Gallbladder Functions and Anatomy PDF

FUNCTIONS OF THE GALLBLADDER CONCENTRATES BILE THROUGH THE GALLBLADDER EPITHELIUM STORES CONCENTRATED BILE CONTRACTS TO RELEASE BILE GALLBLADDER DIVISIONS FUNDUS BODY NECK  GALLBLADDER LOCATION INTRAPERITONEAL LOCATED IN THE GALLBLADDER FOSSA ON THE POSTERIOR SURFACE OF THE...

FUNCTIONS OF THE GALLBLADDER CONCENTRATES BILE THROUGH THE GALLBLADDER EPITHELIUM STORES CONCENTRATED BILE CONTRACTS TO RELEASE BILE GALLBLADDER DIVISIONS FUNDUS BODY NECK  GALLBLADDER LOCATION INTRAPERITONEAL LOCATED IN THE GALLBLADDER FOSSA ON THE POSTERIOR SURFACE OF THE GALLBLADDER LATERAL TO THE INFERIOR VENA CAVA, ANTERIOR AND MEDIAL TO THE RIGHT KIDNEY  GALLBLADDER ANATOMICAL VARIANTS HARTMANN POUCH GALLBLADDER ANATOMICAL VARIANTS JUNCTIONAL FOLD GALLBLADDER ANATOMICAL VARIANTS PHRYGIAN CAP GALLBLADDER SIZE NORMAL FASTING ADULT GALLBLADDER MEASURES 8-10 IN LENGTH AND 3-5 CM IN DIAMATER SONOGRAPHIC APPEARANCE NORMAL FASTING GALLBLADDER ELLIPSOID ANECHOIC STRUCTURE LOCATED IN THE GALLBLADDER FOSSA WITH POSTERIOR ACOUSTIC ENHANCEMENT DEMONSTRATES SMOOTH HYPERECHOIC WALLS 3 mm OR LESS LOCATED IN THE INFERIOR MEDIAL ASPECT OF THE LIVER ABNORMAL FASTING GALLBLADDER TRANSVERSE DIAMETER ABOVE 5 CM THICK OR EDEMATOUS WALL 3 mm IRREGULAR WALL CONTOUR INTRALUMINAL FOCUS OR ECHOES ACOUSTIC SHADOWING POSTERIOR TO THE GALLBLADDER FOSSA SONOGRAPHIC APPEARANCE ABNORMAL FASTING GALLBLADDER -THICK EDEMATOUS WALL EXCEEDING 3 mm IN THICKNESS -IRREGULAR WALL CONTOUR -INTRALUMINAL FOCUS OR ECHOES -ACOUSTIC SHADOWING POSTERIOR TO THE GALLBLADDER FOSSA REASONS FOR NONVISUALIZATION OF THE GALLBLADDER NON FASTING PATIENT SURGICALLY ABSENT OBLITERATION OF THE GALLBLADDER LUMEN BY INTESTINAL AIR OR GALLSTONE PATIENT BODY HABITUS ECTOPIC LOCATION AGENESIS NONINLAMMATORY CAUSES OF GALLBLADDER WALL THICKENING NON FASTING PATIENT ASCITES CIRRHOSIS CONGESTIVE HEART FAILURE HYPOALBUMINEMIA ACUTE HEPATITIS  ENLARGED(DISTENDED) GALLBLADDER DEHYDRATED LOW FAT DIET INTRAVENOUS NUTRITION IF THERE IS NO CONTRACTION, SEARCH FOR: GALLSTONE OR ANY CAUSE OF OBSTRUCTION A STONE OR SOME OBSTRUCTION IN THE COMMON BILE DUCT IF THE GALLBLADDER IS DISTENDED WITH THICKENED WALLS AND FILLED WITH FLUID, THERE MAY BE EMPYEMA IF THE GALLBLADDER IS DISTENDED WITH THIN WALLS AND FILLED WITH FLUID, THERE MAY BE MUCOCELE  SCHEDULES ARE MADE AT THE BEGINNING OF THE PATIENT’S DAY: -DECREASES THE AMOUNT OF INTESTINAL AIR -PATIENT IS FASTING LABORATORY VALUES ALKALINE PHOSPHATASE NORMAL ADULT RANGE 35-150 U/L ENZYME PRODUCED PRIMARILY BY THE LIVER, BONE AND PLACENTA EXCRETED THROUGH THE BILE DUCTS OBSTRUCTIVE JAUNDICE ALANINE AMINOTRANSFERASE NORMAL RANGE 1-45 U/L ENZYME FOUND IN HIGH CONCENTRATION IN THE LIVER REMAINS ELEVATED LONGER THAN AST CIRRHOSIS, HEPATITIS, BILIARY OBSTRUCTION LIVER METASTASIS ASPARTATE AMINOTRANSFERASE NORMAL RANGE 1-36 U/L ENZYME PRESENT IN MANY TYPES OF TISSUE THAT IS RELEASED WHEN CELLS ARE DAMAGED CIRRHOSIS, HEPATITIS AND MONONUCLEOSIS BILIRUBIN A PRODUCT FROM THE BREAKDOWN OF HEMOGLOBIN IN OLD RED BLOOD CELLS LEAKAGE INTO TISSUES GIVES THE SKIN A YELLOW APPEARANCE NORMAL TOTAL BILIRUBIN 0.3-1.1 mg/Dl NORMAL DIRECT BILIRUBIN 0.1-0.4 mg/dL BILIRUBIN ELEVATION OF DIRECT OR CONJUGATED BILIRUBIN -OBSTRUCTION, HEPATITIS, CIRRHOSIS AND LIVER METASTASIS ELEVATION OF INDIRECT OR UNCONJUGATED BILIRUBIN -NON OBSTRUCTIVE CONDITIONS PATHOLOGY PNEUMOBILIA PRESENCE OF GAS IN THE BILIARY SYSTEM ETIOLOGY: SURGICAL PROCEDURE, TRAUMA, INFECTION CLINICAL FINDINGS: ASYMPTOMATIC, RUQ PAIN PNEUMOBILIA SONOGRAPHIC APPEARANCE: -HYPERECHOIC FOCUS IN THE INTRAHEPATIC BILE DUCTS -COMET TAIL ARTIFACT OFTEN CENTRALLY LOCATED PNEUMOBILIA BILIARY ASCARIASIS WORMS THAT COLONIZE THE INTESTINAL TRACT MAY FIND THEIR WAY INTO THE BILIARY TREE AND GALLBLADDER. LIVING WORMS MAY OBSTRUCT THE BILIARY TREE AND GALLBLADDER AND CAUSE CHOLANGITIS, CHOLECYSTITIS, AND PANCREATITIS, WITH A HIGH ASSOCIATED MORTALITY. WORMS ARE SEEN BY US AS MOVING TUBULAR ECHOGENIC STRUCTURES WITH AN ECHOLUCENT CORE.  BILIARY ASCARIASIS ETIOLOGY: INGESTION OF CONTAMINATED WATER OR FOOD CLINICAL FINDINGS: RUQ PAIN, FEVER, LEUKOCYTOSIS BILIARY ASCARIASIS SONOGRAPHIC APPEARANCE: -SPAGHETTI LIKE ECHOGENIC STRUCTURE WITHIN A BILE DUCT -NON SHADOWING -POSTERIOR ACOUSTIC ENHANCEMENT BILIARY ASCARIASIS  GALLBLADDER POLYP APPEAR AS ECHOGENIC NONSHADOWING NODULES THAT EXTEND FROM THE GALLBLADDER WALL MOST ARE CHOLESTEROL POLYPS, WHICH ARE SMALLER THAN 1 CM AND ARE COMMONLY MULTIPLE. ADENOMATOUS POLYPS ARE RARE AND INDISTINGUISHABLE FROM CHOLESTEROL POLYPS. GALLBLADDER POLYP BENIGN EPITHELIAL TUMOR CLINICAL FINDINGS: ASYMPTOMATIC, DULL RUQ PAIN, INTOLERANCE TO FATTY FOODS GALLBLADDER POLYP SONOGRAPHIC APPEARANCE: -ECHOGENIC INTRALUMINAL FOCUS -IMMOBILE -NON SHADOWING -THICKENING OF THE GALLBLADDER WALL GALLBLADDER POLYP ADENOMYOMATOSIS HYPERPLASIA OF THE EPITHELIAL AND MUSCLE LAYERS OF THE GALLBLADDER WALL CLINICAL FINDINGS: ASYMPTOMATIC, DULL RUQ PAIN, INTOLERANCE TO FATTY FOODS ADENOMYOMATOSIS SONOGRAPHIC APPEARANCE: -ECHOGENIC INTRALUMINAL FOCUS -DIFFUSE COMET TAIL ARTIFACT -IMMOBILE ADENOMYOMATOSIS ECHOGENIC BILE BILE BECOMES ECHOGENIC WHEN IT IS HIGHLY CONCENTRATED AND CHOLESTEROL CRYSTALS AND CALCIUM BILIRUBINATE GRANULES PRECIPITATE AS SLUDGE. SLUDGE COMMONLY LAYERS IN THE GALLBLADDER AND MAY BECOME QUITE VISCOUS AND FORM SLUDGE BALLS OR TUMEFACTIVE SLUDGE. SLUDGE BALLS USUALLY MOVE WITHIN THE GALLBLADDER BUT DO NOT CAST ACOUSTIC SHADOWS. ECHOGENIC BILE MIXTURE OF PARTICULATE SOLIDS THAT HAVE PRECIPITATED FROM BILE ETIOLOGY: PROLONGED FASTING, BILIARY STASIS, BILIARY OBSTRUCTION, CHOLECYSTITIS, SICKLE CELL ANEMIA ECHOGENIC BILE CLINICAL FINDINGS: ASYMPTOMATIC, RUQ PAIN, NAUSEA, VOMITING SONOGRAPHIC APPEARANCE: NON SHADOWING LOW AMPLITUDE ECHOES LAYERING IN THE DEPENDENT PORTION OF THE GALLBLADDER, ECHOES MOVE SLOWLY WITH POSITION CHANGE, MAY FILL THE ENTIRE ORGAN ECHOGENIC BILE CHOLELITHIASIS two major types: 1. cholesterol stones and 2. pigment stones Cholesterol- formed in bile that supersaturated with cholesterol and decreased amounts of bile acids and lecithin Pigmentary- composed of calcium bilirubinate (black or brown) black stones - bilirubin, polymers, calcium phosphate and carbonate -common in patients with chronic hemolytic anemia, cirrhosis brown stones - often laminated and consist of alternating layers of calcium bilirubinate and cholesterol admixed with calcium soaps - Common in patients with biliary infections or liver flukes infestation Shadowing Hyperechoic/echogenic foci Cholelithiases CHOLELITHIASIS ULTRASOUND IS THE IMAGING METHOD OF CHOICE FOR DETECTION OF GALLSTONES WITH ITS SENSITIVITY OF GREATER THAN 90%. GALLSTONES APPEAR WITHIN THE GALLBLADDER LUMEN AS ECHOGENIC OBJECTS THAT CAST ACOUSTIC SHADOWS AND MOVE WITH CHANGES IN PATIENT POSITION  CHOLELITHIASIS ETIOLOGY: ABNORMAL BILE COMPOSITION, BILE STASIS, INFECTION RISK FACTORS: FAMILY HISTORY, OBESITY, PREGNANCY, DIABETES, FEMALE PREVALENCE 4:1 CLINICAL FINDINGS: ASYMPTOMATIC, RUQ PAIN, EPIGASTRIC PAIN, CHEST/SHOULDER PAIN, ELEVATED LIVER FUNCTION TESTS, NAUSEA, POST PRANDIAL PAIN, FATTY FOOD INTOLERANCE CHOLELITHIASIS SONOGRAPHIC APPEARANCE -HYPERECHOIC INTRALUMINAL FOCUS -POSTERIOR ACOUSTIC SHADOWING -MOBILE -WES (Wall, Echo, Shadow) CHOLELITHIASIS CHOLELITHIASES CHRONIC CHOLECYSTITIS RECURRENT INFLAMMATION SECONDARY TO INFECTION, OBSTRUCTION OR METABOLIC DISORDERS CLINICAL FINDINGS: ASYMPTOMATIC, VAGUE RUQ PAIN, HEARTBURN, FATTY FOOD INTOLERANCE, INTERMITTENT NAUSEA, MILD INCREASE IN ASPARTATE AMINOTRANSFERASE AND ALANINE AMINOTRANSFERASE, POSSIBLE INCREASE IN ALKALINE PHOSPHATASE AND BILIRUBIN CHRONIC CHOLECYSTITIS SONOGRAPHIC APPEARANCE: -SMALL CONTRACTED GALLBLADDER -THICK HYPERECHOIC WALLS -CHOLELITHIASIS, 90% OF CASES -POSTERIOR ACOUSTIC SHADOWING -SLUDGE CHRONIC CHOLECYSTITIS ACUTE CHOLECYSTITIS ETIOLOGY: OBSTRUCTION OF THE CYSTIC DUCT, INFECTION, IDIOPATHIC CLINICAL FINDINGS: SEVERE EPIGASTRIC PAIN, RUQ PAIN, BILIARY COLIC, POSITIVE MURPHY SIGN, NAUSEA, VOMITING, JAUNDICE, ELEVATED AST, BILIRUBIN, AND ALKALINE PHOSPHATASE ACUTE CHOLECYSTITIS SONOGRAPHIC APPEARANCE -THICK EDEMATOUS GB WALL -IMPACTED STONE IN THE CYSTIC DUCT -CHOLELITHIASIS, 90% -PERICHOLECYSTIC FLUID -POSITIVE MURPHY SIGN -SLUDGE MIRRIZI SYNDROME ETIOLOGY: IMPACTED STONE IN THE GALLBLADDER NECK OR CYSTIC DUCT, OBSTRUCTION OF THE CHD, JAUNDICE CLINICAL FINDINGS: RUQ PAIN, JAUNDICE, ELEVATED BILIRUBIN, ALKALINE PHOSPHATASE, INCREASE IN ALT AND AST, MIRRIZI SYNDROME SONOGRAPHIC APPEARANCE: IMMOBILE CALCULUS IN THE CYSTIC DUCT OR NECK OF THE GALLBLADDER, DILATATION OF THE INTRAHEPATIC AND CHD, NORMAL CBD MIRRIZI SYNDROME MIRRIZI SYNDROME MIRRIZI SYNDROME PORCELAIN GALLBLADDER DECREASE IN THE VASCULAR SUPPLY TO THE GALLBLADDER CLINICAL FINDINGS: ASYMTOMATIC, VAGUE RUQ PAIN SONOGRAPHIC APPEARANCE: GALLSTONES 95%, HYPERCHOIC WALL, MARKED POSTERIOR ACOUSTIC SHADOWING PORCELAIN GALLBLADDER REFERS TO CALCIFICATION OF THE GALLBLADDER WALL COMPLICATING CHRONIC CHOLECYSTITIS. US DEMONSTRATES A HIGHLY ECHOGENIC WALL WITH ACOUSTIC SHADOWING. PORCELAIN GALLBLADDER IS A PREDISPOSING CONDITION TO GALLBLADDER CARCINOMA. PORCELAIN GALLBLADDER extensive mural calcification around the perimeter of the gallbladder Wall-echo-shadow When the gallbladder is completely filled with gallstones, a confident diagnosis becomes more difficult because the gallbladder resembles an air- filled loop of bowel. The WES sign is definitive evidence of a stone-filled gallbladder Gallstones produce a clean dark shadow, and air in the bowel produces a dirty brighter shadow. WES SIGN  GALLBLADDER HYDROPS ETIOLOGY: OBSTRUCTION OF CYSTIC DUCT, PROLONG BILIARY STASIS, SURGERY, HEPATITIS, GASTROENTERITIS, DIABETES CLINICAL FINDINGS: ASYMTOMATIC, RUQ PAIN, EPIGASTRIC PAIN, PALPABLE MASS SONOGRAPHIC APPEARANCE: ENLARGMENT, GB DIAMETER EXCEEDING 5 CM, THIN HYPERECHOIC WALLS PANCREAS  PANCREAS ELONGATED ORGAN LYING TRANSVERSE AND OBLIQUELY IN THE EPIGASTRIC AND HYPOCHONDRIAC REGIONS OF THE BODY RETROPERITONEAL ORGAN  FUNCTIONS OF THE PANCREAS EXOCRINE AMYLASE-BREAKS DOWN CARBOHYDRATES LIPASE-BREAKS DOWN FATS TRYPSIN- BREAKS DOWN PROTEINS INTO AMINO ACIDS  FUNCTIONS OF THE PANCREAS EXOCRINE CHOLECYSTOKININ- STIMULATES SECRETION OF PANCREATIC ENZYMES AND CONTRACTION OF GALLBLADDER GASTRIN- STIMULATES SECRETION OF GASTRIC ACIDS SECRETIN-STIMULATES SECRETION OF BICARBONATE FUNCTIONS OF THE PANCREAS ENDOCRINE SECRETE HORMONES DIRECTLY INTO THE BLOODSTREAM ALPHA CELLS SECRETE GLUCAGON BETA CELLS SECRETE INSULIN DELTA CELLS SECRETE SOMATOSTATIN PANCREAS DIVISION AND LOCATION TAIL MOST SUPERIOR PORTION OF THE PANCREAS ANTERIOR AND PARALLEL WITH SPLENIC VEIN ANTERIOR TO THE UPPER POLE OF LEFT KIDNEY, POSTERIOR TO STOMACH, LATERAL TO THE SPINE GENERALLY EXTENDS TOWARD THE SPLENIC HILUM PANCREAS DIVISION AND LOCATION BODY LARGEST MOST ANTERIOR ASPECT LIES ANTERIOR TO THE AORTA, SUPERIOR MESENTERIC ARTERY, SPLENIC VEIN, LEFT RENAL VEIN AND SPINE LIES POSTERIOR TO THE ANTRUM OF THE STOMACH PANCREAS DIVISION AND LOCATION HEAD LIES IN THE DESCENDING PORTION OF THE DUODENUM, LATERAL TO THE SUPERIOR MESENTERIC VEIN AND ANTERIOR TO THE INFERIOR VENA CAVA MAIN PORTAL VEIN AND HEPATIC ARTERY LIE INFERIOR TO THE PANCREATIC HEAD CBD IS SITUATED IN THE POSTEROLATERAL AND INFERIOR PORTION OF PANCREATIC HEAD DUCTS OF PANCREAS DUCT OF WIRSUNG JOINS THE DISTAL COMMON BILE DUCT ENTERING THE DESCENDING PORTION OF THE DUODENUM THROUGH THE AMPULLA OF VATER FREQUENTLY VISUALIZED IN THE BODY OF THE PANCREAS  DUCTS OF PANCREAS DUCT OF SANTORINI SECONDARY SECRETORY DUCT DRAINING THE UPPER ANTERIOR PORTION OF THE PANCREAS ENTERS THE DUODENUM AT THE MINOR PAPILLA 2 cm PROXIMAL TO THE AMPULLA OF VATER NORMAL PANCREATIC SIZE HEAD 2.0 – 3.0 cm NECK 1.0 – 2.0 cm BODY 1.0 – 3.0 cm TAIL 2.0 – 3.0 cm  SONOGRAPHIC APPEARANCE NORMAL PANCREAS SMOOTH HOMOGENOUS PARENCHYMA ADULT PANCREAS IS EITHER ISOECHOIC OR HYPERECHOIC WHEN COMPARED TO NORMAL LIVER YOUNG CHILDREN-HYPOECHOIC OLDER ADULTS-HYPERECHOIC SONOGRAPHIC APPEARANCE ABNORMAL PANCREAS -IRREGULAR OR HETEROGENOUS PARENCHYMA -CALCIFICATIONS SONOGRAPHIC APPEARANCE NORMAL PANCREATIC DUCT ANECHOIC NON VASCULAR TUBULAR STRUCTURE SMOOTH PARALLEL HYPERECHOIC WALLS