Extends from the point where the common hepatic duct meets they cystic duct; drains into the duodenum after it joins with the main pancreatic duct
common bile duct
storage pouch for bile
gallbladder
Small opening in the duodenum in which the pancreatic common bile duct enter to release secretions
ampulla of Vater
Massive enlargement of the gallbladder
hydrops
Tiny valves found within the cystic duct
Heister’s valve
Refers to common bile and hepatic ducts when cystic duct is not seen
common duct
Connects the gallbladder to the common hepatic duct
cystic duct
Central area of the liver where the portal vein, common duct, and hepatic artery enter
porta hepatis
Small part of the gallbladder that lies near the cystic duct where stones may collect
Hartmann’s pouch
Travels horizontally through the pancreas to join the common bile duct at the ampulla of Vater
pancreatic duct
Small muscle that guards the ampulla of Vater
sphincter of Oddi
Yellow pigment in bile formed by the breakdown of red blood cells
bilirubin
Removal of the gallbladder
cholecystectomy
Gallbladder variant in which part of the fundus is bent back on itself
phrygian cap
Bile duct system that drains the liver into the common bile duct
common hepatic duct
Gallstones in the gallbladder
cholelithiasis
Calcification of the gallbladder wall
porcelain gallbladder
Inflammation of the bile duct
cholangitis
Excessive bilirubin accumulation causes yellow pigmentation of the skin; first seen in the whites of the eyes
jaundice
Small polypoid projections from the gallbladder wall
adenomyomatosis
Sonographic pattern found when the gallbladder is packed with stones
wall echo shadow (WES) sign
Cancer at the bifurcation of the hepatic ducts; may cause asymmetrical obstruction of the biliary tree
Klatskin’s tumor
Low-level echoes found along the posterior margin of the gallbladder; move with change in position
sludge
Hormone secreted into the blood by the mucosa of the upper small intestine; stimulates contraction of the gallbladder and pancreatic secretion of enzymes
cholecystokinin
Variant of adenomyomatosis; cholesterol polyps
cholesterolosis
Inflammation of the gallbladder; may be acute or chronic
cholecystitis
Cystic growth on the common duct that may cause obstruction
choledochal cyst
Small septum within the gallbladder, usually arising from the posterior wall
junctional fold
Small, well-defined soft tissue projection from the gallbladder wall
polyp
Stones in the bile duct
choledocholithiasis
Positive sign implies exquisite tenderness over the area of the gallbladder upon palpation
Murphy’s sign
The gallbladder serves as a reservoir for ______________ that is drained from the hepatic ducts in the liver.
bile
The common hepatic duct joins the common bile duct, and together they open through a small ampulla (the ampulla of _______________) into the duodenal wall.
Vater
The end parts of the common bile duct and main pancreatic duct and the ampulla are surrounded by circular muscle fibers known as the _______________.
sphincter of Oddi
The arterial supply of the gallbladder is from the _______________ artery, which is a branch of the right hepatic artery.
cystic
List the two primary functions of the extrahepatic biliary tract.
transportation of bile from the liver to the intestine and regulation of flow
Describe the normal function of the gallbladder during digestion.
Bile collects during a state of fasting, and is forced into the gallbladder by contraction of the common bile duct and the sphincter of Oddi. During the fasting state, very little bile flows into the duodenum. Food stimulates the gallbladder to force bile into the duodenum. When the stomach is empty, peristalsis relaxes and bile begins to store again.
Bile is the principal medium for excretion of bilirubin _______________.
cholesterol
The _______________ from the small intestine stimulate the liver to make more bile. This activates intestinal and pancreatic enzymes.
bile salts
The sign that indicates an extrahepatic mass compressing the common bile duct, which can produce an enlarged gallbladder, is called ______________.
Courvoisier’s sign
Sonographically, the common duct lies _______________ and to the _______________ of the portal vein in the region of the porta hepatis and gastrohepatic ligament.
anterior, right
The hepatic artery lies _______________ and to the _______________ of the portal vein.
anterior, left
To ensure maximum dilation of the gallbladder, the patient should be given nothing to eat for at least _______________ hours before the ultrasound examination.
8-12
The patient is initially examined with ultrasound in full _______________.
inspiration
The patient should also be rolled into a steep _______________ or upright position (to ensure there are no stones within the gallbladder) in an attempt to separate small stones from the gallbladder wall or cystic duct.
decubitus
The gallbladder may be indentified as a(n) _______________ oblong structure located anterior to the right kidney, lateral to the head of the pancreas and duodenum.
sonolucent
The gallbladder commonly resides in a(n) _______________ on the medial aspect of the liver.
fossa
Because of _______________ tissue within the main lobar fissure of the liver (which lies between the gallbladder and the right portal vein), this bright linear reflector is a reliable indicator of the location of the gallbladder.
fat/fibrous
A small _______________ fold has been reported to occur along the posterior wall of the gallbladder at the junction of the body and infundibulum.
echogenic
On a transverse scan, the common duct, hepatic artery, and portal vein have been referred to as the _______________ sign.
Mickey Mouse
To obtain a cross section of the portal triad, the transducer must be directed in a slightly _______________ path from the left shoulder to the right hip.
oblique
On sagittal scans, the right branch of the hepatic artery usually passes _______________ to the common duct.
posterior
The common duct is seen just _______________ to the portal vein before it dips posteriorly to enter the head of the pancreas.
anterior
When the right subcostal approach is used, the common hepatic duct is seen as a tubular structure anterior to the portal vein. The right branch of the _______________ artery can be seen between the duct and the portal vein as a small circular structure.
hepatic
The most classic symptom of gallbladder disease is _______________ pain, usually occurring after ingestion of greasy foods.
right upper abdominal quadrant
A gallbladder attack may cause pain in the _______________ shoulder.
right
The normal wall thickness of the gallbladder is less than _______________ mm.
3
List the six biliary causes of gallbladder wall thickening.
cholesystitis, adenomyomatosis, cancer, AIDS, cholangiopathy, sclerosing cholangitis
Clinically the patient with acute cholesystitis presents with these symptoms:
acute right upper quadrant pain, positive Murphy’s sign, fever, leukocytosis, increased serum bilirubin and alkaline phosphatase levels may be present
The _______________ sign is described as a contracted bright ballbladder with posterior shadowing caused by a packed bag of stones.
WES
A fairly rare complication of acute cholecystitis associated with the presence of gas-forming bacteria in the gallbladder wall and lumen with extension into the biliary ducts is called _______________.
emphysematous cholecystitis
Clinically the patient falls under the five “F”s:
fat, female, forty, fertile, fair
Explain why the patient’s position should be shifted during the ultrasound examination.
The patient’s position demonstrates the movement of stones. They should be scanned in the left decubitus, right lateral or upright position. The stones should shift in the most dependent area of the gallbladder. Sometimes if the bile has a thick consistency, the stones will remain near the top of the gallbladder. The density and posterior shadow will provide sonographic evidence for stones.
Describe the factors that produce a shadow in the gallbladder.
acoustic impedence of gallstones; refraction through them or defraction around them; their size, central or peripheral location, and position in relation to focus of the beam; intensity of beam
_______________ may be the result of pancreatic juices refluxing into the bile duct because of an anomalous junction of the pancreatic duct into the distal common bile duct, causing duct wall abnormality, weakness, and outpouching of the ductal walls.
choledochal cysts
A hyperplastic change in the gallbladder wall is _______________.
adenomyomatosis
The differential for a porcelain gallbladder would include a packed bag or _______________ sign.
WES
What is the most notable sonographic finding with carcinoma of the gallbladder?
The gallbladder wall is very abnormal and thick.
The most common cause of biliary ductal system obstruction is the presence of a(n) _______________ or _______________ within the ductal system.
tumor, thrombus
The job of the sonographer is to localize the level and cause of the obstruction. List the three primary areas where obstruction occurs.
intrahepatic, suprapancreatic, porta hepatis
An uncommon cause for extrahepatic biliary obstruction as a result of an impacted stone in the cystic duct creating extrinsic mechanical compression of the common hepatic duct is _______________ syndrome.
Mirizzi
_______________ causes increasing pressure in the biliary tree with pus accumulation.
cholangitis
The majority of stones in the common bile duct have migrated from the gallbladder. Common duct stones are usually associated with _______________.
calculous cholecystitis
_______________ within the duodenum may also give rise to a dirty shadow in the right upper quadrant.
air/gas
On ultrasound, multiple cystic structures that converge toward the porta hepatis are seen in _______________ disease.
Caroli’s
What maneuvers may be performed to be sure the sludge in the gallbladder is not a tumor?
The patient’s position should be changed to see if the sludge moves. The bile can be viscous, and movement of sludge may be slow.
Describe the clinical signs and sonographic findings of the patient with acute cholecystitis. What complications should the sonographer be aware of?
RUQ pain and fever are signs; findings include: enlarged gallbladder, positive Murphy’s sign, thick, irregular gallbladder wall, stones and pericholecystic fluid; complications include: rupture of gallbladder, empyema, emphysematous or gangrenous cholecystitis, perforation
What anechoic structure(s) surround the gallbladder that may lead to confusion during the examination?
The duodenum may be in the way, especially if filled with fluid. The sonographer can look for peristalsis or change the patient’s position.
