Ultrasound of the Gallbladder and Biliary Ducts

Ultrasound is used to evaluate patients for biliary stones and cholecystitis. It can detect cystic
duct and neck of the gallbladder obstruction as well as distension and inflammation of the
gallbladder. It can identify carcinoma of the gallbladder, which is highly malignant and
metastasizes quickly. Ultrasound is important because gallbladder cancer has a very low
prognosis; therefore, any early diagnosis of this condition is potentially lifesaving. The
gallbladder on ultrasound can usually be found between the quadrate and right lobe of the
liver on the underside. The fundus may be folded giving a Phrygian cap appearance, which
makes the gallbladder look septated on ultrasound. When seen, this should be differentiated
from a septate or double gallbladder that it could mimic. The cystic duct that joins the neck of
the gallbladder to the common bile duct is only about 2-4 cm. The common hepatic duct
(CHD) is only about 2.5 cm in length and runs to the right of the portal vein and hepatic
artery. The common bile duct (CBD) is generally long, 7.5 to 10 cm. It runs posterior to the
head of the pancreas and can be enclosed in the pancreas distally. Conventionally the union
of the CHD and CBD is called the common duct (CD).

The patient should be NPO (nothing-by-mouth) for imaging the biliary tract with ultrasound.
Fasting distends the gallbladder and bile ducts and reduces bowel gas that may obscure
visualization of portions of the gallbladder. Food may increase the thickness of the
gallbladder wall imitating pathological wall thickening. Four hours is sufficient fasting for
small children, and 6-8 hours for age 12 to adult. They should be told not to smoke during the
fasting period since smoking causes the bile ducts to contract. Ultrasound should be
performed before any barium is administered for gastrointestinal (G.I.) imaging, or when the
stomach and hepatic flexure is clear of barium is order after G.I. imaging procedure.

The scan protocol may vary based on the patient’s condition and pathological indications for
the scan. Real time imaging in the sagittal, coronal, transverse, and appropriate oblique
planes are made. The sonographer takes a patient history to include prior abdominal surgery,
especially cholecystectomy or cholecystostomy for removal of stones. The sonographer also
makes a physical assessment of the patient looking for surgical scars not accounted for in the
patient history, jaundice, and may palpate the abdomen when a mass is felt for solidness or
pulsatility, or tenderness. During the scan the patient may be positioned in the supine, left
posterior oblique, left lateral decubitus, or upright positions as needed.

Longitudinally, the gallbladder appears as a pear-shaped structure with thin white walls
surrounding a black fluid. The normal gallbladder wall is thin, echogenic and an anechoic
lumen, and mild posterior enhancement. Bile is near the consistency of water so its acoustic
impedance is low, as bile does not attenuate the sound waves. Generally there is no acoustic
shadowing posterior to the gallbladder so when imaging near the neck an acoustic shadow
may represent a stone in the cystic duct. The gallbladder and bile ducts are evaluated for size
and shape, wall thickness, contents, course, and caliper. During the procedure the
sonographer checks for a positive Murphy’s sign. The thumb or transducer is placed over the
costal margin of the gallbladder. When the patient takes a deep inspiration they may pause
abruptly due to a sharp pain before “catching” their breath, which is a positive Murphy’s
sign. The sonographer may image the gallbladder during the elicited response to document a
positive finding.
These two ultrasound images demonstrate the normal gallbladder in the supine position (left)
and decubitus (right). The thin wall of the gallbladder is seen as a white ring surrounding bile,
which appears as a black low attenuated fluid. The wall thickness should be less than 3 mm in
adults. There is no acoustic shadowing posterior to the gallbladder, or near the neck.

Dimensions of the Normal Adult Gallbladder on Ultrasound

Length 7-10 cm
Diameter 3-4 cm
Wall thickness < 3 mm

These two ultrasound images demonstrate normal gallbladder wall thicknesses. These are
different patients’ notice the gallbladder on the left is imaged in the decubitus position. The
gallbladder wall of this full gallbladder measures 2.2 mm on transverse section (left). Normal
wall thickness should be less than 3 mm, but may increase in thickness in disease states such
as cholecystitis, or biliary tract stone. The wall thickness can increase temporarily following a
meal. Wall thickness is usually measured on both the transverse and longitudinal sections.
The ultrasound image on the right is taken with the patient in the left posterior oblique
position following a fatty meal. The wall thickness is 2.9 mm, just within normal limits.

The shape of the gallbladder is equally important when diagnosing gallbladder disease. It
should be pear-shaped not round and tense, which indicates a pathological condition. What is
interesting is that the size of the gallbladder increases with age, but the wall thickness is
rather constant. The common bile duct does change with age, pregnancy, and following
cholecysectomy. When choledocholithiasis is present the common duct may measure 7 mm
or more in diameter. The common bile duct is imaged and measured as part of the ultrasound
scan.

Some conditions where diffuse gallbladder wall thickening >3 mm is seen

 AIDS
 Ascites
 Cholecystitis
 Congestive heart failure
 Hepatitis
This ultrasound image of the gallbladder shows a normal shaped gallbladder. Even though it
is not pear-shaped it is not rounded and tense. The shape of the gallbladder is an important
diagnostic criterion since a rounded tense shape can indicate pathology. A large gallbladder
(called hydrops) is large, rounded, and tense having a transverse diameter of greater than 5
cm and a length greater than 20 cm on ultrasound.

This gallbladder is normal in size. No gallstones, gallbladder wall thickening, or

pericholecystic fluid are identified. The patient did not demonstrate tenderness over the
gallbladder during the exam (negative Murphy’s sign).

These two ultrasound images demonstrate the common bile duct (CBD) in a normal patient
(white arrow). The entire common bile duct is not usually visible with ultrasound; however,
portions of it should be imaged and measured. The CBD measures 2.22 mm in this patient.
Color Doppler image on the left proves this is not a vessel containing blood and is in fact the
common bile duct. The CBD of this patient is measured on the supine longitudinal view
(right ultrasound image); it may also be measured in the posterior oblique or decubitus
positions.

Most pathology of the gallbladder and bile ducts can be seen on ultrasound. The two charts
below lists pathology the sonographer looks for during the scan. While there are many
pathologies of the gallbladder we will limit this discussion to gallstones and bile duct stones.
This is because the imaging is the same for these pathologies as for most pathology of the
gallbladder.

Gallbladder Pathology Demonstrated on Ultrasound

 Acute and chronic Cholecystitis

 Adenomyomatosis
 Biliary ascaris
 Carcinoma
 Diffuse wall thickening
 Empyema
 Gallstones
 Gangrenous and emphysematous cholecystitis
 Non-visualized & micro gallbladder
 Sludge (viscid bile)
 Polyps
 Porcelain gallbladder

Some conditions where diffuse gallbladder wall thickening >3 mm is seen

 Air in bile ducts

 Biliary
 Choledochal cyst
 Caroli’s disease
 Choledocholithiasis
 Klatskin tumor
 Obstruction of ducts
o Papilloma
o Cystadenoma
 Sclerosing cholangitis
These two ultrasound images show gallstones in the gallbladder. The ultrasound image on the
left demonstrates multiple stones imaged with the patient in the left lateral decubitus position.
The right ultrasound image demonstrates these stones in the transverse section. Note the
acoustic shadowing posterior to the stones in both images.

This ultrasound image is taken with the patient in the left lateral decubitus position (LLD).
The common bile duct is dilated; however, it can be up to 10 mm in patients who have
undergone a cholecystectomy, are elderly, or during pregnancy. A good clinical history
should be included in all cases and especially if the CBD is larger than 7 mm.

This ultrasound image demonstrates a normal dilated CBD. Color Doppler indicates it is the
duct not a vascular structure. Again, this is within the upper limits of normal but may be a
pathological finding if the patient is not elderly or had a previous cholecystctomy. While a
cholelith is not identified if the patient has other clinical signs of bile duct obstruction a
MRCP or ERCP may be needed to differentiate cause of dilation.