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Biliary Anatomy

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Biliary Calculi

Milk of calcium bilePorcelain gallbladder

CholecystitisMirizzi Syndrome,

Gall stone ileus

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Biliary lithiasis

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Biliary lithiasis

最佳影像診斷線索:

Echogenic foci with posterior

acoustic shadowing (10% stones:No acoustic shadow) in US 

Discrete & (movable) lower signal

(density) filling defects within bileducts in MRC and ERCP

Opaque stones (20%) in plain

radiography

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Gallbladder completely filled with calculi ~

Calculi are molded (鑄造) by the wall of the gall

bladder : the acoustic shadow posterior to the

Calculi that do not change with positional change

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Floating stone

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Clinical issues 

Primary CBD stones (5%) : Form within CBD

2nd CBD stones (95%) : Gallstones into CBD 

Treatment:stone < 3 mm : usu. spontaneously passstone 3-10 mm : endoscopic sphicterotomy* stone retrieval balloon to sweep duct

* basket to snare stones stone > 10-15mm : require fragmentationby mechanical lithotripsy

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Clinical issues

(CBD stones) S/S: RUQ pain, Jaundice, pancreatitis

↑Alkaline phosphate & bilirubin

Gender: Females (middle age) > malesPathology:

Bile stasis / infection ~

Bilirubinate stone formation(Cholesterol + Ca  bilirubinate) 

Obstruction, dilatation, sclerosis,

stricture.

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http://slidepdf.com/reader/full/biliary-anatomy-ultrasound 13/72Crescent (meniscus) lucent sign

Bull’s eye sign 

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Milk of calcium bileCalcium carbonate precipitate within

gall bladder lumen (calcium milk)

最佳影像診斷線索: Identification of

calcified liquid within gallbladder

(echogenic fluid similar to sludges

but with acoustic shadowing)

Incidental finding: asymptom or RUQ pain

Etiology: GB stasis ~ Ca++ carbonate

in bile, thickness of GB wall

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GB sludges (thick bile)

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GB sludges ~ cholecystitis ~ stone

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Milk of calcium bile

(vs. sandy gall stone)

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Porcelain GB

Calcification of gallbladder wall

最佳影像診斷線索: Rim of calcificationin RUQ conforming to GB shape

Usually asymptomatic ; old age

Rish factor for gallbladder carcinomaProphylactic cholecystectomy is

current consensus recommendation

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Cholecystitis

• Acute inflammation of gall bladder

• 95% calculous: 2 to obstructingstone in GB neck or cystic duct

• 5% Acaculous: 2 to ischemia with

secondary inflammation/infection

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Gallstones --> cystic duct

obstruction

Bile secretion

GB distention

Wall edema /

hypervascularity

Intraluminal pressure

Compression on vessels

--> Thrombosis/ ischemia--> GB wall necrosis

--> Perforation / abscess

Pathophysiology

Gallstones (+) : 96 %

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Color Doppler sonogram: marked

Hyperemia & wall thickness of GB

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Tc-HIDA scan: Acute cholecystitis

without isotope filling of GB 

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最佳影像診斷線索: • GS impacted in neck / cystic duct

• Sonographic Murphy sign (+)

• GB wall thickness (> 4 mm)• Distended GB (> 4 cm trans. diameter)

• Pericholecystic fluid/ /abscess

• Intraluminal membranes

• Gas in GB wall / lumen

• Asymmetric GB wall thickness

Cholecystitis

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Clinical issues S/S: Acute RUQ pain, fever

Lab data: ↑WBC count, may have mildelevation in liver enzymes

Demographics

Age: typically > 25y, Gender: M:F = 1:3

Microscopic features

Lumen: GS, sludge; GB mucosa: Ulceration;

GB wall: Acute PMN infiltration;

Bacterial cultures positive in 40-70% of patient

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Acaculous cholecystitis ?

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Non-inflammatory GB wall thickness:

Congestive heart failure with dilated IVC

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Non-inflammatory GB wall thickness:

Acute hepatitis

Acute hepatitis s/p treatment

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Clinical issues 

ComplicationsEmpyema

Emphysematous, GangrenousPerforated with abscess

Chronic cholecystitis

Mirizzi syndrome

Bouveret syndrome (gall stone ileus)

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Intraluminal membranes

Empyema of  gall bladder  

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Emphysematous cholecystitis

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Intraluminal membranes

Sloughed (蛻腐) mucosae(Asymmetrical wall thickness)

Gangrene of gall bladder  

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Perforated GB with abscess

localized peri-cholecystic complicated fluid collections

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Perforated GB with abscess

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Clinical issues Treatment

• Prompt or delayed lap. cholecystectomy

Laparoscopic cholecystectomy for

uncomplicated cases• Percutaneous cholecystectomy

useful for poor operative risk patients with

GB empyema or gangrene

• Percutaneous drainage

well-defined, well-localized pericholecystic

abscesses

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Chronic Cholecystitis

Two appearance

Small, contracted, sclerosed GB

with/without stones (fasting state)

Same imaging appearance as

acute cholecystitis but withoutMurphy sign (terderness)

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Small, contracted, sclerosed GB;even non-visualization of GB

(during fasting state)

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Mirizzi syndrome

Partial or complete obstruction

of common hepatic duct (CHD)

due to gallstone impacted incystic duct or gall bladder neck

最佳影像診斷線索: Impacted cystic

duct stone on US with proximaldilatation of intraheptic ducts 

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Porta hepatis nodes Klatskin tumor

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Gall stone ileus

(Bouveret syndrome)Gall stone erodes into duodenum

causing intestinal obstuction

最 影 診斷線索: (Rigler triad) 

Small bowel obstruction

Gas in biliary tree

Ectopic gallstone (> 2.5 cm) in bowel

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Clinical issues

Age: risk ↑with age; average 65-75 Y/O

Prognosis: high mortality, operative

mortality 19 Treatment

Surgical therapy to relieve bowelobstruction

Cholecystectomy & biliary fistulaexcision; to prevent recurrence

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M/74

•  主  訴：chills and fever for three days

•  現 在 史  previous history of liver cirrhosis with

ascites, started nausea, vomiting, fever and

abdominal pain for three days before admission.He was brought to nearby hospital for

hospitalization. However, signs and symptoms

persist, and he was diagnosed to have

peritonitis of unknown cause. He is then

transferred to our hospital for further evaluation

and management. At the ER, abdomen CT ~~~

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• Vital signs : Blood pressure 93 / 59 mmHg

Pulse rate 97 / minutes

Respiratory rate 19 / minutes

Body temperature 38.3 ℃ 

•  Abdomen : Distended ( + )

Tenderness ( + ) : RUQ ( + )

Rebounding pain ( + )

Murphy's sign ( + )

Shifting dullness ( + )

Bowel sound : Hypoactive ( + )

•   Lab. : WBC: 28230/cumm

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Pathological No.: 962230

Date of Arrival: 2007/8/7

Date of Report: 2007/8/8

Pathological diagnosis:

Gall bladder, cholecystectomy ---------- Chronic cholecystitis with acute exacerbation and cholelithiasis

Gross:

The specimen consists of an opened gall bladder, measuring 9.2 x 4.5 x

3 cm in size. It is enlarged. The wall is thickened and measuring up to

0.5 cm in thickness. The mucosal folds are absent. There are severalpieces of black stone in the lumen. Representative parts are embedded

in one block.

Microscopy:

The sections show a picture of edema, neutrophilic infiltration,

congestion, hemorrhage, abscess formation, fibrosis and focal

chronic inflammatory cell infiltration in the lamina propria,muscular layer and perimuscular layer. Rokitansky-Aschoff

sinuses are present.

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•   主  訴：Left abdominal pain off and on for 10 days

•   病  史：This 52 years old woman, who had history of infertility s/p

laparoscopy > 25 years ago, Intestinal adhesion s/p OP

25 years ago, left ovarian tumor s/p laparoscopy 15 years

ago.

 According to the patient : she has left abdominal pain off

and on for 10 days, aggravated for 3-4 days, can not sleep

due tp severe pain with fullness. Associated with loss ofappetite, nausea was noted. The pain locates on left

abdominal area, subacute, duration 24 hours, dull pain and

fullness in character, aggravated by taken food, relief by

rest, no radiated, no change of bowel habit. She had been

treatment at劉醫院, but the treatment not effective, hence,

she sent to our GI OPD, KUB showed partial intestinal

obstruction, She was admitted.

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Spigelian hernia Lap. Port hernia

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