Gallbladder Pathologies PDF

 PATHOLOGIES OF GALLBLADDER AND BILE DUCTS  THICK WALLED GALLBLADDER Thickening of gallbladder wall can be seen in a number of conditions: CHOLECYSTITIS: acute cholecystitis Chronic cholecystitis gallbladder empyema POSTPRANDIAL PHYSIOLOGICAL STATE SECONDARY THICKENINGhepatic cirr...

 PATHOLOGIES OF GALLBLADDER AND BILE DUCTS  THICK WALLED GALLBLADDER Thickening of gallbladder wall can be seen in a number of conditions: CHOLECYSTITIS: acute cholecystitis Chronic cholecystitis gallbladder empyema POSTPRANDIAL PHYSIOLOGICAL STATE SECONDARY THICKENINGhepatic cirrhosis hepatitis  CAUSES OF THICK WALLED GB congestive heart failure hypoalbuminemia ascites OTHER INFLAMMATORY PROCESSES IN RIGHT UPPER QUADRANT acute pancreatitis perforated duodenal ulcer peritonitis GALLBLADDER CARCINOMA a minority of cases present with focal or diffuse wall thickening  CAUSES OF THICK WALLED GB suspicious features include marked asymmetric wall thickening and irregularity. DIFFUSE ADENOMYOMATOSIS OF THE GALLBLADDER associated with classic comet tail artefact associated with epithelial enhancement DIFFUSE GB WALL THICKENING THICK WALLED GB  CHOLELITHIASIS CHOLELITHIASIS means presence of stones in gallbladder which are concretions that are formed in the biliary tract. Gallstones are highly prevalent, but most (80%) are asymptomatic. Common risk factors include older age, female sex and pregnancy, obesity, rapid weight loss, drugs, and a family history. Abdominal ultrasound provides effective diagnostic imaging. Symptoms ensue if a stone obstructs the cystic, bile, or pancreatic duct.  TYPES OF GALLSTONES Cholesterol stones: These are usually yellow-green. They're the most common, making up 80% of gallstones. Pigment stones: These are smaller and darker. They're made of bilirubin. Mixed stones: This type of gallstone mostly contains cholesterol (20 to 90%) and calcium carbonate.4 Mixed stones are dark green or brown in color. Stones with calcium content. SIZE: Gallstones can range from the size of a grain of sand to that of a golf ball. Gallstone in gallbladder may be single or collection of multiple stones.  SYMPTOMS OF GALLSTONES Asymptomatic Gallstone Disease In few cases single or multiple gallstones does not cause any symptoms or sign for several years. Diagnosis of gallstone is incidental among asymptomatic patients following routine blood or radiological studies. Symptoms of gallstone: Pain in right upper quadrant which often radiates between shoulder blades. Obstruction of bile duct results in colic pain followed by nausea and vomiting. Infection of gallbladder also known as cholecystitis is sometime associated with gallstone. Cholecystitis causes fever with chills  CLINICAL SIGNS & COMPLICATIONS OF GALLSTONES Person suffering from gallstones may show signs of tenderness in right upper quadrant of abdomen Jaundice can also be a sign of gallstone if it causes obstruction any where in the biliary tree. Fever may be present if the patient develops infection. COMPLICATIONS Inflammation- Irritation of gallbladder wall resulting in Inflammation of gallbladder Obstruction- Common bile duct obstruction. Obstruction of Pancreatic duct Cancer of the Gallbladder.  SONOGRAPHIC APPEARANCE OF GALLSTONES Gallstones appear as mobile, echogenic, intraluminal structures that cast acoustic shadowing. Shadowing occurs because of sound beam absorption by the stone. Demonstration of shadowing is important in distinguishing stones from other intraluminal abnormalities. Shadowing primarily depends upon the size of the stone and is independent of stone composition. To a large degree all stones appear similar on ultrasonography.  IMAGE OPTIMIZATION TO DEMONSTRATE A GALL STONE Technical factors need to be optimized to demonstrate shadowing behind a gallstone. Because sound absorption increases at higher frequencies, non shadowing stones may be converted into shadowing stones by switching to a higher transmit frequency. Another important factor is the focal zone. Because the beam profile is the narrowest at focal zone, it should be kept at the depth of the stone. If there are multiple small stones, shadowing may best be demonstrated by positioning the patient so that the stones are clumped together.  WALL ECHO SHADOW SIGN The wall-echo-shadow sign (also known as WES sign) is an ultrasonographic finding within the gallbladder fossa referring to the appearance of a "wall-echo-shadow": a curvilinear hyperechogenic line representing the gallbladder wall a thin hypoechoic space representing a small amount of bile a curvilinear hyperechogenic line representing the near surface of gallstone(s) and acoustic shadowing distal to the surface of the gallstone(s) The sign suggests either a large gallstone or multiple small gallstones filling the lumen of a contracted or incompletely visualized gallbladder. Recognizing this finding helps to avoid misinterpretation of a stone-filled gallbladder as a loop of bowel  DIFFERENTIAL DIAGNOSIS OF WES Differential diagnosis air-filled loop of bowel: character of shadow is important, in most cases stone produces a clean shadow and gas produces a dirty shadow. porcelain gallbladder: lacks the thin hypoechoic bile space between the wall and gallstone, as seen in the wall- echo-shadow sign. Emphysematous gallbladder WALL ECHO SHADOW SIGN WALL ECHO SHADOW SIGN  PORCELAIN GALLBLADDER Porcelain gallbladder refers to extensive calcium encrustation of the gallbladder wall. The term has been used to emphasize the blue discoloration and brittle consistency of the gallbladder wall at surgery but is often an incidental finding on multiple different imaging modalities. On ultrasound, the gallbladder demonstrates echoes and posterior dense shadowing, with usually poor delineation of the gallbladder wall itself. This could be mistaken for gas in the gallbladder wall (emphysematous cholecystitis). PORCELAIN GALLBLADDER  ACUTE CHOLECYSTITIS Acute cholecystitis is an inflammation of the gallbladder. 90-95% of cases are due to gallstones (i.e. acute calculous cholecystitis) with the remainder being acute acalculous cholecystitis. The development of acute calculous cholecystitis follows a sequence of events: Gallstone obstruction of the gallbladder neck or cystic duct inflammation from chemical injury of the mucosa by bile salts reactive production of mucus, leading to increased intraluminal pressure and distention increased luminal distention restricting blood flow to the gallbladder wall (gallbladder hydrops) increasing wall thickness from edema and inflammatory changes secondary bacterial infection in ~66% of patient  SONOGRAPHIC SIGNS OF ACUTE CHOLECYSTITIS Following are the signs of acute cholecystitis: 1. Gallstones 2. Wall thickening >= 3mm 3. Gallbladder enlargement 4. Pericholecystic fluid 5. Impacted stone 6. Sonographic Murphy’s sign. The most sensitive US finding in acute cholecystitis is the presence of cholelithiasis in combination with the sonographic Murphy sign.  SONOGRAPHIC MURPHY’S SIGN Sonographic Murphy sign is defined as maximal abdominal tenderness from pressure of the ultrasound probe over the visualized gallbladder. It is a sign of local inflammation around the gallbladder along with right upper quadrant pain, tenderness and/or a mass 2. It is one of the most important sonographic signs of cholecystitis and when combined with the presence or absence of cholelithiasis it has a high positive and negative predictive value respectively. Sonographic Murphy sign is the radiological correlate of the clinical Murphy sign, which is elicited by deep palpation of the right hypochondrium followed by the examiner asking the patient to inspire. If the patient's breath abruptly stops, then it is a positive Murphy sign ACUTE CHOLECYSTITIS ACALCULOUS CHOLECYSTITIS  ACALCULOUS CHOLECYSTITIS Acalculous cholecystitis is an acute necroinflammatory disease of the gallbladder with a multifactorial pathogenesis. It accounts for approximately 10 percent of all cases of acute cholecystitis and is associated with high morbidity and mortality rates. Acalculous cholecystitis results from gallbladder stasis and ischemia, which then cause a local inflammatory response in the gallbladder wall Pathologically in patients with acalculous cholecystitis, endothelial injury, gallbladder ischemia, and stasis, lead to concentration of bile salts, gallbladder distension, and eventually necrosis of the gallbladder tissue. Once acalculous cholecystitis is established, secondary infection with enteric pathogens, including Escherichia coli, Enterococcus faecalis, Klebsiella spp, Pseudomonas spp, Proteus spp, and Bacteroides fragilis and related strains, is common. Perforation occurs in severe cases  CHRONIC CHOLECYSTITIS Chronic cholecystitis is characterized by repeated attacks of pain (biliary colic) that occur when gallstones periodically block the cystic duct. In chronic cholecystitis, the gallbladder is damaged by repeated attacks of acute inflammation, usually due to gallstones, and may become thick-walled, scarred, and small. The most commonly observed cross-sectional imaging findings in the setting of chronic cholecystitis are cholelithiasis and gallbladder wall thickening. The gallbladder may appear contracted or distended, and pericholecystic inflammation is usually absent. CHRONIC CHOLECYSTITIS  EMPHYSEMATOUS CHOLECYSTITIS Emphysematous cholecystitis is a rare form of acute cholecystitis where gallbladder wall necrosis causes gas formation in the lumen or wall. It is a surgical emergency, due to the high mortality from gallbladder gangrene and perforation. Clinical manifestation is often insidious and may then progress rapidly. Up to one-third of patients may be afebrile and localized tenderness is often not a dominant clinical feature. Sonographic appearance Ultrasonography may demonstrate highly echogenic reflectors with low-level posterior shadowing and reverberation artifact ("dirty" shadowing and "ring-down" artifact) EMPHYSEMATOUS CHOLECYSTITIS EMPHYSEMATOUS CHOLECYSTITIS; CHAMPAGNE SIGN Targeted ultrasound of the gallbladder demonstrates multiple tiny echogenic foci in the gallbladder lumen resembling effervescing bubbles in the glass of champagne.  GALLBLADDER POLYP A gallbladder polyp is a small, abnormal growth of tissue with a stalk protruding from the lining of the inside of the gallbladder. They are relatively common. The vast majority are benign, but malignant forms are seen. Sonographic appearance: They are usually best characterized on ultrasound as a non- shadowing and immobile polypoid ingrowth into gallbladder lumen. Overall size is probably the most useful indicator of malignancy, with polyps over 10 mm in diameter having a reported malignancy rate of 37-88%  DIFFERENTIAL DIAGNOSIS OF GB POLYP The differential for a gallbladder polyp is limited, and includes 6: gallstones usually mobile, but can be adherent usually cast an acoustic shadow biliary sludge tumefactive sludge adenomyomatosis gallbladder carcinoma gallbladder metastases (especially in patients with a history of melanoma. ULTRASOUND IMAGES OF GB POLYP  GALLBLADDER CHOLESTEROL POLYPS These are the most common subtype of gallbladder polyps, representing more than 50% of all polyps. They are frequently seen in middle-aged women and are benign lesions, with no malignant potential. They present usually as multiple intraluminal gallbladder polypoid lesions. small: usually 1 to 2 mm, but always