KAZAKH NATIONAL MEDICAL UNIVERSITY NAMED AFTER S.D.

ASFENDYAROVA

Radiological semiotics of cholelithiasis

Almaty - 2023
 Plan

•Definition
•Pathogenesis
•Classification
•Anatomy of the gallbladder
•Diagnostic methods
•Radiological semiotics
•Differential diagnosis
•Recommendations

KazNMU named after . S.D.ASFENDIYAROVA 2

 Cholelithiasis (cholelithiasis, or, as they are incorrectly called, gallstones)

This is a disease associated with a disorder in the metabolism of cholesterol and bilirubin , resulting in the formation
of stones in the gall bladder ( cholecystolithiasis ) and/or in the bile ducts ( choledocholithiasis ).

KazNMU named after . S.D.ASFENDIYAROVA 3

 Types of
mixed gallstones

pigmented cholesterol

KazNMU named after . S.D.ASFENDIYAROVA 4

 Anatomy of the gallbladder and bile ducts
neck of the gallbladder
cystic duct
gallbladder
body

common bile duct

common
hepatic duct
sphincter muscles

bottom of the
gallbladder

hepatopancre pancreatic duct

atic ampulla
KazNMU named after . S.D.ASFENDIYAROVA 5
FREQUENT LOCALIZATION OF STONES
gallstone location options

this moving stone periodically stones in the

wedges into the mouth of the intrahepatic bile
gallbladder causes biliary colic ducts are rare

cystic duct stone

stones in the common

bile duct - the cause of
jaundice

stones in
gallbladder this stone simultaneously blocks
both the common bile duct and
the pancreatic duct

KazNMU named after . S.D.ASFENDIYAROVA 6

Research methods

Ultrasound (gold standard)

Radiography

CT

MRI

Endoscopic retrograde
cholangiopancreatography

KazNMU named after . S.D.ASFENDIYAROVA 7

 Ultrasound semiotics of cholelithiasis

A highly reflective echogenic focus

in the lumen of the gallbladder ,
usually with pronounced posterior
acoustic shadowing, regardless of
the type of pathology (acoustic
shadowing is independent of the
composition and calcium content)
Gravity- dependent movement is
often observed when the patient
changes position ( RollingStone
sign )

KazNMU named after . S.D.ASFENDIYAROVA 8

Color Doppler can demonstrate
Shimmering artifact and especially useful for identifying small
stones

KazNMU named after . S.D.ASFENDIYAROVA 9

An accumulation of stones is detected in the neck Multiple floating
of the gallbladder , casting an acoustic shadow Gallbladder stones .

KazNMU named after . S.D.ASFENDIYAROVA 10

 Radiography

X-ray data of stones in

Gallbladder ( cholelithiasis ):
• X-ray contrast pigment
stones: 50%
• Radiopaque cholesterol stones: 5%

KazNMU named after . S.D.ASFENDIYAROVA 11

 CT scan for gallstones

CT without contrast enhancement :

-Calcareous stones of the gallbladder have a greater density compared to
bile
-Pure cholesterol stones have a lower density; There is an inverse
relationship between cholesterol levels and X-ray attenuation:
-May have the same density as bile and not be detected on CT
-The central part of the stone may contain nitrogen gas: a symptom of
the Mercedes-Benz

KazNMU named after . S.D.ASFENDIYAROVA 12

On an axial computed
tomogram without
contrast, a cluster of
layered and faceted
stones is determined in
the gallbladder .

KazNMU named after . S.D.ASFENDIYAROVA 13

In a patient with acute
calculous
cholecystitis on the axial
A computed tomogram with
contrast shows thickening of
the gallbladder wall and
calcified stones.

KazNMU named after . S.D.ASFENDIYAROVA 14

 ABDOMEB CT WITH CONTRAST

The patient's sagittal computed tomogram and 3D reconstruction reveal a large

calcified calculus. KazNMU named after . S.D.ASFENDIYAROVA 15
 MRI FOR GALLBLADDER STONES

T1 – pigmented stones ( hyperintense )

- cholesterol stones ( hypointense )
• T2-VI:
A small focus of absent or weak signal limited to highly echogenic bile
within the gallbladder
• MRcholangiopancreatography :
Round lesions of absence of intragallbladder

KazNMU named after . S.D.ASFENDIYAROVA 16

Axial T2 HASTE in a slightly
thickened gallbladder, multiple
stones giving a weak signal are
determined.

KazNMU named after . S.D.ASFENDIYAROVA 17

Small area of absent or weak signal limited to highly echogenic bile, inside the
gallbladder
KazNMU named after . S.D.ASFENDIYAROVA 18
MR tomograms in the axial and frontal planes. Cholelithiasis. Gallstones in the gallbladder cavity are
characterized by a lack of signal within the gallbladder
on T2-VI and STIR
KazNMU named after . S.D.ASFENDIYAROVA 19
 Endoscopic retrograde cholangiopancreatography

ERCP
Mobile filling defects
inside
Contrast-filled gallbladder sensitivity 68
blisters and stones in the - 93%
extrahepatic bile ducts

expansion of the pancreatic

tubular stenosis of the common duct and branches of the 2nd
bile duct with reflux of contrast into and 3rd order, uneven contours
the main hepatic duct against the of the duct and branches
background of cholelithiasis

KazNMU named after . S.D.ASFENDIYAROVA 20

 Forforan gallbladder

General characteristics:
• Best diagnostic criterion:
o Calcification in the form of a curved “rim”
in the right hypochondrium, resembling the
shape of a gallbladder
• Morphology:
Two options:
- Limited mucosal calcification: high risk of
malignancy
- Diffuse wall calcification: low risk of
malignancy

KazNMU named after . S.D.ASFENDIYAROVA 21

DIFFERENTIAL DIAGNOSTICS

Gallbladder polyp
Bladder bile sludge
Gallbladder carcinoma
Focal adenomyomatosis
Parasitic infestation of the gallbladder
Intestinal gases
Emphysematous cholecystitis

KazNMU named after . S.D.ASFENDIYAROVA 22

 VISUALIZATION GUIDELINES:

Ultrasound is the best imaging modality for evaluating patients with upper abdominal pain/discomfort.

➢When evaluating patients with pain/discomfort in the upper right quadrant of the abdomen after a
fatty meal, especially middle-aged obese women , remember the likely presence of cholelithiasis

➢Tips for interpreting images:

the acoustic shadow they cast is of great importance
- Stones that do not cast a shadow can be mistaken for other formations of the gallbladder, for example,
polyp, sludge , carcinoma
- Shrinking, stone-filled gallbladder: assess for wall-echo-shadow sign or examine interlobar fissure

KazNMU named after . S.D.ASFENDIYAROVA 23

KAZAKH NATIONAL MEDICAL UNIVERSITY NAMED AFTER S.D. ASFENDYAROVA

Thank you for attention!

​Mr. Almaty, st. Tole bi, 94 ​@ kaznmu

+7 727 338 70 90 https://
www.kaznmu.kz www.facebook.com/KazNMU
kaznmu@kaznmu.kz https://www.youtube.com/kaznmu _