Gallbladder Pathology: Symptoms and Abnormalities

Pathology of the Gallbladder

Clinical Symptoms of Gallbladder Disease

• Fat intolerance is a clinical symptom.
• Epigastric pain is a clinical symptom.
• Jaundice is a clinical symptom.
• Abdominal pain is a clinical symptom.
• Chills and fever are clinical symptoms.
• Right Upper Quadrant (RUQ) pain that radiates to the right shoulder and/or back is a clinical symptom.

Congenital Gallbladder Abnormalities

• Gallbladder Agenesis is a congenital abnormality.
• Anomalous Gallbladder location is a congenital abnormality.
• Duplication of the Gallbladder is a congenital abnormality.
• Septated Gallbladder is a congenital abnormality.
• Gallbladder diverticulum is a congenital abnormality.

Anomalous Gallbladder Location

• Common locations include the left side, posterior to the left lobe
• Anomalous Gallbladder location can be intrahepatic
• Anomalous Gallbladder location can be Suprahepatic which is by the diaphragm.
• Anomalous Gallbladder location can be Retrohepatic which is posterior to the right lobe.

Gallbladder Duplication

• Occurs in 3000 to 4000 cases
• There are two gallbladders adjacent to each other, with two separate cystic ducts
• Both gallbladders show normal emptying after meals

Septate Gallbladder

• The entire gallbladder or part of the lumen
• Chambers communicate by orifices
• Can be isolated, or coexist with other anomalies
• May cause symptoms of cholecystitis
• Congenital in origin
• Considered very rare

Gallbladder Diverticula

• It is the outpouching of Gallbladder wall
• Considered extremely rare
• Occurs anywhere in the Gallbladder
• Usually single
• Size can vary greatly

Disorders of the Gallbladder

• Gallbladder stones (Cholelithiasis)
• Sludge
• Milk of calcium bile
• Cholecystitis
• Porcelain gallbladder
• Adenomyomatous hyperplasia (Adenomyomatosis)
• Gallbladder polyps
• Gallbladder carcinoma

Cholelithiasis (Gallstones)

• Structures are small
• Can be multiple or solitary
• Gallstones may occur anywhere within the biliary tree

Clinical Findings for Gallstones

• RUQ pain, can radiate to the right shoulder
• Nausea and Vomiting
• Jaundice
• Can be asymptomatic
• Symptoms worsen if stones get stuck in Gall Bladder neck or cystic duct

Gallstones Diagnostic Modality

• Ultrasound (US) is the most accurate modality for diagnosis
• Stones mobility is frequently identifiable
• Small stones are differentiated from small polyps by the demonstration of mobility or the presence of acoustic shadow

Ultrasound Criteria for Gallstones

• Echogenic focus
• Posterior shadow
• Mobility

Gallstones Diagnosis

• Image a gallstone in two perpendicular planes to avoid errors and false diagnosis
• Demonstrate shadowing to avoid errors and false diagnosis
• Demonstrate mobility of stone to avoid errors and false diagnosis
• Check cystic duct carefully to avoid errors and false diagnosis

Gallstones and Shadows

• Optimization of technique is required
• Doppler twinkling artifact may help and occurs posterior to the stone

Optimization of Technique for Gallstones and Shadows

• Use a higher frequency ≥ 5MHz
• Use lower power/gain
• Focal zone
• Use position change to pile up small stones that collectively shadow and make a visible shadow

Biliary Sludge

• A collection of cholesterol, calcium, bilirubin, and other compounds that build up in the gallbladder

Predisposing Factors of Biliary Sludge

• Pregnancy
• Rapid weight loss and prolonged fasting
• Bone marrow transplantation

Evolution of Biliary Sludge (3 years)

• 50% resolve spontaneously
• 20% persist asymptomatically
• 5-15% develop gallstones
• 10-15% become symptomatic

Ultrasound Findings of Biliary Sludge

• Soft echoes layered in the dependent part of the gallbladder that change with patient position

Pseudosludge (Artifact)

• Most commonly found along the posterior surface of the gallbladder
• Produced by side lobe artifact
• Disappears in different positions and when the central portion of the Gall Bladder is scanned

Tumefactive Sludge - Sludge Ball

• Nonshadowing mobile echogenic structures
• Change in appearance or disappearance on follow-up

Tumefactive Sludge

• Gallbladder with tumor-like sludge
• Potential mobility of sludge
• Normal gallbladder wall
• No vascularity is detected on Doppler ultrasound

Milk of Calcium

• The gallbladder becomes very viscous, probably as a result of stasis, and contains a high concentration of calcium bilirubinate
• On US, it causes diffuse echoes, similar to sludge, but is more echogenic with a tendency to layer out and produce an acoustic shadow

Gallbladder Wall Thickness

• Normal is <3 mm using US
• Common causes for >2 mm of thickening of the gallbladder wall include AIDS
• Common causes for >2 mm of thickening of the gallbladder wall include congestive heart failure
• Common causes for >2 mm of thickening of the gallbladder wall include cholecystitis
• Common causes for >2 mm of thickening of the gallbladder wall include nonfasting
• Common causes for >2 mm of thickening of the gallbladder wall include hepatitis
• Common causes for >2 mm of thickening of the gallbladder wall include tumor
• Common causes for >2 mm of thickening of the gallbladder wall include ascites
• Common causes for >2 mm of thickening of the gallbladder wall include drugs

Pericholecystic Fluid Patterns

• Type 1: Thin anechoic fluid collection adjacent to the gallbladder wall
• Type 2: Round or irregular-shaped collection with thick walls, septations, or internal debris; associated with GB perforation and Abscess

Non-Visualization of the Gallbladder

• Cholecystectomy
• Chronic cholecystitis ± stones
• Air in the duodenum
• Gallbladder carcinoma
• Obstruction of the biliary tree proximal to the cystic duct
• Congenital absence of Gall Bladder

Cholecystitis

• Inflammation of the gallbladder and its wall
• Primary complication of gallstones
• The most common reason for emergency cholecystectomy
• Precipitated by obstruction of the neck or cystic duct
• Can be acute or chronic

Signs and Symptoms of Cholecystitis

• Severe pain in the upper right abdomen
• Pain that radiates to the right shoulder or back
• Tenderness over the abdomen when touched
• Nausea and Vomiting
• Fever

Ultrasound Findings of Acute Calculous Cholecystitis

• Impacted stone in the cystic duct or gallbladder neck
• Positive sonographic Murphy's sign
• Thickening of the Gall Bladder wall (> 3mm)
• Distention of the Gall Bladder lumen (>4 cm) – Hydrops
• Pericholecystic fluid collection
• Hyperemic Gall bladder wall on color Doppler.

Acute Acalculous Cholecystitis

• Occurs in the absence of gallstones
• Diagnosed in severely ill patients
• Usually occurs in post-operative states
• Usually occurs with severe trauma
• Usually occurs with sepsis
• Usually occurs in postpartum state
• Usually occurs with severe burns

Acalculous Cholecystitis Findings

• Positive Murphy's sign
• Wall thickening
• Echogenic sludge
• Dilated gallbladder
• Pericholecystic fluid

Mirrizzi Syndrome

• Occurs when an impacted stone within the cystic duct causes acute cholecystitis
• An Extension of the local inflammatory process involves the common hepatic and/or common bile duct
• This compressive effect may result in biliary obstruction and jaundice

Complications of Acute Cholecystitis

• Empyema (suppurative cholecystitis)
• Gangrenous cholecystitis
• Emphysematous cholecystitis
• Hemorrhagic cholecystitis
• Gallbladder perforation

Gallbladder Empyema

• A complication of cholecystitis
• The gallbladder lumen is filled and distended by purulent material (pus)
• The gallbladder neck is usually obstructed by a calculus, which prevents pus from draining through the cystic duct
• The patient is very ill, with fever and acute pain

Ultrasound Findings of Gallbladder Empyema

• Sonographic features of cholecystitis with added echogenic content within the gallbladder lumen

Gangrenous Cholecystitis

• Common complication of acute cholecystitis
• Develops when severe inflammation interrupts the blood supply to the gallbladder
• Without blood supply, the gallbladder tissue will begin to die, causing serious infection, which can quickly spread throughout the body
• The patient is very ill, with fever and acute pain

Ultrasound Findings of Gangrenous Cholecystitis

• There are no specific diagnostic US findings
• Striated thickening of the gallbladder wall
• Intraluminal membranes
• Asymmetry of the Gall Bladder wall
• Echogenic debris within the Gall Bladder
• Pericholecystic fluid collection

Emphysematous Cholecystitis

• An acute infection of the Gall Bladder wall caused by gas-forming organisms (Clostridium and E. Coli)
• Is a surgical emergency
• Characterized by gangrene, perforation, and high mortality
• Diagnosis is made by the presence of air within the Gall Bladder wall or lumen

Emphysematous Cholecystitis Stages

• Stage 1: Gas in the Gall Bladder lumen
• Stage 2: Gas in the Gall Bladder wall
• Stage 3: Gas in pericholecystic tissues

Hemorrhagic Cholecystitis

• Hemorrhage within the gallbladder lumen is an infrequent complication of acute Cholecystitis
• High mortality rate

Ultrasound Findings of Hemorrhagic Cholecystitis

• Variable
• Presence of echogenic material with higher echogenicity than sludge

Gallbladder Perforation

• Results from occlusion of the cystic duct (most often by a calculus), which causes a rise of intraluminal pressure due to retained intraluminal secretion

Chronic Cholecystitis

• Associated with cholelithiasis (90%)
• Can be Calculous or Acalculous
• Symptoms are similar to the acute form

Forms of Chronic Cholecystitis

• Traditional chronic cholecystitis - thick GB wall with gallstones
• Wall-Echo-Shadow complex (WES) – double arc-shadow sign
• Porcelain GB - high incidence of GB carcinoma
• Xanthogranulomatous cholecystitis (XGC) – difficult to distinguish from Adenomyomatosis and GB carcinoma

Clinical Findings of Chronic Cholecystitis

• Asymptomatic in 70%-80% of cases.
• RUQ pain can be a clinical finding
• Abnormal laboratory values, such as bilirubin, amylase, and alkaline phosphatase

Complications of Chronic Cholecystitis

• Empyema
• Perforation
• Cholangitis
• Pancreatitis
• Increased risk for cancer

Porcelain Gallbladder

• Gallbladder calcification
• Thickening of the gallbladder wall due to calcium accumulation
• High risk of gallbladder carcinoma
• US shows a hyperechoic diffusely thickened wall with or without posterior acoustic shadowing

Courvoisier’s Gallbladder

• Is associated with Hydropic GB with “-” Murphy's sign
• It is Gallbladder enlargement secondary to a tumor in the distal CBD or external compression of the distal CBD by, that may be in the pancreatic head or duodenum
• One of the patient characteristic symptoms is painless jaundice

Ultrasound Findings of Courvoisier’s Gallbladder

• Enlarged gallbladder
• Dilated CBD

Gallbladder Neoplasms Types

• Benign: Adenoma, Polyp, Adenomyomatosis
• Malignant: GB Carcinoma

Gallbladder Adenoma

• The most common benign tumor of the gallbladder
• Common locations include the Gallbladder body or fundus
• Small hypo to hyperechoic mass

Gallbladder Polyps

• The majority of Gallbladder polyps are cholesterol crystals
• Usually small, 2-10mm in size
• Polyps appear as small echogenic non-shadowing foci adherent to the Gall Bladder wall
• A lack of mobility favors a polyp rather than a stone

Adenomyomatosis

• A benign condition
• Characterized by hyperplastic changes of unknown etiology involving the gallbladder wall
• Overgrowth of the mucosa, thickening of the muscular wall, and formation of intramural diverticula termed Rokitansky-Aschoff sinuses occur

Ultrasound Findings of Adenomyomatosis

• Wall thickening can be diffuse or focal
• Focal mass is most concerning and difficult to distinguish from cancerous masses
• Comet - tail or ring down artifacts are highly specific, representing the unique acoustic signature of cholesterol crystals within the lumen of Rokitansky-Aschoff sinuses

Gallbladder Carcinoma

• Primary carcinoma of the gallbladder is nearly always a rapidly progressive disease, with a mortality rate approaching 100%
• It is associated with cholelithiasis in about 80% to 90% of cases
• Patients with a porcelain gallbladder have an increased incidence of carcinoma

Clinical Findings of Gallbladder Carcinoma

• Most patients have no symptoms that relate to the gallbladder unless there is complicating acute cholecystitis
• RUQ pain can be a clinical finding
• Nausea and Vomiting can be clinical findings
• Anorexia can be a clinical finding
• Palpable Gall Bladder can be a clinical finding

Ultrasound Findings of Gallbladder Carcinoma

• The tumor infiltrates the gallbladder locally or diffusely
• The tumor causes thickening of the gallbladder wall
• The adjacent part of the liver is often invaded by direct spread of the tumor