Hepatobiliary Ultrasound:Anatomy, Technique, Pathology
Laleh Gharahbaghian, MD FAAEMAssociate Director, EM Ultrasound
Co-Director, EM Ultrasound FellowshipStanford University Medical Center
Seric Cusick, MD RDMSDirector of Emergency Ultrasound
Fellowship Director, Emergency UltrasoundUniversity of California, Davis
Objectives• Review anatomy and landmarks
• Scanning Technique: Gallbladder Evaluation
• Transducer choice, orientation
• Scanning: transverse and longitudinal views
• Measurements: GB, anterior GB wall, CBD
• GB Pathology
• Liver Pathology
• Pitfalls and ‘Tricks of the Trade’
RUQ: Normal Anatomy
• Liver: used as acoustic window; ducts and vessels
• Biliary ducts: CBD
• Bowel: duodenum
• Kidney: retroperitoneal (posterior)
• GB: mobile, folds, contracts, anatomical variations
• General Location
• RUQ
• Subcostal
• Lies within fossa
• Posterior wall approximates duodenumNOTE: The gallbladder does not lie within a standard anatomic plane, and
may be found in many different projectionsTherefore, the long and short axis of the gallbladder may not lie within the
longitudinal and transverse planes of the body
Emergency Ultrasound:Gallbladder Location
RUQ: Abnormal GB: Normal Anatomy
• GB length: 7-10cm; width 2-3cm
• Anterior GB wall: <4mm, linear echo
• CBD: <7mm, above portal vein
• Main Lobar Fissure (MLF): between GB and portal vein
Anterior GB wall
MLF
Technique• Patient Position:
Supine or Left lateral decubitus
• Transducer: Curved, low frequency probe
• Indicator to patient’s right and then toward patient’s head (transverse / longitudinal view)
• Start at Xiphoid process and travel laterally along subcostal margin, flattening probe
• Once find GB: “fan” through it in two orthogonal planes
Technique
• Poor quality image: gas
• Left lateral decubitus
• Thin patients: GB can be elongated, anterior, lower in abdomen
• flatten probe along abdomen
• Obese patients: GB can be higher in abdomen
• X minus 7 approach
LongitudinalTransverse
xyphoid process7cm
Transverse LongitudinalAnatomical Variants
GB fold(s)
Pathology: Gallstones
• Echogenic
• Shadow
• Mobile
• Single or multiple
• Varying sizes
Pathology: Gallstones
• WES sign
• W - wall
• E - Echo
• S - Shadow
• = contracted GB full of stones
WES sign
Pathology: Cholecystitis
• Pericholecystic fluid
• Thickened GB wall
• Sonographic Murphy’s
• CBD Dilatation
FINDINGS:
Sludge
Pathology: Thick GB wall• HTN
• renal disease
• multiple myeloma
• adenomyomatosis
• Tumors
• CHF
• hepatitis
• ascites
• alcoholic liver disease
• hypoproteinemia
• hypoalbuminemia
• pericholecystic
CHOLECYSTITISMain etiology:
Normal
Abnormal
Pathology: Biliary Ducts
• Biliary ducts provide information regarding obstruction
• Common Bile Duct: located above portal vein
• follow MLF to CBD
• Tip: Use Color Doppler box to differentiate biliary ducts from hepatic vessels
longitudinal
Dilated Biliary
Ducts
Portal
Finding the CBD...
Finding the CBD..... Dilated Biliary Ducts
Pitfalls
• Mistaking Duodenum with GB
• Mistaking GB fold for stone/mass
• Gas Scatter - put patient in LLD
• WES sign - not knowing what you see when you see it
Tricks of the Trade: Scanning Tips
• Obtaining window - small liver, gas scatter, anterior GB can result in difficult visualization
• patient positioning, flattening probe
• System controls - adjust Gain, Depth to maximize image quality
When you can’t find the Gallbladder.....
• Left Lateral Decubitus position
• Try between the ribs (X minus 7)
• Try RUQ of FAST view (transducer at midaxillary line; indicator toward head)
• move probe anteriorly
• kidney leaves view, GB comes into view
Other things you may see...
Liver abscess
Other things you may see...
Liver cysts
Other things you may see...
TIPS
free fluid
Other things you may see...
Liver cancer
Summary
• Point-of-care ultrasound of the hepatobiliary system may aid in the care of emergency department patients
• Evaluation for gallstones and secondary features of cholecystitis may be facilitated by sonographic techniques and the appreciation of key pitfalls
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