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KEY POINTS
Ultrasound is the modality of choice and is well suited for the initial evaluation of the gallbladder and
biliary tree.
Ultrasound imaging benefits include lower cost, faster acquisition time, portability, and the advantage of being a dynamic examination.
Although ultrasound may be the initial modality that identifies biliary tract malignancy, crosssectional imaging with computed tomography and MR imaging will be required to evaluate the
extent of disease.
Sonographic findings in the biliary system are often nonspecific, but when combined with clinical
history, these can often help to determine the diagnosis.
ultrasound.theclinics.com
INTRODUCTION
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Fig. 1. Normal gallbladder. (A) Longitudinal view of the gallbladder. The gallbladder is divided into 3 parts:
fundus (F), body (B), and neck (N). Normal gallbladder length less than 10 cm. (B) Transverse view of the gallbladder. Normal gallbladder diameter less than 5 cm (cursors).
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Fig. 5. Dilated intrahepatic bile ducts. (A) Transverse view of the left hepatic lobe demonstrates mild intrahepatic
biliary dilatation (arrows). (B) Color Doppler imaging of the liver is useful in differentiating portal vein (V) from
bile duct (cursors).
ULTRASOUND TECHNIQUE
Fasted patient, 4 to 6 hours
Transverse and longitudinal planes
Patient positioning to assess for mobility and/
or layering
Sonographic Murphy sign
An important factor in gallbladder and biliary ultrasound is the fasting status of the patient. The gallbladder is typically scanned after 4 to 6 hours of
fasting to avoid gallbladder contraction. If a patient
has not fasted for at least 4 hours before the examination, the gallbladder can be anywhere along the
spectrum of distended to contracted and findings
such as gallbladder wall thickening, gallstones,
and gallbladder sludge cannot be reliably assessed (Fig. 7). If the gallbladder is contracted
due to a postprandial state, the examination should
be delayed or rescheduled for a time when the patient can be adequately fasted.
The gallbladder should be imaged in both transverse and longitudinal planes with different patient
positions as necessary to assess for mobile gallstones or layering sludge. Examination of the gallbladder is initially performed in the supine position.
Other maneuvers are routinely used including right
and left decubitus, prone, and upright standing
positions.
A technique that deserves specific attention is
the sonographic Murphy sign. The original Murphy
sign was described by Dr John B. Murphy as a
physical examination maneuver to differentiate
gallbladder pathology from other causes of abdominal pain many years before the advent of
ultrasound. His description involved elicitation of
pronounced pain by hooking a finger beneath the
right costal margin, asking the patient to take a
deep breath, and then striking that finger forcibly
down with the other hand eliciting severe pain.9
The sonographic Murphy sign is a simple adaptation of this original description that takes advantage of the real-time ability to confirm placement of
the transducer directly over the gallbladder. The
transducer is held firmly in place as the patient is
asked to take a deep breath. The sign is considered positive if the patient admits to intense focal
pain at the site of the transducer. Patients may
evidence this pain by abruptly ceasing inspiration.
Absence of a sonographic Murphy sign may be
seen in the setting of recent analgesic administration or altered mental status.
GALLSTONES
Common finding
Major risk factor for acute cholecystitis
Highly echogenic with dense posterior
shadow
Wall-echo-shadow (WES) sign
Fig. 6. Normal common bile duct. The normal common bile duct measures less than 7 mm in diameter
(cursors). Notice the consistent size along the entire
length of the duct.
Fig. 7. Contracted gallbladder. (A) Longitudinal view of the right upper quadrant demonstrates a contracted gallbladder (arrows) with an echogenic inner mucosal layer and hypoechoic outer muscular layer. (B) Transverse view
of the right upper quadrant demonstrates apparent wall thickening due to underdistention (arrows). This patient
was rescheduled and instructed on the appropriate fasting time before the examination (46 hours). Fig. 1 demonstrates a normally distended gallbladder on the repeat examination.
gallbladder is filled with stones, the echogenic gallbladder wall (W) is still visible as a distinct structure
due to a thin layer of hypoechoic bile overlying the
brightly echogenic surface of the gallstones (E),
which is then followed by posterior shadowing (S)
from the stones, hence WES (Fig. 9).
In the instance of porcelain gallbladder or
emphysematous cholecystitis, the calcium or air
within the gallbladder wall disrupts the normal,
thin appearance of the wall and therefore only
one echogenic line and posterior shadowing will
be visualized. Differentiation of cholelithiasis from
emphysematous cholecystitis and porcelain gallbladder is important given the implications of the
latter 2 processes.
BILIARY SLUDGE
Biliary sludge is a mixture of particulate matter that
precipitates in bile.11 Risk factors for the formation
of sludge include rapid weight loss, pregnancy,
critical illness, and prolonged total parenteral
Fig. 8. Gallstones. (A) Single, large gallstone in the gallbladder fundus (solid arrow). (B) Multiple small stones in
the gallbladder body and neck (solid arrow). Note the bright echogenic signal of the stones with homogeneous
posterior shadowing in both images (asterisk).
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CHOLECYSTITIS
Most often caused by gallstones
Acalculous cholecystitis typically seen in critically ill patients
Complicated cholecystitis: gangrenous, emphysematous, perforation
Cholecystitis is defined as inflammation of the gallbladder. It is divided into calculous and acalculous
cholecystitis depending on whether gallstones are
present. Of these 2, calculous cholecystitis accounts for 90% to 95% of cases.14 Calculous
cholecystitis can be further subdivided into acute
and chronic cholecystitis.
Acute cholecystitis is typically caused by gallstones lodged in the gallbladder neck or cystic
duct. This obstruction can lead to gallbladder
distention and inflammatory changes in the gallbladder wall, which may eventually lead to
ischemia, superinfection, and necrosis of the gallbladder wall. The findings classically associated
with the diagnosis of acute cholecystitis include
gallbladder wall thickening (>3 mm), a positive
sonographic Murphy sign, gallbladder distention,
gallbladder wall hyperemia, and pericholecystic
fluid (Fig. 12). The presence of stones, a positive
sonographic Murphy sign, and wall thickening
were originally found to have the highest positive
and negative predictive values.15 Although subsequent studies have challenged the validity of the
sonographic Murphy sign, the overall sensitivity
Fig. 10. Gallbladder sludge. Amorphous, nonshadowing echogenic material within the gallbladder lumen that
moves freely and usually assumes a dependent position (solid arrows) as seen on the supine (A) and prone (B)
images.
Fig. 11. Tumefactive sludge or sludge ball. Globular, echogenic lesion within the gallbladder lumen
(solid arrow) that does not demonstrate posterior
shadowing. On color Doppler, no internal vascularity
was seen. In addition, the sludge ball demonstrated
mobility. A shadowing echogenic gallstone is also
seen (dashed arrow) and provides an excellent comparison in the different appearances of the 2 entities.
Fig. 12. Acute cholecystitis. (A) Longitudinal view. Large shadowing stone in the gallbladder neck (arrow) with
markedly edematous gallbladder wall thickening (cursors). (B) Transverse view of the gallbladder demonstrates
marked edematous wall thickening (asterisk) and trace pericholecystic fluid (FF). The patient presented with right
upper quadrant pain and exhibited a positive sonographic Murphy sign.
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Fig. 14. Perforated gallbladder. (A) Transverse image of the gallbladder demonstrating a defect in the wall (solid
arrow) as well as pericholecystic fluid (arrowhead). (B) T1-weighted axial MR image confirms the findings from
the ultrasound (solid arrow: perforation; arrowhead: pericholecystic fluid). Note that the gallbladder wall is
thickened. Additional findings, not seen on these images, supported the diagnosis of acute cholecystitis with
rupture. (C) Another ultrasound image of gallbladder perforation. A focal defect is identified in the gallbladder
wall (arrow).
INTERVENTIONAL COMPLICATIONS
Common interventions associated with the biliary
tract include cholecystectomy, cholecystostomy,
cholangiostomy, sphincterotomy, and biliary
stent placement. Each of these procedures can
result in injury to the gallbladder and/or the biliary
tree. The 3 major complications include bile leak/
biloma, hemorrhage, and abscess. These complications appear as diffuse or focal fluid collections with varying degrees of echogenicity and
heterogeneity depending on the exact cause
and chronicity (Fig. 18). Biloma can be differentiated with the use of cholescintigraphy or
cholangiography.
Fig. 16. Chronic cholecystitis. Mildly thickened gallbladder wall (cursors) and gallstones (solid arrow). Patient had no additional findings to suggest acute
cholecystitis, including a negative sonographic Murphy sign.
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Fig. 18. Gallbladder fossa hematoma. (A) Patient was several days status post-cholecystectomy with persistent
right upper quadrant pain. A complex collection in the gallbladder fossa is heterogeneous with a retractile
appearance of the central echogenic focus (arrow), typical of hematoma. A drain was placed for concern of developing abscess, but confirmed aseptic hematoma. (B) After the drain was removed, a follow-up ultrasound
demonstrated near complete resolution of the fluid collection (arrow).
Fig. 19. Gallbladder wall thickening. Markedly edematous, thickened gallbladder wall (arrowheads) secondary to hypoproteinemia. Note the wall thickening of
the adjacent bowel loop (solid arrow) and ascites.
Fig. 20. Porcelain gallbladder. (A) Longitudinal and (B) transverse views of the gallbladder demonstrate curvilinear echogenicity in the gallbladder wall (arrow) with posterior acoustic shadowing (asterisk). (C) CT confirmation of calcification in the gallbladder wall (arrowhead).
BILIARY OBSTRUCTION
Obstruction of the biliary system can be identified
sonographically by identifying dilated intra- and
extrahepatic bile ducts (Fig. 23, Video 2). This disease process can be divided into 3 major categories: stone-related, inflammatory/infectious,
and neoplastic. Biliary obstruction due to stones
is the most common of the 3 categories.
CHOLEDOCHOLITHIASIS
Low overall incidence, but significant
morbidity/mortality
Low sensitivity, high operator dependence for
identification on ultrasound
Decreased
conspicuity
compared
to
gallstones
Mirizzi syndrome and other rare complications
of chronic impaction
Pneumobilia
Choledocholithiasis is defined as stones within the
bile ducts. If the stones form within the ducts, it is
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Fig. 21. Gallbladder polyp. Multiple ultrasound images of the gallbladder in the supine (A), left lateral decubitus
(B), and upright (C) views from the same patient demonstrating an echogenic, nonshadowing polypoid lesion on
the posterior gallbladder wall (arrow). The lesion does not demonstrate mobility with changes in patient position. (D) Power Doppler images of the gallbladder polyp demonstrate a vascular stalk within the lesion (arrow).
Fig. 22. Adenomyomatosis. (A) Focal area of subtle gallbladder wall thickening with tiny internal echogenic focus
causing ring-down artifact, typical of adenomyomatosis (arrow). (B) More prominent focal wall thickening at the
gallbladder fundus (arrow) that does not demonstrate vascularity on color Doppler (C). (D) CT image of this same
patient demonstrates the soft tissue density of the focal adenomyomatosis in the gallbladder fundus (arrow).
Fig. 23. Biliary duct dilatation. (A) Severe intrahepatic biliary dilatation (arrows). (B) Marked dilatation of the
common bile duct (cursors). The portal vein (V) and common bile duct are nearly equal in diameter.
Fig. 24. Choledocholithiasis. (A, B) Shadowing common bile duct stone (arrowhead) with ductal dilatation
(arrows).
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Fig. 25. Pneumobilia. (A) Air within the common bile duct. Bright linear echogenic focus in the common bile duct
(arrow) causing heterogeneous posterior shadowing as well as ring-down artifact (dashed arrow). Bowel gas
within the duodenum is also seen (arrowhead). (B) Color Doppler image confirms air is within the common
bile duct (arrow), adjacent to the main portal vein (V). (C) Branching echogenic structures with faint acoustic
shadowing identified in the liver (arrows), indicating air within the intrahepatic ducts. Note that the echogenic
foci are more central in the liver as opposed to portal venous gas, which tends to be more peripheral in location.
these may not be present. Ultrasound can visualize these as vague hypoechoic lesions within
the liver once they develop central liquefactive necrosis. CT and MR imaging are helpful adjuncts in
evaluating for this sequela.
Stones can form directly in the biliary ducts and
result in chronic biliary obstruction, stasis, and
recurrent inflammation. Known as primary hepatolithiasis, recurrent pyogenic cholangitis, or oriental
cholangiohepatitis, this disease process is common in East Asia with reported incidence rates of
up to 20%, but in North America the incidence remains low.42,43 Sonographic findings include
biliary ductal dilatation containing sludge and
stones within one or more segments of the liver.
Longstanding stasis and inflammation often leads
to severe atrophy and cirrhosis of the affected
segment. In addition, there is an increased risk of
cholangiocarcinoma.
HIV cholangiopathy could be considered a subset of both acute bacterial and sclerosing cholangitis; this can be associated with opportunistic
infections, such as cryptosporidium or cytomegalovirus in patients with advanced disease. Sonographic findings include findings of biliary ductal
Fig. 26. Acute cholangitis. (A) Longitudinal and (B) transverse views of the portal triads demonstrate increased
echogenicity about the portal triads and the double barrel appearance of the portal vein and enlarged adjacent bile duct (arrow). The wall of the bile duct demonstrates circumferential thickening. (C) Color Doppler image
at the level of the porta hepatis showing the markedly thickened common bile duct wall (arrowhead), which is
also dilated. Portal vein (V). This patient presented with fever, right upper quadrant pain, and jaundice (Charcot
triad).
dilatation and wall thickening.44 The ductal dilatation is irregular demonstrating areas of focal dilatation and stricture as in PSC. The papilla of Vater is
typically inflamed and can be seen as an echogenic nodule in the distal common bile duct.45
The final infectious cause that will be discussed
is ascariasis, a parasitic roundworm. This entity,
like recurrent pyogenic cholangitis, is exceedingly
rare in the United States compared to other parts
of the world. Of the 1.4 billion cases globally, only
approximately 4 million are diagnosed in the United
States and many of these individuals are immigrants from endemic regions.46 The worm migrates
from the small bowel into the biliary tree through
the ampulla of Vater causing biliary obstruction.
The imaging finding most specific to this cause is
that of the worm itself. The appearance is similar
to that of a biliary stent: a tubular structure
composed of parallel echogenic lines within the
bile ducts. The lack of a history of stent placement
as well as other clinical risk factors such as immigration from an endemic region and young age
should raise the suspicion for ascariasis.46
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Fig. 27. PSC. (A, B) Ultrasound images demonstrate dilated intrahepatic bile ducts (arrows) that have thickened
walls and an irregular beaded appearance. Findings related to the chronic sequela of PSC are seen, including
cirrhosis and ascites. (C) An endoscopic retrograde cholangiopancreatography (ERCP) image demonstrates dilatation, stricturing, and beading of the intrahepatic bile ducts.
CHOLEDOCHAL CYSTS
Congenital cystic dilatation of the biliary tree is
most commonly seen in individuals of East Asian
descent.50,51 The Todani classification system
breaks the cysts down by appearance (Table 1).52
The Type I cysts are the most common and
defined as typically diffuse or focal segmental
Fig. 28. Hilar cholangiocarcinoma (Klatskin tumor). (AC) Massive, diffuse intrahepatic biliary dilatation. The central intrahepatic bile ducts come to an abrupt end (arrow) at the site of a vague, isoechoic mass at the hilum
(arrowhead), adjacent to the main portal vein (V). T2-weighted axial MR image (D) and fluoroscopic spot image
from a percutaneous cholangiogram (E) further demonstrate the characteristic malignant stricture (arrows) and
massive proximal intrahepatic biliary dilatation. The patient was inoperable and nodularity along the gallbladder
raised the suspicion of gallbladder carcinoma, but brushings from the ERCP confirmed cholangiocarcinoma.
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Fig. 29. Gallbladder carcinoma. (A) Invasive mass (M) replacing the gallbladder, difficult to delineate from the
adjacent liver. Central hypoechoic region represents necrosis (arrowhead). Internal calcifications (arrows). (B) Color Doppler image of the same patient demonstrates the internal vascularity of the mass. (C) Different patient.
Heterogeneous mass (M) filling the gallbladder lumen. Pathology confirmed gallbladder carcinoma.
Table 1
Choledochal cysts
Type I (most
common)
Type II
Type III
Type IVa
Type IVb
Type V
SUMMARY
Ultrasound has been and will continue to be the
modality of choice for initial evaluation of the gallbladder and biliary tree. This is due to its low cost,
fast acquisition time, and portability as well as
diagnostic accuracy with regards to the most
common indication for evaluation, right upper
quadrant pain. Although many of the sonographic
findings for other diseases along the biliary tract
are nonspecific, when combined with clinical history, risk factors, and adjunct CT and MR imaging
when indicated, it can often help to make or at
least confirm the diagnosis.
SUPPLEMENTARY DATA
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3. Puente SG, Bannura GC. Radiological anatomy of
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5. Bressler EL, Rubin JM, McCracken S. Sonographic
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