biliary tree ultrasound - in a nutshell · gallbladder polyps • general features of gallbladder...
TRANSCRIPT
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Biliary Tree Ultrasound -
In a nutshell
Pamela Parker
Lead Sonographer
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Aims
• Review what we know about the biliary
system
• Common pathologies
• Pitfalls
• Reporting tips
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The Nutshell
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Background
• Biliary examinations most appropriate and
efficacious uses of US
• Inherently high contrast due to cystic
nature of GB and bile ducts, particularly
when dilated
• High quality examination in the majority of
pts
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Modality of choice
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The things we are good at
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The things we are good at
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The things we are good at
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Gallbladder
• The ultrasound
appearance of the GB
are of a elongated
pear-shaped cystic
structure.
• The gallbladder is
well delineated and
has smooth thin walls
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Gallbladder
• Spiral valves are
small mucosal folds
within the cystic duct
• **Pitfall alert**
• Can mimic stones
within GB neck
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Gallbladder
• The walls are uniform
and thin measuring
less than 3mm in
diameter.
• 3mm is the upper limit
of the normal range.
• There is no lower limit
of normal.
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Gallbladder
• This image could be
improved if the fundus
was more clearly
• Evaluate fully the
whole of the
gallbladder during
every examination.
• May need to evaluate
the neck separately to
the fundus.
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Gallbladder
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Gallbladder
Normal Variants
• Fundal fold known as a
Phrygian cap can also be
present
• An infundibulum (cavity),
called Hartmann’s Pouch,
can be present in the region
of the gallbladder neck,
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Gallbladder
• GS can migrate to the
fundus, particularly if fold
present
• The fundus has a separate
blood supply and this can
be reduced, particularly in
the elderly
• Fundus is prone to
pathology developing
related to chronic
cholecystitis leading to
adenomyomatosis
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Gallbladder
• Polyps
• Gallstones
• Acute Cholecystitis
• Chronic Cholecystitis
• Adenomyomatosis
• Cancer
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Gallbladder Polyps
• A gallbladder polyp is
defined as any elevated
lesion of the mucosal
surface of the gallbladder,
and as such includes a
variety of both benign and
malignant entities.
• Solitary
• Multiple
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Gallbladder Polyps
• Relatively frequent,
seen in up to 5% of
the population.
• Over 90% are
benign, and the
majority are
cholesterol polyps
• Frequently identified
in patients between
40 and 50 years of
age, and are more
common in women
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Gallbladder Polyps
• 95% of all polyps are
benign
• cholesterol polyps : >
50% of all polyps
• adenoma : ~ 30%,
possibly premalignant
• inflammatory polyps
• adenomyomatosis
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Gallbladder Polyps
• 5% of all polyps are
malignant
• adenocarcinoma : ~ 90%
of malignant polyps
• other rare entities
including
– metastases to gallbladder
– squamous cell carcinoma
– angiosarcoma
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Gallbladder Polyps
• Typically polyps are incidentally found on upper
abdominal imaging, in patients with upper abdominal
discomfort.
• In most instances polyps are thought to be asymptomatic
• Surgical management considered if symptomatic and no
other cause found
• The differential for a gallbladder polyp is limited, and
includes:
• gallstone
– usually mobile, but may be adherent
– usually casts and acoustic shadow
• biliary sludge
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Gallbladder Polyps
• In most instances predicting histology based purely on imaging is not possible, with the possible exception of cholesterol
• As adenomas are considered pre-malignant, surgical management is warranted, and thus the important imaging distinction is between a cholesterol polyp and a solid (and thus most likely neoplastic lesion).
• Overall size is probably the most useful indicator of malignancy, with polyps over 10mm in diameter having a malignancy rate of 37-88%.
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Gallbladder Polyps
• General features of gallbladder polyps are a non shadowing polypoid ingrowth into gallbladder lumen, which is usually immobile unless there is a relatively long pedunculated component.
• EUS is useful in further assessing polyps as it is able to generate higher resolution images
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Gallbladder Polyps
Features of cholesterol polyp include:
• small size
• > 90% are less than 10 mm & most are less than 5 mm
• echogenicity varies with size
• small polyps are echogenic but non-shadowing
• larger cholesterol polyps tend to be hypoechoic
• small polyps are adherent to the wall and a smooth
• larger lesions tend to be pedunculated and granular in
outline
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Gallbladder Polyps
• Adenomas on the other
hand tend to be larger,
solitary, more often
sessile with internal
vascularity and of
intermediate
echogenicity.
• It is not possible to
distinguish an adenoma
from an adenocarcinoma
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Gallbladder Polyps
• The risk of GB malignancy resulting from
incidentally detected polyps is extremely
low.
• Incidentally detected GB polyps measuring
6 mm or less may require no additional
follow-up.
• Incidentally Detected Gallbladder Polyps: Is Follow-up Necessary?—Long-term Clinical and US
Analysis of 346 Patients January 2011 Radiology 258, 277-282
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Gallbladder Polyp Management
• Any Polyp >9mm should be referred for consideration of
Cholecystectomy.
• Incidental finding of a polyp <9mm in an asymptomatic patient
should have a follow up scan in 1 year with 3 caveats.
– If patient becomes symptomatic within the year they should be
referred for consideration of Cholecystectomy, regardless of size
of the polyp
– If Polyp has stayed the same after 1 year can be discharged with
advice see GP if becomes symptomatic. If the patient does
develop RUQ symptoms they should be referred for
consideration of Cholecystectomy, regardless of size of the
polyp.
– If small increase in size, annual follow up until either >9mm,
symptomatic or stops growing.
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The things we are good at
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Gallstones
• 10-15% of people in the adult Western
world develop gallstones.
• 1-4% of asymptomatic cases go on to
develop symptoms annually.
• The most common presentations are
biliary colic (56%) and acute cholecystitis
(36%)
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Gallstones
• The adage 'fair, fat, fertile, female and forty' is
only part of the story. Other risk factors include:
– Increasing age.
– Positive family history.
– Sudden weight loss - eg, after obesity surgery.
– Loss of bile salts - eg, ileal resection, terminal ileitis.
– Diabetes - as part of the metabolic syndrome.
– Oral contraception - particularly in young women
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Gallstone Facts
• Female gallstone subjects had a higher BMI
than controls but males did not.
• Gallstones are twice as common in those with
diabetes.
• A third of elderly patients of both sexes have
gallstones but most had not had surgery
• Gallstones are seldom a cause of death
• CBD stones may occur in 3-14.7% of all patients
for whom cholecystectomy is performed
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Gallstones
• Bile contains cholesterol, bile pigments
and phospholipids. If the concentrations of
these vary, different kinds of stones may
be formed.
• Cholesterol stones
• Black pigment stones
• Mixed stones.
• Brown pigment stones
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Gallstones
• Black pigment stones are small, friable,
irregular and radiolucent:
– Risk factors include haemolysis and cirrhosis.
• Mixed stones are faceted and are
comprised of calcium salts, pigment and
cholesterol. 10% are radiopaque.
• Brown pigment stones (<5% in the UK)
form as a result of stasis and infection
within the biliary system,
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Gallstones – US features • Ultrasound appearances are the same regardless of the
composition of the stone.
• The large acoustic impendence between the stone and
the surrounding bile makes them highly reflective.
• Strong acoustic shadow.
* Pitfall Alert*
– Stones of less than 5mm may not shadow, particularly with the
use of compound imaging
• Moving the patient and observe movement.
• Colour Doppler can occasionally aid diagnosis as it may
produce a “twinkle” artefact in the stone.
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Gallstones – US features
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Gallstones – US features
Gallstones?
Gallstones?
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Gallstones ?
*Pitfall Alert*
YES √ No x – Gas filled
duodenum
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Gallstones - Presentation
• Up to 70% of patients with gallstones are
asymptomatic at the time of diagnosis.
• Gallstones may cause acute or chronic
cholecystitis, biliary colic, pancreatitis or
obstructive jaundice.
• Biliary colic is the most common
presentation,
• The second most common presentation is
acute cholecystitis,
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Biliary colic • Caused by a gallstone impacting in the cystic duct or the
ampulla of Vater.
• The pain starts suddenly in the epigastrium (RUQ) and
may radiate around to the back in the interscapular
region.
• Pain persists from 15 minutes up to 24 hours, subsiding
spontaneously or with analgesics.
• Nausea or vomiting often accompanies the pain,
• Occurs as a result of distension of the gallbladder due to
an obstruction or to the passage of a stone through the
cystic duct
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Gallstones - Colic
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Gallstones – Investigations
• US is 90-95% sensitive.
– Immobile stones misinterpreted as polyps; very small
ones may be missed or fail to throw a helpful acoustic
shadow.
• US can also asses CBD liver and hepatic bile
ducts;
– but it can only identify with certainty about half of any
stones in the CBD.
• If US negative but there is a high level of
suspicion, repeat after an interval;
• May pick up stones which were previously missed.
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Causes of Cholecystitis
• Gallstones or biliary sludge (95% of patients).
• Trauma or acute biliary illness (5% acalculus
disease).
• Female gender.
• Increasing age.
• Obesity.
• Rapid weight loss.
• Pregnancy.
• Crohn's disease.
• Hyperlipidaemia
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Cholecystitis Investigations
• FBC - the WCC is likely to be raised.
• Liver enzymes are often mildly abnormal.
• Ultrasound findings for cholecystitis:
– Include a thickened GB wall (greater than 3
mm) and may also include pericholecystic
fluid or air in the GB or the GB wall.
– If the GB wall is thickened but there are no
gallstones present then the diagnosis could
still be acalculous cholecystitis
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Cholecystitis
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Additional Findings
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*Pitfall Alert*
Mural oedema, but not cholecystitis
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Causes of GB wall oedema
• Physiological
o post prandial
• Inflammatory
• Adjacent disease
• Non-inflammatory
o adenomyomatosis, cancer, leukaemia, mets
• Generalised oedema
o Ascites, organ failure, portal hypertension
• Varices
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Complications of Gallstones
1. Obstructive jaundice
2. Cholangitis
3. Severe Perforated Cholecystitis
4. Pancreatitis
5. Gallstone ileus
6. Chronic Cholecystitis
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1: Obstructive Jaundice
Mirizzi Syndrome
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*Pitfall Alert*
Measuring the duct
• What is normal?
• Does size matter?
• Enlarges with age,
bile duct disease
(?cholecystectomy)
• Should taper to
pancreatic head
• Symptomatic vs
Incidental
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Why do we care about a big duct?
• Because it might represent obstruction
• Because of the possible causes…
– Cancer
– Stones
– Inflammation/Stricture
• Because of the possible consequences
– Cholangitis
– Obstructive jaundice
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So if you see a big bile duct…
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So if you see a big bile duct…
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Pancreatic head mass
Staging malignancy of
hollow organs
Chronic pancreatitis
Pancreatic mass evaluation
Endoscopic US
• Staging malignancy of
hollow organs
• Chronic pancreatitis
• Pancreatic mass
evaluation
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What about the incidental big
duct? • Overall clinical picture
• Overall radiological picture
– Intrahepatic ductal dilatation?
– Good views of pancreas?
• Old imaging – any cross-sectional
modality
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Intrahepatic Ducts
• Complex 3D shape
• Subjective
• Confounders
– Arterial hypertrophy in cirrhotics
– Saccular dilatation
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Segmental Intrahepatic Biliary
Dilatation
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Liver Cysts v Duct dilatation
Central dot sign in Caroli’s Disease
(dilatation or ectasia of the bile
ducts)
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2: Ascending Cholangitis
• Charcot's triad:
Infected CBD leading
to jaundice and high
swinging fevers with
rigors and chills
• Retrograde infection
up the CBD as a
result of acute
cholecystitis or ERCP
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3:Severe, Perforated
Cholecystitis
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4: Pancreatitis
• Gallbladder disease and excess alcohol consumption
account for most cases and typically cause periductal
necrosis.
• Gallstones cause pancreatitis by blocking the bile duct,
causing back pressure in the main pancreatic duct
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Normal Pancreas – 50 Shades
of Grey
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Pancreatitis
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5: Gallstone ileus
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6: Chronic Cholecystitis
• GB Walls irregularly
thickened
• Hyperechoic
• Fibrosed
• Complicated by
episodes of acute on
chronic chloecystitis
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6: Adenomyomatosis
• Benign condition associated with stone disease and strictures
• Wall thickening, solid nodules often at the fundus, shadowing from
Rokitanski-Achoff sinuses
• Surgeons tend to take out symptomatic gallbladders
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6: Focal Adenomyomatosis
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What are you going to report?
• Clinical history: Admitted RUQ pain, jaundice and puritis. Mr ****** would like an US to look at CBD. Bil 148, ALP 521 and ALT 201.
• US ABDO
The liver appears normal in size and shape with a homogenous echo pattern. No focal lesions identified. Normal hepatopetal flow shown in the portal vein. Pneumobilia again noted.
Cholecystectomy noted. The common duct is dilated measuring 17mm and intrahepatic duct dilation is present around the porta. There appear to be some filling defects in the CBD.
The right kidney appears normal. Left parapelvic cyst again seen.
The pancreas was obscured by overlying bowel.
No free fluid.
• Patient went on to have CT then MRCP…
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Learning Points
• Clinical History
– Acute, spasmodic, WCC
• Previous history
– Previous cholecystectomy?
• Gallstones present – now what?
– Wall thickness, oedema, pain
• Big ducts
– Why? Intraductal Stones
• Pancreas
– Secondary Signs
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Biliary Tree Ultrasound in a
Nutshell • Fantastic
– Common duct
– Gallbladder and stone disease
– Pancreatic Cancers (!)
• Tricky – Intrahepatic ductal pathology
– Differentiating cancer from inflammation
– Handling the incidentally dilated common duct
• Think beyond the gallstone