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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5780_Библиотеки_им_академика_М_И_Перельмана.pdf
14.3 Wall Changes
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
14.3 Wall Changes
Overview (Table 58):
..............................................................................................................
Table 58.Changes in the gallbladder wall
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Hypoechoic or complex Echogenic
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Acute cholecystitis (p. 339)
Wall thickening (hepatic or pancreatic disease,
trauma, p. 340)
Wall edema (ascites, right heart failure, p. 341) Cholesterosis (p. 343)
Wall abscess (p. 341) Adenomyomatosis (p. 343)
Wall infiltration by carcinoma (p. 341) Xanthogranulomatous cholecystitis
Lymphoma, metastasis, abscess (p. 341) Chronic cholecystitis (p. 344)
Hypoechoic or Complex Wall Changes
..............................................................................................................
n
Acute cholecystitis (Figs. 492 and 493): The differential diagnosis of acute chole-
cystitis includes chronic cholecystitis, wall thickening due to adenomyomatosis,
scirrhous carcinoma, malignant lymphoma (= intrinsic factors), acute hepatitis
and pancreatitis, liver cirrhosis with ascites
x
Hypoechoic layered or stratified wall
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Duplicated gallbladder (p. 342)
Flexion creases, true septa (p. 342)
(p. 344)
Porcelain gallbladder (p. 344)
Emphysematous cholecystitis (p. 345)
14
14
14
Gallbladder
Gallbladder
Gallbladder
ab
Fig. 492a–c Acute cholecystitis.
a Hypoechoic layered wall following
ERCP. No evidence of stones. Gallbladder is hydropic with incipient sedimentation (“stress gallbladder”). b Very
hypoechoic wall thickening (cursors)
with a small amount of free fluid (FL).
c CDS : inflammatory wall vascularity is
clearly demarcated from a pericholecystic area of avascular edema
c
339
14.3 Wall Changes
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
14
14
14
Gallbladder
Gallbladder
Gallbladder
ab
Fig. 493a, b Acute cholecystitis with hydrops (GB, cursors). Length i 8 cm, width
and depth i 4 cm, rarefied wall structure. Local tenderness to compression
(Murphy’s sign), together with the obstructing stone in the infundibulum, confirm
the presence of hydrops. S = acoustic shadows
x
Stone detection (except in acalculous cholecystitis; causes : traumatic, weakened immune status due to chemotherapy, septic hematogenous, abscess formation)
x
Possible associated features: hydrops, empyema, pericholecystic free fluid
(Fig.
n
492c)
Wall thickening due to hepatic or pancreatic disease, AIDS, or trauma (Fig. 494;
Figs.
500–502, p. 344):
x
Thickened wall with a layered or complex structure
x
With portal hypertension: intramural vascularity (Fig. 494d)
b
a
Fig. 494a–c Differential diagnosis of
increased gallbladder wall thickness.
a Wall thickening (cursors) in decompensated hepatic cirrhosis. b In acute
hepatitis and AIDS. c Traumatic gallbladder contusion : massive wall
c
edema with no visible lumen. LE = liver,
GB = gallbladder, PV = portal vein
340
14.3 Wall Changes
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
de
Fig. 494d, e Differential diagnosis of increased gallbladder wall thickness.
d In portal hypertension. CDS: portosystemic collaterals in the gallbladder wall.
e In cholecystolithiasis. CDS: stone shadow behind a wall thickened to 8 mm.
Aberrant “spot-like ” tumor vessels (arrows). Histology: carcinoma.
n
Wall edema (Fig. 494a, p. 346): Possible causes are right heart failure, ascites in
hepatic cirrhosis, and hypalbuminemia (= extrinsic factors). Does not occur with
malignant ascites
x
Uniformly hypoechoic, layered wall
x
Frequent gallbladder congestion
n
Wall abscess (Fig. 495):
x
Intramural hypoechoic or anechoic mass in a splayed wall
x
Signs of acute cholecystitis
14
14
14
Gallbladder
Gallbladder
Gallbladder
Fig. 495 Wall abscess (arrow) in acute
cholecystitis. Scan shows markedly
edematous segments of the gallbladder
wall. GB = gallbladder, L = liver
n
Carcinoma infiltrating the gallbladder wall (Fig. 496): stage I when confined to
the gallbladder, stage II with extension past the gallbladder boundaries, stage III
with infiltration outside the gallbladder
x
Hypoechoic, circumscribed intramural or polypoid area of wall thickening
x
Infiltration
n
Lymphoma, metastasis, abscess:
x
Neoplastic wall thickening
x
Possible pericholecystic spread
x
Metastasis is indistinguishable from primary gallbladder carcinoma (Fig. 496).
341
14.3 Wall Changes
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
14
14
14
Gallbladder
Gallbladder
Gallbladder
ab
Fig. 496a, b Carcinoma of the gallbladder. a Early carcinoma appears as a broadbased, polypoid tumor mass (T) within the gallbladder (GB). b Stage II–III gallbladder carcinoma (T), already infiltrating the wall and starting to invade the liver
(arrow). Stone with acoustic shadow (S)
Echogenic Wall Changes
..............................................................................................................
n
Duplicated gallbladder (Fig. 497):
x
Echogenic, longitudinally oriented, septum-like compartmentalization
x
This results in a second lumen with a wall and second cystic duct (definable by
ERCP).
Fig. 497 Duplicated gallbladder
(GB, GB). The smaller moiety of the
duplicated gallbladder is bounded by a
complete, echogenic wall extending
to the second cystic duct (second duct
not shown here)
n
Flexion creases, septa (Fig. 498):
x
Surface indentation with a normal layered wall structure
x
With flexion creases: kinked gallbladder
x
With true septa: echogenic connective-tissue membranes (subdividing the
lumen into two or more communicating spaces). Complete longitudinal septation can mimic a duplicated gallbladder. The differential diagnosis includes
Heister valves in the gallbladder neck and cystic duct.
342
14.3 Wall Changes
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
ab
Fig. 498a, b Flexion creases vs. true septa. a Flexion creases impart an S shape to
the gallbladder. A scan directed through the creases appears to show separate
compartments. The creases may partially resolve when the patient is repositioned.
b True septa (arrows) remain constant with position changes. Differential
diagnosis: Heister valves
n
Cholesterosis (cholesteatosis, Fig. 499):
x
Multiple or occasionally solitary echogenic foci on the gallbladder wall
(“stippled gallbladder”)
x
No acoustic shadows, but reverberations are usually present
14
14
14
Gallbladder
Gallbladder
Gallbladder
ab
Fig. 499a, b Cholesterosis (cholesteatosis): segments of patchy echogenic wall
change with reverberations. a B-mode image. b CDS: twinkling artifacts in the
reverberations
n
Adenomyomatosis (Fig. 500): hyperplasia of the mucosa, hypertrophy of the
muscular layer, cholesterol deposits, and the formation of mural diverticula
(Rokitansky–Aschoff sinuses)
x
Segmental wall thickening (“hourglass gallbladder,” fundic myomatosis) or
diffuse wall thickening
x
Echogenic cholesterol specks with reverberations
x
Small mural diverticula (Rokitansky–Aschoff sinuses)
343
14.3 Wall Changes
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
14
14
14
Gallbladder
Gallbladder
Gallbladder
a
Fig. 500a, b Adenomyomatosis.
a Segmental or diffuse wall thickening,
diverticula (D), and echogenic
cholesterol deposits (arrows).
b ERC radiograph shows very fine
diverticula with indistinct margins
n
Xanthogranulomatous cholecystitis (Fig. 501): This entity, like cholesterosis and
adenomyomatosis, belongs to the category of “cholecystoses.” Its sonographic features are nonspecific and similar to those of adenomyomatosis and cholesterosis.
Patients present clinically with local tenderness and signs of inflammation.
x
Thickening of the gallbladder wall by an inflammatory mass (arising from
small, inflamed mural diverticula?)
x
Possible echogenic cholesterol deposits, reverberations
b
Fig. 501 Xanthogranulomatous
cholecystitis: circumscribed tumor-like
thickening of the gallbladder wall
(arrows). GB = gallbladder
n
Chronic cholecystitis (Fig. 502):
x
Diffuse or circumscribed echogenic wall thickening
x
Detection of stones
x
Possible decrease in gallbladder size (shrunken gallbladder)
n
Thickened echogenic wall in ascites: “Blooming effect” due to echo saturation,
as in malignant ascites with acoustic enhancement along the gallbladder wall
n
Porcelain gallbladder (Fig. 503): partial or complete calcification of the gallblad-
der wall, considered a premalignant lesion that requires operative treatment
344
14.3 Wall Changes
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
a
Fig. 502a, b Chronic cholecystitis with
recurrent acute attacks due to cholecystolithiasis: layered, echogenic wall up
to 9.8 mm in thickness (cursors). a Oblique longitudinal scan. b Transverse scan.
(S) = incomplete acoustic shadow behind the hyperechoic wall
b
a
14
14
14
Gallbladder
Gallbladder
Gallbladder
Fig. 503a, b Porcelain gallbladder.
a Ultrasound shows a hyperechoic wall
with a combination of complete and
incomplete acoustic shadows (S).
b Radiograph: The different degrees of
acoustic shadowing result from nonhomogeneous calcification of the gallbladder wall
x
Wall intensely echogenic as a result of circumscribed or diffuse calcium encrustation
x
Complete or incomplete distal acoustic shadowing
n
Emphysematous cholecystitis (Fig. 504): common in diabetes, requires immedi-
ate operative treatment
x
Smooth wall with high-amplitude echoes caused by bacterial gas formation
x
Reverberations
x
Plus findings characteristic of a stony gallbladder. May be mistaken for pneumobilia or a porcelain gallbladder (Figs.
b
503, 504)
345
14.4 Intraluminal Changes
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
14
14
14
Gallbladder
Gallbladder
Gallbladder
Fig. 504 Emphysematous cholecystitis:
hydropic gallbladder (GB) with stones
and acoustic shadowing (S). Reverberations (W) arise from echogenic air
bubbles on the anterior wall (arrows)
14.4 Intraluminal Changes
Overview (Table 59):
..............................................................................................................
Table 59.Intraluminal changes in the gallbladder
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Nonshadowing Shadowing Complex echo pattern
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Sludge (p. 346)
Empyema, hydrops (p. 347) Stones (p. 348) Empyema with a stone (p. 349)
Cholesterol polyp (p. 347) Stony gallbladder (p. 349) Phlegmon (p. 350)
Adenoma (p. 347) Pneumobilia (p. 349)
Carcinoma (p. 348)
Intraluminal Changes without Acoustic Shadowing
..............................................................................................................
n
Sludge (Fig. 505): formation of bilirubin and cholesterol crystals (floating,
polypoid, or tumor-like, depending on specific gravity), common in patients on
parenteral nutrition. It results in stone formation.
x
Rounded, fungoid or flat layer of sediment that shows sluggish movement with
position changes
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Gravel (p. 348)
yyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyy
Gallbladder carcinoma with a
stone (p. 349)
ab
Fig. 505 a Sludge in the gallbladder (GB). b The echogenic sediment moves when
346
the patient is repositioned
14.4 Intraluminal Changes
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
x
Individual crystal aggregates: swirl on rapid rotation of the body
x
Sludge completely filling the lumen: echogenic gallbladder
n
Empyema, hydrops (see Fig. 493, p. 340, and Fig. 514, p. 350):
x
Enlarged gallbladder with slightly or markedly echogenic contents
x
Degree of enlargement: length i 80 mm, width i 40 mm
x
Local tenderness to palpation (Murphy’s sign)
x
Gallstones usually present
n
Cholesterol polyp (Fig. 506 ):
x
Round intraluminal mass adherent to the gallbladder wall
x
Size I 5 mm (size i 6 mm indicates a true neoplasm, and i 10 mm probably
signifies the malignant transformation of gallbladder adenoma)
x
Usually echogenic with reverberations, sometimes hypoechoic
ab
Fig. 506a, b Cholesterol pseudopolyps. a Echogenic, intraluminal protuberant
mass on the gallbladder wall (cursors; arrow: side-lobe artifact). b Hypoechoic
sessile polyp (arrow) on the gallbladder wall. Must be differented from adenoma
n
Gallbladder adenoma (Fig. 507): tumor i 6 mm based on the gallbladder wall.
Lesions j 10 mm require close follow-up, and surgery may be considered. Lesions
i 15 mm should always be extirpated as they often signify malignant change.
14
14
14
Gallbladder
Gallbladder
Gallbladder
a
Fig. 507a, b Gallbladder adenoma. a Hyperechoic mass (P) in the gallbladder
(GB). The tumor is broadly adherent to the gallbladder wall but does not infiltrate
it. b CDS: Spectral analysis reveals an intratumoral vessel. Additional color flow
signals: vena cava
b
347
14.4 Intraluminal Changes
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
14
14
14
x
Round or lobulated, polypoid (papillomatous) tumor
x
Adherent to the gallbladder wall, usually by a broad base
x
Does not infiltrate the gallbladder wall
x
Does not cast an acoustic shadow
x
CDS: intratumoral vessels
Gallbladder
Gallbladder
Gallbladder
n
Carcinoma (Fig. 508):
x
Polypoid mass occupying all or part of the gallbladder lumen (lesions i 33 mm
are almost always invasive cancers)
x
Mottled hypoechoic structure
x
Often shows infiltrative growth (liver) with ill-defined margins
x
Stones are usually present
x
CDS: sparse vascularity
Fig. 508 Gallbladder carcinoma
(T, arrows) : hypoechoic, nonhomogeneous mass that completely occupies
the gallbladder lumen (stage II).
Stone echo with a distal shadow (S)
Intraluminal Changes with Acoustic Shadowing
..............................................................................................................
n
Gravel (Fig. 509):
x
Collection of fine granular echoes with no definable stone echo
x
Summation acoustic shadowing
Fig. 509 Gallbladder contents: anechoic (1) = anechoic bile; hypoechoic
(3) = sludge; high-amplitude granular
echoes (2) = gravel (often with a faint
zone of acoustic shadowing). Echogenic
= stone echo with a distal shadow
n
x
Very echogenic focus with a distal acoustic shadow
x
Movement in response to position changes (“rolling stones”)
x
Intraluminal mass
x
Complications:
– Cholecystitis: inflammatory wall thickening, local tenderness (see Fig.
p. 339)
– Hydrops: gallbladder enlarged to i 80 mm long and i 40 mm wide; tender,
palpable mass (see Fig.
– Empyema (see Fig.
493, p. 340)
514, p. 350)
348
492,