Biliary Protocol (Gallbladder)

This protocol includes images of several organs and structures. It has been divided into
sections to assist in determining diagnostic images that should be stored for the physician.
o Pancreas
o Gallbladder and Common Bile Duct
You must always evaluate the entire organ first before you store an image
You should understand completely why you stored the image and identify everything in
the image
Multiple breathing techniques and patient positions will be required

Organ/ Scan Label Key Landmarks Identified

Order Plane
Pancreas head
PANCREAS Portal splenic confluence
CBD
o If CBD is enlarged, measure internal AP diameter
Transvers
Pancreas body
e plane
Pancreas Aorta
on the PANCREAS
Measurement
body o If pancreatic duct is seen measure internal AP
diameter
PANCREAS Pancreas tail
Splenic vein
Organ/ Scan Plane Label Key Landmarks
Order Identified
GB SUPINE Gallbladder body
Sagittal
SAG Gallbladder fundus
plane of
Gallblad GB SUPINE Gallbladder body
the GB
der SAG Gallbladder neck
Transvers GB SUPINE Gallbladder mid body with clear delineation of
Patient in e plane of TX anterior wall
Supine the GB Gallbladder mid body with clear delineation of
position GB SUPINE anterior wall
TX Measurement
o measure anterior wall thickness
GB LLD SAG Gallbladder body
Gallblad Sagittal
Gallbladder fundus
der plane of
GB LLD SAG Gallbladder body
the GB
Gallbladder neck
Patient in Transvers Gallbladder mid body
Left lateral
e
decubitus GB LLD TX
position plane of
the GB
Gallblad Gallbladder body
Sagittal GB RLD SAG
der Gallbladder fundus
plane of
Gallbladder body
the GB GB RLD SAG
Patient in Gallbladder neck
Right lateral Transvers GB RLD TX Gallbladder mid body
decubitus
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 position e plane of
the GB

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 Transvers Portal vein
e plane of CBD TX CBD
the CBD Hepatic artery
Portal vein
Common CBD SAG
CBD
Bile Duct Enlarged image
CBD SAG Portal vein
level of the Sagittal
CBD
porta plane of
hepatis Enlarged image
the CBD
Portal vein
CBD SAG CBD
Measurement
o Internal AP diameter

Anatomical/ Image Correlation

CBD Hepatic

Portal CBD measurement

Inner wall to inner
Anterior GB wall measurement Transverse Portal
wall
Outer wall to inner wall triad
Mickey Mouse Where it enters
sign the liver

Normal Measurement Ranges

Structure Area of Interest Plane Measureme Comments

nt
Common Bile Level of Porta Long Axis <7-8 mm Measure inner wall to
Duct Hepatis inner wall
If duct is enlarged:
o Look for and document
any intrahepatic ductal
dilatation
o Follow CBD to
pancreatic head
If GB removed, CBD may
be enlarged (up to 11
mm)
Gallbladder wall Anterior Wall Transvers <3 mm Calipers are placed
e outside to inside of the
anterior wall
Pancreas Head Transvers Head 2-3.5 Only performed if
e on the cm abnormalities are

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 body suspected
Pancreatic Duct Body of the Transvers 2 mm or less Only performed if duct is
pancreas e on the visualized
body Measure internal duct
diameter anterior to
posterior

Biliary Protocol

Common Laboratory Values to be Reviewed prior to Examination

Lab Value Organ Level Indication or Association

Amylase Pancreas Increased Pancreatitis or other pancreatic disease
Lipase Pancreas Increased Pancreatitis or other pancreatic disease
Alkaline Liver Increased Biliary obstruction or metastases
phosphatase Gallbladder

Bilirubin Liver Increased Jaundice, liver damage or obstruction

Gallbladder

Tips
Patient should be NPO for this study to reduce the amount of gas present and to prevent
contraction of the GB
Have patient poke out their abdomen or take in a deep breath if having trouble seeing the
pancreas
Pancreatic tail may be evaluated using the spleen as a window
Sit the patient erect for scanning if suspicious for stones stuck in the neck that werent
confirmed in LLD or RLD
Watch your gain settings:
o Making the GB lumen too dark with TGC can mask pathology
o Using too much gain can give the appearance of pathology
If the GB appears to have artifacts, change to a higher frequency, use harmonics, use a
different window, or have the patient poke out their abdomen
If the GB is enlarged make sure to evaluate the ducts for signs of stones. These can
obstruct the ducts
To find the CBD:
o Scan from the GB in transverse and follow it to the neck and cystic duct, you will
see CBD
o Follow the portal vein from the portal confluence. The CBD will be anterior to the
vein
If the GB has been surgically removed (postcholecystectomy), document a GB FOSSA
image (main lobar fissure near porta hepatis) instead of the gallbladder images

Pathology Seen
o Gray scale sagittal and transverse images
o Gray scale sagittal and transverse images with 3 measurements (length, width, and
height)
o Color Doppler image to document the presence of blood flow
o Spectral Doppler image to document the type and velocity of blood flow

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 o If the wall measures greater than 3 mm, color Doppler can be used to confirm
increased flow in the wall due to cholecystitis.
o If the patient has gallstones and/or gallbladder wall thickening, they should be
evaluated for a positive Murphys sign (extreme tenderness upon transducer or manual
pressure in the RUQ). This needs to be reported to the interpreting physician as it
indicates acute cholecystitis.
o Must attempt to demonstrate movement of any pathology seen in the GB sludge and
stones will move masses will not!!
o If the CBD is enlarged at the porta hepatis, it should be followed to the pancreatic head
to evaluate for stones or an obstructive lesion

Image
Image 21
Liver
Liver SagTXMPV

RightAnterior liver with

lobe sagittal with main
diaphragm
portal vein

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