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The Common Vein Copyright 2008

Introduction

Ultrasound is the study of choice in almost all instances of suspected gallbladder disease.  A HIDA scan is more sensitive and specific for acute cholecystitis, but is unable to provide structural detail of the gallbladder, its contents nor its surrounding structures.  Ultrasound has a special capability of defining fluid filled structures or disease processes and the fasting gallbladder provides a cystic window to the contents and the wall of the gallbladder often the anatomic origin of disease.


Introduction

                


Principles

Ultrasound utilizes high frequency waves generated from the interaction of electrical energy with piezoelectrical crystal. The piezoelectrical crystals are ceramic crystals that deform when the electrical current passes through them, and this causes a rapid (high frequency) change in their shape. A high frequency vibration is created in the form of sound waves in the 1-20MHz range. These waves can propogate through tissues and will either be transmitted or reflected depending on the nature of the tissue. When these echoes return the kinetic energy that they contain is converted back to electrical energy which when energy is relatively high  is reflected on the screen as bright signal (white), when intermediate strength it is gray, and when there is no gignal it is black.

Tissue Characterization

The energy that returns is a reflection of the nature of the tissue it has interracted with.  If the sound wave returns from a particular position with  almost none of the energy it left with, then there has been little attenuation of the sound wave and this occurs when the sound wave has passed through a fluid structure or a cyst.  The resulting image has no echoes reflected on the screen.  If the signal returns with half the original strength then part has been refllected and part transmitted or absorbed, which may for example indicate a soft tissue structure, and an intermediate signal is seen on the screen.  If the signal returning has a lot of energy on returning, then most of the signal has been reflected and a bright signal ensues.  This occurs when sound interacts with bone or air.  In these instances there is very little signal allowed to pass through the more posterior tissue,s  preventing the sound waves from interacting with deeper tissues and hence they cannot be imaged..  This phenomenon is called shadowing.

Time

Speed Distance and the Image

In general the speed with which ultrasound travels through tissues is fairly uniform.  Hence the time it takes to to travel and return is a reflection of the depth of the tissue.  The   This is an important principle to understand because it helps create the image

Impedence

Sound propagates through different materials at different velocities. The velocity is dependent upon the density of the material. For soft tissues, pulse velocity is approximately constant and taken to be 1540 m/s;  Reflection occurs when the pulse passes between interfaces with differing acoustic impedances;  The more dense a structure the greater its acoustic impedence.   The larger the difference in impedance between two adjacent structures, the more sound is reflected. Reflection is also optimized when the interface is aligned perpendicular to the direction of  pulse.

Shadowing
Two principles are demonstrated in this ultrasound of the gallbladder.  The first is the cystic nature of the gallbladder so that it projects as a mostly anechoic structure.  The second is shadowing.  The presence of gallstones is characterized by multiple echogenic interfaces where sound waves are almost completely reflected, creating both a strong echogenic interface with the stone and shadowing posterior to the stones.

00138 gallbladder small large dependant cholelithiasis thickwalled contracted thickening chronic cholecystitis imaging radiology USscan

Cystic vs Solid

One of the most important roles that ultrasound plays is differentiating cystic from solid disease. Solid tissue has internal structures that have differing acoustic characteristics and reflect the sound waves. A simple cyst is a common entity, containing pure fluid, contains no internal structures and therefore the sound waves passing throigh it go unimpeded manifesting as a anechoic, and black structure.

When the pulse reaches the far side of the cyst, there is a fluid-solid interface which reflects brightly and gives rise to posterior or back wall enhancement. Furthermore, because the signal has not been attenuated while passing through fluid, larger cysts will allow a greater amount of sound energy to penetrate deeper. When the sound energy reaches solid tissue deep to the cyst, small amounts of the pulse are reflected back due to internal reflectors, but appear brighter on the image than adjacent solid tissue in which the reflected sound is weaker because less sound energy penetrated as deeply. This phenomenon is called increased through transmission.

In summary, cyst on ultrasound are characterized by:

  • Anechoic
  • Posterior wall enhancement
  • Increased through transmission

Doppler

Doppler ultrasound utilizes the Doppler principle to detect flow. When sound pulses are reflected off moving substance (such as blood), there is a shift in frequency; The shift in frequency is greater if the substance is moving toward the transducer, and lower if it is moving away. On the ultrasound image, this can be displayed as a waveform (pulsed Doppler waveform ) or as colors on the image (one color for motion towards transducer, and another color for motion away from transducer).

Power Doppler refers to detection of motion but not direction. A single color is displayed on the image for all motion, with low brightness for slow movement and high brightness for rapid motion. It is more sensitive than color Doppler but lack the information on direction.

Practical applications of color Doppler include assessing lesions for vascular flow, which may better characterize or diagnose the lesion. Stenoses in vessels or grafts can be detected, since flow velocity increases with narrowing in vessels. Pseudoaneurysms can be differentiated from hematomas, as there is a typical ?Yin-yang? flow of blood into and out of the lesion.

Acute Calculous Cholecystitis wit Gallbladder Wall Edema and Hyperemia

Using color flow to determine hyperemia and inflammation
The ultrasound images are from a patient who presents with right upper quadrant pain.  Images a and b show gallstones, thickened wall and complex changes in the gallbladder fossa and image c shows hyperemic changes in the gallbladder wall as depicted by doppler technique.  The presence of all the findings characterize the disease and are characteristic of acute cholecystitis.

72365c01 gallbladder wall fluid in gallbladder fossa positive sonographic Murphy’s sign inflammation mechanical obstruction infection hyperemia hypervascularity dx acute calculous cholecystiis Davidoff MD

Aim

The aim of diagnostic sonography is to characterize lesions, document anatomy and, where appropriate, function of the tissues being imaged whilst keeping the cumulative sound energy delivered ALARA (as low as reasonable achieveable).  The purpose of ultrasound of the gallbladder is to define the size shape position and character of the gallbladder, and also to determine if there is gallbladder tenderness.

Indications

Ultrasound is the procedure of choice in patients who present with right upper quadrant pain, in whome acute cholecystitis, acalculous cholecystitis is suspected.  In ppartients in whom gallstone pancreattitis issuspected ultrasound is utilized to document the presence of stones.

Contraindications

 

There are no absolute medical contraindications to ultrasound. It is generally considered to be a safe procedure without significant side-effects. There is a small theoretical risk of damage to tissues from heating, which has been demonstrated with extreme doses in animal studies.  As such, the examination is performed following the ALARA principle (keeping exposure As Low As Reasonably Achieveable).

Advantages

Ultrasound presents numerous advantages.  First, it is fast and requires little preparation.  It can be performed in real time, and is useful for visualize moving structures (heart, fetus), as well as visualizing live structures during interventional procedures.  The machines used to perform ultrasound are extremely portable, and cheap in comparison to other imaging modalities.  It carries few, if any, side-effects, produces no ionizing radiation, and is safe for use in pregnancy, as well as with delicate organs.  Lastly imaging can be performed in any plane.

In the gallbladder, US is particularly useful for evaluating and diagnosing gallstones, acute cholecystitis and acalculous cholecystitis as well as non biliary causes for right upper quadrant pain.

Disadvantages

Ultrasound is not effective in visualizing bone or air-filled structures.  In addition, visualizing deep structures is often only possible at the expense of quality and resolution.  Finally, the quality of studies produced is highly operator-dependent.

Method

Patient Preparation

Patients should be fasting for 8 hours before abdominal examination. This both minimizes gas within the bowel which may obscure organs and allows examination of a non-contracted gallbladder; post prandial contraction of the gallbladder may conceal pathology such as intramural lesions or stones.

Equipment

 

Ultrasound equipment consists of a monitor, control panel and transducer (probe). The entire unit is typically wheeled and portable. Ultrasound machines typically have a number of different transducers, which differ in frequency of pulses generated and shape of the probe (and hence the shape of the image ? sector versus rectangle). Machines routinely used for diagnostic exams are relatively large, but much smaller units are available and are sometimes used in emergency rooms, physician offices and intensive care units for non-diagnostic assessment of, for example, bleeding in early pregnancy, musculoskeletal pain or obtaining intravenous access.

Technique

The transducer is applied firmly against the patient using acoustic gel to improve transmission of the sound waves. The orientation of the transducer determines the imaging plane. The operator will use the images on the monitor to move and rotate the transducer until the organ or tissue of interest is visualized. The image may be optimized on the monitor by altering frequency, gain, focal zone, filed of view and grey-scale curves. Static images are typically saved, though a series of frames may be recorded in certain examinations (echocardiography) in order to evaluate motion of the organ over time.

 Patients are typically places in the supine, position, with additional semierect, left posterior oblique and right posterior oblique positions being used.  A water-soluble gel is applied to transducer, as well as to the surface of skin being imaged.  For visualizing the gallbladder, the transducer will typically be placed on the right upper quadrant of the abdomen, angling superiorly to visualize the gallbladder.  In cases of cholecystitis, a sonographic murphy?s sign is elicited when the transducer is pushed up into the liver while the patient exhales.  If the patient stops breathing or winces, this is considered a positive sign.

 Result

  In cases where acute cholecystitis is suspected, US has replace HIDA scan as the first line study, where the presence of gallstones and presence of murphy?s sign are virtually diagnostic.

Examples of US of the Gallbladder in Various Diseases

Choledocholithiasis

 

Small Stones

 

Crystalline Floaters
77753c01.8s young female right upperquadrant tenderness RUQ gallbladder echogenic irregular fluid fluid layer conforming to the shape of the gallbladder wall thickened linear echoes floaters crystalline SG less than bile cholesterol crystals specific gravity forces space cholelithiasis stones small acute cholecystitis USscan ultrasound Courtesy Ashley Davidoff MD For Radiologists and Detectives

 

Small Shadowing Stones
04753 gallbladder small gallstones shadowing cholelithiasis USscan Davidoff MD

Intermediate Sized Stones

Multiple Medium Sized Shadowing Stones
70026 gallbladder stones shadowing forces reflection transmission dx cholelithiasis USscan Davidoff MD

Multiple Medium Sized Stones

76040b01 gallbladder stones cholelithiasis bile duct normal portal vein liver vein USscan Courtesy Ashley DAvidoff MD

copyright 2008

Large Stones

Mobile Stone
46462c01s gallbladder moderaste size shadowing mobile stones cholelithiasis USscan ultrasound Courtesy Ashley Davidoff MD copyright 2008

Sludge

Sludge – Almost Fluid
78365c.8s gallbladder sludge cholestasis fluid fluid level USscan ultrasound Courtesy Ashley Davidoff MD copyright 2008

Acute Cholecysttis

Fluid and Thickening in the Gallbladder Fossa
00543c03s.8 right upper quadrant pain RUQ pain positive Murphy’s sign gallbladder gallbladder fossa thickened linear lacy thickening gall stones calculi calculous multiple small stones stones dependant position shadowing multiple small stones cholelithiasis cholecystitis acute cholecystitis acute calculous cholecystitis USscan ultrasound Courtesy Ashley Davidoff MD copyright 2008

Positive HIDA scan
  young female vague right upper quadrant pain non distended gallbladder complex fluid in the gallbladder fossa large stone cholelithiasis non visualization non viz radioactive labelled technetium HIDA scan non visualization of the gallbladder at 45 minutes biliary system visualized at 30 minutes consistent with acute cholecystitis

78306c01.8s nuclear medicine Courtesy Ashley Davidoff MD copyright 2008

WES sign

WES sign
04733 gallbladder filling defects stones cholelithiasis WES sign USscan imaging radiology
WES sign
82166c01s 27F gallbladder stone cholelithiasis WES sign wall = pink line echo = white line = front anterior echo of the stone black shadow = shadow of the large stone shadow USscan ultrasound Courtesy Ashley Davidoff MD copyright 2008 Courtesy Ashley Davidoff MD Copyright 2008

HIV cholangiopathy

Cholecystitis probably Cryptosporidium
41257c005 Courtesy Ashley Davidoff MD code gallbladder filling defect question sludge fx hyperemic wall bile duct filling defect question sludge fx enlarged dilated dx HIV cholangiopathy chronic cholecystitis subacute cholecystitis imaging radiology USscan mechanical inflammation

Carcinoma

Lumenal Invasion
16254c04.8s gallbladder space occupation gallbladder carcinoma by CT it appears as a low density centrally and enhancing soft tissue peripherally by USscan looks like the whole lumen is filled with soft tissue tumor question of delayed tumor enhancement vs necrosis CTscan USscan ultrasound Courtesy Ashley Davidoff copyright 2008

Conclusion

Ultrasound is a safe and cost-effective examination for a wide range of imaging indications. Doppler ultrasound further increases the applications, and allows for accurate assessment of a variety of vascular disorders and characterization of anatomical lesions. Endoscopic ultrasound is a powerful tool for imaging structures too deep to accurately visualize externally. Future applications may include intravascular use for assessment of atheromatous plaque in cardiovascular disease, and wider use of microbubbles as contrast.

References

Novelline: Squire?s Fundamentals of Radiology

Scoutt: Ultrasound Evaluation of the Acute Abdomen

Web References

Galllbladder Ultrasonography Procedure MAnual  .gov