Cholelithiasis Cholelithiasis is the pathologic state of stones or calculi within the gallbladder lumen. A common digestive disorder worldwide: 20 million Americans have gallstones 700,000 cholecystectomys performed annually in the U.S. Most common gastrointestinal disorder requiring hospitalization
Cholelithiasis Most gallstones are composed primarily of bile (80%); remainder are composed of a mixture of bile components Each type of stone has a particular pathophysiology and specific set of risk factors that alter the equilibrium and solubility of the components of bile. Cholesterol stones Pigment stones
Cholelithiasis Asymptomatic gallstone patients develop complications at an annual rate of 1-2%. In symptomatic patients, the complication rate increases to 3%. Manifestations of cholelithiasis: Many persons are asymptomaticMany persons are asymptomatic Early symptoms are epigastic fullness after meals or mild distress Biliary colicBiliary colic (if stone is blocking cystic or common bile duct): steady pain in epigastric or RUQ of abdomen lasting up to 5 hours with nausea and vomiting Jaundice may occur if there is obstruction of common bile duct
Cholelithiasis Sonography is the procedure of choice for identifying gallstones Sonography is the procedure of choice for identifying gallstones. sensitivity greater than 95%.Current high-resolution, real-time ultrasound (US) can identify gallstones as small as 2 mm, with a sensitivity greater than 95%. The technique is rapid, noninvasive, can be performed at the bedside, and does not involve ionizing radiation. Ultrasonic Criteria for Cholelithiasis Intraluminal brightly echogenic structure Stones > 3mm will produce an acoustic shadow Stones will usually seek gravitational dependency
Cholelithiasis Ultrasound Ultrasound image obtained with a 3,5-MHz transducer demonstrates the multiple stones in the gallbladder with typical acoustic shadows.
Cholelithiasis Ultrasound Ultrasound image obtained with a 3,5-MHz transducer demonstrates a stone in the gallbladder with typical acoustic shadow. NORMAL GALLBLADER
Cholelithiasis Ultrasound Image Patterns: Stones with shadowing Stones without shadowing Gravel GB filled with stones Floating stones as fluid level in bile Adherent Gallstones Dilation of common bile duct
Cholelithiasis Ultrasound Ultrasound image obtained with a 3-MHz transducer demonstrates pyramidal nonshadowing stones.
Cholelithiasis Ultrasound Wall-echo shadow sign indicates a stone-filled gallbladder.
Cholelithiasis Ultrasound Layer of gravel with shadowing
Cholelithiasis Limitations of Techniques: US: False negatives may occur with small stones in the presence of biliary sludge. The technique is operator-dependent. Inadequate visualization of the gallbladder may occur in obese or contracted patients, or in patients with abdominal wounds. Only 15-20%Radiographs: Only 15-20% of stones are visible on plain radiographs. Only 74-79%CT: Only 74-79% of gallstones are identified in patients with CT. CT is not a screening tool for uncomplicated cholelithiasis. MRI: MRI is not a screening tool. Stones may be incidental findings on abdominal MRI.
Cholelithiasis Only 15-20%Only 15-20% of stones are visible on plain abdominal film.
Cholelithiasis CT Findings CT demonstrates a layer of calcific- dense material in the gallbladder that may be gravel or milk of calcium bile Noncontrast CT demonstrates a typical, laminated, calcified gallstone.
ERCP findings in cholelithiasisCholelithiasis Gallbladder and CBD stones
Acute cholecystitis Manifestations of acute cholecystitis Episode of biliary colic involving RUQ pain radiating to back, right scapula, or shoulder; the pain may be aggravated by movement, or deep breathing and may last 12 – 18 hours Anorexia, nausea, and vomiting Fever with chillsFever with chills
Sonographic features of AC include the following: CalculiCalculi in the GB in more than 90% of patients. more than 3 mmAnterior GB-wall thickness of more than 3 mm Positive Murphy signPositive Murphy sign (pain on compression of the GB with the ultrasound probe) Pericholecystic fluidPericholecystic fluid in severe cases (sign of actual or impending perforation) Acalculous cholecystitis: Five percent of cases are not associated with gallstones. >4-5 cmIncreased transverse GB diameter >4-5 cm GB distension: About 93% of patients with a GB volume of greater than 70 mL have AC. Loss of definition of GB margins Acute cholecystitis
Ultrasound Acute cholecystitis Ultrasound image demonstrates: thickening of the gallbladder wall.
Ultrasound Ultrasound image demonstrates: a calculus at the neck of the gallbladder with acoustic shadowing and thickening of the gallbladder wall. Gallbladder is slightly enlarged Acute cholecystitis
Ultrasound Acute cholecystitis Ultrasound image demonstrates: thickening of the gallbladder wall and loss of definition of GB margins.
Acute nongangrenous cholecystitis. CT scan shows pericholecystic fluid CT Findings Acute cholecystitis From: CT Findings in Acute Gangrenous Cholecystitis G. L. Bennett et al. AJR 2002; 178:275-281
Complications of cholecystitis Chronic cholecystitisChronic cholecystitis occurs after repeated attacks of acute cholecystitis; often asymptomatic Empyema:Empyema: collection of infected fluid within gallbladder Gangrenous cholecystitisGangrenous cholecystitis with perforation leading to peritonitis or abscess formation PancreatitisPancreatitis, liver damage, intestinal obstruction Complications are more common in patients with small, multiple stones. Acute cholecystitis
Ultrasound Transverse and longitudinal scans demonstrate a complex echo pattern in the area of the gallbladder and pericholecystic fluid - acute gangrenous cholecystitis. Acute cholecystitis
CT Findings Acute cholecystitis Acute gangrenous cholecystitis. CT scan with IV contrast material shows intraluminal linear densities corresponding to intraluminal membranes. Note lack of contrast enhancement of gallbladder wall and pericholecystic inflammation. renal cyst From: CT Findings in Acute Gangrenous Cholecystitis G. L. Bennett et al. AJR 2002; 178:275-281
Ultrasound Acute cholecystitis Acute gangrenous cholecystitis. Sonography demonstrates an anechoic fluid mass situated in the wall of the gallbladder. Sonograms shows marked laminated sonolucent thickening of the gallbladder wall, with the lumen of the gallbladder full of sludge. Gallbladder is enlarged
Acute cholecystitis CT Findings Acute gangrenous cholecystitis. CT scan with IV contrast material shows air in gallbladder lumen. From: CT Findings in Acute Gangrenous Cholecystitis G. L. Bennett et al. AJR 2002; 178:275-281
Acute cholecystitis CT Findings From: CT Findings in Acute Gangrenous Cholecystitis G. L. Bennett et al. AJR 2002; 178:275-281 Acute gangrenous cholecystitis. CT scan shows loculated fluid attenuation abnormality adjacent to gallbladder, consistent with abscess (a). Defect in gallbladder wall is shown (perforation). White arrow shows pericholecystic inflammation (leading to peritonitis). Abscess
Gallbladder Sludge biliary sludge The term biliary sludge refers to a characteristic ultrasound picture of movable, low-amplitude echoes that layer in the most dependent part of the gallbladder and are not associated with acoustic shadowing. Sludge is composed of cholesterol crystals, calcium bilirubinate granules, and mucin glycoprotein suspended in bile and forms in an environment that combines a high mucus concentration, dysmotility, and stasis. can lead to gallstone formation The cholesterol and calcium bilirubinate crystals in biliary sludge can lead to gallstone formation.
Ultrasound Longitudinal scan through the gallbladder shows layering of sludge in the gallbladder lumen. Gallbladder Sludge Sludge can appear, disappear, and reappear, its formation is a dynamic, reversible process
This longitudinal view of the gallbladder, as imaged from the gastric antrum, reveals dependent echogenic sludge. Ultrasound Gallbladder Sludge Clinical association with: hyperalimentation, hemolysis, fasting, pregnancy, post-op state, cirrhosis Differentiate from: hematobilia, biliary tract tumors, purulent bile
Gallbladder polyps It is estimated that as many as 4% of gallbladders examined by ultrasound will have evidence of polyp formation. The 95% of all gallbladder polyps do not give rise to cancer. They consist of cholesterol, muscle tissue or inflammatory tissue. The minority are adenomatous polyps, which can progress to cancer. larger than 1 cmIt is believed that the risk of cancer in an adenomatous gallbladder polyp is related to its size, with those larger than 1 cm being at high risk.
Findings: Ultrasound scans demonstrate a small gallbladder with diffusely thickened wall and adjacent fixed small soft tissue polyps. There was no biliary ductal dilatation or shadowing echogenic stones within the gallbladder. Chronic cholecystitis with gallbladder polyps Gallbladder polyps
Porcelain Gallbladder calcified gallbladder Extensive calcium encrustation of the gallbladder wall variably has been termed calcified gallbladder, calcifying cholecystitis, or cholecystopathia chronica calcarea. Most porcelain gallbladders (90%) are associated with gallstones. The term porcelain gallbladder has been used to emphasize the blue discoloration and brittle consistency of the gallbladder wall at surgery.
Porcelain Gallbladder Patients are usually asymptomatic, and porcelain gallbladder is found incidentally on plain abdominal radiographs, sonograms, or CT images.
Porcelain Gallbladder the high frequency (22%) of adenocarcinoma Porcelain gallbladder is uncommon, and recognizing the clinical and imaging characteristics of the disease is important because of the high frequency (22%) of adenocarcinoma in porcelain gallbladder Image from an upper gastrointestinal series demonstrates a porcelain gallbladder