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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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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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