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PATHOLOGY OF THE GALLBLADDER AND BILIARY TREE 47
Table 3.2
look for
Gallstones—other ultrasound signs to
Acute or chronic cholecystitis
Complications of cholecystitis, e.g. pericholecystic
collection
Stone impacted in the neck of gallbladder—mucocoele,
hydrops
CBD stones
Biliary obstruction—dilatation of the CBD and/or
intrahepatic ducts
Pancreatitis
Other causes of RUQ pain unrelated to stones
CBD = common bile duct.
passing into the small intestine may impact in the
ileum, causing intestinal obstruction (Fig. 3.11B).
Biliary reflux and gallstone pancreatitis
A stone may become lodged in the distal common
bile duct near the ampulla. If the main pancreatic
duct joins the CBD proximal to this, bile and pancreatic
fluid may reflux up the pancreatic duct,
causing inflammation and severe pain.
Reflux up the common bile duct may also result
in ascending cholangitis, particularly if the obstruction
is prolonged or repetitive. Cholangitis may
result in dilated bile ducts with mural irregularity
on ultrasound, but endoscopic retrograde cholangiopancreatography
(ERCP) is usually superior in
demonstrating intrahepatic ductal changes of this
nature.
Bile reflux is also associated with anomalous cystic
duct insertion (Fig. 3.12), which is more readily
recognized on ERCP than ultrasound.
Further management of gallstones
ERCP demonstrates stones in the duct with
greater accuracy than ultrasound, particularly at
the lower end of the CBD, which may be obscured
by duodenal gas and also allows for sphincterotomy
and stone removal.
Laparoscopic cholecystectomy is the preferred
method of treatment for symptomatic gallbladder
disease in an elective setting and has well-recognized
benefits over open surgery in experienced
Cholangitis
hepatic abscess
Carcinoma
Acute or
chronic
cholecystitis
Obstructive jaundice
Cholecystoenteric
fistula
Obstruction causing
pancreatitis
Figure 3.11
A
(A) The possible complication of gallstones.
(Continued)