T.

S: Right portal vein branch, ligamentum The interlobar fissure (*), located anterior to
venosum the right portal vein branch, is the landmark
for identifying the gallbladder.
.
*interlobar fissure(MLF), 4.hepatic artery,
17.PV, 10.IVC, 76.duodenum
73.Antrum of stomach 20.right lobe of liver,
92.acoustic shadow
T.S:Gallbladder neck The neck of the gallbladder is located just
caudal to the right portal vein branch and the
interlobar fissure.

37.Cystic duct, 76.duodenum, 70.stomach,

10.IVC, 17.PV, 20.right lobe of liver
92.acoustic shadow
TS:Junction of neck and body of In a transverse scan through the body of the
gallbladder:- gallbladder, the duodenum is located between
the gallbladder and the vena cava

33.Neck of gall bladder, 76.duodenum,

10.IVC, 17.PV20. right lobe of liver,
902.acoustic shadow
T.S:Body of gallbladder: The duodenal bulb can consistently be
identified on the free peritoneal side of the
body or neck of the gallbladder.

32.Body of gall bladder. 76.duodenum,

10.IVC, 14.right renal vein, 20. right lobe of
liver, 92.acoustic shadow
T.S:Gallbladder fundus: The gallbladder fundus may extend almost to
the anterior abdominal wall, but it may also be
placed very deeply behind the liver.

31.Fundus of gall bladder, 76.duodenum,

20.right lobe of liver, 94.artifact, 1.aorta,
14.right renal vein, 60. right kidney, 1. aorta,
92. acoustic shadow, 90. spinal column
T.S: Gallbladder fundus, inferior border:- The right colic flexure often impresses on the
caudal surface of the gallbladder fundus.

78.Right colic flexure, 10.IVC, 1. aorta,

60.right kidney, 20.right lobe of liver.
90.spinal column
L.S: Vena cava, duodenum, The vena cava, the portal bifurcation, and the
bifurcation of portal vein:- echo-dense band of the interlobar fissure
provide conspicuous landmarks for locating
the gallbladder in longitudinal section.

4.Hepatic artery 17.PV 10.IVC 20.right

lobe of liver 76.duodenum 73.antrum of
stomach 94.artifact
L.S: Right portal vein branch, duodenum, The duodenum is adjacent to the gallbladder
gallbladder body:- posteriorly and to the right colic flexure
caudally.

30.Gall bladder, 76.duodenum, 95.psoas

muscle, 94.artifact, 17.PV, 4.hepatic
artery, 10.IVC 20.right lobe of liver
L.S: Right portal vein branch, body and neck The shape and position of the gallbladder are
of gallbladder:-
highly variable. However, the neck of the
gallbladder is always located in the porta
hepatis, caudal to the right portal vein
branch
30.Gall bladder, 76.duodenum, 4. hepatic
artery, 17.PV 20.right lobe of liver 10.IVC
94.artifact 95.psoas muscle
L.S: Body and fundus of gallbladder, kidney:- The healthy gallbladder is typically a pear-
shaped, fluid-filled organ that contains no
internal echoes.

30.Gall bladder ,60.right kidney, 8.right

renal artery, 14.right renal vein 20.right
lobe of liver, 17.PV 78.right colic flexure
L.S: Gallbladder fundus, kidney:- A wedge of liver tissue, variable in size, is
interposed between the gallbladder and
kidney in longitudinal section.

30. Gall bladder, 14.right renal vein, 60.

right kidney, 78.right colic flexure, 20.right
lobe of liver, 94.artifact
L.S:Gallbladder fundus, kidney:- In a more lateral scan, the gallbladder may be
in direct contact with the kidney.

30.Gall bladder, 78.right colic flexure,

60.right kidney, 14.right renal vein 20.right
lobe of liver. 94. artifact
L.S: Regions of gallbladder, spiral folds:- The spiral folds and gallbladder neck are
often clearly visualized in a lateral scan over
the gallbladder.

32.Body of GB, 31.fundus of GB,

35.spiral fold, 34.infundibulum, 33.neck
of GB, 14.right renal vein, 17.PV, 20.
right lobe of liver, 78.right colic flexure,
94.artifact, 60.right kidney
L.S:Layers of gallbladder wall:- The anterior wall of the gallbladder consists
of three identifiable layers. Usually the
posterior wall of the gallbladder is poorly
demarcated from the duodenum.

30.Gall bladder, 78.right colic flexure,

20.right lobe of liver, 76.duodenum
94.artifact
BILIARY SONOGRAPHY

Graphic shows the branching system of the Oblique trans-abdominal ultrasound shows
normal biliary tree, with a detailed view of the the normal globular configuration of the GB:
papilla of Vater:(See text for abbreviation Fundus →;body↪; neck ⇧ and cystic duct EB
keys).
Normal gallbladder

The normal gallbladder : Postprandial the gallbladder:-

pear-shaped anechoic structure, Contracted GB,
well-defined, hyperechoic wall appears duplicated.it mimics acute
normal dimensions : 8/3 cm, cholecystitis.
the maximum accepted is 10/4 cm, over this
dimension raising the suspicion of hydrops.
wall thickness ≤ 4 mm.
Malformations” of the gallbladder

“malformations” gallbladder :
varying from a bisaccular, to a globulous, or to
a drop shaped gallbladder
Porcelain gallbladder

Porcelain gallbladder
1. It is a particular situation characterized by partial or complete calcification and thickening of
the gallbladder wall
2. is of a hyper-echoic crescent, with intense posterior shadow in the projection area of the
gallbladder. It can be a difficult differential diagnosis with a gallbladder filled with stones or
with a large stone that completely fills the gallbladder.
3. considered as a precancerous state
BILIARY SONOGRAPHY Definitions
• Proximal/distal biliary tree
o Proximal represents portion of biliary tree
TERMINOlOGY that is in relative proximity to liver and
Abbreviations hepatocytes
• Extrahepatic biliary structures o Distal refers to caudal end closer to bowel
o Gallbladder (GB) • Central/peripheral
o Cystic duct (CD) o Central denotes biliary ducts close to porta
o Right hepatic (RH) and left hepatic (LH) ducts hepatis
o Common hepatic duct (CHD) o Peripheral refers to higher order branches of
o Common bile duct (CBD) intrahepatic biliary tree extending to hepatic
o Papilla of Vater, choledochal sphincter (CDS), Parenchyma
pancreatic duct sphincter (PDS), sphincter of
ampulla (SA), duodenal papilla (DP) • Cystic duct (CD)
• Intrahepatic duct o Variable length; usually 2-4 cm long
o Right dorsal-caudal (RDC) duct/right o Contains tortuous spiral folds (valves of
posterior duct (RPD) Heister)
o Right ventral-cephalic (RVC) duct/right
anterior duct (RAD) • Normal branching pattern of biliary tree
o Left lateral (LL) duct and left medial (LM) o Division usually in accordance with Couinaud
duct functional anatomy of liver
BILIARY SONOGRAPHY
o RH duct forms from RAD (drains segments 5
& 8) and RPD (drains segments 6 & 7)
o LH duct forms from LM duct (drains
segments 1 &
4) and LL duct (drains segment 2 & 3)
• This normal pattern occurs in 56-58% of
normal population
o Normal variants mainly due to the variability
of site of insertion of the RPD
• RPD extends more to the left and joins the
junction of RH and LH ducts (trifurcation
pattern): - 8%
• RPD extends more to the left and joins the
LH duct: - 13%
• RPD extends in a caudo-medial direction to
join the CHD/CBD directly: - 5%
• Normal measurement limits of bile ducts
o CBD/CHD
• < 6-7 mm in patients without history of
biliary disease in most studies
• Controversy about dilatation related to
previous cholecystectomy and old age
o Intrahepatic ducts
• Normal diameter of first and higher order
branches < 2 mm or < 40% of the diameter of
adjacent portal vein
• First (Le., LH duct and RH duct) and second
order branches are normally visualized
• Visualization of third and higher order
branches is often abnormal and indicates
dilatation
ANATOMY-BASED IMAGING ISSUES
Imaging Approaches
• Transabdominal ultrasound is an ideal initial
investigation for suspected biliary tree or GB
pathology
o Cystic nature of bile ducts and GB, especially
if these are dilated, provides an inherently high
contrast resolution
o Acoustic window provided by liver and
modern state-of-art ultrasound technology
provides good spatial resolution
o Common indications of US for biliary and GB
diseases include
BILIARY SONOGRAPHY
o Common indications of US for biliary and GB
diseases include
• Right upper quadrant/epigastric pain
• Deranged liver function test or jaundice
• Suspected gallstone disease
Imaging Pitfalls
• Common pitfalls in US evaluation of GB
o Posterior shadowing may arise from GB neck, neck on itself
valves of Heister of CD or from adjacent gas-
filled bowel oops
• Mimics cholelithiasis
• Scan after repositioning patient in prone or
left lateral decubitus positions
o Food material within gastric
antrum/duodenum
• Mimics GB filled with gallstones or GB
containing milk-of-calcium
• On real time, carefully evaluate peristaltic
activity of involved bowel ± oral administration after oral intake of water
of water
o Presence of slice-thickness or side-lobe
artifacts
• May mimic intraluminal, dependent, low
level echoes within GB
• Minimize by changing US settings and
scanning after repositioning patient
• Common pitfalls in US evaluation of biliary
tree
o Redundancy, elongation or folding of GB
• Mimics dilatation of CHD or proximal CBD
• Avoided by scanning patient in full
suspended inspiration
• Careful real-time scanning allows separate
visualization of CHD/CBD medial to GB neck
o Presence of gas-filled bowel loops adjacent
to distal extrahepatic bile ducts
• Obscure distal biliary tree and render
detection of choledocholithiasis difficult
• Scan with patient in decubitus positions or
o Gas/particulate material in adjacent
duodenum and pancreatic calcification
BILIARY SONOGRAPHY
Clinical Importance • Choledocholithiasis in CBD
• In patients with obstructive jaundice, US • Ampullary tumor/stricture
plays a key role • Criteria for malignant obstruction
o Differentiates biliary obstruction from liver o Abrupt transition from dilatation to
parenchymal disease narrowing
o Determines the presence, level and cause o Eccentric ductal wall thickening with contour
of biliary obstruction irregularity
• Level and causes of biliary obstruction o Mass in or around duct
o Intrahepatic causes o Presence of enlarged regional lymph nodes,
• Primary sclerosing cholangitis liver
• Liver mass with extrinsic compression of metastases or vascular invasion
bile ducts
o Porta hepatis/hepatic confluence
• Cholangiocarcinoma
• Choledocholithiasis
• Primary sclerosing cholangitis
• GB carcinoma
o Distal extrahepatic/intra pancreatic
• Pancreatic ductal carcinoma
• Cholangiocarcinoma
• Chronic/acute pancreatitis
BILIARY SONOGRAPHY

gallbladder wall appears duplicated and

sandwiched :
1.Postprandial GB(due to the thickening of
the muscular layer by contraction)
2.Acute cholecystitis
3.Cirrhosis of liver
4. Acute viral hepatitis
5.Nephrotic sybdrome.
6.Chronic renal failure( due to
hypoalbuminemia
BILIARY SONOGRAPHY
Oblique transabdominal ultrasound shows the
normal position and size of the CBD → relative
to the main portal vein (MPV) ↪ . The CBD is
anterior to and of smaller caliber than the MPV
Oblique transabdominal ultrasound shows the
normal anatomical relationship of the CBD →
anterior to MPV ↪ and hepatic artery ⇧ at the
porta hepatis. The CBD is dilated due to distal
obstruction.
BILIARY SONOGRAPHY
(Left) Oblique
transabdominal ultrasound
shows the normal position of the RH duct →
anterior to the right portal vein (RPV)
↪. Caliber of the RH duct is normally smaller
than that of the RPV (
Right) Oblique
transabdominal ultrasound
shows branching of the RH duct →into the RAD
↪ and RPD ⇧. All of them are dilated due to an
obstructing CBD stone.
BILIARY SONOGRAPHY
(Left) Transverse
transabdominal ultrasound
shows the normal position of the LH duct
↑anterior to the left portal vein (LPV) ↪.
A non-dilated LH duct is smaller than LPV
(Right)
Transverse transabdominal ultrasound
shows branching of the LH duct ⬆into the
LM duct ↪ and the LL duct ⇧. These are
markedly dilated due to distal extrahepatic
obstruction.
BILIARY SONOGRAPHY

(Left) Oblique Right) Transverse

transabdominal ultrasound
shows abrupt truncation of a dilated CBD→ by
an obstructing ductal carcinoma ⇧ at the
pancreatic head.
transabdominal ultrasound
shows presence of echogenic biliary sludge →
within a dilated LL duct ⇧ and its branches.
Note the LM duct ↪is also dilated but free of
sludge.
CHOLELITHIASIS

Oblique transabdominal ultrasound shows an Oblique transabdominal ultrasound shows

echogenic focus → casting marked posterior multiple echogenic foci → within the
acoustic shadowing ⇧ within the dependent gallbladder representing gallstones. Note the
position of a non-distended gallbladder↪. posterior acoustic shadow ⇧.
CHOLELITHIASIS
IIMAGING FINDINGS
General Features
• Best diagnostic clue
o Ultrasound of gallbladder (GB)
• Highly reflective echoes
• Posterior acoustic shadowing
• Mobile on changing patient's position
• Location: Gallbladder
• Size: Variable
Ultrasonographic Findings:-
o High reflective echogenic focus within
gallbladder lumen
o Prominent posterior acoustic shadow
o Gravity dependent movement on change of
patient position
o Reverberation artifact
o Variant ultrasound features
• Non-visualization of gallbladder with large
collection of bright echoes with acoustic
shadowing (GB packed with stones), may be
mistaken for duodenal bulb.
• Double-arc shadow sign or wall-echo-shadow
(WES) sign: Two echogenic curvilinear lines
separated by sonolucent line (anterior GB wall,
bile, stone)
• Non-shadowing gallstone (stone < 5 mm in
size)
• Immobile adherent stone or impacted in GB
neck
o Associated ultrasound findings if
superimposed complications
• Acute cholecystitis: Thick walled and
distended gallbladder, positive sonographic
Murphy sign, pericholecystic fluid
• Acute cholangitis: Obstructing common bile
duct (CBD) stones, biliary dilatation
• Acute pancreatitis: III-defined swelling of
pancreatic parenchyma, inflammatory change
in adjacent soft tissue
• Biliary fistula
• Gallstone ileus
CHOLELITHIASIS
• Power Doppler
o No color flow demonstrated
o "Twinkling" artifact
o Increased flow in pericholecystic region in
cholelithiasis complicated by acute cholecystitis
• False negative ultrasound: Small contracted GB
full of stones, small gallstones, GB in
ectopic/unusual position, obese/uncooperative
patient Consider
• Ultrasound is the best imaging tool for
evaluation of patients with upper abdominal
pain/discomfort
• Consider cholelithiasis in patients with RUQ
pain/discomfort after fatty meal, especially in
obese middle-age female.

Image Interpretation Pearls:-

Nonshadowing calculi may be mistaken for other
lesions in GB such as polyp, sludge, carcinoma
• Important to demonstrate posterior acoustic
shadowing and mobility on changing patient's
position
Cholelithiasis

hyperechoic image, with posterior Air in the duodenal bulb:

shadow, with “gravitational fall” echodense image ( GB stone) must be inside the
gallbladder (thus, it will be differentiated from
The only situation when the gallstone digestive air, situated outside the gallbladder)
does not have gravitational fall is when it
is blocked in the infundible, in gallbladder
hydrops
Cholelithiasis
Gallbladder hydrops, gallstone stuck Small
gallstone, with weak posterior the
infundibulum, ant 2 others on the bottom
shadow of the gallbladder.
No gravitation effect of stone when it is
impacted in the infundibulum.
Small gallstone, with weak posterior shadow.
.
Regarding the posterior shadow, it
can be weak or almost absent for small stones
(2-3 mm), due to their size (
Cholelithiasis

Single gallstone Three gallstones

Cholelithiasis
Gallbladder molded on gallstones:-
in case of a gallbladder full of calculi, when
the absence of the bile makes the vesicular
bed difficult to visualize, but in this case the
intense posterior shadow must draw our
attention (
Single large calculus - the shell sign:-
a large vesicular calculus, occupying all the
gallbladder, where again, the bile is absent, and
it will generate the "shell sign" (reflective
crescent with large posterior shadow)
Cholelithiasis

Fig. 26. Porcelain gallbladder Fig. 27. Porcelain gallbladder

Porcelain gallbladder is a particular situation
characterized by
partial or complete calcification and thickening
of the gallbladder wall,precancerous,operation
indicated even if asymptomatic.
It can be a difficult differential diagnosis with
a gallbladder filled with stones or with a large
stone that completely fills the gallbladder.
Cholelithiasis

Small gallstones, with weak posterior shadow – Blocked infundibular gall stone.
differential diagnostic with biliary sludge.
The infundiblar blocked gallstone is also
gallstones that do not generate posterior difficult to assess in which case what draws
shadow (generally those of bilirubinate) that our attention is just a large gallbladder with
may be mistaken with a gallbladder polyp, but the "feeling“ that is under tension (globular)
the latter will not fall with gravity.
Cholelithiasis

Multiple tiny stones combining to form a

posterior band of shadow.

Floating stones just below the anterior

gallbladder wall
Cholelithiasis

(A) Longitudinal section and (B) transverse

section images of the gallbladder containing stones with
strong distal acoustic shadowing. Note the thickened
gallbladder wall.
Cholelithiasis

(A) The stones are outside the focal zone,

and do not appear to shadow well. (B) The
focal zone has
been moved to the level of the stones,
allowing the
shadow to be displayed.
Cholelithiasis

The shadow behind the gallstone (left

image) is obscured if the time gain
compensation is set
too high behind the gallbladder (right image).
CHOLELITHIASIS

(A) Supine and (B) erect views

demonstrating movement of the tiny stone into the fundus of the gallbladder. Note how
duodenum posterior to the gallbladder masks the shadow in the erect state
IMAGE GALLERY OF CHOLELITHIASIS
(Left) Oblique
transabdominal ultrasound
→shows an echogenic focus within the
dependent part of the gallbladder lumen
casting marked posterior acoustic shadowing ⇧
(Right) Oblique
transabdominal ultrasound
shows multiple calcified gallstones → which
are echogenic and gravitate to the dependent
part of the gallbladder casting posterior
acoustic shadow ⇧.
IMAGE GALLERY OF CHOLELITHIASIS
(Left) Oblique
transabdominal ultrasound
shows a gallstone ⇧ associated inflamed and
thickened CB wall → and sludge ↪ in the CB
lumen. Features are suggestive of calculus
cholecystitis.
Right)
Oblique transabdominal
ultrasound shows a large gallstone →inside a
contracted gallbladder with wall thickening ↪
consistent with chronic cholecystitis.
IMAGE GALLERY OF CHOLELITHIASIS (VARIANT)
(Left) Oblique
transabdominal ultrasound
shows a large echogenic gallstone →in the
dependent part of the gallbladder. Note the
absence of posterior acoustic shadowing. Color
Doppler would be important in this
case to rule out mass.
(Right)
Oblique transabdominal
ultrasound shows a gallbladder packed with
small shadowing echogenic stones →. This may
sometimes be mistaken for gas in the duodenal
bulb.
IMAGE GALLERY OF CHOLELITHIASIS
(Left) Abdominal radiograph
showing a large, well-defined
calcified =opacity in the
RUQ. Ultrasound confirmed
this to be a gallstone.
(Right)
Transverse NECT shows a
large stone =occupying the
whole CB lumen. Note the
whorled internal pattern of
the stone.
IMAGE GALLERY OF CHOLELITHIASIS
(Left) Transverse NECT
shows multiple, incidental
gallstones =. The CB wall
appears norma/~. Note the
right adrenal lesion E!l:I for
which the CT was
performed.
(Right)
Transverse CECT shows
multiple incidental gallstones =.Note the
wedge-shaped
perfusion defect noted in the
right lobe of liver ~ for
which the CT
IMAGE GALLERY OF CHOLELITHIASIS

(Left) Supine abdominal (Right) Small bowel follow through study

radiograph showing features of small bowel shows the level of obstruction =coincides
obstruction due to a migrated gallstone with the position of the gallstone shown in the
=impacted at the distal ileum. Note the air in adjoining plain radiograph.
the gallbladder ~ due to fistula formation. (
IMAGE GALLERY OF CHOLELITHIASIS
(Left) Obliquetransabdominal ultrasound:-
shows a solitary echogenic gallstone → with
marked posterior acoustic shadowing
↪ (normal CB wall, no pericholecystic fluid).
. (Right)Oblique power Doppler:-
ultrasound shows a large, sessile,
nonshadowing, soft tissue lesion in CB lumen
→. It shows mild vascularity ↪; features
suggestive of a sessile CB polyp. Dopplers
helps to differentiate polyps from gallstone.
IMAGE GALLERY OF CHOLELITHIASIS

(Left) Oblique (Right) Oblique

transabdominal ultrasound transabdominal ultrasound
shows two echogenic foci → in the CB lumen shows two echogenic gallstones → within the
casting marked posterior acoustic shadowing CB lumen with sludge ↪ overlying them.
↪, suggestive of CB stones. Sludge and stones are often associated.
IMAGE GALLERY OF CHOLELITHIASIS
(Left) Oblique
transabdominal ultrasound
shows two echogenic → floating gallstones.
Note the marked posterior acoustic
shadowing, and lack of any changes to
suggest associated cholecystitis.
(Right) Transverse
transabdominal ultrasound
shows a thickened and edematous CB wall →
with echogenic sludge ↪ within the lumen;
features suggestive of cholecystitis.
DDx: Cholelithiasis

Gallbladder Polyp Gallbladder Sludge

• Small round mass with smooth contour
arising from gallbladder wall
• Low/medium echogenicity, usually multiple
• Not mobile, may have a short stalk or may
be sessile
• No posterior acoustic shadowing
• Normal GB wall
• Mass in gallbladder lumen, sludge ball
• Low/medium echogenicity
• Mobile
• Lack of posterior acoustic shadowing
• Fluid-sludge level
DDx: Cholelithiasis
Focal Adenomyomatosis:-
• Focal wall thickening due to
hypertrophied Rokitansky-Aschoff sinuses
• Gallbladder fundus
• Reverberation/comet-tail artifacts due to
co-existent cholesterol deposits

Parasite Infestation in Gallbladder:-

• Tubular configuration
• Double parallel echogenic lines
• Active movement in viable

Gallbladder Carcinoma
• Ill-defined mass from gallbladder wall
• Infiltrates adjacent liver parenchyma
• Not mobile
• Increased vascularity within the lesion on color
Doppler
• Associated lymphadenopathy
ECHOGENIC BILE, BLOOD CLOTS, PARASITES

Oblique transabdominal ultrasound Oblique transabdominal ultrasound

shows a "mass" shows a mobile echogenic "lesion" → with
with medium level echoes → in the dependent globular contour within the
position of the gallbladder. Note the absence gallbladder,consistent with sludge ball. Note
of posterior acoustic shadowing. absence of posterior acoustic shadowing.
ECHOGENIC BILE, BLOOD CLOTS, PARASITES
Definitions
• Presence of particulate material (calcium
bilirubinate +/- cholesterol crystals) in bile
IIMAGING FINDINGS
General Features
• Best diagnostic clue
o Echogenic bile: Mobile "mass" within
gallbladder (GB) with mid/high level echoes,
lack of posterior acoustic shadowing
o Blood clot: Heterogeneous low-level echoes
floating within GB, mobile
o Parasites: Elongated, tubular, mobile
structures, parallel echogenic walls
• Location: Within gallbladder, occasionally
parasite found within
intrahepatic/extrahepatic bile ducts
• Size: Variable
Ultrasonographic Findings
• Grayscale Ultrasound
o Echogenic bile
• Amorphous, mid/high level echoes within GB
• Floating echoes, mobile echoe
• Sediment in dependent positions
• Lack of posterior acoustic shadowing
• "Hepatization" of gallbladder: Sludge-filled
GB with same echotexture as the liver
• Lack of internal vascularity
o Tumefactive sludge
• Round low to intermediate level mass-like
"lesion"
• No posterior acoustic shadowing
• Gravitates to dependent position on
changing patient position
• Lack of intralesional vascularity on color
Doppler examination
o Blood clot
• Echogenic/mixed echoes within GB
• Occasional retractile and conforms to
configuration of GB
• Blood-fluid level within GB
• Hemobilia +/- aerobilia inside biliary ducts if
originates from instrumentation of biliary tree
o Parasitic infestation
ECHOGENIC BILE, BLOOD CLOTS, PARASITES
• Ascariasis: Tubular or echogenic parallel lines
within bile duct or gallbladder, sonolucent
center, active movement of the worm
• Daughter hydatid cysts: Round anechoic cysts
within bile duct/gallbladder, mother cyst in
liver
• Power Doppler: No internal vascularity in
"mass-like“ GB filling defects
ECHOGENIC BILE

Biliary sludge is:- The differential diagnosis of biliary sludge:-

a mixture of mucus, calcium bilirubinate and 1.a gallbladder tumor
cholesterol crystals, a precursor state for (easy through contrast ultrasound – CEUS: the
gallstones, a reversible condition. sludge will not enhance following contrast,
Usg appearance:- since it is avascular, while the tumor will
1.a mobile echoic material in the gallbladder, enhance);
sometimes with a horizontal level 2.with gallbladder polyps (which have no
2. Does not display a ”posterior shadow” gravitational fall); or
3. its shape and location in the gallbladder 3.with gallbladder stones (they have posterior
change with the change in the patient’s shadow).
position.
4. Sometimes, biliary sludge can fill the entire
gallbladder (Fig.9), conferring the appearance
known as ”hepatization” of the gallbladder (in
gallbladder hydrops, during pregnancy, or after
prolonged parenteral nutrition).
5. Another particular variant of biliary
sludge is the ball-like or pseudotumoral aspect
(Fig.10), characterized by a globulous
appearance, which can be maintained after
gravitational fall, or it can “disintegrate”.
ECHOGENIC BILE

Biliary sludge with horizontal level ”Hepatization” of the gallbladder

ECHOGENIC BILE

Fig. 10. "Ball-like" biliary sludge

IMAGE GALLERY ECHOGENIC BILE, BLOOD CLOTS, PARASITES

(Left) Oblique (Right)

transabdominal ultrasound
shows heterogeneous echogenic material → in
the gallbladder lumen due to a blood clot,
following a percutaneous transhepatic
biliary drainage.
Oblique transabdominal
ultrasound shows markedly echogenic material
→ almost completely filling the gallbladder
(hepatization of gallbladder). Note absence of
posterior acoustic shadowing.
IMAGE GALLERY ECHOGENIC BILE, BLOOD CLOTS, PARASITES

(Left) Oblique (Right) Oblique

transabdominal ultrasound shows a mildly
hyperechoic sludge ball→ within the
gallbladder. Note absence of posterior acoustic
shadowing. Note CB wall ↪ is normal in
thickness.
transabdominal ultrasound
shows a daughter cyst → within the dilated
common bile duct due to a rupture of
a hepalic hydatid cyst into the biliary tree.
IMAGE GALLERY ECHOGENIC BILE, BLOOD CLOTS, PARASITES

(Left) Oblique (Right)

transabdominal ultrasound
shows a tubular, mobile structure →,with
parallel echogenic lines, within the CB
suggeslive of parasitic infestation by Ascaris
lumbricoides.
Oblique transabdominal ultrasound shows
another long, tubular structure →. with
parallel echogenic lines, within the dilated
common bile duct. It showed active movement
on real time ultrasound, compatible with
viable worm infestation.
DDx: Filling Defect in Gallbladder
Cholelithiasis
• Densely echogenic material within GB
• Marked posterior acoustic shadowing
o Occasionally GB stone may be non
shadowing
• Mobile and gravitate to dependent position
• No GB wall thickening or pericholecystic fluid
if uncomplicated
Focal Adenomyomatosis
• Most common at GB fundus
• Mass-like filling defect arising from wall of GB
• No posterior acoustic shadowing
• Not mobile on changing patient position
• Lack of internal vascularity
• May have associated features of
adenomyomatosis in the rest of GB (e.g.,
echogenic foci with comet-tail artifacts)
DDx: Filling Defect in Gallbladder Gallbladder Empyema
• Heterogeneous echoes within GB due to
presence of pus/inflammatory exudate
• Distended GB
• Presence of impacted gallstones in GB neck
• GB wall thickening, pericholecystic fluid
collection, positive sonographic Murphy sign
• Clinically septic with localized peritoneal
signs in right upper quadrant

Gallbladder Carcinoma
• If large, can completely occupy GB with
heterogeneous echoes
• Infiltrative mass with early invasion of
adjacent liver parenchyma
• Increased internal vascularity

Gallbladder Polyp
• Small (usually < 1 em) smooth polypoidal
mass in GB wall
• Smooth contour, immobile
• Usually avascular, occasionally with increased
internal vascularity
GALLBLADDER CHOLESTEROL POLYP
Graphic shows well-circumscribed,
pedunculated nodules →arising from the
gallbladder wall suggestive of cholesterol
polyps. Note the preserved GB wall without
invasion to the adjacent liver parenchyma.
Oblique transabdominal us shows small,
non-shadowing, well-defined, round, slightly
hyperechoic nodules → adherent to the
gallbladder wall, characteristic of gallbladder
polyps.
GALLBLADDER CHOLESTEROL POLYP
Definitions
• Abnormal deposit of cholesterol ester
producing a villous-like structure covered with
a single layer of epithelium and attached via a
delicate stalk
IIMAGING FINDINGS
General Features
• Best diagnostic clue: Multiple, small, non-
shadowing lesions attached to gallbladder wall
• Location
o Anywhere on GB wall
o Most commonly in middle 1/3 of gallbladder
• Size: Usually 2-10 mm in size
• Morphology
o More than one half of all polypoidal
gallbladder lesions are cholesterol polyps
o Well-circumscribed, ovoid/round in
configuration
Ultrasonographic Findings
• Grayscale Ultrasound
o Transabdominal ultrasound is the most
sensitive technique for detecting small
cholesterol polyps
o Polypoidal mass arising from GB wall
• Small, usually in the range of 2-10 mm in size
• Multiple lesions: Occasionally appear solitary
and only the dominant is detected
• Medium to high level internal echoes
• Smooth in contour, sometimes multi-
lobulated
outline
• Round or ovoid shape, broad-base with
gallbladder wall
• Does not cast posterior acoustic shadow (vs.
gallstone)
• Not mobile on changing patient's position
(vs. biliary sludge)
• Overlying GB wall is intact & normal
• No invasion of adjacent liver parenchyma or
regional nodal metastases
o Variation of US appearances
GALLBLADDER CHOLESTEROL POLYP
• Large size: Lesions up to 20 mm have been
described
• Pedunculated with well-defined stalk from
GB wall
• Fine pattern of echogenic foci within larger
lesions
• Power Doppler
o Avascular or hypovascular on Doppler
examination
o Larger lesions may have slight internal
vascularity
Imaging Recommendations
• Best imaging tool: Transabdominal US
• Protocol advice
o Adequate fasting prior to US is essential for
detection and characterization of GB
polypoidal mass
o Scan in supine, decubitus and lateral
positions to demonstrate immobility of GB
polyp
o Set depth of focal zone at level of GB mass
maximize accuracy of mass characterization
o Imaging algorithm for polypoid GB mass
• For lesion < 10 mm with no suspicious
features, serial follow-up to monitor size
• For lesion> 10 mm with atypical features
(sessile appearance, singularity, internal
vascularity), further evaluation with CECT or
proceed to surgery to exclude the possibility of
malignancy
Consider
• Consider neoplastic or malignant GB polyp if
size> 10
mm, irregular outline, growth on serial US
examinations and invasion to adjacent
structures
Image Interpretation Pearls
• Multiple, small, round/ovoid masses
attached to GB
wall with no posterior acoustic shadowing
• Easily differentiated from non-shadowing
cholelithiasis or biliary sludge by
demonstrating
immobility of polyp
Adenomatous polyps

rounded structures,
adherent to the gallbladder wall,
No gravitational effect
Isoechogenic to GB wall, size ; 3 to 10 mm , can
be single or multiple. No post acoustic shadow
The use of high-frequency
transducers (5 or 7.5 MHz) may reveal more
diagnostic elements.
Cholesterol polyps

"comet tail" appearance, with the transverse

diameter generally less than 5 mm.
no pathological significance
Polyps larger than 10-15 mm should be
differentiated from gallbladder carcinoma.
when the diagnosis is not
clear only by imaging methods (CT, MRI),
diagnostic cholecistectomy is preferred
Biliary sludge
Biliary sludge with horizontal level:
Biliary sludge is a mixture of mucus, calcium
bilirubinate and cholesterol crystals, a
consequence of the imbalance of the bile
components and of gallbladder evacuation
disorders. it is a precursor state for gallstones.
Mobile echoic material, no posterior shadow,
sometimes horizontal level.
”Hepatization” of the gallbladder:
Sometimes, biliary sludge can fill the entire
gallbladder , conferring the appearance known
as ”hepatization” of the gallbladder (in
gallbladder hydrops, during pregnancy, or after
prolonged parenteral nutrition.
" biliary sludge

"Ball-like" biliary sludge:

ball-like or pseudotumoral aspect
characterized by a globulous appearance,
which can be maintained after gravitational
fall, or it can “disintegrate.not enhanced e CT.
Ddx of biliary sludge:-
Gb tumor:it will enhance with contrast as it is
vascular
Gb polyps: no gravitational effect.
Gb stone; have post. Shadow. Gravity effect.
IMAGE GALLERY OF GALLBLADDER CHOLESTEROL POLYP

(Left) Oblique (Right) Oblique

transabdominal ultrasound
shows a well-circumscribed, homogeneously
hyperechoic mass → with a smooth margin,
arising from the gallbladder wall compatible
with a gallbladder polyp.
transabdominal ultrasound
shows a small, well-defined, echogenic nodule
→ adherent to the gallbladder wall. The
nodule was immobile and not casting posterior
acoustic shadow.
 IMAGE GALLERY OF GALLBLADDER CHOLESTEROL POLYP

(Left) Transverse CECT (Right) Oblique transabdominal ultrasound:-

shows a well-defined
gallbladder polyp ~. Note
normal gallbladder wall~.
shows a large polypoid growth → with a
slightly lobulated contour, arising from the
anterior gallbladder wall. A similar lesion with
a sessile appearance ⇧ is present on the
posterior CB wall.
Variant IMAGE OF CHOLESTEROL POLYP OF GB
(Left) Oblique
transabdominal ultrasound shows a large
papilliform hyperechoic mass → in the
non-dependent wall of the gallbladder. Note
surface irregularities and lack of posterior
acoustic shadowing.
(Right) Oblique
power Doppler ultrasound shows presence of
internal vascularity ↪ within a large
gallbladder polyp. The gallbladder wall is intact
with no invasion to adjacent liver parenchyma.
DDx: Gallbladder Cholesterol Polyp

Gallbladder Carcinoma
• Irregular soft tissue thickening of GB wall
Hyperplastic Cholecystosis
• Destruction of GB wall
• Focal (fundal) form
• Evidence of invasion to adjacent liver
• Smooth sessile mass in fundal region
parenchyma and regional nodal metastases
• Non-shadowing & immobile
• Increased chaotic internal vascularity
• Comet-tail artifacts from the GB wall
• Presence of gallstones
DDx: Gallbladder Cholesterol Polyp
Non-Shadowing Cholelithiasis
• Densely echogenic
• Mobile on changing patient's position
• Gravitate to dependent portion of GB lumen
Adenoma/ Adenomyoma
• True benign neoplasm of gallbladder
• Account for < S% of gallbladder polyp
• Solitary lesion
• Larger size (> 10 mm)
• Usually pedunculated in appearances
Biliary Sludge
• Medium to high level echogenicity
• Mobile on changing patient's position
• No posterior acoustic shadowing
• Fluid sediment level
Inflammatory Polyp
• Comprise 5-10% of gallbladder polyps
• Multiple in 50% of cases
• Background of gallstone disease and chronic
cholecystitis
GB Metastases
• Most common from melanoma and
adenocarcinoma of GI origin
• Hyperechoic, broad-based polypoidal mass
• Usually> 10 mm in size
• Clinical history of known primary
malignancy
THICKENED GALLBLADDER WALL

Oblique transabdominal ultrasound shows Transverse transabdominal ultrasound shows

diffuse gallbladder wall thickening →, with diffuse gallbladder wall thickening (between
echogenic striations ⇧. Note presence of biliary the two echogenic lines ⇧), with
sludge ↪ within the CB. heterogeneous hypoechoic areas ↪.
IMAGE GALLERY OF THICKENED GALLBLADDER WALL

(left) Oblique transabdominal ultrasound (Center) Oblique transabdominal ultrasound

shows a diffusely thickened gallbladder shows marked diffuse hypoechoic gallbladder
wall→with a small gallstone ↪ in the wall thickening →obliterating the gallbladder
gallbladder neck. Note ascites ⇧ related to liver lumen ↪ in a patient with acute hepatitis.
cirrhosis
IMAGE GALLERY OF THICKENED GALLBLADDER WALL

(Right) Oblique transabdominal ultrasound

shows a diffusely thickened gallbladder
wall→due to lymphomatous infiltration. Note
abnormal lymph node ⇧ in porta hepatis.
DDx: Diffuse Gallbladder Wall Thickening

Acute Calculous Cholecystitis Hyperplastic Cholecystosis

• Impacted gallstone in distended, tender • Fundal type: Focal wall thickening in GB
gallbladder fundus
• Pericholecystic fluid collection • Diffuse type: Hour-glass appearance
• Positive sonographic Murphy sign • Presence of comet-tail artifacts
DDx: Diffuse Gallbladder Wall Thickening

Gallbladder Carcinoma with Diffuse Wall

Infiltration
• Irregular wall thickening
• Tumor invasion of adjacent liver parenchyma,
nodes
• Increased intra-tumoral vascularity
ACUTE CALCULOUS CHOLECYSTITIS
Oblique transabdominal ultrasound
shows a distended gallbladder wall thickening
→ stones ⇧ and sludge ↪. The patient had a
positive sonographic Murphy sign.
Transverse CECT
shows a pericholecystic collection → with
perigallbladder stranding ↪ and multiple
intraluminal calculi ⇧.
ACUTE CALCULAR CHOLECYSTITIS • Diffuse GB wall thickening (> 4 mm)
IMAGING FINDINGS • Striated wall thickening: Several alternating
General Features irregular discontinuous lucent and echogenic
• Best diagnostic clue bands with GB wall
o Impacted gallstone in cystic duct • GB hydrops: Distension with AP diameter> 5
o Gallbladder wall thickening cm• Sludge inside GB
o Pericholecystic collection • Clear pericholecystic fluid
o Positive sonographic Murphy sign • Crescent-shaped/loculated pericholecystic
• Location: Stone impacted in GB neck or cystic fluid:
duct Inflammatory intraperitoneal exudate/abscess
• Size: Distended GB (> 5 cm transverse o Complicated cholecystitis
diameter) • Gallbladder perforation: Pericholecystic
• Morphology: Distended GB more rounded in abscess
shape than normal "pear-shaped“ • Gangrenous cholecystitis: Asymmetric wall
configuration. thickening, marked wall irregularities,
Ultrasonographic Findings intraluminal membrane
• Grayscale Ultrasound • Emphysematous cholecystitis: Gas in GB
o Uncomplicated cholecystitis wall/lumen
• Gallstones +/- impaction in GB neck or cystic • Empyema of gallbladder: Highly reflective
duct intraluminal echoes without shadowing,
• Hazy delineation of GB wall purulent exudate/debris
• GB wall lucency "halo sign", sonolucent • Gallstone ileus
middle layer (edema) • Bouveret syndrome: Gallstone erodes in to
• Positive sonographic Murphy sign duodenum leading to duodenal obstruction
ACUTE CALCULOUS CHOLECYSTITIS
Acute cholecystitis
1.thickened and duplicated gallbladder wall.
thickening in acute cholecystitis is
symmetrical, affecting the entire wall
2.wall may reach 6-8 mm (even 10 mm).
3.there is an echo-poor ‘halo’ around the
gallbladder as a result of oedematous
changes .
3.duplication of the gallbladder wall with a
“sandwich” appearance is quite common
4. inflammatory pericholecystic exudate
can be found, which appears as an anechoic or
hypoechoic band.
5. ultrasound Murphy’s sign. 92% positive
predictive value for the diagnosis of acute
cholecystitis
ACUTE CALCULOUS CHOLECYSTITIS

Acute cholecystitis:- Acute cholecystitis:

gallbladder hydrops Calculus blocked in the thickened and doubled wall, echoic material–
infundibulum, and 2 others on the bootom of biliary sludge?
the gallbladder, doubled gallbladder wall
ACUTE CALCULOUS CHOLECYSTITIS

Acute cholecystitis: TS LS
of an oedematous, thickened gallbladder with a thickened wall (arrows). Stones and
wall with a stone debris are present.
ACUTE CALCULOUS CHOLECYSTITIS

TS demonstrating pericholecystic fluid LS demonstrating pericholecystic fluid

ACUTE CALCULOUS CHOLECYSTITIS
Colour or power Doppler can be helpful in
diagnosing acute cholecystitis and in
differentiating it from other causes of
gallbladder wall thickening.
Hyperaemia in acute cholecystitis can be
demonstrated on colour Doppler around the
thickened wall . In a normal gallbladder,
colour Doppler flow may be seen around the
gallbladder neck in the region of the cystic
artery but not elsewhere in the wall.
The increased ensitivity of power Doppler, as
opposed to colour Doppler, does enable the
operator to demonstrate vascularity in the
normal gallbladder wall and the
Colour Doppler demonstrates hyperaemia
operator should be familiar with normal
in the thickened gallbladder wall in acute
appearances for the machine in use when
cholecystitis
making the diagnosis of acute cholecystitis.
ACUTE CALCULOUS CHOLECYSTITIS

Normal gallbladder wall vascularity. Normal gallbladder wall vascularity.

(A) In a normal gallbladder, colour Doppler can (B) Power Doppler is more sensitive and can
demonstrate the cystic artery (arrowhead) but demonstrate flow throughout the wall
does not demonstrate flow near the fundus (arrows) in a normal gallbladder; this must
not be mistaken for hyperaemia.
ACUTE ON CHRONIC CHOLECYSTITIS

Acute on chronic cholecystitis.

chronic cholecystitis presents with an episode
of acute gallbladder pain.
1. The wall is considerably more thick.
2.may become focally thickened with both
hypo- and hyperechoic regions.
3.Stones are usually present.
ACUTE CHOLECYSTITIS ( EMPHYSEMATOUS CHOLECYSTITIS)

Emphysematous cholecystitis.
(B)LS with gas and debris in the gallbladder
Emphysematous cholecystitis. lumen( one form of acute gangrenous
(A) TS with gas and debris in the gallbladder cholecystitis, in DM patient with gas forming
lumen organism)
1.Both the lumen and the wall of the gallbladder may contain air, which is highly reflective, but
which casts a ‘noisy’, less definite shadow than that from stones.
2. Discrete gas bubbles have been reported on ultrasound within the gallbladder wall and may
also extend into the intrahepatic biliary ducts.
ACUTE CHOLECYSTITIS (EMPHYSEMATOUS CHOLECYSTITIS)

Emphysematous cholecystitis. X-ray demonstrating gas in the gallbladder

Gas in the gallbladder lumen completely in emphysematous cholecystitis.
obscures the contents.
.ACUTE CHOLECYSTITIS (GANGRENOUS)

Gangrenous cholecystitis.
1.The gallbladder wall is focally(asymmetrically) thickened and an intramural abscess has formed
on the anterior aspect.
2. a pericholecystic collection. Inflammatory spread may be seen in the adjacent liver tissue as a
hypoechoic, ill-defined area.
3. damaged inner mucosa sloughs off, forming the appearance of membranes in the gallbladder
lumen
4.Loops of adjacent bowel may become adherent to the necrotic wall, forming a
cholecystoenteric fistula.
ACUTE CHOLECYSTITIS ( EMPYEMA GB)

Gallbladder empyema. (A) and (B) LS and TS of the same gallbladder.

1.The gallbladder has ruptured,forming a cholecystoenteric fistula which had resealed at
surgery. The gallbladder contains pus and stones, with several anterior septations, forming
pockets of infected bile which also contained stones (arrows)
2. Fine echoes caused by pus are present in the bile
ACUTE CHOLECYSTITIS (EMPHYEMA GB)

CT scan confirming the (D) Gallbladder empyema demonstrating a

ultrasound appearances. large gallbladder full of pus and stones.
IMAGE GALLERY OF ACUTE CALCULOUS CHOLECYSTITIS

(Left) Oblique (Right)

transabdominal ultrasound shows a distended CECT with coronal reformation shows a
gallbladder =with an impacted gallstone 81at distended gallbladder with =an impacted
the gallbladder neck and diffuse wall stone at its neck with thickened wall and
thickening r:=. ( pericholecystic fluid r:=.
IMAGE GALLERY OF ACUTE CALCULOUS CHOLECYSTITIS
(Left) Oblique
transabdominal ultrasound shows
pericholecystic fluid ⇧ adjacent to a distended
and thick-walled gallbladder ↪ containing
sludge
(Right)
Radionuclide scan with tracer uptake in the CB
fossa showing a classical "rim sign" =. Non-
visualization of the CB at 4 hours has a 99%
specificity. This can be a helpful study when
the ultrasound findings are equivocal.
IMAGE GALLERY OF ACUTE CALCULOUS CHOLECYSTITIS
(Left) Oblique
transabdominal ultrasound shows a
gangrenous gallbladder with asymmetric wall
thickening, sloughed mucosa →impacted
stones at the gallbladder neck ↪, and sludge ⇧.
(Right)
Oblique transabdominal ultrasound shows a
distended gangrenous gallbladder =containing
echogenic debrism irregular wall, and
intraluminal membrane 81 due to sloughing of
mucosa.
DDx: Acute Calculous Cholecystitis

Acute Acalculous Cholecystitis

• Thickened GBwall> 4-5 mm
Nonspecific GB Wall Thickening
• Distended GB
• Negative sonographic Murphy sign
• Absence of gallstone
• Lack of gallstone
• Pericholecystic fluid in absence of ascites
• Clinical evidence of underlying etiology:
• Positive Murphy sign: Pain and tenderness
Congestive heart failure, hypoalbuminemia
with transducer pressure over the gallbladder
• Subserosal edema
DDx: Acute Calculous Cholecystitis

Acute Pancreatitis
• Gallbladder distension and thickening
secondary to
peri-pancreatic inflammation
• Enlarged hypoechoic pancreas
• Peripancreatic fluid or inflammatory changes

Liver Abscess
• Irregular, hypoechoic mass with thick walls
and
posterior enhancement

Gallbladder Siudge/Echogenic Bile

• Echogenic material within gallbladder
• Mobile, gravity dependent
• No GB wall thickening or pericholecystic
collection
• Negative sonographic Murphy sign
ACUTE ACALCULOUS CHOLECYSTITIS
Transabdominal ultrasound shows a
distended C8 with hypoechoic wall
thickening →. Part of the C8 wall appears
irregular ⇧ & asymmetric due to sloughed
mucosa. Note absence of impacted
gallstone
Oblique transabdominal ultrasound shows
focal fluid → in the right pericholecystic region
in a patient with acute acalculous cholecystitis.
Note presence of internal echoes in the GB ⇧
due to inflammatory debris
ACUTE ACALCULOUS CHOLECYSTITIS
(Left) Oblique ultrasound shows a distended
CB with diffuse wall thickening & a striated
hypoechoic appearance →.Sonographic
Murphy sign was positive & there was no
impacted gallstone.
Center) Oblique ultrasound shows marked
CB distension →with mild wall thickening &
presence of floating low level echoes ⇧due
to CB empyema.
ACUTE ACALCULOUS CHOLECYSTITIS

(Right) Oblique ultrasound shows diffuse CB

wall thickening →in acute acalculous
cholecystitis. Note layer of hypoechoic
inflammatory change in adjacent liver
parenchyma ⇧ due to extension of GB
inflammation
DDx: Acute Acalculous Cholecystitis

Acute Calculous Cholecystitis Sympathetic GB Wall Thickening

• us features similar to acalculous cholecystitis • Smooth diffuse GB wall thickening
• Presence of impacted gallstone • Clinically not septic, underlying causes (e.g.,
hypoalbuminemia, cirrhosis, congestive heart
failure)
DDx: Acute Acalculous Cholecystitis

Hyperplastic Cholecystosis
• Focal (fundal/mid body) or diffuse GB wall
thickening
• Comet-tail artifacts, intramural cystic spaces
CHRONIC CHOLECYSTITIS

Graphic shows multiple gallstones inside a Transverse transabdominal ultrasound shows a

contracted thick-walled gallbladder, which are contracted GB with diffuse wall thickening
characteristic features of chronic cholecystitis →and containing an echogenic sludge ball and
gallstones ↪. Note absence of pericholecystic
inflammation
CHRONIC CHOLECYSTITIS

1. Thickening of the gallbladder wall over 4

mm, most commonly with a hyperechoic
appearance, generally without duplicated
aspect,
2.with negative ultrasound Murphy’s sign.
CHRONIC CHOLECYSTITIS

Chronic cholecystitis Chronic cholecystitis:-

.(A) A hyperechoic,
irregular, thickened wall. The gallbladder
contains a small stone and thickened,
echogenic bile. It was mildly tender on
scanning.
(B) The wall is focally thickened anteriorly,
and the gallbladder contains a large stone and
a polyp in the fundus.
IMAGE GALLERY OF CHRONIC CHOLECYSTITIS

(Left) Transverse transabdominal ultrasound (Center) Oblique transabdominal ultrasound

shows diffuse wall thickening →within shows diffuse wall thickening → with a
contracted gallbladder. Note presence of striated hypoechoic appearance & multiple
echogenic sludge & stones ⇧ within CB. stones ⇧ within a contracted gallbladder.
IMAGE GALLERY OF CHRONIC CHOLECYSTITIS

(Right) Oblique transabdominal ultrasound

shows ill-defined thickening of the CB wall →
which contains stones ↪. Note presence of
echogenic band & foci ⇧within thickened CB
wall. Ox: Xanthogranulomatous cholecystitis.
DDx: Chronic Cholecystitis
Sympathetic/Reactive GB Wall Thickening
• Known underlying causes (e.g.,
hypoalbuminemia, cirrhosis, congestive heart
failure etc.) usually detected clinically
• Smooth hypoechoic wall thickening ± linear
striations
Adenomyomatosis of Gallbladder
• Comet-tail artifacts
• More commonly affects fundus or mid GB
with focal
thickening rather than diffuse involvement
 DDx: Chronic Cholecystitis

Gallbladder Carcinoma
• Ill-defined infiltrative wall thickening/mass
• Invasion of adjacent liver parenchyma and
regional nodal metastases
PORCELAIN GALLBLADDER

Graphic shows diffuse calcifications of the Transabdominal ultrasound shows a curvilinear

gallbladder walls in a porcelain gallbladder. echogenicity in the GB wall → casting dense
posterior acoustic shadowing ⇧. Absence of
wall-echo-shadow sign suggestsporcelain GB,
radler than large gallstone.
IMAGE GALLERY OF PORCELAIN GALLBLADDER

(Center) Plain radiograph of the abdomen

(Left) Oblique transabdominal ultrasound
shows a globular, curvilinear calcification
shows diffuse GB wall calcification, which
→projected over the right upper
appears as an echogenic band →with dense
abdomen suggestive of a porcelain gallbladder.
posterior acoustic shadowing ⇧.
IMAGE GALLERY OF PORCELAIN GALLBLADDER

(Right) Transverse CECT shows heavily calcified

GB wall → There is no associated enhancing
50ft tissue mass to suggest GB carcinoma.
 DDx: Porcelain Gallbladder

Large Gallstone Emphysematous Cholecystitis

• Wall-echo-shadow (WES) complex • Echogenic crescent in gallbladder,
appearance reverberation
• Mobile on changing patient's position artifacts
• Clinical information of fulminant biliary
sepsis
DDx: Porcelain Gallbladder

Hyperplastic Cholecystosis
• Diffuse or focal GB wall thickening
• Echogenic foci with comet-tail artifacts
HYPERPLASTIC CHOLECYSTOSIS

Oblique transabdominal ultrasound shows a

Graphic shows characteristic features of
thickened GB wall, with "comet-tail" artifacts
adenomyomatosis. Note thickened gallbladder
⇧ and focal mid GB wall constriction
wall with multiple intramural cystic spaces ⇧.
→(hourglass appearance).
IMAGE GALLERY OF HYPERPLASTIC CHOLECYSTOSIS

(Right)
(Leh) Oblique
Transverse transabdominal
transabdominal ultrasound
ultrasound shows a focal adenomyoma →in
shows eccentric gallbladder wall thickening
the non-dependent part of the gallbladder
→mainly involving the fundus. Note the
fundus. No posterior acoustic shadowing
presence of echogenic sludge ⇧ within the
or "comet-tail" artifact is seen.
gallbladder.
IMAGE GALLERY OF HYPERPLASTIC CHOLECYSTOSIS
(Leh) Oblique
transabdominal ultrasound
shows a dilated intramural cystic space
→within the CB wall. Low-level homogeneous
echoes and echogenic foci are noted within.
Right) Oblique
transabdominal ultrasound
shows presence of "comel-tail" artifact→
within the anterior wall of the CB suggesting
presence of cholesterol deposition within the
GB wall.
IMAGE GALLERY OF HYPERPLASTIC CHOLECYSTOSIS

(Left) Oblique (Right) Oblique

transabdominal ultrasound
shows focal nodular wall thickening →in the
mid body with an hourglass appearance of the
gallbladder. Note presence of gallstones ⇧ in
CB fundus.
CECTshows wall thickening at the fundus →and
mid body ⇧ creating an hourglass appearance
of the gallbladder. Note associated gallstone↪.
DDx: Hyperplastic Cholecystosis
GB Carcinoma
• Polypoid mass> 2 em
• Infiltrative and ill-defined margin
• Increased internal vascularity
• Associated with gallstones in most cases
• Adjacent liver parenchymal invasion and
regional metastatic lymphadenopathy
Adenomatous Polyp
• May mimic focal form of adenomyomatosis
• Polypoid mass 5-15 mm
• Sessile in configuration
• Solitary lesion
• Usually avascular or hypovascular
DDx: Hyperplastic Cholecystosis
Chronic Cholecystitis:-

• Generalized GB wall thickening

• Contracted GB lumen
• Presence of gallstones within GB
• Lack of mural "comet-tail" artifacts or
intramural cystic
space
Diffuse GB Wall Thickening:-

• Related to systemic illness (e.g., hepatitis,

cirrhosis,
congestive heart failure, etc.)
• Diffuse GB wall involvement
• Striated hypoechoic appearance
Echogenic Bile:- • Lack of "comet-tail" artifacts or intramural
• Medium to high-level of echoes within GB cystic
lumen spaces
• Layering in dependent portion within GB
• Mobile on changing patient's position
• Lack of "comet-tail" artifacts or posterior
acoustic
shadowing
GALLBLADDER CARCINOMA

Graphic shows pathways of local tumor Oblique transabdominal ultrasound shows a

invasion from carcinoma of gallbladder↪ : large soft tissue mass → in the gallbladder
Direct tumor infiltration to liver parenchyma → fossa, surrounding a large gallstone ⇧ . There is
retrograde spread along biliary tree ⇧. invasion to inferior liver edge ↪.
~.
IMAGE GALLERY OF GALL BLADDER CARCINOMA
Polypoid gallbladder cancer (>>). Invasion in
the adjacent liver parenchyma (hypoechoic
area) and biliary stones.
Early stage – polypoidal mass irregular outline
size larger than 15-20mm-disruption of
continuity of GB wall layers and invasion of
liver parenchyma
Advances gallbladder carcinoma,with invasion
of the adjacent liver. Ultrasound aspect of a
hypoechoic area centered by a calculus.
(GB wall is thick,anfractuous,hypoechoic,
thickening is much more obvious & irregular as
compared to cholecystitis)
IMAGE GALLERY OF GALL BLADDERCARCINOMA

Advanced gallbladder carcinoma

Hypoechoic mass centered by a calculus.
Carcinomatous ascites (top right)
Advanced stage-a hypoechoic mass in GB
projection area centred by a calculus
(hypoechoic image with posterio shadow)
IMAGE GALLERY OF GALL BLADDER CARCINOMA

(Left) Oblique (Right)

transabdominal ultrasound
shows a focal eccentric
mildly echogenic wall
thickening =arising from
the anterior wall of the
gallbladder.
Transverse transabdominal
ultrasound shows a
polypoidal intraluminal mass =of medium
echogenicity
in the right lateral wall of the
gallbladder.
IMAGE GALLERY OF GALL BLADDER CARCINOMA

(Leh) Oblique (Right) Transverse

transabdominal ultrasound transabdominal ultrasound
shows a large, mildly shows marked, ill-defined,
e=chogenic gallbladder mass with an irregular circumferential wall
margin. thickening of the gallbladder
The tumor infiltrates into the wall =- with medium
adjacent liver parenchyma echogenicity.
IMAGE GALLERY OF GALL BLADDER CARCINOMA

(Leh) Oblique (Right)

transabdominal ultrasound
shows an ill-defined
gallbladder mass=with
adjacent liver infiltration at
the hepatic confluence, right
intrahepatic ductal dilatation
8l and gallstone~.
Oblique transabdominal
ultrasound shows an
irregular gallbladder mass= with tumor
infiltration to the
proximal common bile duct
~ and extrahepatic ductal
dilatation 82.
DDx: Gallbladder Carcinoma
GB Polyp
• Non-shadowing, mucosal mass
o Moderately echogenic without shadowing
• Non-mobile, attached to wall
• Typically < 1 cm for cholesterol polyp
• No vascularity detected on Doppler
Xanthogranulomatous Cholecystitis
• Gallstones
• III-defined, infiltrative GB wal1 thickening
• Indistinguishable from gal1bladder
carcinoma,
diagnosis is usual1y made following surgery
• No lymph node enlargement
 DDx: Gallbladder Carcinoma
Adenomyomatosis
• Localized fundal GB wal1 thickening,
hyperechoic tumorous thickening due to
hypertrophy of Rokitansky-Aschoff sinuses
• Focal thickening of midportion of GB
("hourglass GB")
• May demonstrate diffuse wal1 thickening
• Intramural cholesterol crystals as bright
echoes with
"comet-tail" reverberation echoes
• No adjacent infiltration or lymph node
metastases
Chronic Cholecystitis
• Contracted gallbladder
• Gallstone
• Wall thickening
Metastatic Disease to GB Fossa
• Most often nodal distribution around portal
vein
• Melanoma may directly metastasize to GB
mucosa
• Hepatoma and other hepatic tumors may
secondarily
spread to GB via duct invasion
• Porta hepatis lymphadenopathy
o Lymphoma and GI tract carcinoma most
common
BILIARY DUCTAL DILATATION

Transverse transabdominal ultrasound of the Transverse transabdominal ultrasound shows

right lobe shows marked dilatation of the dilatation of intrahepatic duct =in left lobe.
intrahepatic ducts = due to malignant biliary Note normal looking accompanying portal vein
obstruction at proximal extrahepatic bile duct. ~ in parallel with the dilated left intrahepatic
duct
 IMAGES OF BILIARY DUCTAL DILATATION

(Left) Oblique transabdominal ultrasound (Center) Oblique transabdominal ultrasound

shows tortuous dilatation of the left
intrahepatic ducts ~ due to a large stone
impacted at the distal
common bile duct. The stone was fragmented
and removed via ERCP
shows dilatation of the right
intrahepatic ducts !!:it which is continuous
with dilated proximal extrahepatic bile duct =.(
IMAGES OF BILIARY DUCTAL DILATATION

Right) Oblique transabdominal ultrasound

shows
dilatation of common duct =due to obstructing
CBO stone. Note normal caliber of
accompanying main portal vein ~ and hepatic
artery SiI.
DDx: Biliary Ductal Dilatation
Portal Vein Cavernoma
• Cavernous transformation of portal vein;
racemose
conglomerate of collateral veins
• Doppler: Portal venous flow
Thrombosed Portal Vein Branch
• Hypoechoic (acute) or echogenic (chronic)
filling
defect within main portal vein & its branches
• Color Doppler: Patchy flow or complete
absence of
flow
DDx: Biliary Ductal Dilatation

Veno-Venous Collaterals
• Collateral between thrombosed/stenosed
hepatic veins & normal hepatic veins/portal
veins
• Color Doppler: Venous flow
• Seen in Budd Chiari syndrome
CHOLEDOCHAL CYST
Graphic shows Todani classification of
choledochal cyst:Type
I: Extrahepatic involvement; II:Diverticulum;
III: Choledochocele; IV: Multiple extrahepatic
(lVa with intrahepatic involvement); V: Caroli
disease.
Oblique transabdominal ultrasound shows
fusiform cystic dilatation of the extrahepatic
biliary duct → continuous with non-dilated
intrahepatic ducts; typicalappearances of type
7 lesion
IMAGE GALLERY OF CHOLEDOCHAL CYST
(Left) Oblique
transabdominal ultrasound
shows fusiform dilatation of the common bile
duct →. which is continuous with mildly
dilated intrahepatic ducts ↪.
Right) Oblique
transabdominal ultrasound
shows fusiform dilatation of the intrahepatic
bile duct → in the left lobe of liver. Note the
presence of biliary sludge ⇧in its dependent
part.
IMAGE GALLERY OF CHOLEDOCHAL CYST

(Left) Axial MRCP shows a

Right) Reformatted MRCP
large choledochal cyst → The normal
image showing the choledochal cyst →. Note
gallbladder shows layering of sludge ↪note the
the relatively non dilated intrahepatic biliary
non-dilated intrahepatic biliary ducts 81.
ducts↪.
IMAGE GALLERY OF CHOLEDOCHAL CYST

(Left) Oblique (Right) Oblique color

transabdominal ultrasound of Doppler ultrasound shows a grossly dilated,
a choledochal cyst shows fusiform dilatation of globular appearance of the common bile duct
the common bile duct →with non-shadowing →anterior to the main portal vein ↪ with
stones ⇧in its dependent portion. normal hepatopetal blood flow.
DDx: Choledochal Cyst

Biliary Obstruction of Various Causes

Acute Cholangitis
• Ectatic (rather than fusiform) dilatation
• Ductal wall thickening
• Degree of dilatation less than choledochal
• Obstructing choledocholithiasis
cyst
• Primary lesion identifiable (e.g.,
choledocholithiasis,
cholangiocarcinoma/pancreatic head tumor)
DDx: Choledochal Cyst
Caroli Disease
• Technically classified as type V choledochal
cyst
• Congenital nonobstructive dilatation of the
large intrahepatic bile ducts
• Localized saccular ectasia, producing multiple
cyst-like structures of varying size

Pancreatic Pseudocyst
• Well-defined, cystic lesion related to
pancreatic head
• Previous history of acute pancreatitis
• May be associated with changes of chronic
pancreatitis
CHOLEDOCHOLITHIASIS

Craphic shows mulUple, non-obstrucUve Oblique transabdominal ultrasound shows an

stones in thedistal CBO ↪ and gallbladder →. echogenic focus →within the distal portion of
a dilated CBO ↪ with posterior acoustic
shadowing ⇧ suggesting extrahepatic
choledocholithiasis.
CHOLEDOCHOLITHIASIS

Fig. 30. The choledochus (MBD) and the Fig. 31. Dilated intrahepatic bile ducts –
common portal vein (PV) in the hepatic hilum "spider-like" appearance
CHOLEDOCHOLITHIASIS

Fig.32. Air in the choledochus Fig.33. Air in the intrahepatic bile ducts post
ERCP
CHOLEDOCHOLITHIASIS

Fig. 34. Obstructive jaundice – Klatzkin Fig.35. Segmental dilations of intrahepatic bile
tumor ducts in
the left liver lobe through tumoral invasion
CHOLEDOCHOLITHIASIS

Fig. 36. Intrahepatic lithiasis

CHOLEDOCHOLITHIASIS

Fig. 37. Obstructive jaundice – 10 mm MBD

Fig. 38. Courvoisier-Terrier ultrasound sign
CHOLEDOCHOLITHIASIS

Fig. 39. Obstructive jaundice – MBD stone Fig. 40. Obstructive jaundice – MBD stone
CHOLEDOCHOLITHIASIS

Fig. 41. “Gritted MBD” (three stones in the

distal MBD)
 CHOLEDOCHOLITHIASIS

Fig. 42 and Fig. 43: Dilated MBD ending in a

hypoechoic mass in the pancreatic head
CHOLEDOCHOLITHIASIS

Fig. 44. Dilated MBD ending in a hypertrophic Fig. 45. Echoic material without posterior
pancreatic head with calcifications shadow in the lumen of a dilated MBD
CHOLEDOCHOLITHIASIS
(Left) Oblique
transabdominal ultrasound
shows a small echogenic stone → with faint
acoustic shadowing↪ within the dependent
portion of the dilated common bile duct
⇧.
Right) Transverse CECT
shows an impacted stone ↪
at the terminal portion of the CBO at the head
of the pancreas. Note ascites →in the
subhepatic region.
CHOLEDOCHOLITHIASIS
(Left) Oblique
transabdominal ultrasound
shows two intraductal stones → within the mid
portion of a non-dilated CBD↪ Note
the presence of posterior acoustic shadowing
⇧. Main portal vein
(Right)
Transhepatic cholangiography shows
multiple filling defects → with a faceted
contour within the dilated CBD compatible
with extrahepatic choledocholithiasis. The
patient underwent tract dilatation for
percutaneous stone extraction.
CHOLEDOCHOLITHIASIS

(Left) Oblique (Right) Oblique

transabdominal ultrasound
shows large, intrahepatic ductal stones →with
strong posterior acoustic shadowing ⇧ in the
intrahepatic bile ducts of the right lobe of the
liver.
transabdominal ultrasound
shows intrahepatic ductal stones →in a dilated
intrahepatic duct ⇧. Note hyperechogenicity
along the portal triad ↪ representing
an intrahepatic duct packed with stones.
DDx: Choledocholithiasis
Cholangiocarcinoma
• Infiltrative mass at hepatic confluence
• Soft tissue growth within ductal lumen
• Obstruction & dilatation of CBD/IHBD
• Regional nodal and liver metastase
Biliary Parasitic Infestation
• Most common infestation: Ascaris,
Clonorchis
• Parallel echogenic tubular structures with
sonolucent centre within bile duct
• Active movement of the parasite
• Lack of posterior acoustic shadowing
DDx: Choledochal Cyst
Acute Bacterial Cholangitis:-
• Clinical information suggesting biliary sepsis
• Ductal wall thickening
• Presence of CBD stone obstruction with
proximal

extra- and intra-hepatic ductal dilatation:-

• Echogenic biliary sludge within ducts
Primary Sclerosing Cholangitis (PSC)
• Idiopathic or autoimmune reaction or
genetic
• CBD always involved; IHBD & extrahepatic
(68-89%)
• ERCP: Classic "beaded appearance"
Pancreatic or Ampullary Cancer
• Hypodense mass in head of pancreas or
ampulla
• III-defined infiltrative margin
• "Double duct" sign
o Obstruction & dilatation of pancreatic
duct/CBD
• Vascular encasement
• Contiguous organ invasion/regional nodal
metastases may be seen
BILIARY DUCTAL GAS

Transverse transabdominal ultrasound Transverse transabdominal ultrasound

shows echogenic Foci → in a linear shows an abundant amount 0f biliary ductal
conliguration adjacent to the lelt portal vein ↪ gas within the lelt intrahepatic ducts → casting
casting posterior acoustic shadowing and posterior acoustic shadowing. Patient
reverberation artilact ⇧. underwent ERCP two days prior
 BILIARY DUCTAL GAS

(Left) Oblique transabdominal ultrasound (Center) Transverse transabdominal ultrasound

shows gas within the proximal right shows
intrahepatic ducts →and collapsed gallbladder linear echogenicity in portal triad →with
⇧ due to presence of cholecystoduodenal posterior acoustic shadowing ~ and
fistula following prolonged cholecystitis. reverberation artifacts ⇧.
BILIARY DUCTAL GAS

(Right) Transverse CECT shows biliary

ductal gas→within intrahepatic bile ducts in
left lobe of liver Note accompanying left portal
venous radicle ⇧.
DDx: Biliary Ductal Gas

Portal Venous Gas Intrahepatic Ductal Stones/Sludge

• Branching echogenic foci in periphery of liver • Echogenic foci casting dense posterior
parenchyma within portal venous radicle acoustic shadowing, ± fluid level
• Gas in mesenteric vessels • In region of portal triad or within dilated
intrahepatic ducts
DDx: Biliary Ductal Gas

Calcified Hepatic Granuloma

• Coarse echo genic focus with marked
posterior shadowing, solitary/multiple
• Not related to portal triad
CHOLANGIOCARCINOMA

Graphic shows an infiltrativemass at the Transverse transabdominal ultrasound shows

confluence of the right and left hepatic ducts an ill-defined isoechoic mass→at the hepatic
(Klatskin tumor). It is invading the adjacent confluence associated with marked
liver parenchyma and hepatic veins, a common intrahepatic ductal dilatation↪ .
finding with cholangiocarcinoma.
CHOLANGIOCARCINOMA

(Leh) Oblique transabdominal ultrasound (Right) Transverse CECTshows an ill-defined,

shows an ill-defined hyperechoic tumor →at heterogeneously enhancing, central
the hepatic confluence, causing marked cholangiocarcinoma =("Klatskin tumor"), with
dilatation of the intrahepatic ducts ↪ in both associated dilatation of IHBD ⇧. Note stent ↪
lobes. in the left sided duct system.
CHOLANGIOCARCINOMA

(Leh) Transverse transabdominal ultrasound (Right) Oblique transabdominal ultrasound

shows marked intrahepatic biliary dilatation ↪ shows an intraluminal nodular growth
secondary to malignant biliary obstruction by with medium echogenicity →within the
cholangiocarcinoma. proximal extrahepatic duct. Note presence of
intrahepatic ductal dilatation ↪.
CHOLANGIOCARCINOMA

(Left) Oblique transabdominal ultrasound (Right) Oblique transabdominal ultrasound

shows an ill-defined, circumferential tumor ↪ shows a dilated common bile duct filled with a
along the proximal extrahepatic bile duct, with mildly echogenic mass → The gallbladder ↪is
extension to the hepatic confluence. distended and the main portal vein ⇧
remains patent.
DDx: Cholangiocarcinoma
Pancreatic Head Ductal Carcinoma
• Irregular, heterogeneous, hypo echoic mass
on US • Abrupt obstruction of pancreatic
and/or distal CBD o Distal CBD block mimics
cholangiocarcinoma • Dilated pancreatic duct
& obliteration of retropancreatic fat
• 60% in pancreatic head
Choledocholithiasis
• Intra- & extrahepatic bile duct stones
• Biliary sludge of medium echoes mimic
intraluminal form of extrahepatic tumor
• Echogenic filling defects with posterior
acoustic shadowing • CBD obstruction &
intrahepatic duct dilatation
DDx: Cholangiocarcinoma

Primary Sclerosing Cholangitis (PSC):-

• Dilatation of both intra- & extrahepatic bile
ducts
• PSC often shows isolated obstructions of
IHBDs
• PSC strictures indistinguishable from
scirrhous infiltrating cholangiocarcinoma
• ERCP: Skip dilatations, strictures, beading,
pruning & thickening of ductal wall.

Porta Hepatis Tumor:-

• Bulky primary (HCC) & secondary liver
tumors
• HCC & metastases may invade or obstruct
IHBD

Recurrent Pyogenic Cholangitis

• Dilatation of mainly intrahepatic ducts
• Intrahepatic and extrahepatic ductal stones
• Echogenic biliary sludge
• Clinically present with repeated episodes of
acute ascending cholangitis
ASCENDING CHOLANGITIS

Oblique transabdominal ultrasound

Oblique transabdominal ultrasound shows
shows marked periportal hyperechogenicity
a dilated CBD ⇧ with a distal obstructing stone
→adjacent to a right portal venous radicle, due
↪ & markedly thickened wall →. The patient
to periportal inflammation in acute cholangitis
was in septic shock & features suggest acute
cholangitis.
IMAGE GALLERY OF ASCENDING CHOLANGITIS

(Left) Oblique transabdominal ultrasound (Right) Transverse transabdominal ultrasound

shows a large echogenic calculus →casting shows an irregular contour and mild degree of
marked posterior acoustic shadowing within wall thickening ofdilated intrahepatic ducts →
the dilated common bile duct ⇧. Subsequent in left lobe of liver.
ERep drained pus.
IMAGE GALLERY OF ASCENDING CHOLANGITIS

(Left) Oblique transabdominal ultrasound (Right) Oblique transabdominal ultrasound

shows a dilated common hepatic duct shows a markedly dilated common bile duct ↪
↪containing echogenic material→ within its the wall is mildly thickened ⇧ and it is filled
distal portion. Note intrahepatic ductal with echogenic material →due to infected
dilatation ⇧. bile.
IMAGE GALLERY OF ASCENDING CHOLANGITIS

(Left) Transverse transabdominal ultrasound (Right) Oblique transabdominal ultrasound

shows dilatation of intrahepatic ducts →in the shows a grossly dilated intrahepatic duct →in
left lobe of the liver. Echogenic material ↪ the right lobe of the liver containing echogenic
within the dilated ducts represents infected material ⇧due to infected biliary sludge.
biliary sludge
DDx: Acute Cholangitis
Cholangiocarcinoma
• Ill-defined infiltrative mass
• Commonly at hepatic confluence
• Dilated intrahepatic ducts with non-dilated
extrahepatic ducts distal to site of tumor
• Regional metastatic lymph node and liver
metastases
Ductal Pancreatic Carcinoma
• Infiltrative hypoechoic mass in pancreatic
head
• Dilatation of intra- and extrahepatic and
pancreatic ducts
• Vascular encasement
• Regional nodal and liver metastases
DDx: Acute Cholangitis
Choledocholithiasis
• Clinically patient is not septic
• Echogenic focus casting posterior acoustic
shadowing
• +/- Biliary ductal dilatation
Primary Sclerosing Cholangitis (PSC):-
• Segmental strictures, beaded and pruned
ducts
• Involves both intrahepatic & extrahepatic
ducts
• End-stage: Liver (lobular, hypertrophy &
atrophy Recurrent Pyogenic Cholangitis (RPC):-
• Mainly intrahepatic ductal involvement
• Intrahepatic ductal stones/sludge
• Presence of multifocal intrahepatic ductal
strictures with segmental dilatation
• Clinical information of ethnic origin and
recurrent attacks of cholangitis help in
suggesting etiology.
Other Forms of Secondary Cholangitis:-
• AIDS-related cholangitis
• Chemotherapy-induced cholangitis
• Ischemic cholangitis
• Due to overlap in ultrasound features of
various cholangitis, clinical correlation &
laboratory data are essential to suggest correct
diagnosis
RECURRENT PYOGENIC CHOLANGITIS

Graphic shows marked dilation of intrahepatic Transverse transabdominal ultrasound in a

bile ducts with multiple common bile duct and patient with RPC shows echogenic filling
intrahepatic stones. defects → within dilated intrahepatic ducts ⇧
of the lateral segment of the left
lobe.
IMAGES OF RECURRENT PYOGENIC CHOLANGITIS
(Left) Oblique transabdominal ultrasound
shows thickening of intrahepatic ducts → and
stones ↪ in the right lobe of the liver. There is
increased periportal echogenicity ⇧due to
periductal inflammation.
(Right) Oblique transabdominal ultrasound
shows an echogenic stone →in the
distal portion of the dilated CBD ⇧ casting
posterior acoustic shadowing↪. The presence
of intrahepatic stones (not shown) supported
diagnosis of RPC.
IMAGES OF RECURRENT PYOGENIC CHOLANGITIS

Right) Oblique transabdominal ultrasound

(Left) Oblique transabdominal ultrasoun shows
shows multiple heterogeneous liver masses →
a serpiginous echogenic mass→adjacent
with a cystic component containing low-level
to the right portal vein ↪. Note presence of
internal echoes, compatible with cholangitic
subtle posterior acoustic shadowing ⇧
abscesses in patient with RPC.
IMAGES OF RECURRENT PYOGENIC CHOLANGITIS

(Left) Transverse CECT Right) MRCP shows RPC

shows multiple high attenuation stones changes in a patient with a previous right
→within dilated intrahepatic ducts ⇧ in the segmentectomy and hepatojejunostomy. Note
posterior segment of the right lobe of the liver. presence of signal void filling defects → within
Features suggest RPC the dilated ducts ⇧ in left lateral segment.
DDx: Recurrent Pyogenic Cholangitis

Ascending Cholangitis
• Obstructing CBD stones Sclerosing Cholangitis
• Dilated intra- and extrahepatic ducts • Diffuse thickening of CBD
• Wall thickening in inflamed bile ducts • Multiple intrahepatic strictures and dilatation
• Periportal hypo- or hyperechogenicity due to • Stones form distal to strictures
periductal inflammation. • Associated with inflammatory bowel disease
DDx: Recurrent Pyogenic Cholangitis
Intrahepatic Stones Secondary to Biliary
Stricture
• Stricture may be due to prior surgery, trauma
or chemotherapy
• Non-Asian patient
• Similar clinical presentation with RUQ pain,
fever and chills

Cholangiocarcinoma
• Infiltrative type at confluence of right and
left ducts most common
• Ill-defined parenchymal mass close to
hepatic confluence
• Intrahepatic ductal dilatation of involved
segments
• Presence of liver or regional nodal
metastases
AIDS-RELATED CHOLANGIOPATHY

Graphic of AI~S-related cholangiopathy shows Oblique transabdominal ultrasound

multiple segments of biliary wall thickening in an HIV-infected padent shows diffuse wall
with stenosis involving both the intrahepadc thickening involving the common bile duct →
and extrahepadc bile ducts. Also note and gallbladder ⇧ due to CMV infecdon of the
gallbladder wall thickening. biliary tree.
AIDS-RELATED CHOLANGIOPATHY

(Left) Oblique transabdominal ultrasound (Center) Oblique transabdominal

in an AIDS-infected patient with impaired liver ultrasound shows marked wall thickening of
function shows mild intrahepatic ductal an extrahepatic bile duct → with focal
dilatation, with diffuse echogenic wall extrinsic narrowing of the common duct ⇧
thickening →. at the porta hepatis.
AIDS-RELATED CHOLANGIOPATHY

(Right) Oblique transabdominal ultrasound

shows diffuse wall thickening →in a distended
CB. Note the presence of trace pericholecystic
fluid ⇧ and absence of an impacted gallstone.
DDx: AIDS-Related Cholangiopathy

Acute Bacterial Cholangitis Cholangitis (Sclerosing/Recurrent Pyogenic)

• Obstructing CBD stone • Multiple intrahepatic strictures and stones
• Intrahepatic ductal dilatation, biliary wall • Stricture formation in extrahepatic ducts
thickening and periportal changes
DDx: AIDS-Related Cholangiopathy

Cholangiocarcinoma
• Infiltrative mass along ductal epithelium
• Invades hepatic parenchyma and regional
lymph node metastases