MODULE I

ABDOMEN II
 Learning outcome

1.Identify types of congenital disease of the

biliary system.
2.Describe sonographic appearance of
different congenital disease of the biliary
system.
3. Describe sonographic appearence of
varies biliary disease.
 GALL BLADDER AND BILE
DUCTS
Biliary tree
Congenital disease
Choledochal cysts
Focal or diffuse cystic dilation of biliary tree
East Asian population
Most present early in life
20% encountered in adulthood
GALL BLADDER AND BILE DUCTS
Biliary tree
Congenital disease
Choledochal cysts
Type I
Most common
Fusiform dilation of CBD
Type II
True diverticuli
Very rare
Type III
Choledochocoeles
Confined to intraduodenal portion of CBD
Type IVa
Multiple intra- and extrahepatic biliary dilatations
Type IVb
Cysts confined to extrahepatic biliary tree
Types of Choledochal cyst
 GALL BLADDER AND BILE
DUCTS
Biliary tree
Congenital disease
Choledochal cysts
Sonographic appearance
Cystic structure
Internal sludge possible
Important to show connection with biliary tree
Differential findings
Pancreatic pseudocyst
Enteric duplication cysts
Proven risk of cholangiocarcinoma
Surgical resection advocated
 GALL BLADDER AND BILE
DUCTS
Obstruction of the biliary tree
Sonography highly sensitive in detecting a dilated
biliary tree
Scan performed with knowledge of patient clinical
condition
? Painless or painful jaundice
Latter – acute obstruction +/- infection
Examination should assess
? Duct or gb dilation
Level of dilation
Cause of dilation
GALL BLADDER AND BILE DUCTS
Obstruction of the biliary tree
Causes
Neoplastic
Choledocholithiasis
Cholangiocarcinoma
Congenital biliary disease
Gall bladder
Infections carcinoma
Acute pyogenic Locally invasive
cholangitis tumours (pancreatic)
Biliary parasites Ampullary tumors
Recurrent pyogenic Metastasis
cholangitis Extrinsic compression
HIV cholangiopathy Mirizzi’s syndrome
Sclerosing cholangitis pancreatitis
GALL BLADDER AND BILE DUCTS
Obstruction of the biliary tree
Choledocholithiasis
Primary type
Common in East Asia
De novo formation of stones within ducts
Calcium Bilirubinate (pigment stones)
Aetiologic factors related to disease causing
strictures/duct dilation leading to stasis
Sclerosing cholangitis
Caroli’s disease
Parasitic infection of the liver (Fascioli and Ascaris)
Chronic haemolytic diseases – sickle cell
Prior biliary surgery eg. biliary-enteric anastamosis
Secondary type
Migration of stones from the gall bladder into CBD
Choledocholithiasis
GALL BLADDER AND BILE DUCTS
Obstruction of the biliary tree
Intrahepatic stones
Sonographic appearance
Depends on size and texture
Most are highly echogenic with posterior
shadowing
Soft pigment stones (recurrent pyogenic
cholangitis) may not shadow
For stone-filled ducts – echogenic linear
structure with shadowing in the region of the
portal triad
Intrahepatic ducts should be surveyed using
Harmonic Imaging
Intrahepatics stones
Intrahepatic stones
GALL BLADDER AND BILE DUCTS
Obstruction of the biliary tree
Common bile duct stones - choledocholithiasis
Majority stones in distal CBD
Assess entire duct
Classical appearance of stone should be
demonstrated
Small stones may lack shadowing
Pitfalls
Haemobilia (clots)
Papillary tumors
Sludge
Surgical clips from previous cholecystectomy
Duodenum – bowel gas
Choledocholithiasis
GALL BLADDER AND BILE DUCTS
Biliary tract
Haemobilia
Blood within biliary tree
Iatrogenic biliary trauma
Percutaneous procedures, liver biopsies
approx 65% cases
Cholangitis/cholecystitis 10%
Vascular malformations 7%
Abdominal trauma 6%
Malignancies 7%

Ultrasonic appearance is usually an echogenic or mixed

echogenicity clot conforming to the shape of the duct.
Acute haemorrhage appears as fluid with low level
echoes
Haemobilia in GB
Haemobilia in duct
 GALL BLADDER AND BILE
DUCTS
Biliary tract
Pneumobilia
Air within biliary tree
Commonly a result of biliary intervention
Biliary-enteric anastamosis
Bile duct stent
Acute abdomen – three entities
Emphysematous cholecystitis
Choledochoduodenal fistula – inflamed impacted
stone
Prolonged acute cholecystitis – cholecysto-enteric
fistula
 GALL BLADDER AND BILE
DUCTS
Biliary tract
Pneumobilia
Sonographic appearance
Typical air in duct appearance
Bright, echogenic linear structures following
portal triad
Reverberation artifact (ringdown) dirty
shadowing
Movement of air bubbles with pt movement
PNEUMOBILIA
PNEUMOBILIA
PNEUMOBILIA
Pneumobilia
Pneumabilia
 GALL BLADDER AND BILE
DUCTS
Biliary tract
Sclerosing cholangitis (SC)
Chronic inflammatory disease
Unknown aetiology
Primary and secondary types
 GALL BLADDER AND BILE
DUCTS
Biliary tract
Primary sclerosing cholangitis
Chronic disease
Men affected more frequently
80% pts have concomitent inflammatory bowel disease
Autoimmune disorders
Systemic sclerosing conditions
Most pts asymptomatic
Affects entire biliary tree
Fibrosing inflammation of small and large ducts
Biliary strictures and cholestasis
Eventually
Biliary cirrhosis
Portal hypertension
Hepatic failure
 GALL BLADDER AND BILE
DUCTS
Biliary tract
Primary sclerosing cholangitis
Sonographic appearance
Irregular, circumferential bd wall thickening
Narrowed lumen
Focal strictures and dilatation
Choledocholithiasis considered a
complication
Frequently seen in symptomatic pts
 GALL BLADDER AND BILE
DUCTS
Biliary tract
Causes of secondary sclerosing cholangitis
AIDs cholangiopathy
Bile duct neoplasm
Biliary tract surgery, trauma
Choledocholithiasis
Congenital abnormalities of biliary tract
Ischaemic stricturing of bile ducts
Post treatment for hydatid cyst
sclerosing cholangitis
sclerosing cholangitis
 GALL BLADDER AND BILE
DUCTS
Biliary tree
Cholangiocarcinoma
Uncommon neoplasm
Incidence relies on populations harboring known risk factors
High incidence NW Thailand – liver fluke
Frequency increases with age
Peak incidence – 8th decade of life
Chronic biliary stasis and inflammation
Primary sclerosing cholangitis mc risc factor in western world
Classification :
Intrahepatic
Hilar
distal
 GALL BLADDER AND BILE
DUCTS
Biliary tree
Intrahepatic cholangiocarcinoma
Least common location
Second most common primary malignancy of the
liver
Rising incidence in last 2 decades
Liver cirrhosis
Hepatitis C infection
Poor prognosis
Mass often unresectable
 GALL BLADDER AND BILE
DUCTS
Biliary tree
Intrahepatic cholangiocarcinoma
Sonographic appearance
Solid mass
Hypovascular
Heterogeneous echotexture
Hypo-, hyper- or isoechoic
Higher incidence of ductal obstruction than
HCC
 GALL BLADDER AND BILE
DUCTS
Biliary tree
Hilar cholangiocarcinoma
U/S important in diagnosis and staging
U/S performed prior to bilary manipulation or
stent placement
Clinical
Jaundice
Pruritus
Elevated cholestatic parameters
Vague symptoms
Elevated serum alk phos levels
Hilar cholangiocarcinoma
( klatskin)
GALL BLADDER AND BILE DUCTS
Biliary tree
Hilar cholangiocarcinoma
Patterns of tumor growth
Begin in either rt or lt bile ducts
Extend prox into higher order branches
Spread
Subendothelial
Peribiliary connective tissue
Obstruction
Portal vein and arteries
LNs of the portahepatus and hepatoduodenal
Mets to liver and peritoneal surfaces
Tx
Curatave - Surgical resection
 UNRESECTABLE HILAR
CHOLANGIOCARCINOMA

Rumack et al
 GALL BLADDER AND BILE
DUCTS
Biliary tree
Hilar cholangiocarcinoma
Sonographic evaluation and assessment
Level of obstruction
Presence of a mass
Lobar atrophy
Patency of main, right, and left portal veins
Encasement of hepatic artery
Local and distant adenopathy
Presence of metastasis
GALL BLADDER AND BILE DUCTS
Biliary tree
Distal cholangiocarcinoma
Clinically indistinguishable from hilar
Surgical resection most effective therapy
Sonographic appearance
Several appearances
Polypoid tumor appears as duct expanding, well
defined intraductal mass
Often has no internal vascularity
In more advanced cases
Hypoechoic, hypovascular mass with poorly
defined margins invading adjacent structures
 DISTAL
CHOLANGIOCARCINOMA

Rumack et al
 GALL BLADDER AND BILE
DUCTS
The gall bladder
Pear shaped organ
Lies in the posteroinferior margin of liver
Between left and right lobes of the liver
Same anatomic plane as middle hepatic vein
Fundus, body and, neck
Hartmann’s pouch – neck
Spiral valves of Heister
 GALL BLADDER AND BILE
DUCTS
The gall bladder
Embryology
Initially intrahepatic structure
Migrates to surface
Acquires peritoneal covering (part of liver)
Potential space between gb and liver
Reflects oedematous process
GALL BLADDER AND BILE DUCTS
The gall bladder
Congenital variations
Partial or Intrahepatic gallbladder
Rare
Failure to migrate
Gb enveloped in visceral peritoneum
Hangs from mesentery
Increased mobility
Risk of volvulus (rare)
Agenesis
ectopic
Septate gall bladder
Two or more intercommunicating compartments
Duplication
Duplication of cystic duct
 GALL BLADDER AND BILE
DUCTS
The gall bladder
Sonographic non-visualisation of gb
Previous cholecystectomy
Physiologic contraction
Fibrosed gb duct – chronic cholecystitis
Emphysematous cholecystitis
Tumefactive sludge
Agenesis of gb
Ectopic location
 GALL BLADDER AND BILE
DUCTS
The gall bladder
Gallstone disease
Common worldwide
High incidence in Europe and N America
Low incidence in East Asia
Risk
5Fs !
Diabetes
Pregnancy
Incidental finding on u/s in most cases
~ 1 in 5 develop complications – biliary colic
GALLSTONES
 GALL BLADDER AND BILE
DUCTS
Gallstone disease
Sonography
Highly sensitive imaging modality
Stones are highly reflective
Large bile-stone impedance mismatch
Echogenic focus with posterior shadowing
Stones <5mm may not shadow
Mobility a key feature (stone vs polyps)
Multiple stones resemble single large stone
Wall-echo-shadow (WES complex)
GALL BLADDER AND BILE DUCTS
Gallstone disease
Biliary sludge
Biliary sand or microlithiasis
Precipitation of bile solutes
Predisposition
Pregnancy
Rapid weight loss
Prolonged fasting
Critical illness
Long-term parenteral nutrition
Bone marrow transplantation
Progression over 3 year period
50% cases resolved
20% persist asymptomatically
5% - 15% develop gallstones
10% - 15% become symptomatic
 GALL BLADDER AND BILE
DUCTS
Gallstone disease
Biliary sludge
Complications
Stone formation
Biliary colic
Acalculous cholescystitis
Pancreatitis
Sonographic appearance
Amorphous, low-level echoes in dependent
portion of gb
No shadowing
“Tumefactive sludge” mimics tumor
Sludge
Tumefactive sludge
GALL BLADDER AND BILE DUCTS
Gallstone disease
Acute cholecystitis
Relatively Common
5% pts reporting to A&E with RUQ abdominal pain
radiates to the right shoulder blade.
Caused by gallstones in 90% cases
Obstruction due to impaction in gb neck
Luminal distention
Ischaemia
Necrosis of gb – gangrenous
Findings
Fever
Leucocytosis
Incerased serum bilirubin and alk phos levels
 GALL BLADDER AND BILE
DUCTS
Gallstone disease
Acute cholecystitis
Sonographic findings
Thickened gb wall (> 3mm)
Over Distended gb (diameter > 4cm)
Gallstones
Impacted stone in neck or cystic duct
Pericholecystic fluid collections
+ve sonographic Murphy’s sign
Hyperaemic gb wall on colour doppler
GALL BLADDER AND BILE DUCTS
Gallstone disease
Causes of gall bladder wall thickening
Generalised oedematous states
Congestive heart failure
Renal failure
End-stage cirrhosis
Hypoalbumenaemia
Inflammatory conditions
Primary
Acute cholecystitis
Cholangitis
Chronic cholecystitis
Secondary
Acute hepatitis
Perforated duodenal ulcer
Pancreatitis
Diverticulitis/colitis
Neoplastic conditions
adenomyomatosis
 GALL BLADDER AND BILE
DUCTS
Gallstone disease
Acute cholecystitis
Complications
Gangrenous cholecystitis
Perforated cholecystitis
Emphysematous cholecystitis
Pericholecystic fluid
collection
gangrenous cholecystitis
Perforated cholecystitis
Empysematous cholecystitis
 GALL BLADDER AND BILE
DUCTS
Gall bladder
Acalculous cholecystitis
May occur with no risk factors
More common in critically ill pts – worse prognosis
Risk factors
Major surgery
Severe trauma
Sepsis
Total parenteral nutrition
Diabetes
HIV infection
Acalculous cholecystitis
 GALL BLADDER AND BILE
DUCTS
Gall bladder
Acalculous cholecystitis
Diagnosis can be difficult
Signs may be present without cholecystitis
Pt on analgaesics reducers +ve sonographic
Murphy’s sign
 GALL BLADDER AND BILE
DUCTS
Gallstone disease
Chronic cholecystitis
Associated with gallstones
Most commonly asymptomatic
More advanced cases it leads to fibrosis and
thickening of wall
Sonographic signs of a thickened wall with stones
Differs from acute in that all other signs are absent
 GALL BLADDER AND BILE
DUCTS
Gall bladder
Porcelain gallbladder
Calcification of the gall bladder wall
Unknown aetiology
Rare
Most common in 6th decade of life
Sonographic appearance
Hyperechoic semilunar line
Dense posterior acoustic shadowing
Differential – emphysematous cholecystitis
Porcelain GB
US and AXR
 GALL BLADDER AND BILE
DUCTS
Gall bladder
Adenomyomatosis
Benign condition
Luminal epithelial and muscular wall defect
Rokitansky-Ashkoff sinuses
Focal or diffuse
Focal – common in fundus
Can appear as prominent mass-like focal areas
Evaluation with high frequency probe
Must differentiate from neoplasm
 GALL BLADDER AND BILE
DUCTS
Gall bladder
Adenomyomatosis
Sonographic appearance
Tiny echogenic foci
Comet tail artifact
Cystic space – reverberation, or
Internal Debris
Adenomyomatosis
Adenomyotomatosis
 GALL BLADDER AND BILE
DUCTS
Gall bladder
Polypoid masses of the gall bladder
Common types

Cholesterol polyps 50-60%

Inflammatory polyps 5-10%
Adenoma < 5%
Gall bladder adenocarcinoma
Metastasis (melanoma)
 GALL BLADDER AND BILE
DUCTS
Gall bladder
Polypoid masses of the gall bladder
Differentiating benign from malignancy is important
Multiplicity and size up to 10 mm are criteria for
benignancy
37% - 88% > 10 mm were found to be malignant
Risk of malignancy
> 60 years of age
Singularity
Gall stone disease
Rapid change in size
Blood velocity > 20 cm/s
RI < 0.65
 GALL BLADDER AND BILE
DUCTS
Polypoid masses of the gall bladder
Cholesterol polyps
~ ½ of all types seen
Common non-neoplastic condition
Cholesterolosis
Rarely exists with gallstone disease
Multiple, non-shadowing, oval lesions
attached to gb wall
Gallbladder polyp
 GALL BLADDER AND BILE
DUCTS
Polypoid masses of the gall bladder
Adenomas and inflammatory polyps
True benign neoplasms
Very low premalignant potential
Usually pedunculated
Larger lesions may demonstrate malignant
transformation
Homogeneously hyperechoic
Adjacent gb wall thickening should raise suspicion
of malignancy
Adenamatous GB polyps
Adenamatous GB polyps
 GALL BLADDER AND BILE
DUCTS
Polypoid masses of the gall bladder
Malignancy
Polypoid masses can lead to malignancy
50-60% mets to gb caused by melanoma
Hyperechoic broad-based lesions – multiple
Often > 10mm – suspicious
>18mm usually invasive malignancy]
 GALL BLADDER AND BILE
DUCTS
Gall bladder
Gall bladder carcinoma
Uncommon malignancy
Elderly population
3:1 female to male predominance
Chronic gall stone disease
98% adenocarcinomas
Surgical resection is only chance of cure
 GALL BLADDER AND BILE
DUCTS
Gall bladder carcinoma
Patterns of disease
Mass arising in gb fossa invading liver
Focal or diffuse wall thickening
Intraluminal polypoid mass
GALL BLADDER AND BILE DUCTS
Gall bladder carcinoma
Patterns of tumor spread
Liver invasion most common – thin gb wall
Extends along cystic duct to porta hepatus
Mimic hilar carcinoma
Direct invasion of bowel loops
Duodenum
Colon
Lymphatic spread is common
Absence or with local organ invasion
Adenopathy
Hepatoduodenal ligament
Peripancreatic nodes
Mesenteric nodes
 GALL BLADDER AND BILE
DUCTS
Gall bladder carcinoma
Sonographic appearance
Depends on pattern of disease
Mass replacing gb blends in with liver
Absent gb without h/o cholecystectomy should raise
suspicion
“trapped-stone” appearance
Internal flow
Diffuse malignant thickening
Large immobile polypoid mass with increased vascularity
u/S useful in staging carcinoma
GB carcinoma
GB carcinoma