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Gallbladder Disease and Normal Variants { Common Clinical Findings

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Gallbladder Disease and Normal Variants { Common Clinical Findings 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 Altun E, Semelka RC, Elias J et-al. Acute cholecystitis: MR findings and differentiation from chronic cholecystitis. Radiology. 2007;244 (1): 174- 83. doi:10.1148/radiol.2441060920 - Pubmed citation 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 .
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