Gallbladder Disease and Normal Variants { Common Clinical Findings
Eva Tutone BS,RDMS,RVT Duke University Hospital
Gallbladder Anatomy
Right lobe of Liver
Three sections : Fundus, Body, Neck
Cystic duct connects gallbladder to common bile duct
Hartmann’s Pouch…common place for Gallstones! Gallbladder Anatomy Gallbladder Function
Bile storage
Concentration of bile
Release into small intestine
Fat emulsification
Anatomical Variants
Abnormal Positioning
Agenesis
Duplication
Phrygian Cap
Micro gallbladder
Multiseptate
Abnormal Position
Very rare to be in left lobe. About 1 case per year in population imaged
Detached gallbladder or Ectopic positioning
Suprahepatic GB in right lobe of liver Agenesis of Gallbladder
Very rare condition
Often asymptomatic if only anomaly
Sometimes seen with other internal malformations such as : genitourinary renal reproductive Agenesis Gallbladder duplication
No increased chance of malignancies or stones
Can be bilobed, incomplete gallbladder with common cystic duct
Complete duplication with separate cystic ducts that lead to hepatic duct
Complete duplication with common cystic duct entering to hepatic duct Gallbladder duplication Gallbladder Duplication
Phrygian Cap
Most common variant
Fold in the fundus
No pathological significance and asymptomatic
Phrygian Cap Micro Gallbladder
Usually less than 2-3 cm long and .5-1.5cm wide
Often thick walled
Due to Cystic Fibrosis
Micro Gallbladder due to Cystic Fibrosis Multiseptate
Common finding
3-10 communicating compartments of columnar epithelium
Can cause immobility of bile leading to sludge and stones Multiseptate Gallbladder Cholecystitis
Acute
Chronic
Porcelain Gallbladder Acute Cholecystitis
Inflammation of the gallbladder
Primary complication of cholelithiasis
Most common cause of RUQ pain
Sonographic Murphy’s sign
Wall thickness >3mm
Pericholecystic fluid
Increased wall thickness in case of calculus cholecystitis Pericholecystic fluid Chronic Cholecystitis
Prolonged inflammatory condition
Seen with cholelithiasis
Wall thickening
Gallbladder contracted or distended
Pericholecystic inflammation is absent Chronic Cholecystitis Porcelain Gallbladder
Calcifying cholecystitis
Extensive calcium encrustation of wall of gallbladder
Asymptomatic Porcelain Gallbladder Non-tumor Gallbladder findings
Adenomyomatosis
Cholesterolosis
Cholelithiasis
Hydrops
Cholesterol deposits in Gallbladder wall Adenomyomatosis
Hyperplastic cholecystosis-focal wall thickening. Also used to describe cholesterolosis
Cholesterol crystals form in the Rokitansky- Aschoff sinuses
Asymptomatic although associated with biliary stasis, gallstones and pancreatitis Adenomyomatosis Cholesterolosis
Unrelated to atherosclerosis
Triglycerides and cholesterol esters are deposited in the lamina of GB wall
Lipid deposits are visible
Strawberry Gallbladder Cholesterolosis Strawberry Gallbladder Cholelithiasis
Gallstones or cholelith
Can be asymptomatic for years
The 4 F’s Fat, Forty, Fertile, and Female
Leading cause of Cholecystitis if stone blocks duct Stones form when bile is saturated with cholesterol or bilirubin
Often managed by waiting for them to pass naturally
If thought to be causing RUQ pain, nausea, and vomiting then cholecystectomy can be performed Gallstone with shadow! Multiple stones WES Sign
Wall-Echo-Shadow
Causes include one large stone or multiple stones taking up entire gallbladder
Triad-GB wall, echo from stones beneath wall, posterior shadow from stones WES sign Hydrops in Gallbladder
Accumulation of fluid (bile, water) from cystic duct blockage
Gallbladder tends to be very large greater than 9cm
Main causes are stones but tumors can also cause this Hydrops Benign Tumor Findings
Cholesterol Polyp
Inflammatory Polyp
Cholesterol Polyp
Lesions of mucosal surface of GB
Non-shadowing polyploidy growth
Majority are benign 95%
Malignant 5% (Adenocarcinoma 95%) Greater than 50% are cholesterol polyps
Most are less than 10mm with majority less than 5mm Size greater than 10mm increases malignancy rate 37- 88% Multiple Polyps So many polyps! Inflammatory Polyps
Rare variant of benign polyp
Difficult to differentiate from carcinoma if over 10mm
Tend to be vascular in nature with stalk
Polyp with color flow Malignant Gallbladder Tumor
Adenocarcinoma Adenocarcinoma
Most common cancer of gallbladder (90%)
Can affect patients with chronic cholecystolithiasis
Often asymptomatic in early treatable stages
Patient will present with jaundice in late stage due to tumor involvement of bile ducts
Extension into liver and small bowel Adenocarcinoma Gangrenous Gallbladder
Can be caused by acute cholecystitis rare 10% become gangrenous
A gallstone blocking duct leads to inflammation of wall and thus cutting off blood supply
Gangrene can look like septations in GB Gangrenous cholecystitis with membrane
A Bit about the Bile Ducts!
Choledocholithiasis
One or more stones in the common bile duct.
Pain can be similar to cholecystitis
Can block passage of bile to duodenum
Cholecystectomy or ERCP to remove stone
Choledocholithiasis
Choledochal Cyst
Congenital dilation of biliary tree
Rare finding and 60% are found before age 10
Can cause abdominal pain and jaundice if bile is backed up into cyst
When scanning look for any blockage that might cause the cystic structure. Choledochal Cyst
QUESTIONS???
References Jon W. Meilstrup (1994). Imaging Atlas of the Normal Gallbladder and Its Variants. Boca Raton: CRC Press. p. 4.
Dhulkotia, A; Kumar, S; Kabra, V; Shukla, HS (1 March 2002). "Aberrant gallbladder situated beneath the left lobe of liver". HPB: Official Journal of The International Hepato Pancreato Biliary Association 4 (1): 39–42.
Strasberg, SM (26 June 2008). "Clinical practice. Acute calculous cholecystitis". The New England Journal of Medicine 358 (26): 2804–11.
Abbruzzese JL, Willett C. Gastrointestinal oncology. Oxford University Press, USA. (2004) ISBN:0195133722.
Greenberger N.J., Paumgartner G (2012). Chapter 311. Diseases of the Gallbladder and Bile Ducts. In Longo D.L., Fauci A.S., Kasper D.L., Hauser S.L., Jameson J, Loscalzo J (Eds), 'Harrison's Principles of Internal Medicine, 18e.Retrieved November 08, 2014 fromhttp://accessmedicine.mhmedical.com.ucsf.idm.oclc.org/content.a spx?bookid=331&Sectionid=40727107
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Smith EA, Dillman JR, Elsayes KM et-al. Cross-sectional imaging of acute and chronic gallbladder inflammatory disease. AJR Am J Roentgenol. 2009;192 (1): 188-96.
Kane RA, Jacobs R, Katz J et-al. Porcelain gallbladder: ultrasound and CT appearance. Radiology. 1984;152 (1): 137-41