelain GB often associated with?
Gallstones
What is the sonographic appearance of porcelain GB?
echogenic line
hyperechoic line with posterior acoustic shadowing
What percentage of porcelain GBs develop into cancer?
25%
What is the mortality rate for GB carcinoma?
near 100%
What type of cancer is rare, rapidly progressive, affects elderly women, arises in the body of the GB and can obstruct the cystic ducts?
gallbladder carcinoma
What pathology is associated 80-90% with GB carcinoma?
cholelithiasis
What is type of carcinoma is rare, affects the bile duct, and originates at the junction of the RT and LT hepatic ducts?
Klatskin's Tumor
Name a clinical symptom of Klatskin's Tumor.
slowly worsening jaundice
What is the sonographic appearance of Klatskin's tumor?
no CBD dilatation
dilatation may be seen elsewhere in the biliary tract
What are benign, small, well-defined, soft tissue projections from the GB wall?
polyps
Polyps can look like small stones but they will not be _____ or _____.
mobile or shadow
What type of GB adenoma is the most common?
benign
What is the sonographic appearance of GB adenomas?
stalk
hyperechoic
occur with GB disease
flat elevation located in the body near the fundus
What pathology is an accumulation of cholesterol deposits on the mucosa of the GB?
cholesterolosis
What is the name given to cholesterolosis because it's mucosal surface resembles a fruit?
Strawberry GB
What pathology has a hyperplastic change in the GB wall that does not move when patient changes orientation?
Adenomyomatosis
What is the name of the artifacts associated with adenomyomatosis?
