Biliary AnatomyBiliary Anatomy

Biliary CalculiBiliary CalculiMilk of calcium bileMilk of calcium bile

Porcelain gallbladderPorcelain gallbladderCholecystitisCholecystitis

Mirizzi Syndrome, Mirizzi Syndrome, Gall stone ileusGall stone ileus

Biliary lithiasisBiliary lithiasis

Biliary lithiasisBiliary lithiasis最佳影像診斷線索最佳影像診斷線索 ::

Echogenic foci with posterior Echogenic foci with posterior acoustic shadowing (10% stones: acoustic shadowing (10% stones: No acoustic shadow) in No acoustic shadow) in USUS

Discrete & (movable) lower signal Discrete & (movable) lower signal (density) filling defects within bile (density) filling defects within bile ducts in ducts in MRC and ERCPMRC and ERCP

Opaque stones (20%) in Opaque stones (20%) in plain plain radiographyradiography

Gallbladder completely filled with calculi ~ Calculi are molded ( 鑄造 ) by the wall of the gall bladder : the acoustic shadow posterior to the Calculi that do not change with positional change

Floating stone

Clinical issuesClinical issues Primary CBD stones (5%) : Form within CBD

2nd CBD stones (95%) : Gallstones into CBD Treatment: stone <

3 mm : usu. spontaneously pass stone 3-10 mm : endoscopic sphicterotomy * stone retrieval balloon to sweep duct * basket to snare stones stone > 10-15mm : require fragmentation by mechanical lithotripsy

Clinical issues Clinical issues (CBD stones)(CBD stones)

S/S: RUQ pain, Jaundice, pancreatitis ↑Alkaline phosphate & bilirubin Gender: Females (middle age) > malesPathology: Bile stasis / infection ~ Bilirubinate stone formation

(Cholesterol + Ca ＋＋ bilirubinate) Obstruction, dilatation, sclerosis,

stricture.

Crescent (meniscus) lucent sign

Bull’s eye sign

Milk of calcium bileMilk of calcium bile Calcium carbonate precipitate within

gall bladder lumen (calcium milk)

最佳影像診斷線索最佳影像診斷線索 : : Identification of Identification of calcified liquid within gallbladder calcified liquid within gallbladder (echogenic fluid similar to sludges (echogenic fluid similar to sludges but with acoustic shadowing)but with acoustic shadowing)

Incidental finding: Incidental finding: asymptom or RUQ painasymptom or RUQ pain

Etiology: GB stasis ~ Ca++ carbonate Etiology: GB stasis ~ Ca++ carbonate in bile, thickness of GB wall in bile, thickness of GB wall

GB sludges (thick bile)

GB sludges ~ cholecystitis ~ stone

Milk of calcium bileMilk of calcium bile(vs. sandy gall (vs. sandy gall stone)stone)

Porcelain GBPorcelain GB

Calcification of gallbladder wallCalcification of gallbladder wall最佳影像診斷線索最佳影像診斷線索 : : Rim of calcification Rim of calcification

in RUQ conforming to GB shapein RUQ conforming to GB shape

Usually asymptomatic ; old ageUsually asymptomatic ; old age

Rish factor for Rish factor for gallbladder carcinomagallbladder carcinoma

Prophylactic cholecystectomy is Prophylactic cholecystectomy is current consensus recommendationcurrent consensus recommendation

Cholecystitis

• Acute inflammation of gall bladder

• 95% calculous: 2°to obstructing stone in GB neck or cystic duct

• 5% Acaculous: 2°to ischemia with secondary inflammation/infection

Gallstones --> cystic duct obstruction

Bile secretion

GB distentionWall edema / hypervascularity

Intraluminal pressure

Compression on vessels--> Thrombosis/ ischemia--> GB wall necrosis--> Perforation / abscess

Pathophysiology

Gallstones (+) : 96 %

Color Doppler sonogram: marked Hyperemia & wall thickness of GB

Tc-HIDA scan: Tc-HIDA scan: Acute cholecystitis Acute cholecystitis without isotope filling of GBwithout isotope filling of GB

最佳影像診斷線索最佳影像診斷線索 ::

• GS impacted in neck / cystic ductGS impacted in neck / cystic duct

• Sonographic Murphy sign (+) Sonographic Murphy sign (+)

• GB wall thickness (> 4 mm)GB wall thickness (> 4 mm)

• Distended GB (> 4 cm trans. diameter)Distended GB (> 4 cm trans. diameter)

• Pericholecystic fluid/Pericholecystic fluid//abscess/abscess

• Intraluminal membranesIntraluminal membranes

• Gas in GB wall / lumenGas in GB wall / lumen

• Asymmetric GB wall thicknessAsymmetric GB wall thickness

Cholecystitis

Clinical issuesClinical issues S/S: Acute RUQ pain, feverLab data: ↑WBC count, may have mild

elevation in liver enzymesDemographics Age: typically > 25y, Gender: M:F = 1:3Microscopic features Lumen: GS, sludge; GB mucosa: Ulceration;

GB wall: Acute PMN infiltration; Bacterial cultures positive in 40-70% of patient

Acaculous cholecystitis ?

Non-inflammatory GB wall thickness: Congestive heart failure with dilated IVC

Non-inflammatory GB wall thickness: Acute hepatitis

Acute hepatitis s/p treatment

Clinical issuesClinical issues Complications

Empyema

Emphysematous, Gangrenous

Perforated with abscess

Chronic cholecystitis

Mirizzi syndrome Bouveret syndrome (gall stone ileus)

Intraluminal membranes

Empyema of gall bladder

Emphysematous cholecystitis

Intraluminal membranes

Sloughed ( 蛻腐 ) mucosae (Asymmetrical wall thickness)

Gangrene of gall bladder

Perforated GB with abscess

localized peri-cholecystic complicated fluid collections

Perforated GB with abscess

Clinical issuesClinical issues Treatment• Prompt or delayed lap. cholecystectomy

Laparoscopic cholecystectomy for uncomplicated cases

• Percutaneous cholecystectomy useful for poor operative risk patients with GB empyema or gangrene

• Percutaneous drainage well-defined, well-localized pericholecystic abscesses

Chronic CholecystitisTwo appearance

Small, contracted, sclerosed GB with/without stones (fasting state)

Same imaging appearance as acute cholecystitis but without Murphy sign (terderness)

Small, contracted, sclerosed GB; even non-visualization of GB (during fasting state)

Mirizzi syndrome Partial or complete obstruction Partial or complete obstruction

of common hepatic duct (CHD) of common hepatic duct (CHD) due to gallstone impacted in due to gallstone impacted in cystic duct or gall bladder neckcystic duct or gall bladder neck

最佳影像診斷線索最佳影像診斷線索 :: Impacted cystic Impacted cystic duct stone on US with proximal duct stone on US with proximal dilatation of intraheptic ductsdilatation of intraheptic ducts

Clinical issues Clinical issues S/S: fever, jaundice, RUQ painD/D:

Porta hepatis obstruction from nodes with proximal IHDs dilatation Porta hepatis obstruction by cholangiocarcinoma (Klatskin tumor) with proximal IHDs dilatation

Treatment: Cholecystectomy with careful dissection of cystic duct to avoid injury to CHD

Porta hepatis nodes Klatskin tumor

Gall stone ileus Gall stone ileus (Bouveret syndrome)(Bouveret syndrome)

Gall stone erodes into duodenum causing intestinal obstuction

最佳影像診斷線索最佳影像診斷線索 : : (Rigler triad)(Rigler triad)

Small bowel obstruction Small bowel obstruction Gas in biliary tree Gas in biliary tree Ectopic gallstone (> 2.5 cm) in bowelEctopic gallstone (> 2.5 cm) in bowel

Clinical issuesClinical issuesAge: risk ↑with age; average 65-75 Y/OPrognosis: high mortality, operative

mortality 19 ％Treatment Surgical therapy to relieve bowel

obstruction Cholecystectomy & biliary fistula

excision; to prevent recurrence

M/74

• 主 訴： chills and fever for three days• 現 在 史 previous history of liver cirrhosis with

ascites, started nausea, vomiting, fever and abdominal pain for three days before admission. He was brought to nearby hospital for hospitalization. However, signs and symptoms persist, and he was diagnosed to have peritonitis of unknown cause. He is then transferred to our hospital for further evaluation and management. At the ER, abdomen CT ~~~

• Vital signs : Blood pressure 93 / 59 mmHg

Pulse rate 97 / minutes

Respiratory rate 19 / minutes

Body temperature 38.3 ℃

• Abdomen : Distended ( + )

Tenderness ( + ) : RUQ ( + )

Rebounding pain ( + )

Murphy's sign ( + )

Shifting dullness ( + )

Bowel sound : Hypoactive ( + )

• Lab. : WBC: 28230/cumm

Pathological No.: 962230 Date of Arrival: 2007/8/7 Date of Report: 2007/8/8 Pathological diagnosis: Gall bladder, cholecystectomy ----- ----- Chronic cholecystitis with acute exacerbation and cholelithiasis

Gross: The specimen consists of an opened gall bladder, measuring 9.2 x 4.5 x 3 cm in size. It is enlarged. The wall is thickened and measuring up to 0.5 cm in thickness. The mucosal folds are absent. There are several pieces of black stone in the lumen. Representative parts are embedded in one block.

Microscopy: The sections show a picture of edema, neutrophilic infiltration, congestion, hemorrhage, abscess formation, fibrosis and focal chronic inflammatory cell infiltration in the lamina propria, muscular layer and perimuscular layer. Rokitansky-Aschoff sinuses are present.

• 主 訴： Left abdominal pain off and on for 10 days• 病 史： This 52 years old woman, who had history of infertility s/p

laparoscopy > 25 years ago, Intestinal adhesion s/p OP

25 years ago, left ovarian tumor s/p laparoscopy 15 years

ago.

According to the patient : she has left abdominal pain off

and on for 10 days, aggravated for 3-4 days, can not sleep

due tp severe pain with fullness. Associated with loss of

appetite, nausea was noted. The pain locates on left

abdominal area, subacute, duration 24 hours, dull pain and

fullness in character, aggravated by taken food, relief by

rest, no radiated, no change of bowel habit. She had been

treatment at 劉醫院 , but the treatment not effective, hence,

she sent to our GI OPD, KUB showed partial intestinal

obstruction, She was admitted.

Spigelian hernia Lap. Port hernia