Diagnostic Ultrasound - Abdomen and Pelvis
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Diagnostic Ultrasound - Abdomen and Pelvis

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09.07.2019 Views

Gallbladder Cholesterol Polyp (Left) Longitudinal left lateral decubitus ultrasound shows a cholesterol polyp with a normal gallbladder wall . (Right) Sagittal CECT of the same patient at another time shows a cholesterol polyp with mild, nonspecific gallbladder wall thickening. Diagnoses: Biliary System (Left) Longitudinal ultrasound shows 2 small cholesterol polyps . These were not mobile and did not shadow. (Right) Coronal T2 HASTE MR performed for a renal mass shows an incidental, tiny, low signal polyp ſt with a normal gallbladder wall. (Left) Transverse ultrasound in a patient with cirrhosis shows a large, less echogenic polyp with a thin stalk ſt and dependent shadowing gallstones . (Right) Axial T1 C+ delayed phase MR of the same patient shows a smooth, enhancing gallbladder polyp . The adjacent gallbladder wall was edematous ſt. 299

Acute Calculous Cholecystitis Diagnoses: Biliary System TERMINOLOGY • Acute inflammation of gallbladder (GB) secondary to calculus obstructing cystic duct IMAGING • Distended GB (> 5 cm transverse diameter) • Gallstones ±impaction in GB neck or cystic duct • Diffuse GB wall thickening (> 4-5 mm) • Hazy delineation of GB wall with echogenic pericholecystic fat • Positive sonographic Murphy sign: Pain and tenderness with transducer pressure directly over gallbladder • US is first-line imaging tool • HIDA after equivocal US, more sensitive than US • CT and MR for complicated cholecystitis • Gangrenous cholecystitis: Asymmetric wall thickening, marked wall irregularities, intraluminal membranes • Gallbladder perforation: Defect in GB wall with pericholecystic abscess or extraluminal stones KEY FACTS • Emphysematous cholecystitis: Gas in GB wall/lumen • Empyema of gallbladder: Highly reflective intraluminal echoes without shadowing, purulent exudate/debris • Move patient to confirm impacted GB stone, assess Murphy sign and surrounding area CLINICAL ISSUES • May progress to gangrenous cholecystitis and perforation if untreated DIAGNOSTIC CHECKLIST • Combination of gallstones, wall thickening, and positive Murphy sign increase specificity • Possibility of adjacent inflammatory disease such as perforated ulcer, acute hepatitis, or acute pancreatitis mimicking acute cholecystitis (Left) Left lateral decubitus ultrasound shows a shadowing stone in the neck of the gallbladder ſt. Note the thick wall with subserosal edema st. Murphy sign was positive. (Right) Left lateral decubitus ultrasound shows a shadowing stone in the fundus of the gallbladder. Note the thick wall with subserosal edema ſt. (Left) Transverse ultrasound shows dependent shadowing gallstones with a sludge level ſt. Note the thickened gallbladder wall with a central hypoechoic halo st. (Right) Axial contrast-enhanced CT of acute calculous cholecystitis shows a thick-walled gallbladder st containing calcified gallstones ſt. 300

Gallbladder Cholesterol Polyp<br />

(Left) Longitudinal left lateral<br />

decubitus ultrasound shows a<br />

cholesterol polyp with a<br />

normal gallbladder wall .<br />

(Right) Sagittal CECT of the<br />

same patient at another time<br />

shows a cholesterol polyp <br />

with mild, nonspecific<br />

gallbladder wall thickening.<br />

Diagnoses: Biliary System<br />

(Left) Longitudinal ultrasound<br />

shows 2 small cholesterol<br />

polyps . These were not<br />

mobile <strong>and</strong> did not shadow.<br />

(Right) Coronal T2 HASTE MR<br />

performed for a renal mass<br />

shows an incidental, tiny, low<br />

signal polyp ſt with a normal<br />

gallbladder wall.<br />

(Left) Transverse ultrasound in<br />

a patient with cirrhosis shows<br />

a large, less echogenic polyp<br />

with a thin stalk ſt <strong>and</strong><br />

dependent shadowing<br />

gallstones . (Right) Axial T1<br />

C+ delayed phase MR of the<br />

same patient shows a smooth,<br />

enhancing gallbladder polyp<br />

. The adjacent gallbladder<br />

wall was edematous ſt.<br />

299

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