Ultrasound and Jaundice Quiz

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.