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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5780_Библиотеки_им_академика_М_И_Перельмана.pdf
13.2 Intrahepatic Ductal Changes
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
ab
cd
Fig. 481a–d Intrahepatic bile duct tumors with associated biliary stasis. a Cholangiocellular carcinoma (4) with peripheral obstruction of the bile ducts (2) and
accompanying divisions of the portal vessels (3). b Cholangiocellular carcinoma (T)
of the left hepatic duct (LHD). c Type 1 Klatskin tumor. Obstructed intrahepatic bile
ducts are seen only in the less echogenic left hepatic lobe. d Type 3 Klatskin tumor:
obstructed intrahepatic bile ducts and divisions of the portal vessels
13
13
13
Bile Ducts
Bile Ducts
Bile Ducts
n
Ductal dilatation due to compression or invasion by metastases:
x
Circumscribed dilatation of the bile duct
x
Evidence of metastasis
Fig. 482 Intrahepatic bile ducts (BD)
obstructed by an infiltrating metastasis
(T) from pancreatic carcinoma (Not
detectable on CT)
329
13.3 Extrahepatic Ductal Changes
Schmidt, Ultrasound © 2007 Thieme
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13
13
13
Echogenic or Sonodense Changes
..............................................................................................................
n
Intrahepatic duct stones:
x
Solitary or multiple echogenic foci projected into the duct lumen
x
Distal acoustic shadows or summation acoustic shadowing
Bile Ducts
Bile Ducts
Bile Ducts
n
Pneumobilia: air in the biliary tract:
x
Echogenic string-of-beads or band-like structures (mobile with position
changes) in the portal tracts
x
With a spontaneous biliary–enteric fistula caused by a perforating stone, the
stone can be detected outside the biliary tract. With a surgical biliary–enteric
anastomosis or papillotomy, any obstructing stone is generally cleared.
13.3 Extrahepatic Ductal Changes
Overview (Table 56):
..............................................................................................................
Table 56.Extrahepatic duct changes
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Anechoic or hypoechoic Echogenic or sonodense
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Ductal dilatation due to obstructive cholestasis
(p. 330)
Papillomatosis (p. 331) DD: vascular calcification (p. 332)
Ascariasis (p. 331) Pneumobilia (p. 332)
Sludge or pus (p. 331)
Anechoic or Hypoechoic Changes
..............................................................................................................
n
Anechoic ductal dilatation in obstructive cholestasis (Figs. 483 and 484):
x
Diffuse, anechoic intraductal area i 7mm
x
Detectable obstructing lesion (tumor, stone)
x
With sclerosing cho langitis : segmental ductal dilatation, string-of-beads luminal
irregularities (Fig.
483b)
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyy
Biliary stones (p. 332)
ab
Fig. 483a, b Extrahepatic cholestasis. a Dilated bile duct, obstructed cystic duct
(CYD) with cutoff (BD) due to bile duct carcinoma. Arrow: anechoic lumen with
sludge. b Significant thickening of the duct wall (arrows) as far as the duodenum
(D). The duct does not contain fluid. End stage of sclerosing cholangitic cirrhosis
(L). PV = portal vein
330
13.3 Extrahepatic Ductal Changes
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
Fig. 484 Complete obstruction of
the bile duct in chronic pancreatitis.
The orifice of the cystic duct (3) marks
the junction of the hepatic duct (1) with
the common bile duct (2). 4 = Head of
the pancreas
n
Obstructing cystic duct stone: dilated infundibulum continuous with a postero-
superiorly expanded cystic duct, often with a definable obstructing stone
n
Biliary papillomatosis: lobulated intra- and extrahepatic masses partially occupy-
ing the bile ducts
n
Ascaris lumbricoides (Fig. 485): serpentine or band-like intraluminal structures
ab
Fig. 485a, b Ascaris lumbricoides in the bile duct. a Ultrasound shows a hypoechoic
intraluminal mass (arrow). b At endoscopy, an ascarid worm is visible in the papilla.
The patient presented clinically with necrotizing pancreatitis
13
13
13
Bile Ducts
Bile Ducts
Bile Ducts
n
Biliary sludge or pus (Fig. 486):
x
Hypoechoic intraluminal material, generally associated with an extrahepatic
obstruction (stone or tumor, Fig.
Fig. 486 Hypoechoic bile duct (BD) in
suppurative cholangitis. PV = portal vein,
L = liver, D = duodenum
483a)
331
13.3 Extrahepatic Ductal Changes
Schmidt, Ultrasound © 2007 Thieme
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13
13
13
Echogenic or Sonodense Changes
..............................................................................................................
n
Biliary stones (Fig. 487):
x
Round or oval intraluminal foci of high echogenicity
x
Complete or incomplete acoustic shadow (may provide the only sonographic
Bile Ducts
Bile Ducts
Bile Ducts
evidence of a nonobstructing stone)
n
Hepatic artery calcification:
x
Typical location at the site where the hepatic artery passes beneath the common duct
x
Duct compression
x
Generally does not cast an acoustic shadow
n
Pneumobilia: string-of-beads or band-like (mobile) echo structure (after papil-
lotomy or fistula)
a
b
cd
Fig. 487a–d Obstructing stones in the extrahepatic bile ducts. a Mirizzi stone (1)
with an acoustic shadow (2), gallbladder lumen (4), and an obstructed hepatic duct
(3). Typical location of the proper hepatic artery between the portal vein and
hepatic duct. b Cystic duct stone (arrow, C). The stone oscillates within the duct,
causing intermittent cystic duct obstruction. c Large oblong stone (arrows,
35 mm): acoustic shadow (S) in the bile duct (BD) with dilatation of the right and
left hepatic ducts (RHD, LHD). L = liver d Small prepapillary stone (arrow) with an
acoustic shadow (S)
332
13.4 Evaluation and Further Testing
Schmidt, Ultrasound © 2007 Thieme
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13.4 Evaluation and Further Testing
Sonography
..............................................................................................................
n
Changes in the intra- and extrahepatic bile ducts can be detected sonographically
with very high confidence and can generally be identified.
n
Diagnostic accuracy:
x
Obstructive cholestasis can be disti nguished from nonobstructive forms in
almost 100 % of cases.
x
Intra- and extrahepatic stones i 15 mm can be correctly diagnosed in 100 % of
cases.
x
Intrahepatic tumors can be detected and identified indirectly based on circumscribed ductal dilatation, and extrahepatic tumors can be directly visualized.
x
Prepapillary stones are more difficult to detect (although this is examinerdependent).
x
Sclerosing cholangitis can be correctly diagnosed in approximately 80 % of
cases.
Further Testing
..............................................................................................................
n
Primary biliary cirrhosis: The clinical picture is that of cholestasis, but ultrasound
does not show significant hepatic or biliary abnormalities. Can be diagnosed by
the determination of antimitochondrial antibodies (positive in 96 % of cases).
n
Sclerosing cholangitis: Sonography shows echogenic wall thickening, string-of-
beads irregularities due to mural fibrosis, and circumscribed foci of intrahepatic
ductal dilatation. Liver histology and ERC confirm the diagnosis, with ERC showing
duct irregularities (suppurative cholangitis secondary to biliary obstruction
should be excluded). Ulcerative colitis is a common associated finding in many
patients.
n
Suspicion of carcinoma: ERC is the best modality for the further investigation of
canalicular lesions, but it is not useful for evaluating the pericanalicular spread of
a biliary tumor. Even CT is of limited value in this regard, and ultrasound is the
imaging modality of choice.
n
A detected tumor can be investigated further by FNAB with cytologic and histologic evaluation.
n
Other indeterminate lesions of the extrahepatic bile ducts can be investigated by
endosonography (biliary tumor or stone) or by biliary tract endoscopy.
n
Metastases can be identified as the circumscribed cause of cholestasis by ultrasound and/or CT, or can be confirmed by FNAB.
13
13
13
Bile Ducts
Bile Ducts
Bile Ducts
333
14.1 Examination
Schmidt, Ultrasound © 2007 Thieme
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14
14
14
14 Gallbladder
14.1 Examination
Gallbladder
Gallbladder
Gallbladder
Scan Planes
..............................................................................................................
n
Right subcostal oblique scan (see p. 22)
n
Intercostal scan, extended intercostal scan (see p. 23)
Sonographic Anatomy and Normal Findings
..............................................................................................................
n
The gallbladder nestles in the gallbladder fossa on the visceral surface of the liver,
with only its fundus projecting past the inferior hepatic surface.
n
The gallbladder is bounded on the right side by the right lobe of the liver, on the
left side by the quadrate lobe, and posteriorly by the antrum or duodenal bulb
(Fig.
474a, p. 323, and Fig. 474b, p. 323).
n
Although many variants may be encountered (e.g., spherical, oblong, serpentine),
the “textbook” gallbladder is pear-shaped and displays typical cystic features on
ultrasound (anechoic interior, distal acoustic enhancement, smooth margins).
n
Normal dimensions: longitudinal diameter I 100 mm, transverse diameter
I 40 mm; volume I 100 mL, wall thickness I 3 mm (Fig.
488).
ab
c
Fig. 488a–d Sonographic appearance of the gallbladder and its dimensions
(cursors; length and depth in a, width in b). a Intercostal scan. b Right subcostal
oblique scan. GB = gallbladder, L = liver
d
334
14.2 Changes in Size, Shape, and Location
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
Scanning Protocol
..............................................................................................................
n
Transducer: 3.5–5.0 MHz
n
Patients are generally examined in a fasting state.
n
The patient is usually positioned supine, or occasionally in left lateral decubitus or
a standing position (“rolling stones,” polyps).
n
The patient can be rapidly turned to mobilize crystal aggregates and microliths,
causing them to swirl within the gallbladder lumen.
n
The examination includes digital palpation (Murphy’s sign of acute cholecystitis
= pain on gallbladder compression).
n
Intercostal scans are helpful in patients with an elevated hemidiaphragm,
in heavy-set patients, and after surgical operations.
Overview and Classification of Findings
..............................................................................................................
n
Classification: Gallbladder abnormalities seen on ultrasound are classified as
changes of size, shape, or location; intraluminal changes; and wall changes.
x
Change in gallbladder size: This may have a functional or organic cause.
x
Intraluminal and wall changes: It is important to distinguish between intraluminal and wall changes because of their different therapeutic implications. When
wall changes are found, it is essential to make a detailed evaluation with magnified views and to document the findings in multiple planes (to determine
whether operative treatment is indicated).
n
Overview:
x
Changes in size, shape, and location: see Table 57, p. 335.
x
Wall changes: see Table 58, p. 339.
x
Intraluminal changes: see Table 59, p. 364.
14.2 Changes in Size, Shape, and Location
14
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14
Gallbladder
Gallbladder
Gallbladder
Overview (Table 57):
..............................................................................................................
Table 57.Changes in the size, shape, and location of the gallbladder
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Large gallbladder Small gallbladder
yyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyy
Congested gallbladder, Courvoisier gallbladder (p. 336)
yyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyy
Contracted gallbladder (p. 336)
Hydrops (p. 336) Empty gallbladder (p. 337)
Cystic duct obstruction (p. 332) Hypoplasia (p. 340)
Gallbladder tumor (p. 341, 352) Shrunken gallbladder (p. 340),
perforated gallbladder (p. 337)
Change in gallbladder shape Change in gallbladder location
Gallbladder diverticulum (p. 337) Atypical location (p. 337)
Siphon gallbladder (p. 337)
“Phrygian cap” (p. 337)
Nonvisualization of the gallbladder (p. 337)
335
14.2 Changes in Size, Shape, and Location
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
14
14
14
Changes in the Size of the Gallbladder
..............................................................................................................
n
Congested gallbladder (Fig. 489a): may result from hepatic cirrhosis or func-
tional causes (acute abdomen, bowel obstruction, gastrointestinal diseases).
n
Courvoisier gallbladder (Fig. 489b): may result from carcinoma of the pancreatic
Gallbladder
Gallbladder
Gallbladder
head
x
Enlarged gallbladder with dilatation of the cystic duct and common bile duct
x
Pre- or peripapillary duct cutoff sign
n
Contracted gallbladder (Fig. 489c):
x
Increased gallbladder wall thickness with a normal three-layered wall structure
n
Hypoplasia:
x
Small gallbladder with no detectable cause
n
Shrunken (stony) gallbladder (Figs. 489d; Fig. 491c, p. 338) :
x
Small gallbladder (in two planes)
x
Ultrasound almost always demonstrates stones or stone shadows.
x
The gallbladder wall is often echogenic (suggestive of chronic cholecystitis).
ab
cd
Fig. 489a–d Changes in gallbladder size. a Congested and enlarged gallbladder
(cursors) in a patient with bowel obstruction. b Courvoisier gallbladder: requires
differentiation from a congested gallbladder due to an obstructed cystic duct (CY)
and common duct (DC). c Contracted gallbladder (GB): thickened wall with a
normal layered structure (cursors). d Shrunken gallbladder: echogenic wall with
irregular thickening (arrows). S = acoustic shadows
336
14.2 Changes in Size, Shape, and Location
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
Changes in the Shape and Location of the Gallbladder
..............................................................................................................
n
Gallbladder diverticulum (Fig. 490a): anechoic wall protrusion with a definable
neck or stalk
n
Siphon gallbladder: S-shaped tortuosity
n
“Phrygian cap” (Fig. 490b): anatomical variant in which the gallbladder is kinked
at the fundus
n
Atypical location: intrahepatic or occupying an unusually low or lateral position
ab
Fig. 490a, b Changes in gallbladder shape and location. a Gallbladder (GB)
diverticulum (D). b Gallbladder (GB) kinked at the fundus. L = liver
Nonvisualization of the Gallbladder
..............................................................................................................
n
Scanning tip: If you are having difficulty visualizing the gallbladder, look for it in
the lesser pelvis, to the left or right of its typical location, or just beneath the abdominal wall (using the correct probe focus). Generally it can be located by moving the probe from a flank scan toward the midline while watching the inferior
border of the liver, or by scanning subcostally along the interlobar fissure from
the vena cava to the gallbladder bed.
n
Gallbladder agenesis: often misinterpreted as a shrunken gallbladder; extremely
rare
n
Contracted gallbladder (see Fig. 489c, p. 336): History: “Have you recently eaten
or smoked?”
n
Unusual location: just beneath the abdominal wall in thin patients; in the midab-
domen or lower abdomen in elderly cachexic patients. May be displaced laterally
or medially in patients with hepatic cirrhosis
n
Empty gallbladder (Fig. 491a): obstructing stone with a check-valve mechanism
in the cystic duct or infundibulum
n
Echogenic gallbladder (Fig. 491b): e.g., sludge, empyema, tumor
n
Stony gallbladder (see Fig. 512, p. 349): stone-filled gallbladder that does not
have an anechoic lumen
n
Shrunken gallbladder (Fig. 491c): often identifiable only by distal shadowing
n
Perforated gallbladder (Fig. 491d):
x
Bizarre hypoechoic formation
x
Free or confined fluid
n
Postoperative gallbladder
14
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14
Gallbladder
Gallbladder
Gallbladder
337
14.2 Changes in Size, Shape, and Location
Schmidt, Ultrasound © 2007 Thieme
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14
14
14
Gallbladder
Gallbladder
Gallbladder
ab
cd
Fig. 491a–d Nonvisualization of the gallbladder.
a Empty gallbladder (GB) resulting from an infundibular and cystic duct stone with
a check-valve mechanism.
b Echogenic gallbladder (GB) isoechoic to the liver. The impacted stones (arrow)
and absence of tumor vessels (CDS) are consistent with empyema.
c Shrunken stony gallbladder. Only a distal acoustic shadow (S) marks the presence
of the gallbladder (arrow).
d Perforated gallbladder. This gallbladder can still be identified owing to the confined fluid collection (FL) outside the perforation site. With a free perforation, the
absence of the gallbladder and the presence of free intra-abdominal fluid (possible
pneumobilia with a biliary–enteric fistula) raise suspicion of a perforation
338