Gallbladder and Biliary Disease - HD

Contrast Agents in Gallbladder Disease

Contrast agents in gallbladder disease and cholecystitis is one of the most important indications.

Can we turn down the light, please?

To start with, an uncomplicated cholecystitis does not require contrast, but on the other side, yes, it is a standard procedure.

If you have the clinical idea of a cholecystitis that you use, of course, ultrasound, it is helpful in diagnosing ulcerative cholecystitis and to prove perforation and thus helping us to define the best time for surgery.

And I think this is a very important point.

Patient comes into the hospital. The question is, should cholecystitis, when should we go for surgery?

A complicated cholecystitis may clinically remain undetected under antibiotic therapy.

That is an important point because we see, and I will show you some examples of that, where patients under antibiotic therapy have no complaints anymore, although we have a necrosis of the wall, we have gangrenous cholecystitis under the perforation.

You have to have in mind that, when you have a necrosis of the wall, that also means you have a dilation of the wall and a relief of pain.

The Murphy sign has been reported to be negative in more than 60% of gangrenous cholecystitis.

And of course, it helps in characterizing and staging of benign malignant gallbladder tumors.

And that will be the last point in my talk.

What to Expect from CEUS

Number one, inflammatory process of the wall. We can image that early enhancement of the thickened wall, no enhancement of adjacent organs.

And when the inflammation proceeds, then we have basically edema enhancement of the adjacent fatty tissue, the liver parenchyma, and the duodenal wall.

And then we have mucosal ulcerations, gangrenous cholecystitis, and that is leading to perforation.

And we have these Niemeier classification type one, two, and three.

Acute Cholecystitis and Reactive Hepatitis

This is just to show you acute cholecystitis, elevated liver tests.

What we can see then is what we named reactive hepatitis.

And this is a term that was used by a in clinical pathology in 94.

When we give contrast, then you can see quite largely the enhancement of the adjacent hepatic or liver tissue.

It is hyper vascularized, and that is something as a reaction due to the inflammatory process that you can see, not only of course with CEUS, but you can see that also of course on CT, as you all know.

This is a patient also with elevated liver tests. What you can see here, these are ulcerations of the wall.

This patient is, or we will, well, we can expect perforation if we do not perform treatment and cholecystectomy, because this is the first step to the perforation of the gallbladder.

And when the contrast is arriving, you can see again the peri vesicular enhancements of the reactive hepatitis.

When the loop is starting again, you can, or I can go back.

When we look at that, you see this is the reactive hepatitis here.

This is one of the first things that you can see when you have an inflammation that is going beyond the wall of the gallbladder.

And this is from this patient. This is the graft specimen after the gall after cholecystectomy.

Asymptomatic Cases with Ulcerations

Another patient coming in and had no complaints. The referring doctor was quite surprised what he saw when he looked at the gallbladder and said, there is something wrong with the gallbladder. Please go and have a specialist for examination to examine your gallbladder.

And this is what we saw. We saw ulcerations of the gallbladder wall. Patient also had a gallbladder stone. This is not in this image.

This is what we can do in a 3D technique. This is certain seconds after injection of the contrast agent. You can see the vessels of the wall of the gallbladder.

And when we wait a little bit, then you can see the ulcerations. Here are the ulcerations. Nice to see.

I think this is another patient. This patient was symptomatic with an acute cholecystitis, and this is how the gallbladder looked like.

And when you give contrast, then you can see very nicely the enhancement of the gallbladder wall.

And you can see there are ulcerations here, perforation, perforation into the wall of the thickened gallbladder wall.

Here is a suspected abscess of the gallbladder wall.

And this is again, from another or from the intercostal approach. You can see again, this is the perforation of the wall.

Gangrenous cholecystitis in this symptomatic patient, and it matches very well with the intraoperative findings and the gross specimen that we got from our pathologist.

Patient Refusing Hospitalization

This is another patient who had right upper quadrant pain, went to his doctor and he said, I will not go into hospital, please do something else. But I refused to go into hospital.

So he got antibiotics and then the patient came back, and that was the order from his doctor, please come back no matter if it becomes better or worse.

So he came back to him and says, I was completely right. I have no complaints anymore.

And then the doctor says, oh, fine. Done everything correctly.

So he looked again at his gallbladder and had this image, and he said, please do me a favor. Go to the hospital. And if they say you can go home again, that is okay, but I do not think so.

So he came and I could compress with my transducer every part of the subcostal area without any complaints.

And this is how the gallbladder looked like.

And this is the power of imaging is also a power for convincing patients, because this patient, I was explaining to him, this is a perforation of your gallbladder, and this is an abscess.

And this patient then said, okay, you convinced me. I will stay here and get my gallbladder removed.

So that was interesting, this is another patient.

Elderly Patient with Vomiting

He comes from the home of the elderly. He had right upper quadrant pain five days ago now, no pain anymore. He called the doctor and received antibiotics. And after that, he felt fine again.

But two days later, he started vomiting. And that was the reason.

An old patient after vomiting, losing fluid, he was in a bad condition, but not because of pain, but because he was very sick and low blood pressure and yeah, but no pain.

So this is his stomach filled with fluid, and this is how the gallbladder looked like.

Of course, everybody can see that this is perforation of the gallbladder into the duodenum.

That is not the problem. The question is why is he vomiting all the time?

And that is something that we can see by using contrast. You can see again this reactive hepatitis.

And this is a perforation actually in two places here. So this is the duodenum, and the patient was vomiting because he has had an occlusion of his duodenum.

Nothing was going through the duodenum because of the inflammation of the wall. And that was there was an edema here, severe edema.

So I showed that to our surgeon. And one hour later, he was operated. And that was of course confirmed the diagnosis.

Post-Cholecystectomy Complication

This is a patient after cholecystectomy, no fever, but his white blood cell count was rising.

So we were looking at him, and again, what you can see here is a reactive hepatitis, and you can see fluid, yes.

So we performed puncture, and yeah, that was pus, so was an abscess post surgery, you can see reactive hepatitis.

Perforation Niemeier Type One

This is a perforation Niemeier type one. You do not see any gallbladder anymore.

With contrast across, you can see a little bit better the free fluid. So this is a bile in the free peritoneum.

This is another emergency case.

Emergency Procedure Complication

This patient had stones in his common bile duct and was referred to our hospital.

They said, okay, no problem. We will get these stones and will put a stent in it.

And during this procedure, the patient had severe pain all of a sudden, so they had to stop that procedure.

And then they went to our lap, and then we had to look at it.

And we saw that there is a problem here in the artery.

So we gave contrast. What you can see here is an aneurysm of the hepatic artery.

The wire that they pulled in first, they perforated the wall of the common bile duct and perforated also the wall of the hepatic artery.

What you can see quite nicely here, this is the common bile duct show you soon here. This is the common bile duct, and you can see blood flowing into the common bile duct.

Okay? So then that was of course something for our radiologists.

They put in then a stent. So you can see the stent here, and of course, we can control that, and we can see that everything is okay.

You can still see this is a common bile duct, but no blood anymore, no fistula anymore into the common bile duct.

Interestingly, a day later, 24 hours later, there was no hematoma in the common bile duct anymore.

Vascular Shunts and Gallbladder Cancer Prognosis

This is something I would like to show you because it is not a pathology of the gallbladder wall, but it shows you the background maybe why a carcinoma of the gallbladder wall has such a poor prognosis.

This is something that you can see every day. You see a fatty liver disease and areas are spared.

This is focal fatty sparing here in the close to the gallbladder.

Now we give contrast. And what you can see now is some vessels flowing from the wall of the gallbladder into the portal venous branches.

This is a shunting between the veins of the gallbladder wall and the portal veins.

This is very important because this is the reason why we have a focal fatty sparing.

Focal fatty sparing in the liver is always a not balanced distribution of systemic blood with less fatty free fatty acids and insulin and systemic blood.

Systemic blood has less insulin concentration, and less fatty acids.

An area which is dominantly perfused by systemic blood has less fatty infiltration.

This is just to have that in mind.

We can see that also, of course, in the segment four B in the liver lobe.

Okay, and this is not, okay, so we are talking about less than one millimeter vessel signs here.

Okay? This is a gallbladder polyp, you can see very nicely the perfusion of the wall of the polyp.

That is not so interesting. What is more interesting is maybe this case.

Here is the polyp. When you look again very carefully, you can see that there are vessels here from the wall of the gallbladder going into the portal venous branches here.

And my idea is that this is one of the reasons why the prognosis of gallbladder cancer is so poor, because you have very often these shunts.

And these shunts also mean that tumor cells are immediately going into the adjacent liver tissue, making the prognosis of her.

Okay? Okay.

Incidental Finding: Gallbladder Adenoma

This was an incidental finding of a 3-year-old female, four weeks after delivery.

She had some problems because there was a she had pain in her lower or in her abdomen.

And we were looking at her, and this is what we found in the gallbladder.

That looked like a tumor. She quite nicely here.

And then we gave contrast. And you can see this is the only case I have of a gallbladder adenoma.

Gallbladder adenomas are very rare in Europe and in North America, much more often in Asian countries.

And this is the specimen, the graft specimen. And this was a cancerous gallbladder adenoma.

There were cancerous cells invading the gallbladder wall, but not invading the liver tissue.

That was, and we have now a follow up over eight years. And she has no recurrence of the tumor.

Adenomyomatosis

Adenomyomatosis, you all know this. We have these intramural cystic lesions, these KY ova, and we very often find in these cystic areas within the thickened gallbladder wall, we find calcifications or small stones.

This makes the diagnosis easy. Okay?

This is adenomyomatosis at the tip of the gallbladder.

This is a very typical finding, and when we give contrast, we can confirm that this is not a tumor invading the wall.

The wall can be delineated very nicely here. So this is the wall, and we can even see a little bit better the tonka of sinus.

This is typical finding for adenomyomatosis, gallbladder cancer.

Gallbladder Cancer Challenges

You all know the statistics. Less than 50% of the gallbladder cancers are diagnosed preoperatively.

It is very often an incidental finding by the pathologist.

Gallbladder cancers are diagnosed in later stages. The overall five year survival rate is less than 5%.

Okay? This is one of the challenges that we have.

This is a patient with a gallbladder stones. You see sludge that is completely fills the lumen of the gallbladder.

But what we were thinking about is what is this here?

We had, we were lucky because this area here is a little bit more echo compared to the sludge in the gallbladder wall.

So then we decided to perform a contrast study.

Have a look here. This is a tumor.

This is a gallbladder tumor that was confirmed by histology after surgery.

And this is of course, a patient, 61 years old, asymptomatic.

And she told us, I have gallbladder stones. I know that since 30 years. There I have no complaints, nothing.

But it looked really, very serious because we could not really delineate the wall of the gallbladder from the liver.

And this is the study, contrast study. And you can see hyper enhancing tissue here in the liver adjacent to the gallbladder wall.

And when we wait a bit, and you can see it is here washing out, the tumor is washing out, and that makes it much more clearer than the gray scale image.

So we confirm here an infiltrating adenocarcinoma of the gallbladder wall.

Malignant Melanoma Metastases

This is my last case, the patient with the malignant melanoma.

And when we looked at the gallbladder, we could see, yeah, here is a tumor. It is a mass that it is not the only one.

We counted, I think, four or five masses. This is the biggest one.

And then we gave contrast. And it was interesting to see the behavior because the bubbles are running from the gallbladder wall into the tumor, but not invading the liver.

And that is what we found. We have now, I think, four or five patients with metastasis from melanoma into the gallbladder wall.

And they all on contrast, behave in the same way. They all do not infiltrate the liver.

They, the tumor grows from the wall into the lumen of the gallbladder.

This is number one. This is tumor number 2, 3, 4, and this is sludge. Here is another one. Okay.

Thank you very much for your attention.