Podcast
Questions and Answers
Which condition is NOT part of the differential diagnosis for jaundice?
Which condition is NOT part of the differential diagnosis for jaundice?
What feature is characteristic of a hepatic cyst seen on ultrasound?
What feature is characteristic of a hepatic cyst seen on ultrasound?
What is a potential consequence associated with a porcelain gallbladder?
What is a potential consequence associated with a porcelain gallbladder?
What ultrasound finding suggests the presence of cholecystitis?
What ultrasound finding suggests the presence of cholecystitis?
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What should be measured to look for evidence of biliary obstruction in cases of jaundice?
What should be measured to look for evidence of biliary obstruction in cases of jaundice?
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What distinctive feature is associated with the ultrasound images labelled 'Nodular'?
What distinctive feature is associated with the ultrasound images labelled 'Nodular'?
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Which condition is indicated by the imaging characteristic of 'markedly hyperechoic to Kidney'?
Which condition is indicated by the imaging characteristic of 'markedly hyperechoic to Kidney'?
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Which combination of features is associated with portal hypertension?
Which combination of features is associated with portal hypertension?
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What imaging characteristic is commonly seen in hepatocellular carcinoma?
What imaging characteristic is commonly seen in hepatocellular carcinoma?
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Which of the following features indicates possible hepatic metastasis?
Which of the following features indicates possible hepatic metastasis?
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What is a common complication associated with cystic duct obstruction?
What is a common complication associated with cystic duct obstruction?
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Which imaging technique is NOT typically effective for visualizing cholesterol stones?
Which imaging technique is NOT typically effective for visualizing cholesterol stones?
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Which of the following is a key finding indicative of acute cholecystitis on ultrasound?
Which of the following is a key finding indicative of acute cholecystitis on ultrasound?
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What is a common cause of acute pancreatitis associated with choledocholithiasis?
What is a common cause of acute pancreatitis associated with choledocholithiasis?
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Which of the following symptoms is associated with ascending cholangitis?
Which of the following symptoms is associated with ascending cholangitis?
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What can be seen on CT when evaluating acute cholecystitis?
What can be seen on CT when evaluating acute cholecystitis?
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What is one of the lab findings associated with choledocholithiasis?
What is one of the lab findings associated with choledocholithiasis?
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Which of the following conditions is falsely indicated by the presence of shadows on imaging?
Which of the following conditions is falsely indicated by the presence of shadows on imaging?
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What is a key feature of chronic pancreatitis observed on imaging?
What is a key feature of chronic pancreatitis observed on imaging?
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Which of the following describes the condition of necrotizing pancreatitis?
Which of the following describes the condition of necrotizing pancreatitis?
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What is a common ultrasound finding in cirrhosis?
What is a common ultrasound finding in cirrhosis?
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Which of the following statements is true regarding hepatic steatosis?
Which of the following statements is true regarding hepatic steatosis?
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What imaging feature distinguishes uncomplicated acute pancreatitis from necrotizing pancreatitis?
What imaging feature distinguishes uncomplicated acute pancreatitis from necrotizing pancreatitis?
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What is the best imaging modality for detecting hepatic metastases?
What is the best imaging modality for detecting hepatic metastases?
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What is NOT a symptom associated with chronic pancreatitis?
What is NOT a symptom associated with chronic pancreatitis?
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Which of the following is NOT a feature of hepatic metastasis?
Which of the following is NOT a feature of hepatic metastasis?
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Which statement correctly summarizes the implications of portal hypertension related to cirrhosis?
Which statement correctly summarizes the implications of portal hypertension related to cirrhosis?
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What characteristic is common for gallstones observed through ultrasound?
What characteristic is common for gallstones observed through ultrasound?
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What sign would suggest the presence of hepatic steatosis on ultrasound?
What sign would suggest the presence of hepatic steatosis on ultrasound?
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Which structure is primarily involved in the hematogenous spread of metastasis from the GI tract?
Which structure is primarily involved in the hematogenous spread of metastasis from the GI tract?
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Which condition could obscure the identification of hepatic metastasis?
Which condition could obscure the identification of hepatic metastasis?
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What sign is illustrated by the arrangement of the CBD, HA, and PV on an ultrasound image?
What sign is illustrated by the arrangement of the CBD, HA, and PV on an ultrasound image?
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Which ultrasound finding is NOT associated with a diagnosis of acute cholecystitis?
Which ultrasound finding is NOT associated with a diagnosis of acute cholecystitis?
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Which vascular structure is associated with hematogenous spread from systemic circulation?
Which vascular structure is associated with hematogenous spread from systemic circulation?
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What is the normal maximum wall thickness of the gallbladder?
What is the normal maximum wall thickness of the gallbladder?
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Which of the following is NOT a purpose of right upper quadrant ultrasound?
Which of the following is NOT a purpose of right upper quadrant ultrasound?
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What is a key indicator of a positive sonographic Murphy's sign during gallbladder assessment?
What is a key indicator of a positive sonographic Murphy's sign during gallbladder assessment?
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What diameter is considered the upper limit of normal for the common bile duct in adults?
What diameter is considered the upper limit of normal for the common bile duct in adults?
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In assessing for pericholecystic fluid, which finding could be a false positive?
In assessing for pericholecystic fluid, which finding could be a false positive?
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Which anatomical structure runs anterior to the portal vein before entering the duodenum?
Which anatomical structure runs anterior to the portal vein before entering the duodenum?
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What kind of ultrasound probe is recommended for gallbladder assessment?
What kind of ultrasound probe is recommended for gallbladder assessment?
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During a gallbladder ultrasound, the patient should ideally be in which position?
During a gallbladder ultrasound, the patient should ideally be in which position?
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Study Notes
Photo Album - Gallstones
- This album is by Wisam Neriman
- It features images and information about gallstones.
- A doctor named Joseph W. Owen, MD, is involved in the presentation.
RUQ Ultrasound Introduction
- RUQ ultrasound is a quick and safe method for patient care.
- It has various applications, including assessing RUQ/epigastric pain, jaundice, and ascites.
Anatomy Key Concepts
- The common bile duct (CBD), portal vein, and hepatic artery form the portal triad.
- The CBD runs anterior to the portal vein before entering the duodenum.
- Significant anatomical variations in the gallbladder (GB) exist in position, shape, and size.
Technique
- The patient should ideally be NPO (nothing by mouth) to avoid bowel gas.
- A curvilinear or phased array probe is utilized with a low frequency (3-5 MHz).
- Patient positioning can include supine, left lateral decubitus, and other positions.
Normal Gallbladder
- Ultrasound images show a normal gallbladder (GB) in the fasting and post-prandial states.
Examine Gallbladder
- Scan the GB in multiple longitudinal and transverse planes.
- Look for gallstones, wall thickness, and pericholecystic fluid (PCF) findings.
Pericholecystic Fluid
- Pericholecystic fluid (PCF) appears as anechoic (no echoes) fluid around the GB.
- Ascites can sometimes mimic PCF, creating false positives.
Gallbladder Wall Thickness
- Normal GB wall thickness is up to 4 mm.
- Thickening may indicate acute cholecystitis, chronic heart failure (CHF), low protein states/end-stage liver disease (ESLD), or GB carcinoma.
Murphy's Sign
- During sonographic examination, check for Murphy's sign.
- A positive Murphy's sign is when the patient experiences pain during inspiration when the GB is compressed.
Portal Triad
- Identify the portal triad (PV, CBD, hepatic artery) on RUQ ultrasound.
- Start by locating the portal vein in a long-view, using the probe marker to point towards the right axilla.
- Note the hyperechoic (high-echo) vessel walls and their course towards the porta hepatis.
Measure CBD
- Normal CBD diameter is less than 5 mm.
- With age, the upper limit of normal can increase up to nearly 1 cm after cholecystectomy.
- Enlarged CBD and associated RUQ pain suggest choledocholithiasis (stones in the bile duct).
Gallstones - General
- Gallstones are best visualized through ultrasound or MRI.
- Pigment stones are evident on CT scans.
- Gallstones in the cystic duct may cause biliary colic or cholecystitis.
- Stones in the common bile duct can cause ascending cholangitis or acute pancreatitis.
Gallstones - Ultrasound
- Gallstones typically appear echogenic (bright) on ultrasound with or without acoustic shadowing.
Gallstones - MRI
- MRI images display gallstones.
Gallstones - CT
- Pigment stones are typically seen on CT scans, cholesterol stones are not.
Acute Cholecystitis - Ultrasound
- Acute cholecystitis can be identified by features such as gallstones or sludge, GB wall thickness greater than 3 mm, pericholecystic fluid, and a positive sonographic Murphy's sign.
Pearls, Pitfalls, and Variants
- Not all shadows on an ultrasound mean gallstones (bowel gas, artifacts, spiral valves are examples)
- Gallstones do not always indicate cholecystitis/inflammation
- Gallstones are a common finding in people over 50, around 20%
Acute Cholecystitis - MRI/CT
- These imaging techniques can reveal gallstones, thickened gallbladder walls and peripancreatic stranding, signs of acute cholecystitis.
Choledocholithiasis
- Choledocholithiasis (bile duct stones) can cause issues, such as dilated bile ducts, elevated lab values (alkaline phosphatase, GGT, direct bilirubin), acute pancreatitis, and cholangitis.
Pancreatitis
- Acute pancreatitis is associated with epigastric pain, elevated lipase, and peripancreatic stranding.
- Necrotizing pancreatitis can damage pancreatic tissue and blood vessels.
- Chronic pancreatitis frequently results in calcifications and duct irregularities.
- Common radiologic features of pancreatitis include uncomplicated acute pancreatitis, necrotizing pancreatitis, and chronic pancreatitis.
- CT or MRI can reveal peripancreatic stranding and pancreatic necrosis in cases of necrosis or walled-off necrosis.
Cirrhosis
- Cirrhosis is characterized by hepatic fibrosis, surface nodularity, and heterogeneous liver parenchyma.
- It can manifest as portal hypertension, splenomegaly, ascites, and varices.
- Hepatocellular carcinoma is a potential complication.
Ultrasound of the Liver
- Liver echogenicity (brightness) can be normal or increased in conditions like steatosis (fatty liver disease).
- Echotexture describes the internal structure, which can be homogenous (uniform) or coarse.
- Liver surface can be smooth or nodular.
Learning Objectives
- Identify and describe increased liver echogenicity related to hepatic steatosis.
- Recognize surface nodularity and coarse hepatic echotexture, characteristics linked with hepatic cirrhosis.
Hepatic Steatosis
- Hepatic steatosis results from lipid accumulation in hepatocytes (liver cells).
- The condition is frequently associated with non-alcoholic fatty liver disease (NAFLD) or alcoholic fatty liver disease.
- The most apparent sign is increased echogenicity (brightness) of the liver on ultrasound compared to the kidney.
Liver and Kidney
- Liver and kidney have similar levels of echogenicity in a normal scenario.
- A markedly hyperechoic liver, meaning unusually bright compared to the kidney, might point towards conditions like hepatic steatosis or other liver diseases.
Hepatic Metastasis
- Different appearance types are associated with the primary tumour.
- CT and MRI can identify subtle changes in the primary lesion that may indicate metastasis.
- Detecting hidden metastasis by MRI, including assessing for metastases hidden by steatosis.
Most Common Metastatic Sites
- Portal vein, hepatic artery are the typical locations for cancer spread from the GI tract.
- Fenestrations permit tumour cells from other parts of the body to lodge in the liver.
Gallstone with Acoustic Shadow
- An acoustic shadow forms behind a denser object on an ultrasound scan.
- Gallstones can create such shadows due to their density in the gallbladder (GB), a helpful indicator of a gallstone.
GB Polyp
- A polyp is a growth in the GB, either benign or malignant.
- An ultrasound scan can detect such growths, distinguishing them from other conditions or growths.
Sonographic Characteristics of Gallstones
- Gallstones are extremely echogenic (bright) on ultrasound, with an acoustic shadow forming behind them.
- They typically show gravity-dependent movement.
- Gallstones are usually mobile except for stones that may become entrapped.
Dilated Common Bile Duct
- This refers to an enlarged common bile duct (CBD).
- An ultrasound scan can be conducted to detect dilated CBDs.
Mickey Mouse Sign
- Identify the connection points of the common bile duct (CBD), hepatic artery (HA), portal vein (PV), and inferior vena cava (IVC) on the ultrasound (US).
Pathology Cholecystitis
- Acute cholecystitis diagnosis is based on factors like stones, sludge, GB wall thickness, pericholecystic fluid and sonographic Murphy's sign.
- Likelihood of diagnosis increases with each positive finding/assessment.
Pathology Jaundice
- Potential diagnoses for jaundice include hepatitis, malignancy, and gallstones.
- Check for biliary obstruction by evaluating the CBD and examining the GB for stones.
Pathology Porcelain GB
- Porcelain gallbladder is recognized by marked acoustic shadowing.
- Potential association with gallbladder adenocarcinoma (cancer).
Pearls, Pitfalls, and Variants: Hepatic Cyst
- Acute cysts are shown by their sharp margins, anechoic (lacking echoes, no echoes), and posterior acoustic enhancement.
Radiology Key Points
- In this study, multiple radiological imaging techniques, including ultrasound, CT, and MRI, were used for diagnosis.
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Description
Test your knowledge on the key features and conditions related to jaundice and abdominal ultrasound findings. This quiz covers differential diagnosis and imaging characteristics associated with liver and gallbladder issues. Ideal for medical students and practitioners.
