The next anatomical location where gallstones can be found is outside the gallbladder but within the pancreaticobiliary system.
When gallstones exit the gallbladder into the common bile duct choledocholithiasis , they can often obstruct the normal drainage of bile which can lead to jaundice. This is typically associated with pain, unlike malignant biliary obstruction which is characteristically painless Fig. These images demonstrate multiple filling defects arrows within the common bile duct with associated biliary duct dilatation consistent with obstructing choledocholithiasis.
The obstruction of biliary drainage and stasis of bile may result in infection in the form of ascending cholangitis and associated sepsis. These patients may require urgent decompression of the biliary system. In rare cases, there can be retrograde passage of gallstones into the common hepatic duct or the right or left main hepatic ducts, or stones can form in intrahepatic ducts due to biliary stasis.
If a gallstone passes down the common bile duct and comes to rest at the ampulla of Vater, it may block the drainage of the pancreatic duct causing back pressure on the pancreatic cells and resulting in gallstone pancreatitis.
These patients present with epigastric pain radiating to the back and the severity ranges from mild to severe. There is a significant mortality associated with severe pancreatitis, and critically ill patients should be managed in a high dependency or intensive care monitored environment. While imaging is not usually required or indicated to confirm the diagnosis of acute pancreatitis, an ultrasound of the gallbladder can confirm or rule out the presence of gallstones.
Axial contrast-enhanced CT of the abdomen a and axial fat-suppressed T2-weighted MRI of the abdomen b in the same patient demonstrating extensive inflammation and oedema of the pancreas secondary to gallstone pancreatitis with a peripancreatic collection arrow.
In general, larger gallstones are more likely to obstruct higher in the common bile duct, and as such are more likely to cause obstructive jaundice or cholangitis. Smaller gallstones are more likely to cause pancreatitis as they more freely pass down to the level of the ampulla of Vater [ 4 , 5 ]. Gallstones can also cause pathology outside of the biliary system. The most common cause, although rare, is a cholecystoenteric fistula. Chronic irritation from a large gallstone can erode through the gallbladder wall with fistulisation into small bowel.
This can be seen on imaging with air seen within the gallbladder or biliary tree pneumobilia. When a gallstone passes through the fistula into the small bowel, this can result in intestinal obstruction, either proximal or more commonly distal.
The most common place for distal small bowel obstruction and gallstone ileum is at the level of ileocecal valve as this is the narrowest point; however, gallstone ileus can occur anywhere in the gastrointestinal tract. The diagnosis is suggested on abdominal X-ray by the presence of pneumobilia in the right upper quadrant with dilated loops of bowel consistent with bowel obstruction.
Gallstone ileus is more accurately diagnosed with CT which may show pneumobilia or may directly demonstrate the presence of a cholecystoenteric fistula and associated bowel obstruction Fig. Coronal a and axial b contrast-enhanced CT of the abdomen demonstrating multiple dilated loops of small bowel. There is a 3-cm peripherally hyperattenuating obstructing gallstone in the left flank arrow 1.
There is an extensive inflammatory process in the gallbladder bed with air in the gallbladder arrow 2 consistent with a cholecystoenteric fistula. Appearances are consistent with a bowel obstruction secondary to a gallstone ileus.
Patients typically present with copious vomiting owing to the proximal level of obstruction. There may be little or no small bowel dilatation; in particular, the X-ray abdomen may be completely normal which can falsely reassure.
Imaging will demonstrate evidence of gastric outlet or duodenal obstruction related to a gallstone in the upper GI tract Fig. Demonstrating a large calcified gallstone in the proximal duodenum with a massively dilated stomach. Finally, there are a number of imaging features post-cholecystectomy that the radiologist should be aware of. Immediate complications can include post-operative bleeding or an injury to the common bile duct resulting in a bile leak and subsequent biloma.
CT is the optimal imaging modality for the initial imaging of post-operative complications, where these complications and fluid collections are well appreciated.
It can be difficult to differentiate between blood and bile on CT, and measuring a region of interest to obtain the Hounsfield attenuation value of the fluid can help differentiate between the two.
Other factors should be considered to ascertain the aetiology of any visualised collection, for example, a layering haemotocritl level with altered attenuation values can be a feature seen with haemorrhagic collections where the inferior denser haemorrhagic component is seen dependently [ 16 ] Fig.
Axial and coronal contrast enhanced CT of the abdomen in a patient several hours post-cholecystectomy. There is large volume perihepatic fluid with an average Hounsfield unit of 55 consistent with post-cholecystectomy bleeding. Dropped gallstones at time of laparoscopy can have a delayed presentation with post-operative complications such as intrabdominal abscess formation and CT demonstrating a radio-opaque gallstone surrounded by abscess Fig.
Gallstone abscesses without radiopaque gallstones can pose a particular diagnostic challenge as the nidus for infection is not definitely confirmed on imaging. Abscesses related to dropped gallstones can be complex and may extend through abdominal planes and extend extra-peritoneally into adjacent subcutaneous and soft tissue plains. The clinical history will often include a history of prior or difficult cholecystectomy.
Gallbladder clips or an absent gallbladder can be seen on cross-sectional imaging as clues. Axial and sagittal images of a contrast-enhanced CT abdomen in a patient several days post-laparoscopic cholecystectomy.
There is a rim-enhancing fluid collection compatible with an abscess which contains multiple dropped gallstones. Patients with occult choledocholithiasis that proceed to cholecystectomy can present with obstructive jaundice and cholangitis in the post-operative period.
It is important that any patient in whom choledocholithiasis is suspected undergo MRCP prior to surgery. Alternatively, an intra-operative cholangiogram or choledochoscope can be performed intra-operatively to ensure the common bile duct is clear of stones. Late post-cholecystectomy complications can include stump cholecystitis or a retained cystic duct stump or common bile duct stone.
These findings result from incomplete cholecystectomy and can be identified on imaging [ 17 ] Fig. Coronal magnetic resonance MIP image of the biliary tree.
The gallbladder is absent consistent with a prior cholecystectomy. There is a filling defect in the distal common bile duct arrow with associated biliary duct dilatation consistent with an obstructing gallstone. Radiologists should be familiar with the wide range of pathological processes that can be seen secondary to gallstones in order to aid prompt diagnosis, treatment and intervention.
It is hoped that through understanding the role of multimodality imaging and understanding the anatomic locations of the manifestations of gallstone-related disease, this review paper will assist the radiologist in diagnosing common and less common manifestations of gallstone-related pathology.
Gastroenterology 3 Friedman G Natural history of asymptomatic and symptomatic gallstones. Am J Surg — Radiographics 20 3 — Wiley-Blackwell Press. Arch Intern Med 22 — Download references. Murphy, B. Gibney, C. Gillespie, J. You can also search for this author in PubMed Google Scholar. MM contributed to the drafting of manuscript, image provision and final approval of manuscript. BG contributed to the manuscript edits and image provision. CG contributed to the manuscript edits and image provision.
JH contributed to the manuscript edits and image provision. FB contributed to the manuscript edits, image provision and final approval of manuscript. All authors read and approved the final manuscript. Correspondence to M. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. If you have symptoms of gallstones , make an appointment with your GP so they can try to identify the problem.
Your GP will ask about your symptoms in detail and may carry out the Murphy's sign test to help determine if your gallbladder is inflamed. During this test, your GP places their hand or fingers on the upper-right area of your tummy and asks you to breathe in. If you find this painful, it usually means your gallbladder is inflamed and you may need urgent treatment.
Your GP may also recommend having blood tests to look for signs of infection or check if your liver is working normally. If your symptoms and test results suggest you may have gallstones, you'll usually be referred for further tests. You may be admitted to hospital for tests the same day if it's thought you may have a more severe form of gallbladder disease. Gallstones can usually be confirmed using an ultrasound scan , which uses high-frequency sound waves to create an image of the inside of the body.
The type of ultrasound scan used for gallstones is similar to the scan used during pregnancy, where a small handheld device called a transducer is placed onto your skin and moved over your upper abdomen. Sound waves are sent from the transducer, through your skin and into your body. They bounce back off the body tissues, forming an image on a monitor. When gallstones are diagnosed, there may be some uncertainty about whether any stones have passed into the bile duct.
Abdominal pain is often referred to the right shoulder. Patients may demonstrate this radiation to the tip of the scapula by placing their hand behind the back and thumb pointing upwards: " Collins sign ". Calcified gallbladder stones are hyperattenuating to bile, making them the only type to be clearly visualized on CT scan images. Pure cholesterol stones are hypoattenuating to bile, and other gallstones are isodense to bile and these may not be clearly identified on CT. Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys.
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Sign Up. Become a Gold Supporter and see no ads. Log in Sign up. Articles Cases Courses Quiz. About Recent Edits Go ad-free. Edit article. View revision history Report problem with Article. Citation, DOI and article data. Sorrentino, S. Reference article, Radiopaedia. Gallbladder calculi Gallbladder calculus Gallbladder stones Biliary microliths Biliary microlith Biliary microlithiasis Gallbladder microlithiasis Cholecystolithiasis Gallstone Gallbladder calculosis Cholelithiasis Biliary calculi Biliary calculus.
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