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Flashcards in Gallbladder Deck (63):
1


—Pear shaped hollow organ
—Lies on the visceral surface of the liver
—Divided into neck/body/fundus
—Neck is continuous with the cystic duct 
 

Anatomy of the gallbladder

2


—Size is variable,

but approx 7-10cm in length and 2.5-4cm in width
 

Gallbladder size

3

An increase in GB size is termed 

Gallbladder Hydrops

4


—in the neck keeps the cystic duct from kinking
 

Heister’s valves function

5


—CYSTIC ARTERY
—CYSTIC VEIN
 

gallbladder Vascular Supply 

6


—a branch of the right hepatic artery
 

CYSTIC ARTERY- 

7


—drains the blood directly into the portal vein
 

CYSTIC VEIN- 

8


—Lies intrahepatic and then migrates to the surface of the liver
—Covered with a peritoneal layer on most of the surface.  The rest of the gallbladder is covered with an adventicia tissue layer. 

There is a potential space where these meet that can be an area where infection or inflammation can occur
—If migration does not occur, the gallbladder can be termed ectopic
 

Gallbladder location

9

gallbladder not developed

still has biliary duct system

gallbladder agenesis

10

Stores bile produced by the liver  can hold approx 50 ml

  -Concentrates bile when the body is in a fasting state

gallbladder function

11

Bile is forced into the gallbladder due to an increased pressure within the CBD produced by the  action of the sphincter of Oddi

How does the bile get into the gallbladder

12

As the stomach empties the food into the duodenum, the intestines secrete enzymes and bile salts that stimulate the gallbladder to contract and push the bile into the duodenum

How does bile get out of the gallbladder

13


There are folds within the mucous membrane of the wall that has a honeycomb appearance and unite with each other 
 

How does the gallbladder concentrate bile

14


—Consists of the right and left hepatic duct,

common hepatic duct,

common bile duct,

pear shaped gallbladder,

and cystic duct
 

Anatomy of the Bile Ducts

15


—come from the right lobe of the liver in the Porta hepatis and unite to form the CHD
 

Right and left hepatic ducts 

16

approx 4mm in diameter, joins the cystic duct(draining the gallbladder) and is now called the CBD


Common Hepatic Duct
 

17

by piercing into the wall of the duodenum where is joins the main pancreatic duct and together, they open into the duodenum through a small opening called the ampulla of Vater

CBD ends 

18


—lies lateral to the hepatic artery and anterior to the portal vein  (left ear of Mickey Mouse) 
 

CBD (prox portion) location

19


—Normal measurement is <6mm  for people 60 years or younger.  1mm per decade after age 60 
 

CBD measurement

20

approx 4 cm long,

connects the neck of the gallbladder to the CHD to form the CBD 

normally not seen by ultrasound

Cystic Duct- 

21


—Termed cholecystectomy
—The tone of the spincter of Oddi is lost, and bile is free to move into the duodenum at a fasting or non fasting state.
—Normal size of the CBD is increased, and normal is < 10mm
—Normally cannot see surgical clips by ultrasound
 

Physiology after removal of gallbladder

22

Bilobed gallbladder

Septated gallbladder

Phrygian cap

Hartmann pouch

Junctional fold

Normal variants of the Gallbladder

23

Hourglass  appearance

Bilobed gallbladder

24

Appear as thin separations within the gallbladder

Septated gallbladder

25

Gallbladder fundus is folded onto itself

Phrygian cap

26

Outpouching of gallbladder neck

Hartmann pouch

27

Prominent fold located at the junction of the gallbladder neck

Junctional fold

28


¨Should not exceed 8-10 cm in length, and 5 cm in width
¨Transverse measurement is a better indicator of enlargement
¨Referred to as hydropic gallbladder
¨An enlarged often palpable on physical exam caused by a pancreatic head mass is termed Courvoisier gallbladder
¨Patients will have painless jaundice
 

Gallbladder enlargement

29


¨Cholelithiasis
¨Gallbladder sludge
¨Gallbladder polys
¨Adenomyomatosis
¨Acute cholecystitis
¨Acalculous cholecystitis
¨Gallbladder enlargement
¨Gallbladder carcinoma
 

Gallbladder Pathology

30


¨Obesity
¨Pregnancy
¨Increased parity
¨Gestational diabetes
¨Estrogen therapy
¨Oral contraceptive use
¨Rapid weight loss programs
¨Hemolytic disorder
¨Total parenteral nutrition (TPN)
 

Cholelithiasis Risk factors and predisposing conditions

31


¨Asymptomatic
¨Biliary colic
¨Abdominal pain after fatty meals
¨Epigastric pain
¨Nausea and vomiting
¨Pain that radiates to shoulders
 

Clinical findings of cholelithiasis

32


¨Echogenic, mobile, shadowing structure(s) within the lumen of the gallbladder
¨Stones that lodge within the cystic duct or neck of the gallbladder may not move
¨WES sign may be present (gallbladder completely filled with stones)
 

Sonographic findings of cholelithiasis

33


¨Echogenic, nonshadowing, and nonmobile masses that projects from the gallbladder wall into the gallbladder lumen
¨Also called adenoma 
 

Sonographic findings of polyps

34


¨Asympomatic
¨Caused by a disturbance in cholesterol metabolism and accumulation of cholesterol within the wall of the gallbladder
¨May be single or multiple
¨Most measure less than 5mm
¨Benign
¨If these adenomas grow rapidly or >2cm, worrisome for gallbladder carcinoma
 

Clinical findings of polyps

35


¨Benign hyperplasia of the gallbladder
¨
¨Epithelium and muscular layers of the wall have tiny sinuses called Rokitansky-Aschoff sinuses.  These contain cholesterol crystals that produce comet tail artifacts
¨
¨May be focal or diffuse
 

Adenomyomatosis

36


¨Sudden onset of gallbladder inflammation
¨Focal tenderness, caused by inflammation is termed a positive sonograghic Murphy’s sign

 

Acute Cholecystitis

37


¨RUQ tenderness
¨Epigastric or abdominal pain
¨Leukocytosis
¨Possible elevation in alkaline phosphatase, aminotransferase, and/or bilirubin
¨Fever
¨Pain that radiates to the shoulders
¨Nausea and vomitting
 

Clinical Findings of Acute Cholecystitis

38


¨Gallstones
¨Positive sonographic Murphy’s sign
¨Gallbladder wall thickening
¨Pericholecystic fluid
¨Sludge
 

Sonographic findings of Acute cholecystitis

39

local tenderness over the gallbladder with transducer pressure

Murphy’s sign

40

Chronic cholecystitis

Gangrenous cholecystitis

Emphysematous cholecystitis

(bacterial invasion within the gallbladder wall)

Gallbladder perforation

Sequela of Acute Cholecystitis

41

Nontender gallbladder/intolerance to fatty foods/belching

Gallstones

Possible gallbladder wall thickening

Chronic cholecystitis

42

Elevated symptoms of acute cholecystitis

Linear echogenic membranes within the lumen of the gallladder/striated gallbladder wall

Gangrenous cholecystitis

43

Elevated symptoms of acute cholecystitis

Diabetes

Gas within the gallbladder wall that leads to ring down artifact/gallstones may not be present

Emphysematous cholecystitis

(bacterial invasion within the gallbladder wall)

44

Elevated symptoms of acute cholecystitis

Small opening or tear in the gallbladder wall

Gallbladder perforation

45


¨Most common form of gallbladder inflammation
¨Results from numerous attacks of acute cholecystitis which causes fibrosis of the gallbladder wall
¨Clinically, patients have transient pain RUQ, but not a positive Murphys sign
¨Sonographically, contracted gallbladder filled with stones (WES) sign
 

Chronic cholecystitis

46


¨Presents with all the clinical and sonographic findings of cholecystitis except no gallstones are present
¨More commonly seen in children, recently hospitalized patitents , and those who are immunocompromised
¨Uncommon
¨Caused by decreased blood flow through the cystic artery
¨Can also be caused by extrinsic compression of the cystic duct by a mass or lymphadenopathy
 

Acalculous Cholecystitis

47


¨Rare
¨Seen mostly in elderly females
¨Associated with a mobile gallbladder with a long suspensory mesentery
¨Clinical symptoms mimic acute cholecystitis
¨
¨Sonographic findings  massively inflamed and distended gallbladder, gangrene can develop
¨Treatment is surgical removal of GB
 

Torsion of the gallbladder

48


¨Results from the calcification of the gallbladder wall
¨Occurs mainly in older female patients
¨May appear sonographically similar to WES sign
¨Has been associated with the potential development of gallbladder carcinoma (25%)
 

Porcelain gallbladder

49


¨Rare, although most common cancer of the biliary tract
¨Caused by chronic irritation of the gallbladder wall by gallstones
¨Size > 2cm , suspicous for carcinoma vs poloyp
¨Color doppler can reveal vessels within the malignancy
¨Most common metastatic disease of the gallbladder is malignant melanoma
 

Gallbladder carcinoma

50


¨Weight loss
¨Right upper quadrant pain
¨Jaundice
¨Nausea and vomiting
¨Hepatomegaly
 

Clinical findings of gallbladder carcinoma

51


¨Nonmobile mass within the gallbladder lumen that measures >2cm
¨Gallstones seen in approx 90%
¨Diffuse or focal gallbladder wall thickening
¨Irregular mass that may completely fill the gallbladder fossa
¨Invasion of the mass into surrounding liver tissue
 

Sonographic findings of gallbladder carcinoma

52


¨Choledocholithiasis
¨Cholangitis
¨Pneumobilia/hemobilia
¨Cholangiocarcinoma
¨Ascariasis
 

Bile Duct Pathology

53


¨Primary – formation of stones in the bile duct resulting from a disease that leads to stasis or dilation of the ducts
¡Sclerosing cholangitis
¡Caroli’s disease
¡Parasitic infections
¡Chronic hemolytic diseases
¡Prior biliary surgery
 

Choledocholithiasis

54


¨Secondary
¡Stones found in the bile duct that has migrated down from the gallbladder
 

Choledocholithiasis

55


¨Inflammation of the biliary ducts
¨
5mm

Several types
Acute bacterial
AIDS
Pyogenic
Sclerosing
¡All of these have similar sonographic findings that include varying degrees of biliary dilatation,   biliary sludge, and bile duct wall thickening
 

Cholangitis

56

Recent biliary surgery

Sequela of emphysematous cholecystitis

Hemobilia-blood within biliary tree due to percutaneous intervention (liver bx)

Symptoms of acute cholecystitis

Pneumobilia
Hemobilia

57

Dilated intrahepatic ducts that abruptly terminate at the level of the tumor

A solid mass may be noted within the liver or ducts

Cholangiocarcinoma

58


¨Congenital disorder
¨Found in younger adult or pediatric population
¨
¨Characterized by segmental diliation of the intrahepatic ducts
¨May appear segmental, saccular, or berry shaped
¨
¨Often seen in association with cystic renal disease and may precede the development of cholangiocarcinoma, a hepatic abscess, cholangitis and sepsis
 

Caroli disease

59


¨Biliary atresia  and Choledochal Cyst
¡Congenital disease thought to be caused by a viral infection at birth, although some think it may be an inherited disorder
¡A narrowing or obliteration of all or a portion of the biliary tree
¡This leads infants to suffer from cirrhosis and portal hypertension
 

Pediatric pathology of the bile ducts

60

4 types

Most common being described as the cystic dilatation of the Common bile duct

Discovered in infancy or the first decade of life

 Jaundice

Pain

Fever 

Choledochal cyst

61


¨Cystic mass in the area of the porta hepatis  (separate from the gallbladder)
¨Biliary dilatation
 

Sonographic findings of a choledochal cyst

62


¨Jaundice
¨Pruitis
¨Unexplained weight loss
¨Abdominal pain
¨Elevated bilirubin
¨Elevated alkaline phosphatase
 

Clinical findings of cholangiocarcinoma

63


¨Dilated intrahepatic ducts that abruptly terminate at the level of the tumor
¨A solid mass may be noted within the liver or ducts
¨Klatskin tumor- found at the junction of the left and right hepatic ducts 
 

Sonographic findings of cholangiocarcinoma