Gallbladder Disease and Normal Variants

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 RokitanskyAschoff 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 3788%
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): 17483. 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