Biliary Protocol (Gallbladder


 This protocol includes images of several organs and structures. It has been divided into
sections to assist in determining diagnostic images that should be stored for the physician.
o Pancreas
o Gallbladder and Common Bile Duct
 You must always evaluate the entire organ first before you store an image
 You should understand completely why you stored the image and identify everything in
the image
 Multiple breathing techniques and patient positions will be required

Organ/ Scan Label Key Landmarks Identified
Order Plane
 Pancreas head
PANCREAS  Portal splenic confluence
o If CBD is enlarged, measure internal AP diameter
 Pancreas body
e plane
Pancreas  Aorta
 Measurement
body o If pancreatic duct is seen measure internal AP
PANCREAS  Pancreas tail
 Splenic vein
Organ/ Scan Plane Label Key Landmarks
Order Identified
GB SUPINE  Gallbladder body
SAG  Gallbladder fundus
plane of
Gallblad GB SUPINE  Gallbladder body
the GB
der SAG  Gallbladder neck
Transvers GB SUPINE  Gallbladder mid body with clear delineation of
Patient in e plane of TX anterior wall
Supine the GB  Gallbladder mid body with clear delineation of
position GB SUPINE anterior wall
TX  Measurement
o measure anterior wall thickness
GB LLD SAG  Gallbladder body
Gallblad Sagittal
 Gallbladder fundus
der plane of
GB LLD SAG  Gallbladder body
the GB
 Gallbladder neck
Patient in Transvers  Gallbladder mid body
Left lateral
decubitus GB LLD TX
position plane of
the GB
Gallblad  Gallbladder body
Sagittal GB RLD SAG
der  Gallbladder fundus
plane of
 Gallbladder body
Patient in  Gallbladder neck
Right lateral Transvers GB RLD TX  Gallbladder mid body
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position e plane of
the GB

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Transvers  Portal vein
e plane of CBD TX  CBD
the CBD  Hepatic artery
 Portal vein
Common CBD SAG
Bile Duct  Enlarged image
CBD SAG  Portal vein
level of the Sagittal
porta plane of
hepatis  Enlarged image
the CBD
 Portal vein
 Measurement
o Internal AP diameter

Anatomical/ Image Correlation

CBD Hepatic

Portal CBD measurement
Inner wall to inner
Anterior GB wall measurement Transverse Portal
Outer wall to inner wall triad
Mickey Mouse Where it enters
sign the liver

Normal Measurement Ranges

Structure Area of Interest Plane Measureme Comments
Common Bile Level of Porta Long Axis <7-8 mm  Measure inner wall to
Duct Hepatis inner wall
 If duct is enlarged:
o Look for and document
any intrahepatic ductal
o Follow CBD to
pancreatic head
 If GB removed, CBD may
be enlarged (up to 11
Gallbladder wall Anterior Wall Transvers <3 mm  Calipers are placed
e outside to inside of the
anterior wall
Pancreas Head Transvers Head 2-3.5  Only performed if
e on the cm abnormalities are

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body suspected
Pancreatic Duct Body of the Transvers 2 mm or less  Only performed if duct is
pancreas e on the visualized
body  Measure internal duct
diameter anterior to

Biliary Protocol

Common Laboratory Values to be Reviewed prior to Examination

Lab Value Organ Level Indication or Association
Amylase  Pancreas Increased  Pancreatitis or other pancreatic disease
Lipase  Pancreas Increased  Pancreatitis or other pancreatic disease
Alkaline  Liver Increased  Biliary obstruction or metastases
phosphatase  Gallbladder

Bilirubin  Liver Increased  Jaundice, liver damage or obstruction
 Gallbladder

 Patient should be NPO for this study to reduce the amount of gas present and to prevent
contraction of the GB
 Have patient poke out their abdomen or take in a deep breath if having trouble seeing the
 Pancreatic tail may be evaluated using the spleen as a window
 Sit the patient erect for scanning if suspicious for stones stuck in the neck that weren’t
confirmed in LLD or RLD
 Watch your gain settings:
o Making the GB lumen too dark with TGC can mask pathology
o Using too much gain can give the appearance of pathology
 If the GB appears to have artifacts, change to a higher frequency, use harmonics, use a
different window, or have the patient poke out their abdomen
 If the GB is enlarged make sure to evaluate the ducts for signs of stones. These can
obstruct the ducts
 To find the CBD:
o Scan from the GB in transverse and follow it to the neck and cystic duct, you will
see CBD
o Follow the portal vein from the portal confluence. The CBD will be anterior to the
 If the GB has been surgically removed (postcholecystectomy), document a “GB FOSSA”
image (main lobar fissure near porta hepatis) instead of the gallbladder images

 Pathology Seen
o Gray scale sagittal and transverse images
o Gray scale sagittal and transverse images with 3 measurements (length, width, and
o Color Doppler image to document the presence of blood flow
o Spectral Doppler image to document the type and velocity of blood flow

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o If the wall measures greater than 3 mm, color Doppler can be used to confirm
increased flow in the wall due to cholecystitis.
o If the patient has gallstones and/or gallbladder wall thickening, they should be
evaluated for a positive Murphy’s sign (extreme tenderness upon transducer or manual
pressure in the RUQ). This needs to be reported to the interpreting physician as it
indicates acute cholecystitis.
o Must attempt to demonstrate movement of any pathology seen in the GB – sludge and
stones will move – masses will not!!
o If the CBD is enlarged at the porta hepatis, it should be followed to the pancreatic head
to evaluate for stones or an obstructive lesion

Image 21
Liver SagTXMPV

RightAnterior liver with
lobe sagittal with main
portal vein

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