GB Pathology Flashcards
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______ is Debris within the gallbladder made up of cholesterol and bile salts that fall out of solution and are seen as echogenic material that may layer out, and without an acoustic shadow.
sludge
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Development of biliary _____ typically secondary to stasis
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etiology: Anorexia, IV feedings, Non functioning GB, Long term illness, Pregnancy
sludge
describe viscid
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Thick Fluid; low level echoes that will layer in the dependent portion of the GB. Stones may or may not be present. Is mobile, so movement
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Fluid Fluid level seen within the gb, when pt. is decubed sludge may take a while to settle.
what are these? describe.
Tumefactive: Aggregate of intraluminal sludge on ultrasound can mimic soft tissue density mass. aka sludge ball
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Viscid: having a glutinous/viscose consistency
what types of sludge are there? describe them.
ddx?
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Tumefactive – Clumps of sludge. No layering, can be confused with a stone, polyp or mass. Doppler will not show a vascular supply. Will move, roll into dependent portion of the GB. Stones may or may not be present
Viscid– Thick Fluid; low level echoes that will layer in the dependent portion of the GB. Stones may or may not be present. Is mobile, so movement. Fluid Fluid level seen within the gb, when pt. is decubed sludge may take a while to settle.
DDX: Polyp, GB CA (mass or stone)
what is this?
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Tumefactive: Aggregate of intraluminal sludge on ultrasound can mimic soft tissue density mass. aka sludge ball
what is this?
severe sludge aka chronic cholecystitis.
pic b – chronically theickening, pain is gone.
what is the dif b/t cholelithiasis and choledocholithiasis
define.
what is the etiology?
gall stones and gallstone in the duct
The presences of stones within the GB
Choledocholithiasis is stones within the bile duct.
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Etiology
Cholesterol – 80% are made primarily of cholesterol. Pure cholesterol stones are rare.
The other 20% are composed of the following.
Bile pigments
Calcium bilirubinates
Calcium carbonate
wha types of etiology are there for cholelithiasis?
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Metabolic
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Stasis
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Inflammation
what are the metobolic etiologies of the gb? (3)
Metabolic
-Hypercholesteremia: Liver produces too much cholesterol. This is called Hypercholesteremia. DM, Pregnancy, Obesity, Genetics can all lead to this condition
-Hyperbilirubinemia: Another mechanism for stone formation is too much bilirubin. Any prolonged hemolytic anemia (breaking down of RBC), sickle cell anemia or thalassemia (An inherited form of anemia occurring chiefly among people of Mediterranean descent, caused by faulty synthesis of part of the hemoglobin molecule). This condition is termed
Hyperbilirubinemia, - Celiac Dz. Inherited autoimmune, lining of the small bowel is damaged from eating gluten and other proteins found in wheat, barley, rye.
- CF Cystic Fibrosis
- Pregnancy
- Various Meds
what is the function of the gallbladder.
is it necessary?
gb will start to release more mucous thickening the blie. gallbladder takes water out of the bile
the gallbladder is a small pouch that sits just under the liver. The gallbladder stores bile produced by the liver. After meals, the gallbladder is empty and flat, like a deflated balloon. Before a meal, the gallbladder may be full of bile and about the size of a small pear.
In response to signals, the gallbladder squeezes stored bile into the small intestine through a series of tubes called ducts. Bile helps digest fats, but the gallbladder itself is not essential. Removing the gallbladder in an otherwise healthy individual typically causes no observable problems with health or digestion yet there may be a small risk of diarrhea and fat malabsorption
If a pt. is not eating regularly, and the GB is not being emptied stones can form. what is this called?
how does it happen?
stasis
IV feedings
anorexic
low fat dieting
non-functioning GB
some medications
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______ is described as Bile makeup is altered. Cholesterol is less soluble, the inflamed mucosa secretes calcium bilirubinates (salts) into the bile. Proteins are secreted into the gallbladder from the from the inflamed gallbladder wall providing a NIDUS or nucleus for stone development.
what is NIDUS?
inflammation - GB or ducts
nidus - little grain of sand that gets into an oyster turns into a pearl. this is like that.
what clinical signs are associated w/ cholelithiasis ?
Asymptomatic; you can have gallstones and not have pain
More common in females, 4:1 ratio. Typically you hear the five F’s.
- Fat
- Female
- Fertile
- Forty
- Fair
RUQ pain associated with eating; Not with eating itself but after the meal. Pain usually occurs post meal 1-3 hrs roughly. WHY doe this occur?
If pt. passes a stone through the bile duct or if the stone becomes stuck in the distal duct they can have complications. i.e. jaundice, gallstone pancreatitis May have fever
May have jaundice
Stones are thought to be a cause to GB CA. The etiology of gallbladder cancer has eluded researchers thus far, but it has been associated with gallstone disease, estrogens, cigarette smoking, alcohol consumption, obesity, and female sex.
what labs are associated choleithiasis?
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Alkaline Phosphatase is usually elevated in a non-functioning GB, or stone stuck within a bile duct.
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Also Bilirubin can be elevated in cases of ductal obstruction.
what do u see?
cholethiasis
describe the sonographic appearance of choleithiasis.
It is possible for the stone to be wedged in the GB neck area. It may not move when the pt.’s position is changed and may go unseen if the patient has a lot of gas. Notice how small this stone is and how easy it could be missed.
The stone could be wedged for several reasons.
It may be due to inflammation, the GB walls are swollen and are impinging on the stone.
A non-fasting state. GB partially contracted due to that egg McMuffin they had on the way to the hospital that morning. Again the walls are holding on to the stone and not allowing it to move freely.
who can you tell the difference b/t non-WES and WESin cholelithiasis??
wall echo shadow complex.
what is this?
GB Diseases
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Cholelithiasis. Pseudo Stones – False Positive
Bowel gas can mimicking gallstones stones as well as
Polyp
Sludge ball – Tumefactive sludge
Surgical clips
what may be mistaken as false neg cholelithiasis
False negatives
Small stones
Contracted gallbladder – hiding stones
Sludge
Stone in fundal (Phrygian) cap, or junctional fold.
what do you see here?
cholelithiasis - Milk of Calcium
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You will see a bright echo with posterior shadowing. It is made up of a pasty substance made mostly of calcium carbonate.
explain the etiology of a contraced gb.
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Physiologic contraction – Pt. non prepped correctly
Inflammation – Acute or Chronic Cholecystitis, Hepatitis
Hypoalbuminemia
Hypoplasia of gallbladder rare
what does the following describe.
Small, thin gallbladder
May have thickened wall > 2mm
History will be important for accurate diagnosis. Is it physiologic or disease?
Generally physiologic contraction will not have an overtly thickened GB wall.
contracted gb
what does the following describe?
Distention of the GB, generally due to total obstruction of the cystic duct.
The GB wall secretes mucinous substance and becomes tense and enlarged.
The GB wall becomes thin.
Some people have large a GB, it should not appear tense, or “ready to burst”.
Cystic duct obstruction
CBD obstruction
Courvoisier’s GB – Occurs from biliary obstruction (Panc. Head tumor, Distal CBD tumor, duodenal Tumor)
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gb hydrops
what clinical signs are associated with hydrops
Clinical Signs
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RUQ, Epigastric pain, discomfort particularly with palpation over GB, N/V
May be asymptomatic, particularly in diabetics due to neuropathy
what is Courvoisier’s sign?
In 1890 Courvoisier observed that a palpable, non-tender gallbladder in a patient with obstructive jaundice is often caused by a non-calculus abnormality of the biliary system, such as pancreatic cancer or cholangiocarcinoma, distal to the insertion of the cystic duct. He attributed his findings to a higher likelihood of fibrosis of the gallbladder, with stone disease rendering it less distensible.
The etiology of the non-distended gallbladder is in cases of non-calculus biliary obstructions is still not well understood to this day.
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Although often associated with malignancy, the Courvoisier sign can also be seen in benign processes causing obstruction of the common bile duct.
what does the following describe
GB ≥ 12cm in length and ≥ 4cm wide
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The GB will appear tense, like a very full balloon. Rounded. No undulations in the GB wall.
hydrops
what does the following etiology describe?
Inflammation of the GB, Common, accounts for 5% of pt. presenting to ER with Abd. pain. 3-9% of hospital admissions.
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Acalculous cholecystitis: No stones involved, pt. typically have sludge or debris within the GB. This is caused from Post trauma or Long term IV hyper alimentation. Typically found in critically ill patients.
Acute Cholecystitis
what is the following sequela to?
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Impaction of a stone in the neck, causing obstruction, results in luminal distention, ischemia, infection and necrosis of the GB.
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GB contracts physiologically, stones in GB irritate the wall causing inflammation, possible infection. Not all people with gallstones have symptoms.
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Stone can become lodged in the duct causing an obstruction, if the become stuck in the distal duct they can cause pancreatitis
acute cholecystitis
what are these clinical signs of?
Variable
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Female 3 X more likely
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Acute RUQ pain sometimes radiating to shoulder ( due to irritation of the phrenic nerve) by exudate fluid. Often occurs after eating certain foods. Fatty, Greasy
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Positive Murphy’s sign “John Benjamin Murphy”
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A sonographic Murphy’s sign is maximal tenderness directly over the GB. Use the transducer to visualize the GB and apply pressure directly over the GB. It is often best to not ask the pt. “does this hurt”? Just apply pressure and observe.
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Ileus: Gallstone Ileus. Results from and intestinal obstruction. A gallstone which has passed from the biliary tree into the Duodenum become stuck at the ilieocecal valves. The proximal bowel becomes dissented with gas
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Jaundice in 25% of patients
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Fever
acute cholecystitis
These symptomatic signs are what differentiates them from the chronic cholecystitis.
how do you check for murphys sign?
Murphy’s sign exam - Clip
The clip demonstrates how to check for a clinical Murphy’s sign. Notice that it is not specific for cholecystitis but can be positive in cases of Hepatitis. Many patients who are constipated will have RUQ pain and thus a positive Murphy’s sign. A sonographic Murphy’s sign is when you can elicit pain with pressure directly over the GB.
_____ is Intestinal obstruction is a partial or complete blockage of the bowel that results in the failure of the intestinal contents to pass through
An Ileus, gallstone ileus
what are the following labs associated with
Increased Alkaline Phosphatse, Increased WBC (leukocystosis), Increased bilirubin
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Mild increase in AST, ALT
acute cholecystitis
describe the sonographic appearance of acute cholecystitts
GB wall greater then 3mm in thickness, may be irregular, pericholecystic fluid, Stones or Sludge.
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May have hydrops of the GB
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Murphy’s sign is usually present
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Hyperemia of the wall (increased blood flow noted on color Doppler)
____ is Repeated acute episodes or “attacks” can lead to fibrotic changes take places in then GB wall leading to dysfunction and irregular wall appearance
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Patience are most commonly asymptomatic, this is what differentiates it from acute
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Most common form of GB wall inflammation
chronic cholecystitis
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_______ is a term used clinically to refer to symptomatic gallbladder stones that cause transient obstruction, leading to a low-grade inflammation with fibrosis
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Strong history of certain food intolerances, generally fatty, fried foods
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Correlation of the imaging finding of a stone-containing slightly thick-walled gallbladder with the clinical history is critical
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Labs
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May have Increase in Alk. Phosphatase, AST, ALT
Chronic cholecystitis
what do you see here?
Chronic Cholecystitis
US presents of stones, WES sign, stone disease, small contracted GB, may be hard to located secondary to its small and contracted state.
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____ is Inflammation of wall in the absence of stones
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Etiology
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Decreased cystic artery flow
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Depressed motility
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Extrinsic compression of cystic duct
it has the same clinical signs and labs and cholecystitis
Acalculous Cholecystitis
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____ is Rare – seen in .8% of cholecystectomy specimens
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Calcification of the Gallbladder wall. Usually only part of the wall is calcified
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Unknown why this occurs
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Associated with stones 95% of the time
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Clinical signs - Same as stones
Labs- Same as stones
describe it sonographically
porcelain gb
A rare manifestation of chronic cholecystitis. Will be similar to WES. Hyperechoic, curved interface, shadowing from the strong reflectors
____ is –
A complication of acute cholecystitis in which gas producing organisms are within the GB wall, lumen and biliary duct
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50% of pt. will emphysematous cholecystitis have diabetes.
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May look like WES sign only with a dirty posterior shadow.
Emphysematous Cholecystitis
what is this?
emphysematous cholecysititis
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_____ is Another complication of acute cholecystitis in which the gallbladder may perforate secondary to necrosis
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Etiology
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Cystic artery becomes blocked
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Sonographic appearance
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echogenic material within the GB, representing sloughed GB wall and blood
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Gangrenous Cholecystitis
____ is A benign condition. It is caused by an exaggeration of the normal invaginations of the luminal epithelium (Rokitansky-Aschoff sinuses) with associated smooth muscle proliferation.
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Hyperplasia change within the wall of the GB, which is not a precursors to CA. It is not caused by inflammation.
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Clinical Signs
•More common in females:
Asymptomatic
Incidental finding
adenomyomatosis
what is this? describe it
adenomyomatosis
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There are papillomas which appear in the GB. These can be single (focal) or found multiple (defuse) and can be found over a large part of the mucosal surface of the GB. They have a distinct “ring-down” or “Comet tail” artifact associated with them.
focal
____ is •
An abnormal deposition of cholesterol into the GB wall. A benign condition that is the result of accumulation of lipids within macrophages. A diffuse form, known as “Strawberry GB”, is not visible on imaging modalities. The strawberry GB comes from the way it looks to the pathologists
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The focal form is visible as polyps adhered to the mucosal wall of the GB
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The most common pseudo tumor of the GB
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Etiology
Unknown (idiopathic)
50-70% patient will have cholesterol stones
cholesterosis
what clinical signs are associated w/ cholesterosis?
labs?
Asymptomatic
Incidental finding
More common in females
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Labs
None, typically does not disrupt GB function
*No elevation of serum cholesterol levels*
what is this? describe it.
Cholesterosis
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Typically non shadowing hyperechoic mass or masses. Adhered to the GB wall. These are not mobile. With larger polyps you can often seen them sway back and forth.
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Small size < 10mm and multiplicity are features most suggestive of benignity. No blood flow is seen within these polyps. These are important to keep in mind to help differentiate from GB carcinomas.
who usually has carcinoma of the gallbaldder.
is it common
what is it generally associated w/
what type is the majority?
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Uncommon malignancy, mainly found in elderly, with a 3:1 CR (4:1 HA) female to male predominance.
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Accounts for 4% of all cancers.
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Majority are associated with gallstones.
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98% of the carcinomas are adenocarcinomas, with squamous cell carcinoma and metastases making up the rest.
what are these clinical signs of?
Extremely insidious (lack of symptoms) Asymptomatic
Loss of appitite
N/V
Intolerance to fatty foods
Belching
RUQ pain in half of patients.
carcinoma of the bladder
what is this? how can you tell?
any labs associated?
former 2 are adeno carcinoma. the below is carcinoma
Most common appearance is
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Mass arising within the GB fossa, obliterating the GB and invading the nearby liver
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Focal or diffuse, irregular wall thickening
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Intraluminal polypoid mass, generally > 1cm often with flow detected by Doppler.
Why do you think the cancer is typically greater than 1cm?
no specific labs
what is the most common type of metastases to gb? describe it.
clinical signs?
labs?
Etiology
Melanoma is the most common cancer to spread to the GB
Can come from Stomach, Pancreas, Bile Ducts, Ovary and Colon
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Clinical signs
Same as primary
Extremely insidious (lack of symptoms) Asymptomatic
Loss of appetite
N/V
Intolerance to fatty foods
Belching
RUQ pain in half of patients.
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Labs
None
what could this bE?
This is metastases for melanoma. Look similar to a polyp or other CA.
what are some common causes of increased gb wall thickness?
Hypoalbuminemia – Ascites
CHF
AIDS
Cholecystitis
Hepatitis
Tumor
Drugs
Non-fasting
what are common reasons for nonvisulaization of the gb?
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Prior Cholecystectomy – You would be surprised to know that we are asked to check for GB dz. In patients that have had there GB removed.
Physiologic contraction
Fibrosed gallbladder
Air-Filled gallbladder
Total sludge filled GB
Agenesis of the GB
Ectopic location
