Gallstone disease ultrasound: Difference between revisions

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==Overview==
==Overview==


Generally transabdominal ultrasound (TAUS) is considered to be the most useful test to detect gallstones. TAUS is noninvasive, readily available, relatively inexpensive and doesn't expose patients to ionizing radiation. The patient should fast for at least eight hours before the examination this is to ensure that the gallbladder is distended with bile, which is best for visualizing stones.  
Generally [[Ultrasound|transabdominal ultrasound]] (TAUS) is considered to be the most useful test to detect gallstones. TAUS is noninvasive, readily available, low cost and doesn't expose patients to [[ionizing radiation]]. The patient should fast for at least eight hours before the examination this is to ensure that the [[gallbladder]] is distended with [[bile]], which is best for visualizing stones.
==Transabdominal ultrasound==


===Transabdominal ultrasound===
The initial imaging study of choice in patients with suspected gallstones is a transabdominal [[ultrasound]] of the [[Right upper quadrant (abdomen)|right upper quadran<nowiki/>t]].<ref name="pmid7979854">{{cite journal |vauthors=Shea JA, Berlin JA, Escarce JJ, Clarke JR, Kinosian BP, Cabana MD, Tsai WW, Horangic N, Malet PF, Schwartz JS |title=Revised estimates of diagnostic test sensitivity and specificity in suspected biliary tract disease |journal=Arch. Intern. Med. |volume=154 |issue=22 |pages=2573–81 |year=1994 |pmid=7979854 |doi= |url=}}</ref><ref name="pmid108978">{{cite journal |vauthors=Conrad MR, Janes JO, Dietchy J |title=Significance of low level echoes within the gallbladder |journal=AJR Am J Roentgenol |volume=132 |issue=6 |pages=967–72 |year=1979 |pmid=108978 |doi=10.2214/ajr.132.6.967 |url=}}</ref><ref name="pmid981625">{{cite journal |vauthors=Leopold GR, Amberg J, Gosink BB, Mittelstaedt C |title=Gray scale ultrasonic cholecystography: a comparison with conventional radiographic techniques |journal=Radiology |volume=121 |issue=2 |pages=445–8 |year=1976 |pmid=981625 |doi=10.1148/121.2.445 |url=}}</ref>


Ultrasound  may be helpful in the diagnosis of gallstones. Findings on an ultrasound suggestive of gallstones include:
*[[Ultrasound]] may be helpful in the diagnosis of gallstones. Findings on an ultrasound suggestive of gallstones include:
*Gallstones - echogenic foci that cast an acoustic shadow  
**'''Gallstones''' - [[Echogenicity|echogenic foci]] that cast an [[acoustic shadow]].
*Gravel -  multiple, small echogenic foci and cast shadows  
**'''Gravel''' -  multiple, small [[Echogenicity|echogenic foci]] and cast [[Acoustic shadow|shadows]].
*Sludge - microlithiasis that is echogenic but doesn't cast a shadow<ref name="pmid108978">{{cite journal |vauthors=Conrad MR, Janes JO, Dietchy J |title=Significance of low level echoes within the gallbladder |journal=AJR Am J Roentgenol |volume=132 |issue=6 |pages=967–72 |year=1979 |pmid=108978 |doi=10.2214/ajr.132.6.967 |url=}}</ref>
**'''Sludge''' - microlithiasis that is [[Echogenicity|echogenic]] but doesn't cast a [[Acoustic shadow|shadow]].
*[[Type I and type II errors|False-negative]] or misleading results may be obtained if the gallbladder is completely filled with stones or if it is contracted around many stones.
*A [[systematic review]] estimated that the [[Sensitivity (tests)|sensitivity]] was 84% and [[Specificity (tests)|specificity]] was 99%.
*The [[Accuracy and precision|accuracy]] is, however, operator dependent.
*In patients who complain of [[Gallstone disease history and symptoms|biliary colic]] but have not shown evidence of gallstones on [[ultrasound]], the examination is usually repeated a few weeks later.
*If the repeated TAUS is still negative, then this patient may have sludge in the [[gallbladder]] and thereafter, invasive procedures are considered on an individual case basis.
[[Image:gus.jpg|thumb|center|500px|Stones shown near the gallbladder neck. Case courtesy of radiopaedia.org by Dr Derek Smith, https://radiopaedia.org/cases/42795]]


False-negative or misleading results may be obtained if the gallbladder is completely filled with stones or if it is contracted around many stones.<ref name="pmid981625">{{cite journal |vauthors=Leopold GR, Amberg J, Gosink BB, Mittelstaedt C |title=Gray scale ultrasonic cholecystography: a comparison with conventional radiographic techniques |journal=Radiology |volume=121 |issue=2 |pages=445–8 |year=1976 |pmid=981625 |doi=10.1148/121.2.445 |url=}}</ref>
===Endoscopic ultrasound===


[[Image:gallstonesus.jpg|thumb|center|500px|Source:radiopedia.org <ref name="urlGallstones | Radiology Reference Article | Radiopaedia.org">{{cite web |url=https://radiopaedia.org/articles/gallstones-1 |title=Gallstones &#124; Radiology Reference Article &#124; Radiopaedia.org |format= |work= |accessdate=}}</ref>]]
*The gallbladder can be visualized through an [[Endoscopy|endoscopic]] [[Ultrasound guided injections|ultrasound]] (EUS).<ref name="pmid8801211">{{cite journal |vauthors=Dahan P, Andant C, Lévy P, Amouyal P, Amouyal G, Dumont M, Erlinger S, Sauvanet A, Belghiti J, Zins M, Vilgrain V, Bernades P |title=Prospective evaluation of endoscopic ultrasonography and microscopic examination of duodenal bile in the diagnosis of cholecystolithiasis in 45 patients with normal conventional ultrasonography |journal=Gut |volume=38 |issue=2 |pages=277–81 |year=1996 |pmid=8801211 |pmc=1383037 |doi= |url=}}</ref><ref name="pmid10625791">{{cite journal |vauthors=Liu CL, Lo CM, Chan JK, Poon RT, Fan ST |title=EUS for detection of occult cholelithiasis in patients with idiopathic pancreatitis |journal=Gastrointest. Endosc. |volume=51 |issue=1 |pages=28–32 |year=2000 |pmid=10625791 |doi= |url=}}</ref>  
*During EUS, an [[ultrasound]] [[endoscope]] is placed at the gastric [[antrum]], which is in close proximity to the [[gallbladder]].
*This allows for [[imaging]] that is free of bowel gases or the [[liver]].
*Consequently, EUS is more [[sensitive]] than transabdominal [[ultrasound]] for the detection of gallstones in the following cases:
**Obese patients
**Microlithiasis
**Anatomic abnormalities that limit [[gallbladder]] visualization with a conventional transabdominal [[ultrasound]].


 
[[Image:eug.jpg|thumb|center|500px|Stone shown near the gallbladder tip. Source:Journal of Pancreas<ref name="urlMorris-Stiff G, et al. Does Endoscopic Ultrasound Have Anything to Offer in the Diagnosis of Idiopathic Acute Pancreatitis?. JOP. J Pancreas (Online) 2009 Mar 9; 10(2):143-146. [Full text]">{{cite web |url=http://www.joplink.net/prev/200903/06.html |title=Morris-Stiff G, et al. Does Endoscopic Ultrasound Have Anything to Offer in the Diagnosis of Idiopathic Acute Pancreatitis?. JOP. J Pancreas (Online) 2009 Mar 9; 10(2):143-146. [Full text] |format= |work= |accessdate=}}</ref> ]]
 
 
 
 
 
 
Test characteristics — Multiple studies have evaluated the ability of transabdominal ultrasound to detect gallstones, though it is important to recognize that precise estimates of sensitivity and specificity are difficult to determine since surgical confirmation of a negative sonogram is unlikely.
 
A systematic review estimated that the sensitivity was 84 percent (95% confidence interval [CI] 76 to 99%) and specificity was 99 percent (95% CI 97 to 100%) [33]. Rarely, advanced scarring and contraction of the gallbladder around gallstones leads to nonvisualization of the gallbladder lumen, which has a specificity of 96 percent, but it should also raise the possibility of gallbladder cancer.
 
When compared with other cross-sectional imaging modalities and cholecystography, ultrasound has the highest sensitivity [34,35]. Modern sonographic equipment is able to detect stones as small as 1.5 to 2 mm in diameter [34]. Smaller stones may be missed, and the sensitivity falls to 50 to 60 percent for stones less than 3 mm in diameter [36-38].
 
The accuracy of transabdominal ultrasonography is operator-dependent. The entire gallbladder must be examined axially and sagittally. Every effort should be made to examine the outlet of the gallbladder (Hartmann's pouch), where gallstones may be difficult to detect. The gallbladder neck must be traced all the way into the porta hepatis to exclude stones in this region. If an out-pouching from the gallbladder (Phrygian cap) is present, the redundant portion of the fundus must not be overlooked.
 
Even with an experienced operator, it is difficult to determine the number or size of stones in the gallbladder with transabdominal ultrasound. This is especially true for very small stones (1 or 2 mm in diameter) that frequently, when present in large numbers, can appear on transabdominal ultrasound as one large stone.
 
In patients with typical biliary colic but no gallstones on ultrasonography, we usually repeat the transabdominal ultrasound in a few weeks. If the repeat transabdominal ultrasound is negative, the patient may have microlithiasis or may be a category 4 patient (typical biliary symptoms without gallstones on ultrasound). In such patients the next step is debatable. The approach depends on the patient's preferences, age, and risk factors for adverse outcomes with invasive procedures.
 
 
 
Imaging studies — Most patients with uncomplicated gallstone disease will have gallstones demonstrated on transabdominal ultrasound.
 
 
Endoscopic ultrasound — Imaging of the gallbladder can be obtained by EUS. During EUS, an ultrasound transducer on the tip of an endoscope is placed into contact with the gastric antrum, which is in close proximity to the gallbladder. This permits gallbladder visualization without interference from bowel gas, subcutaneous tissue, or the liver. As a result, EUS is more sensitive than transabdominal ultrasound for the detection of gallstones, particularly in patients who are obese or have other anatomic considerations that limit gallbladder visualization with transabdominal ultrasound [40,41].
 
Several studies have demonstrated that EUS is useful for the detection of small stones and microlithiasis [40-43]. In one study of 45 patients in whom there was a clinical suspicion of cholelithiasis but with at least two normal transabdominal ultrasound examinations, EUS detected evidence of cholelithiasis in 26 patients (58 percent). The sensitivity and specificity of EUS for detecting cholelithiasis were 96 and 86 percent, respectively [40].
 
In a second study of 89 patients with acute pancreatitis, EUS revealed small gallbladder stones (1 to 9 mm) in 14 of 18 patients who had otherwise negative standard imaging studies, including transabdominal ultrasound [41]. Subsequent endoscopic retrograde cholangiopancreatography (ERCP) and cholecystectomy confirmed the presence of stones in all 14 patients. None of the remaining four patients developed evidence of cholelithiasis during a median follow-up of 22 months.
 
The initial imaging study of choice in patients with suspected common bile duct stones is a transabdominal ultrasound of the right upper quadrant. Transabdominal ultrasound can evaluate for cholelithiasis, choledocholithiasis, and common bile duct dilation. It is readily available, noninvasive, permits bedside evaluation, and provides a low-cost means of evaluating the common bile duct for stones. (See "Ultrasonography of the hepatobiliary tract".)
 
The sensitivity of transabdominal ultrasound for choledocholithiasis ranges from 20 to 90 percent [14]. In a meta-analysis of five studies, the pooled sensitivity of ultrasound for detecting a common bile duct stone was 73 percent, with a specificity of 91 percent [20]. Transabdominal ultrasound has poor sensitivity for stones in the distal common bile duct because the distal common bile duct is often obscured by bowel gas in the imaging field [21-25]. Occasionally, a definite common bile duct stone (one that casts a shadow) can be imaged by transabdominal ultrasound (image 1).
 
A dilated common bile duct on transabdominal ultrasound is suggestive of, but not specific for, choledocholithiasis [6,8,10]. A cutoff of 6 mm is often used to classify a duct as being dilated [14]. However, using a cutoff of 6 mm may miss stones [26]. One study of 870 patients undergoing cholecystectomy found that stones were often detected in patients whose ducts would have been classified as "nondilated" using the 6 mm cutoff [27]. In addition, the probability of a stone in the common bile duct increased with increasing common bile duct diameter:
 
●0 to 4 mm: 3.9 percent
●4.1 to 6 mm: 9.4 percent
●6.1 to 8 mm: 28 percent
●8.1 to 10 mm: 32 percent
●>10 mm: 50 percent
Conversely, because the diameter of the common bile duct increases with age, older adults may have a nolder adults may have a normal duct with a diameter that is >6 mm. (See "Ultrasonography of the hepatobiliary tract", section on 'Normal measurements on ultrasound'.)


==References==
==References==
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Hadeel Maksoud M.D.[2]

Overview

Generally transabdominal ultrasound (TAUS) is considered to be the most useful test to detect gallstones. TAUS is noninvasive, readily available, low cost and doesn't expose patients to ionizing radiation. The patient should fast for at least eight hours before the examination this is to ensure that the gallbladder is distended with bile, which is best for visualizing stones.

Transabdominal ultrasound

The initial imaging study of choice in patients with suspected gallstones is a transabdominal ultrasound of the right upper quadrant.[1][2][3]

  • Ultrasound may be helpful in the diagnosis of gallstones. Findings on an ultrasound suggestive of gallstones include:
  • False-negative or misleading results may be obtained if the gallbladder is completely filled with stones or if it is contracted around many stones.
  • A systematic review estimated that the sensitivity was 84% and specificity was 99%.
  • The accuracy is, however, operator dependent.
  • In patients who complain of biliary colic but have not shown evidence of gallstones on ultrasound, the examination is usually repeated a few weeks later.
  • If the repeated TAUS is still negative, then this patient may have sludge in the gallbladder and thereafter, invasive procedures are considered on an individual case basis.
Stones shown near the gallbladder neck. Case courtesy of radiopaedia.org by Dr Derek Smith, https://radiopaedia.org/cases/42795

Endoscopic ultrasound

Stone shown near the gallbladder tip. Source:Journal of Pancreas[6]

References

  1. ↑ Shea JA, Berlin JA, Escarce JJ, Clarke JR, Kinosian BP, Cabana MD, Tsai WW, Horangic N, Malet PF, Schwartz JS (1994). "Revised estimates of diagnostic test sensitivity and specificity in suspected biliary tract disease". Arch. Intern. Med. 154 (22): 2573–81. PMID 7979854.
  2. ↑ Conrad MR, Janes JO, Dietchy J (1979). "Significance of low level echoes within the gallbladder". AJR Am J Roentgenol. 132 (6): 967–72. doi:10.2214/ajr.132.6.967. PMID 108978.
  3. ↑ Leopold GR, Amberg J, Gosink BB, Mittelstaedt C (1976). "Gray scale ultrasonic cholecystography: a comparison with conventional radiographic techniques". Radiology. 121 (2): 445–8. doi:10.1148/121.2.445. PMID 981625.
  4. ↑ Dahan P, Andant C, Lévy P, Amouyal P, Amouyal G, Dumont M, Erlinger S, Sauvanet A, Belghiti J, Zins M, Vilgrain V, Bernades P (1996). "Prospective evaluation of endoscopic ultrasonography and microscopic examination of duodenal bile in the diagnosis of cholecystolithiasis in 45 patients with normal conventional ultrasonography". Gut. 38 (2): 277–81. PMC 1383037. PMID 8801211.
  5. ↑ Liu CL, Lo CM, Chan JK, Poon RT, Fan ST (2000). "EUS for detection of occult cholelithiasis in patients with idiopathic pancreatitis". Gastrointest. Endosc. 51 (1): 28–32. PMID 10625791.
  6. ↑ "Morris-Stiff G, et al. Does Endoscopic Ultrasound Have Anything to Offer in the Diagnosis of Idiopathic Acute Pancreatitis?. JOP. J Pancreas (Online) 2009 Mar 9; 10(2):143-146. [Full text]".

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