Gallbladder and Common Bile Duct
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Patient position:Assess supine, left lateral decubitus and erect.Use the liver as a window especially when rolling the patient onto their left side.Equipment settings:Narrow the dynamic range and use harmonics. Use the highest frequency probe initially such as 7 or 8MHz then come down in frequency if required.Measurethe wall should be <3mm Is the gallbladder enlarged?>10cm n length.What to look for:
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Measureextrahepatically(CHD) at porta hepatis and at the head of the pancreas where it enters the duodenum at the Ampulla of Vater.Size:CBD &>5mm inner to inner wall then add 1mm for each decade of life.Up to 10mm post cholecystectomyPatient position:Start with the patient left lateral decubitus then roll back so the pt is slightly oblique.You may need to scan with the patient erect if there is gas overlying the distal portion or use compression to push the bowel out of the way.Look for:the Portal vein as the common bile duct runs parallel to this at the porta hepatis. Put the colour on to make sure it is not the hepatic artery or portal vein. The intrahepatic biliary ducts are seen in the liver views with an oblique view to see both the left and right hepatic ducts simultaneously. The cystic duct may be seen although its junction with the CBD can be variable.
PATHOLOGY
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- Assess the cystic duct, neck , body and fundus (sometimes there is a phyrigian cap)
- Check with colour Doppler for increased vascularity of the wall.
- If there is marked oedema of the wall, ensure the wall is intact. With prolongued obstruction, the wall may become necrotic.
- Is there a positiveMurphy's sign? ie pain when compressing the gallbladder.
- Gallstones/cholelithiasis- check for mobility of stones or sludge by rolling patient and standing them erect.
- Sludge
- Cholecystitis: Acute calculus cholecystitis and acalculus cholecystitis.
- Peri colic fluid collections
- Adenomyomatosis "strawberry gallbladder". Rokitansky-Aschoff (R-A) sinuses are pathognemonic.
- Gallbladder Cancer
- Polyps or any intraluminal masses.
- Cholesterol cystals in the GB wall
- If the patient has ascites, there is often reactive thickening of the GB wall.
- A phrygian cap should not be confused with a mass or R-A sinus.
- Folds in the wall may mimic polyps.
- If prolongued illness, fasting and inactivity,biliary stasiswill be seen as echogenic/complex bile/sludge in the GB
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Common Bile Duct
Measureextrahepatically(CHD) at porta hepatis and at the head of the pancreas where it enters the duodenum at the Ampulla of Vater.Size:CBD &>5mm inner to inner wall then add 1mm for each decade of life.Up to 10mm post cholecystectomyPatient position:Start with the patient left lateral decubitus then roll back so the pt is slightly oblique.You may need to scan with the patient erect if there is gas overlying the distal portion or use compression to push the bowel out of the way.Look for:the Portal vein as the common bile duct runs parallel to this at the porta hepatis. Put the colour on to make sure it is not the hepatic artery or portal vein. The intrahepatic biliary ducts are seen in the liver views with an oblique view to see both the left and right hepatic ducts simultaneously. The cystic duct may be seen although its junction with the CBD can be variable.
PATHOLOGY
- Choledochal cysts
- stone(choledocholithiasis)
- Primary (formed in the duct)
- Secondary (more common)
- Stones are most commonly found in the distal duct, impacted at the Ampulla of Vater.
- stricture
- cholangitis
- tumour (cholangiocarcinoma)
- sludge
- congenital causes
- Budd Chiari
- Liver tumour
- Cirrhosis
- Metastases
- Pancreatic tumour
- Pancreatitis
- Duodenal tumour
- Bilary obstruction results in dilatation due to:
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