Diagnostic ultrasound ( PDFDrive )

CHAPTER 6 The Biliary Tree and Gallbladder 199
A
B
C
D
FIG. 6.41 Systemic Causes of Gallbladder Wall Edema. (A) Sagittal and (B) transverse images of patient with hypoalbuminemia show
marked thickening of the gallbladder wall with a small lumen. (C) Sagittal image of the gallbladder in a patient with cirrhosis demonstrating similar
changes to those in (A) and (B). Note nodular liver ascites. (D) Patient with congestive heart failure, small amount of ascites, no pain, and negative
Murphy sign has marked gallbladder wall thickening and incidental gallstones.
oten better elicited with deep inspiration, which displaces the
gallbladder fundus below the costal margin, allowing for direct
compression. Sonographic Murphy sign may be absent in older
patients, if analgesics were taken before the study, or when
prolonged inlammation has led to gangrenous cholecystitis.
Hyperemia in the gallbladder wall and the adjacent liver and a
prominent cystic artery are relatively speciic indings in acute
cholecystitis (see Fig. 6.39D). Power Doppler has been shown
to be superior to color Doppler in detecting such hyperemia. 85
Hyperemia is only qualitatively assessed, however, and motion
artifact somewhat limits the utility of power Doppler. he latest
generation of sonography equipment has highly sensitive Doppler
techniques, and detection of low in the cystic artery of a normal
gallbladder is common. In our experience this limits the qualitative
assessment of gallbladder wall hyperemia. We rely heavily on
the morphologic changes in the gallbladder for the diagnosis of
acute cholecystitis but ind Doppler ultrasound quite useful in
equivocal cases.
Although none of the signs just described is pathognomonic
of acute cholecystitis, the combination of multiple indings
should lead to the correct diagnosis. Some patients with acute
cholecystitis may not show classic indings, making diagnosis
challenging. his occurs in patients with mild inlammation but
occurs more oten in patients hospitalized for other reasons, not
receiving an oral diet, and unable to communicate symptoms.
A distended gallbladder in these patients should trigger a high
index of suspicion, and careful RUQ scanning is recommended.
Perforated duodenal ulcer, acute hepatitis, pancreatitis, colitis