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Bedside Ultrasound of the Biliary Tract PowerPoint Presentation

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Description : Check out this medical presentation on Bile Duct Cancer (Cholangiocarcinoma), which is titled "Bedside Ultrasound of the Biliary Tract", to know about the approaches to performing biliary tract imaging.

Tags : Bile Duct Cancer, Cholangiocarcinoma, Ultrasound, Biliary Tract, imaging

Published on : May 10, 2021 | Views : 1819 | Downloads : 0

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Slide 1-

5/11/2021 1 Bedside Ultrasound of the Biliary Tract Gary Quick, M.D., FACEP
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5/11/2021 2 Objectives Clinical indications for performing directed ED US Approach to performing biliary tract imaging Normal exam findings Abnormal findings Clinical impact Problems/Pitfalls Case Presentations
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5/11/2021 3 Diagnostic Modalities Oral cholecystography (HIDA) Computed tomography (CT) Magnetic resonance imaging (MRI) Ultrasound
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5/11/2021 4 Case History A 30 y.o. female presents with C/C of epigastric pain, nausea and vomiting for the past 6 hr. The pain is sharp, intermittent, and doubles her over at its peak intensity. The pain is located in the RUQ and radiates to her back. She had an appendectomy 5 yr. prior
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5/11/2021 5 Case History On physical examination she is afebrile with normal vital signs. She appears uncomfortable and vomits bilious material twice in the ED. She has midepigastric tenderness, no guarding, masses or hepatosplenomegaly and no CVA tenderness. Murphy’s sign is absent. Pelvic and rectal exams are normal.
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5/11/2021 6 Case History Within 5 min., a focused bedside US is performed by the EP. The GB is 3 cm in diameter with anterior wall < 2 mm thick. CBD measures 4 mm in diameter. There is a positive ultrasonic Murphy’s sign.The GB contains a large hyperechoic structure that casts an acoustic shadow
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5/11/2021 7
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5/11/2021 8 Clinical Indications for Bedside US of the Biliary Tract Clinical presentation consistent with symptomatic cholelithiasis Undifferentiated epigastric/RUQ pain Jaundice
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5/11/2021 9 Clinical Impact of Bedside Biliary Tract Imaging Rapid, accurate modality for diagnosis of cholelithiasis Ultrasonic Murphy’s sign allows corroboration of physical findings Fast and noninvasive No radiation or contrast exposure Performed at the bedside Cost-effective procedure
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5/11/2021 10 Incidence of Biliary Tract Disease Cholelithiasis affects > 15 million in U.S. Contributes to 6-10,000 deaths annually >500,000 cholecystectomies per year Annual cost of surgery > $3 billion Majority of gallstones clinically silent 18-50 % become symptomatic over 10-15 yr
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5/11/2021 11 Performance and Accuracy of RUQ US by EP’s Kendall JL, Shimp RJ. Performance and interpretation of focused right upper quadrant ultrasound by emergency physicians, J Emerg Med 2001 Jul;21(1):7-13 EP RUQ US v. formal RUQ US 109 pts. enrolled: 51 with stones; 49 detected by EP’s. Sensitivity 96%.
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5/11/2021 12 Performance and Accuracy con’t. 58 without stones; 51 correctly identified by EP’s: Specificity 88% 83% of emergency studies completed in < 10 min. Conclusion: Gallstones accurately detected by EP’s in timely fashion.
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5/11/2021 13 Acute Cholecystitis Correlation Among Clinical, Laboratory, and Hepatobiliary Scanning Findings in Patients With Suspected Acute Cholecystitis AJ Singer, Ann Emerg Med 1996;28:3:267-272. “No single or combination of clinical or laboratory findings at the time of ED presentation identified all patients with (acute cholecystitis).”
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5/11/2021 14 Acute Cholecystitis Correlation Among Clinical, Laboratory, and Hepatobiliary Scanning Findings in Patients With Suspected Acute Cholecystitis AJ Singer, Ann Emerg Med 1996;28:3:267-272. “Liberal use of . . . . ultrasound is encouraged to avoid underdiagnosis of acute cholecystitis.”
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5/11/2021 15 If you use fever and an elevated white count as your criteria for diagnosing cholecystitis in the ED, you will misdiagnose 20% of these cases.
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5/11/2021 16 Bedside US Diagnostic Applications Congenital anomalies Cholelithiasis Acute and chronic cholecystitis Gallbladder sludge Gallbladder cancer Adenomyomatosis Bedside US facilitates diagnosis of:
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5/11/2021 17 Uncommon Gallbladder Anomalies Agenesis Hypoplasia Hyperplasia Total reduplication Subtotal division of fundus Phrygian cap Septated gallbladder
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5/11/2021 18 Technical Considerations Knowledge of US physics and machine operation Anatomic relationships Patient preparation Patient positioning Probe positioning
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5/11/2021 19 Skin Preparation and Probe Selection Appropriate conductive medium (US gel) reduces skin artifact enhancing image quality For general abdominal imaging use 3.5 MHz probe. 5 MHz may suffice in child
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5/11/2021 20 Patient Preparation 6-8 hr. fasting period for elective scanning; not as critical for acutely ill pt If pt has recently eaten Small contracted gallobladder Increased wall thickness GB often distended in acute illness due to poor oral intake, abdominal pathology, or biliary tract obstruction
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5/11/2021 21 Patient Positioning Usually begin with pt supine Utilize at least two positions for exam Provide better or multiple views of pathology Demonstrate stone or sludge movement Left or right lateral decubitus, left posterior oblique, partially upright, or prone
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5/11/2021 22 Probe Positioning Function of personal preference, experience and patient body habitus Employ liver as hepatic window. Alternate window is retroperitoneum. Anterior subcostal, coronal, right posterior oblique Visualize the portal triad
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5/11/2021 23 Portal vein R kidney GB
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5/11/2021 24 Right Upper Quadrant Anatomy Liver Gallbladder Biliary tree Head of pancreas Upper pole R kidney Portions of stomach and duodenum Hepatic flexure Vascular structures Retroperitoneal structures
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5/11/2021 25 RUQ Anatomy
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5/11/2021 26 RUQ Anatomy: GB Location GB lies inferior to liver Between the right and quadrate hepatic lobes Hollow viscus in the gallbladder fossa Consists of fundus, body, and neck Neck tapers to cystic duct
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5/11/2021 27 Sonographic Appearance of Gallbladder Fluid-filled structure 3-layered wall Strongly reflective outer layer Minimally reflective inner layer Anechoic layer between Wall thickness < 2 mm. in 97%
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5/11/2021 28 Anatomy of Common Bile Duct CBD is tethered to liver at juncture of right and left hepatic ducts and enters duodenum distally through ampulla of Vater CBD passes across and then parallel to portal vein coursing along the hepatoduodenal ligament
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5/11/2021 29 CBD CBD internal diameter is < 4 mm in 98% of normal individuals Cystic duct 1.8 mm diameter and 1-2 cm long CBD Portal vein
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5/11/2021 30 CBD Scanning Tips Roll pt 45° into left posterior oblique Scan with transducer perpendicular to costal margin Tweak transducer to image longest portion of portal vein . CBD should lie anterior to (“above” on screen) portal vein. CBD crosses then parallels the portal vein
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5/11/2021 31 Gallbladder Scanning Problems Small liver, anterior GB, or bowel gas Have pt sit up or roll to left to enlarge hepatic window. Scan thin pt or anterior GB with 5 mHz transducer
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5/11/2021 32 Pathologic Conditions of the Biliary Tract Cholelithiasis Cholecystitis Sludge Cancer Adenomyomatosis
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5/11/2021 33 Cholelithiasis Prevalence: 6-10 % men, 12-20 % women Three types of stone: Mixed cholesterol 80 % Pure cholesterol 10 % Pigment 10 % 18-50% become symptomatic over 10-15 yr.
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5/11/2021 34 Processes of Gallstone Formation Abnormal bile production Bile stasis Infection
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5/11/2021 35 Scanning Considerations: Cholelithiasis Accuracy 90-95 % Liver as acoustic window Location: inferior hepatic surface, medial and anterior to kidney, lateral and anterior to vena cava
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5/11/2021 36 Ultrasonic Criteria for Cholelithiasis Intraluminal brightly echogenic structure Stones > 3mm will produce an acoustic shadow Stones will usually seek gravitational dependency
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5/11/2021 37 Image Patterns: Cholelithiasis Stones with shadowing Stones without shadowing Gravel GB filled with stones Floating stones as fluid level in bile Adherent Gallstones Dilation of common bile duct
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5/11/2021 38 Large stone with shadowing
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5/11/2021 39 Many small stones
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5/11/2021 40 Layer of gravel with shadowing
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5/11/2021 41 Cholecystitis Represents both acute and chronic inflammation Risk factors: obstruction and bile stasis Bacterial growth common but secondary Acute cholecystitis: fever, chills, RUQ pain and leukocytosis, jaundice, and positive Murphy’s. Acalculous cholecystititis 1- 5 %
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5/11/2021 42 Acute Cholecystitis Fever and Leukocytosis in Acute Cholecystitis Gruber PJ,Annals EM 1996;28:3,277-279 …”patients with acute cholecystitis in the ED frequently lacked fever and leukocytosis. The clinician should not rely on these findings in making the diagnosis of acute cholecystitis.”
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5/11/2021 43 Acute Cholecystitis Age > 70 yr Women < 40 yr: 1.5 X greater for acute cholecystitis 5 X greater for chronic cholecystitis
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5/11/2021 44 Acute Cholecystitis: Complications Gangrenous cholecystitis Gallbladder perforation Pericholecystic abscess formation Sepsis Peritonitis Ascending cholangitis Peritoneal abscess formation Cholecystoenteric fistula
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5/11/2021 45 Scanning Considerations: Cholecystitis Cholelithiasis Stones present in the majority of cases. If no stones, consider acalculous cholecystitis. Increased transverse GB diameter >4-5 cm GB wall thickness > 4-5 mm (anterior wall) Averages 5 mm in acute cholecystitis Averages 9 mm in chronic cholecystitis
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5/11/2021 46 Additional Sonographic findings Decreased echogeneity of the entire wall Sonographic Murphy’s sign Pericholecystic fluid Diffuse, homogeneous echogeneity with GB lumen (pus in lumen or GB empyema)
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5/11/2021 47 Acute cholecystitis
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5/11/2021 48 Sonographic Murphy’s Sign Place the probe directly over the gallbladder and apply pressure Reproduction of the patients symptoms is highly suggestive of symptomatic cholelithiasis or acute cholecystitis Look for gallbladder wall thickening, increased transverse diameter of the gallbladder and pericholestistic fluid indicating obstrcution and/or inflammation
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5/11/2021 49 Gallbladder wall thickening Present in many non-inflammatory conditions Post-prandial most common Congestive heart failure Starvation/hypoproteinemic states Ascites HIV
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5/11/2021 50 Thickened gb wall with stone
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5/11/2021 51 Contracted gb w/ wall thickening
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5/11/2021 52 Gallbladder Sludge Equals echogenic bile May represent biliary tract disease or benign bile stasis with increased pigment Clinical association with hyperalimentation, hemolysis, fasting, pregnancy, post-op state, and cirrhosis
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5/11/2021 53 Gallbladder Sludge Differentiate from hematobilia, biliary tract tumors, and purulent bile. May hide stones Found on 2% of RUQ US Serial studies if asymptomatic; but treat aggressively if thickened wall, pericholecystic fluid or sonographic Murphy’s
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5/11/2021 54 Scanning Considerations: Sludge Sludge is slow-moving compared to stones When sludge is present, look for: Gallstones: floating or hidden within Cholecystitis: Murphy’s, wall-thickening Polyps: medium density; adherent to wall Malignancy: filled with solid masses or focal masses within thickened walls.
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5/11/2021 55 Sludge
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5/11/2021 56 Gallbladder Cancer 1-2 % of all GI malignancies 75% of GB Ca patients have cholelithiasis Focal wall thickening, typically in fundus Lumen filled with tumor mass; wall calcified (porcelain gallbladder)
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5/11/2021 57 Scanning Considerations: Cancer High rate of false positives and false negatives Patterns aiding recognition: Gallbladder mass: complex, partially or completely filling lumen Diffuse wall thickening Polypoid or fungating intraluminal masses
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5/11/2021 58 Take Home Points Reposition the patient on their left side or have them breathe to optimize imaging windows Stones can be incidental… presence of a sonographic Murphy’s sign important The acuostic shadow may be the only songraphic sign of a stone All echogenic masses/shadowing within the GB or asymmetric wall thickening should be followed up closely!