Figure 720 gallbladder g with thickened wall calipers

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Figure 7.20 Gallbladder (G) with thickened wall (calipers) and ascites (*). Liver (L) visible at right of screen. 164 Diagnostic ultrasound Gallbladder ultrasound
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Ultrasound findings of acalculous cholecystitis would be the same for cholecystitis, except for the absence of gallstone shadowing. A sonographic Murphy sign, thickened gallbladder wall, dilated bile ducts ( Figures 7.22 and 7.23 ), and pericholecystic fluid are all ultrasound evidence used to help make the diagnosis in these patients. An uncommon subtype known as acute emphysematous cholecystitis is generally caused by infection with clostridial organisms and occlusion of the cystic artery associated with atherosclerotic vascular disease and, often, diabetes. These patients will have air in the Figure 7.21 Longitudinal ( left ) and transverse ( right ) views of gallbladder containing sludge (*). Figure 7.22 Color Doppler helps identify dilated common bile duct. Courtesy of Dr. Manuel Colon, Hospital of the University of Puerto Rico, Carolina, PR. Diagnostic ultrasound 165 Gallbladder ultrasound
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gallbladder wall, and the image will show speckled scattering of the ultrasound waves with distal reverberation artifacts. These patients are often clinically very sick, and this diagnosis carries a much higher mortality rate [ 9 ]. (A) (B) Figure 7.23 ( A ) Dilated bile duct (arrow) visible within liver parenchyma. Note the lack of color Doppler flow within the CBD compared to the vessels. ( B ) Significant intrahepatic ductal dilatation with tortuous bile ducts visible (arrow). Again the lack of flow within the ducts is highlighted using color Doppler. 166 Diagnostic ultrasound Gallbladder ultrasound
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Mimics There are several common mimics which are important to discuss. The duodenum is often mistaken for gallbladder by the novice sonographer. Since a normal duodenum can appear similar to an abnormal gallbladder, this is important to distinguish. Differentiating the two relies upon an understand- ing of anatomy and the typical sonographic appearance of a cystic structure versus bowel. Figure 7.24 demonstrates gallbladder and duodenum in the same image, and Table 7.3 offers a list of features helpful in distinguishing the two structures. First, the gallbladder wall is fibrous and typically acts as a bright reflector. Even in the setting of wall edema with cholecystitis, there are bright areas of wall between areas of edema. The wall of the duodenum is dark, like most bowel wall. The duodenum courses near the liver but is never surrounded by Figure 7.24 Gallbladder (G) is seen within liver parenchyma (L). The duodenum (D) is visible posterior to the gallbladder in this image. Table 7.3 How to distinguish gallbladder from duodenum Gallbladder Duodenum Bright wall Dark wall Surrounded by liver Next to liver Middle hepatic ligament Not present Static Peristalsis Contained Tubular Connects to portal vein Does not Diagnostic ultrasound 167 Gallbladder ultrasound
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it like the gallbladder. The middle hepatic ligament connects the portal vein to the gallbladder; no connection exists to the duodenum. Observing the
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