(Left) Oblique grayscale ultrasound of gallbladder (GB) shows a distended gallbladder lumen with diffuse wall thickening , multiple gallstones , and pericholecystic fluid . Sonographic Murphy sign was positive. These are classic clinical and US features of acute cholecystitis.
(Right) Tc-99m HIDA scan shows flow of the radiotracer from the liver into the common bile duct (CBD) and bowel but not into the gallbladder, indicating obstruction of the cystic duct and indirectly suggesting acute cholecystitis.
(Left) This elderly woman has jaundice and RUQ pain. MR cholangiopancreatography (MRCP) shows numerous stones within the dilated CBD. The gallbladder is marked for identification.
(Right) Endoscopic retrograde cholangiopancreatography (ERCP) in the same patient confirms the CBD stones . During the same procedure, a papillotomy was performed with balloon sweep clearing of the ductal stones followed by placement of a temporary plastic biliary stent. All symptoms resolved.
Right anterior-cephalic (segments 5 and 8) Right posterior-caudal (segments 6 and 7) Right hepatic duct Minor papilla Major papilla (hepatoduodenal papilla) Ducts to segment 4 Ducts to segments 2 and 3 Left hepatic duct (Top) Note the distribution of the larger intrahepatic bile ducts. The CBD usually joins with the pancreatic duct in a common channel or ampulla (of Vater) but may enter the major duodenal papilla separately. The distal bile duct has a sphincteric coat of smooth muscle, the choledochal sphincter (of Boyden), which regulates bile emptying into the duodenum. When contracted, this sphincter causes bile to flow retrograde into the gallbladder for storage. The common hepaticopancreatic ampulla may be surrounded by a smooth muscle sphincter (of Oddi).
(Bottom) Graphic shows common variations of cystic duct entry into common duct.
(Left) In this 36-year-old man, CT shows gas and fluid within the GB and common duct due to the presence of a biliary stent (not shown). The GB wall is normal.
(Right) In this 68-year-old man with diabetes and sepsis, CT shows gas within the lumen and wall of the GB with a hazy margin where the GB abuts the liver. This emphysematous cholecystitis was treated urgently with percutaneous cholecystostomy and later with cholecystectomy.
(Left) In this 50-year-old woman with acute cholecystitis, US shows a large echogenic stone with an acoustic shadow and a thickened GB wall (calipers). These findings, along with a positive sonographic Murphy sign, are diagnostic of acute cholecystitis.
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