Abd (outcome 2) Flashcards
1
Q
Which artery are the GB and cystic duct supplied by?
A
-cystic artery (branch of RHA)
2
Q
Normal Total Bilirubin
A
0.3 to 1.1 d/L
3
Q
Normal Direct Bilirubin
A
0.1 to 0.4 d/L
4
Q
What is a product from the breakdown of?
A
-hemoglobin in old rbc’s
5
Q
What does bilirubin reflect?
A
-balance between production and excretion of bile
6
Q
What is elevation of direct/conjugated bilirubin associated with?
A
- obstruction
- hepatitis
- cirrhosis
- metastases
7
Q
What is elevation of indirect/unconjugated bilirubin associated with?
A
-non obstructive conditions (ex. steatosis)
8
Q
Risk Factors of Cholelithiasis (gallstone disease)
A
- increasing age
- female
- obesity
- diabetes
- pregnancy
- fecundity (premenopausal women have increased estrogen which causes increased cholesterol an decreases GB contractions)
9
Q
Cholelithiasis (Gallstone Disease)
A
- asymptomatic
- sonography is highly sensitive in detection of stones
- lg difference in acoustic impedance of stones and bile makes them highly reflective
- 1 in 5 patients develop complications (biliary colic, acute cholecystitis)
10
Q
Sonographic Appearance of Cholelithiasis (gallstone disease)
A
- echogenic with strong posterior enhancement
- sm echogenic stones (<5mm may not shadow)
- mobility is a key feature of stones (differentiation from polyps)
- patient must change position to observe motility of stones (supine, decub or upright)
11
Q
WES Complex
A
- wall echo shadow
- GB wall is 1st visualized in the near field
- bright echo of the stone
- acoustic shadowing
12
Q
Milk of Calcium Bile
A
- rare
- GB is filled with semisolid calcium carbonate
- caused by stasis
- rarely causes acute cholecystitis
- forms bile calcium level on US
13
Q
Biliary Sludge
A
- appears as amorphous, low level echoes with no acoustic shadowing
- may move when patient changes position
- lacks vascularity
- noraml GB wall
- tumefactive sludge (sludge balls) mimic polyps
14
Q
Predisposing Factors of Biliary Sludge
A
- pregnancy
- rapid weight loss
- prolonged fasting
- critical illness
- long term parental nutrition (IV feeding)
- bone marrow transplant
15
Q
What comprises 5 % of patients who present to emerg. dept.?
A
-acute cholecystitis
16
Q
S/S of Acute Cholecystitis
A
- constant RUQ pain
- epigastric pain
- RUQ tenderness
- nausea/vomiting
17
Q
What is acute cholecystitis caused by in 90% of cases?
A
-stones
18
Q
Who does acute cholecystitis affect?
A
- women 3x more than men
- < 50 years old group
19
Q
The impaction of stones in cystic duct or GB neck causes…
A
- obstruction of bile flow (tntrahepatic duct dilation)
- luminal distension
- ischemia
- superinfection
- necrosis
- fever
- leukocytosis
- increase ALP and bilirubin
- CT is useful in determining complications
20
Q
Sonographic Signs of Acute Cholecystitis
A
- gallstones
- thick GB wall (>3mm)
- edematous wall (can see layers)
- distension of GB lumen (>4cm TRV)
- impacted stone in cystic duct or GB neck
- pericholecystic fluid collections
- hyperemic wall (use colour doppler and lower PRF)
- positive Murphy’s sign
- intrahepatic duct dilation/CBD dilation
21
Q
How to Determine a Positive Murphy’s Sign
A
- locate the GB is SAG in decub
- ask patient to take a deep breath in
- apply pressure over GB
- if patient pertinence pain, then it is a positive Murphy’s sign
22
Q
Gangrenous Cholecystitis
A
-necrosis due to severe or prolonged acute cholecystitis
23
Q
Gangrenous Cholecystitis on US
A
- non layering bands of echogenic tissue within the lumen (sloughed membranes and blood)
- wall becomes irregular
- sm collections within wall (abscess or hemorrhage)
- absent Murphy’s sign (nerves necrosed)
24
Q
GB Perforation
A
- focal defect in wall
- deflation of GB (loss of normal shape)
- pericholecystic fluid collection (abscess type stranding)
- periofration extends into adjacent liver parenchyma, forming abscess
25
What occurs in 5 to 10% of patients with acute cholecystitis due to prolonged inflammation?
-GB perforation
26
What does a cystic liver lesion around the GB fossa suggest?
-pericholecystic abscess
27
Emphysematous Cholecystitis
- rapid progression and fatal in 15% of cases
- more common in men and people with diabetes
- frequently acalculus
- higher incidence of perforation
- gas forming bacteria after ischemic event appears as gas in lumen and wall
- pneumobilia (air in ducts) may be present
28
Emphysematous Cholecystitis on US
- echogenic line
- posterior dirty shadow
- reverberation (ring down artifact)
29
Chronic Cholecystitis
- longstanding
- mild
- presence of gallstones
- usually asymptomatic
- same incidence and risk factors as gallstone diseases
- acute bouts may complicate chronic bouts
- advanced cases may involve wall thickening and fibrosis on US
30
Chronic cholecystitis is differentiated from acute cholecystitis by absence of...
- Gb distension
- positive Murphy's sign
- hyperemia of the wall
31
Who is acalculous cholecystitis common in?
- common in critically ill (major surgery, severe trauma, spits, TPN/IV feeding, diabetes, atherosclerotic disease, HIV)
- eldery, non hospitalized males with atherosclerosis
32
Diagnosis of Acalculous Cholecystitis
- difficult to assess (same signs are common in critically ill without cholecystitis)
- murphy's sign sensitivity may be reduced by analgesics
- cholescintigraphy
33
Torsion of GB
- twisting of cystic duct or artery
- rare acute entity
- massively distended, inflamed GB
- GB is unusual horizontal position
- gangrene may ensure if torsion > 180 degrees
- surgical treatment
34
Symptoms of Torsion of GB
- in elderly women
| - GB is mobile with long suspensory mesentery
35
Porcelain GB
- wall is thickly calcified with dense posterior acoustic shadowing
- WES complex is absent
- unknown cause
- stones
- may represent a form of chronic cholecystitis
- female predominate in 60th decade
- resection is advised
36
Adenomyomatosis
- adenomatous hyperplasia
- benign and asymptomatic
- exaggeration of the normal invagination of luminal epithelium
37
Rokitansky Aschoff Sinuses
-may appear as cystic spaces or echogenic foci with comet tail artifact
38
Key to Diagnosis of Rokitansky Aschoff Sinuses
-thickeing of adjacent GB wall
39
Adenomyomatosis on US
- twinkeling on doppler
- focal or diffsue
- focal seen in fundus
- hourglass appearance
40
Benign Polypoid Masses
- more common
- may be multiple
- < 10mm (do not change in size)
41
Malignant Polypoid Masses
- > 10mm (rapid change in size when followed)
- singular
- > age 60
- gallstone disease
42
Indications for a Biliary US
- increased LFT's
- painless or painful jaundice (acute obstruction or infection of biliary tree)
- r/o obstruction of ducts (dilation, cause of obstruction)
43
What may a biliary US be used to r/o?
- stones
- infection
- neoplasms
- extrinsic compression
44
Choledochal Cysts
- cogenital disease
- type 1, 2 and 3 (cystic dilation of CBD)
- type 4 involves tntrahepatic ducts
- type 5 is caroli's disease (not a true choledochal cyst)
- focal or diffuse dilation
- common in east Asia
45
Caroli's Disease
- rare, congenital disease
- type 5
- involves tntrahepatic biliary tree
- associated with medullary sponge kidneys
- affects men and women equally
- usually diffuse
46
Complications of Caroli's Disease
- biliary stasis
- cholangitis
- stones and sepsis
- hepatic fibrosis
- portal hypertension
- risk for cholangiocarcinoma
47
Primary Choledocholithiasis
-stones form within ducts related to diseases causing strictures or dilation of bile ducts, resulting in stasis
48
Causes of Primary Choledocholithiasis
- sclerosing cholangitis
- caroli's disease
- parasitic infections of liver
- chronic hemolytic disease (sickle cell anemia)
- prior biliary surgery (enteric anastomosis)
49
Secondary Choledocholithiasis
- migration of stones from the GB into the CBD
| - patients present to emergency with RUQ/epigastic pain
50
Sonographic Signs of Secondary Choledocholithiasis
- dilated CBD proximal to stone
- intrahepatic ducts may also be dilated
- lg stones shadow, smaller stones may not shadow
- GB distension
51
CBD Stones
- majority of stones will be in distal CBD at eh Ampulla of Vater
- complete CBD must be assessed
- sometimes seen in patients post cholecystectomy
52
Differential Diagnosis of CBD Stones
- blood clot (hemobilia)
- papillary tumor
- biliary sludge
- none of these shadow
53
Intrahepatic Bile Duct Stones
- US is sensitive in visualizing sm stones in ducts
- sm stones may or may not shadow depending on composition
- proximal dilated ducts help to delineate them
- harmonic raging improves the contrast resolution
- seen in patients with cystic fibrosis
54
Mirizzi Syndrome
- painful jaundice
- fever
- obstruction of CHD (by adema and inflammation)
55
Obstruction of Cystic Duct with Mirizzi Syndrome
- recurrent bouts of cholecystitis/impacted stone may erode into CHD
- results in fistula between the cystic duct and common hepatic duct
- acute cholecystitis, cholangitis and pancreatitis may occur
56
What is a fistula?
-abnormal connection between an organ, vessel, intestine or other structure
57
What is a fistula usually the result of?
- injury
- surgery
- infection
- inflammation
58
Hemobilia
- latrogenic causes in 65% of cases
- percutaneous biliary procedures (ERCP)
- liver biopsies
- pain, bleeding, increased bilirubin occurs
- clinical history essential in the diagnosis
59
Other Etiologies of Hemobilia
- cholangitis/cholecystitis
- vascular malformations
- trauma
- malignancies
60
Hemobilia on US
- echogenic/mixed echogenicity
- conforms to shape of duct
- clot within biliary tree
61
Pneumobilia on US
- air in biliary tree appears as bright echogenic linear structures following portal triads
- reverberation ring down artifact
62
Etiology of Pneumobilia
- previous biliary intervention (iatrogenic)
| - patient presents with acute abd
63
What 3 things cause pnemobilia?
1) emphysematous cholecystitis
2) choledochoduodenal fistula (caused by stone in CBD-inflammation)
3) cholecystoenteric fistula (prolonged acute cholecystitis erodes into an adjacent bowel loop)
64
Gallstone Ileus
- paralysis of nerves
- stones may pass from GB into the bowel by a cholecystoenteric fistula
- frequently involves duodenum or transverse colon
- result of prolonged inflammation of GB
65
Acute Bacterial Cholangitis
- antecedent biliary obstruction (associated in 85% of cases with CBD stones)
- medical emergency
66
Other Causes of Acute Bacterial Cholangitis
- structure due to trauma or surgery
- choledochal cysts
- patially obstructive tumors
67
Clinical Presentation of Acute Bacterial Cholangitis
- classic Charcot's triad (fever, RUQ pain, jaundice)
- leukocytosis
- increased ALP and bilirubin
- gram neg. enteric bacteria in blood
68
Sonographic Findings with Acute Cholangitis
- dilation of tntrahepatic biliary tree
- choledocholithiasis (stone in distal CBD)
- CBD wall thickening
- hepatic abscess
- dilated CBD (>6mm)
- pneumobilia suggests fistula (choledochoenteric)
- Gb wall may be thickened
69
Fascioliasis (flukes)
- larvae travel through bowel wall to peritoneal cavity (liver capsule into liver parenchyma)
- matures and produces eggs in biliary tree
70
Symptoms of Fascioliasis (flukes)
- jaundice
- fever
- abscess
71
Sonographic Findings of Fascioliasis (flukes)
- hepatomegaly
- hilar adenopathy
- lesions
72
What do the lesions of fascioliasis (flukes) look like on US?
- hypoechoic/mixed
- present in 90% of cases
- flukes may be seen within ducts and GB
73
Clonorchiasis and Opisthorchiasis (flukes)
- larvae migrate through the Ampulla of Vater into CBD
| - mature within the tntrahepatic bile ducts
74
Sonographic Findings of Clonorchiasis and Opisthorchiasis (flukes)
- diffuse dilation of peripheral intraheptaic ducts
- periportal echoes (edema)
- floating echogenic foci in GB (flukes or debris)
75
Ascariasis (flukes)
- roundworm (20 to 30cm long)
- fecal, oral route
- common in children
- active in sm bowel (enters biliary tree via Ampulla of Vater)
76
Sonographic Appearance of Ascariasis (flukes)
- appears as a tube or parallel echogenic line within bile ducts or GB
- movement of the worm during US facilitates diagnosis
- may be multiple
77
Recurrent Pyogenic Cholangitis
- chronic biliary obstruction, stasis and stone formation
- leads to reccurent episodes
- unknown etiology
78
Sonographic Findings with Reccurent Pyogenic Cholangitis
- lateral Lt lobe more affected
- septis (acute complication)
- biliary cirrhosis and cholangiocarcinoma (chronic complications)
79
Primary Sclerosing Cholangitis
- chronic inflammatory disease of entire biliary tree
- fibrosing inflammation of sm and lg bile ducts
- more frequent in men
- median age 39 years
- etiology not known
- 80% of patens have inflammatory bowel disease (colitis)
80
What can primary sclerosing cholangitis lead to?
- biliary strictures
- cholestasis
- biliary cirrhosis
- portal hypertension
- hepatic failure
81
Etiology of Secondary Sclerosing Cholangitis
- AIDS cholangiopathy
- bile duct neoplasm
- biliary tract surgery
- trauma
- choledocholithiasis
- congenital anomalies
- ischemic stricturing of bile ducts
- toxic strictures (infusion of fluxuride)
- primary sclerosing cholangitis
82
Cholangiocarcinoma
- cancerous (malignant) growth in one of the ducts that carries bile from the liver to the sm intestine
- uncommon neoplasm
- 90% are adeenocarcinoma
- poor prognosis
- classified based on anatomic location in liver
83
Risk Factors of Cholangiocarcinoma
- age
- recurrent biliary infections
- stone disease
84
Classifications of Cholangiocarcinoma
Hilar/Klatskin's- 60% (also called klatskin's tumor)
Distal- 30% (distal CBD)
Intrahepatic/Peripheral- 10%
85
Klatskin's/Hilar Tumor
- most common
- located in porta hepatis
- causes fibrous tissue formation
- difficult to ID and stage
86
Symptoms of Klatskin's/Hilar Tumor
- jaundice
- pruritus
- increased LFT's
- nodes
87
Distal (CBD) Cholangiocarcinoma
- polypoid masses (expanding duct, hypovascular)
- jaundice
- surgical resection is the most effective treatment
- tumors extend beyond the ductal walls
- nodal involvement is common
88
Intrahepatic Cholangiocarcinoma
- 2nd most common primary malignancy tumor
| - due to increased numbers of liver cirrhosis and hep C
89
What does intrahepatic cholangiocarcinoma look like on US?
- large
- solid
- hypovascular mass
- varying echogenicity
90
How can an intrahepatic cholangiocarcinoma be differentiated from an HCC?
-presence of ductal obstruction
91
Intraductal CHolangiocarcinoma
- intraductal mass
- polypoidal (distends the affected ducts with mucin)
- less commonly solid/cystic mass within an extremely distended duct
92
Metastases to Biliary Tree
- mimics appearance of cholangiocarcinoma
- affects tntrahepatic and extraheptaic ducts
- presence of past or concurrent malignancy long with multiple lesions suggest mets
- breast, colon and melanoma are primary sites
93
What does HIDA diagnose?
- GB inflammation (cholecystitis)
- bile duct obstruction
- congenital abnormalities in bile ducts (biliary atresia)
- postoperative complications (bile leaks, fistulas)
- assessment of liver transplant
94
HIDA Scan
- evaluates GB and the bile excreting function of your liver
| - tracks the flow of bile from your liver into sm intestine
95
Why might a HIDA scan be done?
-to measure the rate that bile is released from your GB (GB ejection fraction)
96
What is jaundice/icerus a sign of?
- not a disease
| - sign of many possible underlying pathological processes the may occur
97
Jaundice
-yellowish pigmentation of the skin, whites of the eyes and other mucous membranes
98
Hyperbilirubinemia
-increased levels of bilirubin in blood and extracellular fluid
99
What is hyperbilirubinemia caused by?
-hyperbilirubinemia
100
How is bilirubin usually excreted?
-bile and urine
101
Etiology of Jaundice
- often seen in liver disease (hepatitis and cirrhosis)
- liver or pancreatic cancer
- may also indicate an obstruction of the biliary tract (stones in CBD)
102
Symptoms of Jaundice
- pruritis (itchiness)
- fatigue
- abd pain
- weight loss
- vomiting
103
Signs of Jaundice
- yellow skin and eyes
- fever
- pale stools
- dark urine
