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Term 2 > Abd (outcome 2) > Flashcards

Abd (outcome 2) Flashcards

1
Q

Which artery are the GB and cystic duct supplied by?

A

-cystic artery (branch of RHA)

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2
Q

Normal Total Bilirubin

A

0.3 to 1.1 d/L

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3
Q

Normal Direct Bilirubin

A

0.1 to 0.4 d/L

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4
Q

What is a product from the breakdown of?

A

-hemoglobin in old rbc’s

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5
Q

What does bilirubin reflect?

A

-balance between production and excretion of bile

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6
Q

What is elevation of direct/conjugated bilirubin associated with?

A
  • obstruction
  • hepatitis
  • cirrhosis
  • metastases
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7
Q

What is elevation of indirect/unconjugated bilirubin associated with?

A

-non obstructive conditions (ex. steatosis)

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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)
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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)
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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)
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11
Q

WES Complex

A
  • wall echo shadow
  • GB wall is 1st visualized in the near field
  • bright echo of the stone
  • acoustic shadowing
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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
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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
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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
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15
Q

What comprises 5 % of patients who present to emerg. dept.?

A

-acute cholecystitis

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16
Q

S/S of Acute Cholecystitis

A
  • constant RUQ pain
  • epigastric pain
  • RUQ tenderness
  • nausea/vomiting
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17
Q

What is acute cholecystitis caused by in 90% of cases?

A

-stones

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18
Q

Who does acute cholecystitis affect?

A
  • women 3x more than men

- < 50 years old group

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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
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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
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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
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22
Q

Gangrenous Cholecystitis

A

-necrosis due to severe or prolonged acute cholecystitis

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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)
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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
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25
Q

What occurs in 5 to 10% of patients with acute cholecystitis due to prolonged inflammation?

A

-GB perforation

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26
Q

What does a cystic liver lesion around the GB fossa suggest?

A

-pericholecystic abscess

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27
Q

Emphysematous Cholecystitis

A
  • 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
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28
Q

Emphysematous Cholecystitis on US

A
  • echogenic line
  • posterior dirty shadow
  • reverberation (ring down artifact)
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29
Q

Chronic Cholecystitis

A
  • 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
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30
Q

Chronic cholecystitis is differentiated from acute cholecystitis by absence of…

A
  • Gb distension
  • positive Murphy’s sign
  • hyperemia of the wall
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31
Q

Who is acalculous cholecystitis common in?

A
  • common in critically ill (major surgery, severe trauma, spits, TPN/IV feeding, diabetes, atherosclerotic disease, HIV)
  • eldery, non hospitalized males with atherosclerosis
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32
Q

Diagnosis of Acalculous Cholecystitis

A
  • difficult to assess (same signs are common in critically ill without cholecystitis)
  • murphy’s sign sensitivity may be reduced by analgesics
  • cholescintigraphy
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33
Q

Torsion of GB

A
  • 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
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34
Q

Symptoms of Torsion of GB

A
  • in elderly women

- GB is mobile with long suspensory mesentery

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35
Q

Porcelain GB

A
  • 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
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36
Q

Adenomyomatosis

A
  • adenomatous hyperplasia
  • benign and asymptomatic
  • exaggeration of the normal invagination of luminal epithelium
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37
Q

Rokitansky Aschoff Sinuses

A

-may appear as cystic spaces or echogenic foci with comet tail artifact

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38
Q

Key to Diagnosis of Rokitansky Aschoff Sinuses

A

-thickeing of adjacent GB wall

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39
Q

Adenomyomatosis on US

A
  • twinkeling on doppler
  • focal or diffsue
  • focal seen in fundus
  • hourglass appearance
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40
Q

Benign Polypoid Masses

A
  • more common
  • may be multiple
  • < 10mm (do not change in size)
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41
Q

Malignant Polypoid Masses

A
  • > 10mm (rapid change in size when followed)
  • singular
  • > age 60
  • gallstone disease
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42
Q

Indications for a Biliary US

A
  • increased LFT’s
  • painless or painful jaundice (acute obstruction or infection of biliary tree)
  • r/o obstruction of ducts (dilation, cause of obstruction)
43
Q

What may a biliary US be used to r/o?

A
  • stones
  • infection
  • neoplasms
  • extrinsic compression
44
Q

Choledochal Cysts

A
  • 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
Q

Caroli’s Disease

A
  • rare, congenital disease
  • type 5
  • involves tntrahepatic biliary tree
  • associated with medullary sponge kidneys
  • affects men and women equally
  • usually diffuse
46
Q

Complications of Caroli’s Disease

A
  • biliary stasis
  • cholangitis
  • stones and sepsis
  • hepatic fibrosis
  • portal hypertension
  • risk for cholangiocarcinoma
47
Q

Primary Choledocholithiasis

A

-stones form within ducts related to diseases causing strictures or dilation of bile ducts, resulting in stasis

48
Q

Causes of Primary Choledocholithiasis

A
  • sclerosing cholangitis
  • caroli’s disease
  • parasitic infections of liver
  • chronic hemolytic disease (sickle cell anemia)
  • prior biliary surgery (enteric anastomosis)
49
Q

Secondary Choledocholithiasis

A
  • migration of stones from the GB into the CBD

- patients present to emergency with RUQ/epigastic pain

50
Q

Sonographic Signs of Secondary Choledocholithiasis

A
  • dilated CBD proximal to stone
  • intrahepatic ducts may also be dilated
  • lg stones shadow, smaller stones may not shadow
  • GB distension
51
Q

CBD Stones

A
  • 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
Q

Differential Diagnosis of CBD Stones

A
  • blood clot (hemobilia)
  • papillary tumor
  • biliary sludge
  • none of these shadow
53
Q

Intrahepatic Bile Duct Stones

A
  • 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
Q

Mirizzi Syndrome

A
  • painful jaundice
  • fever
  • obstruction of CHD (by adema and inflammation)
55
Q

Obstruction of Cystic Duct with Mirizzi Syndrome

A
  • 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
Q

What is a fistula?

A

-abnormal connection between an organ, vessel, intestine or other structure

57
Q

What is a fistula usually the result of?

A
  • injury
  • surgery
  • infection
  • inflammation
58
Q

Hemobilia

A
  • latrogenic causes in 65% of cases
  • percutaneous biliary procedures (ERCP)
  • liver biopsies
  • pain, bleeding, increased bilirubin occurs
  • clinical history essential in the diagnosis
59
Q

Other Etiologies of Hemobilia

A
  • cholangitis/cholecystitis
  • vascular malformations
  • trauma
  • malignancies
60
Q

Hemobilia on US

A
  • echogenic/mixed echogenicity
  • conforms to shape of duct
  • clot within biliary tree
61
Q

Pneumobilia on US

A
  • air in biliary tree appears as bright echogenic linear structures following portal triads
  • reverberation ring down artifact
62
Q

Etiology of Pneumobilia

A
  • previous biliary intervention (iatrogenic)

- patient presents with acute abd

63
Q

What 3 things cause pnemobilia?

A

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
Q

Gallstone Ileus

A
  • 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
Q

Acute Bacterial Cholangitis

A
  • antecedent biliary obstruction (associated in 85% of cases with CBD stones)
  • medical emergency
66
Q

Other Causes of Acute Bacterial Cholangitis

A
  • structure due to trauma or surgery
  • choledochal cysts
  • patially obstructive tumors
67
Q

Clinical Presentation of Acute Bacterial Cholangitis

A
  • classic Charcot’s triad (fever, RUQ pain, jaundice)
  • leukocytosis
  • increased ALP and bilirubin
  • gram neg. enteric bacteria in blood
68
Q

Sonographic Findings with Acute Cholangitis

A
  • 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
Q

Fascioliasis (flukes)

A
  • larvae travel through bowel wall to peritoneal cavity (liver capsule into liver parenchyma)
  • matures and produces eggs in biliary tree
70
Q

Symptoms of Fascioliasis (flukes)

A
  • jaundice
  • fever
  • abscess
71
Q

Sonographic Findings of Fascioliasis (flukes)

A
  • hepatomegaly
  • hilar adenopathy
  • lesions
72
Q

What do the lesions of fascioliasis (flukes) look like on US?

A
  • hypoechoic/mixed
  • present in 90% of cases
  • flukes may be seen within ducts and GB
73
Q

Clonorchiasis and Opisthorchiasis (flukes)

A
  • larvae migrate through the Ampulla of Vater into CBD

- mature within the tntrahepatic bile ducts

74
Q

Sonographic Findings of Clonorchiasis and Opisthorchiasis (flukes)

A
  • diffuse dilation of peripheral intraheptaic ducts
  • periportal echoes (edema)
  • floating echogenic foci in GB (flukes or debris)
75
Q

Ascariasis (flukes)

A
  • roundworm (20 to 30cm long)
  • fecal, oral route
  • common in children
  • active in sm bowel (enters biliary tree via Ampulla of Vater)
76
Q

Sonographic Appearance of Ascariasis (flukes)

A
  • 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
Q

Recurrent Pyogenic Cholangitis

A
  • chronic biliary obstruction, stasis and stone formation
  • leads to reccurent episodes
  • unknown etiology
78
Q

Sonographic Findings with Reccurent Pyogenic Cholangitis

A
  • lateral Lt lobe more affected
  • septis (acute complication)
  • biliary cirrhosis and cholangiocarcinoma (chronic complications)
79
Q

Primary Sclerosing Cholangitis

A
  • 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
Q

What can primary sclerosing cholangitis lead to?

A
  • biliary strictures
  • cholestasis
  • biliary cirrhosis
  • portal hypertension
  • hepatic failure
81
Q

Etiology of Secondary Sclerosing Cholangitis

A
  • 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
Q

Cholangiocarcinoma

A
  • 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
Q

Risk Factors of Cholangiocarcinoma

A
  • age
  • recurrent biliary infections
  • stone disease
84
Q

Classifications of Cholangiocarcinoma

A

Hilar/Klatskin’s- 60% (also called klatskin’s tumor)

Distal- 30% (distal CBD)

Intrahepatic/Peripheral- 10%

85
Q

Klatskin’s/Hilar Tumor

A
  • most common
  • located in porta hepatis
  • causes fibrous tissue formation
  • difficult to ID and stage
86
Q

Symptoms of Klatskin’s/Hilar Tumor

A
  • jaundice
  • pruritus
  • increased LFT’s
  • nodes
87
Q

Distal (CBD) Cholangiocarcinoma

A
  • polypoid masses (expanding duct, hypovascular)
  • jaundice
  • surgical resection is the most effective treatment
  • tumors extend beyond the ductal walls
  • nodal involvement is common
88
Q

Intrahepatic Cholangiocarcinoma

A
  • 2nd most common primary malignancy tumor

- due to increased numbers of liver cirrhosis and hep C

89
Q

What does intrahepatic cholangiocarcinoma look like on US?

A
  • large
  • solid
  • hypovascular mass
  • varying echogenicity
90
Q

How can an intrahepatic cholangiocarcinoma be differentiated from an HCC?

A

-presence of ductal obstruction

91
Q

Intraductal CHolangiocarcinoma

A
  • intraductal mass
  • polypoidal (distends the affected ducts with mucin)
  • less commonly solid/cystic mass within an extremely distended duct
92
Q

Metastases to Biliary Tree

A
  • 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
Q

What does HIDA diagnose?

A
  • GB inflammation (cholecystitis)
  • bile duct obstruction
  • congenital abnormalities in bile ducts (biliary atresia)
  • postoperative complications (bile leaks, fistulas)
  • assessment of liver transplant
94
Q

HIDA Scan

A
  • evaluates GB and the bile excreting function of your liver

- tracks the flow of bile from your liver into sm intestine

95
Q

Why might a HIDA scan be done?

A

-to measure the rate that bile is released from your GB (GB ejection fraction)

96
Q

What is jaundice/icerus a sign of?

A
  • not a disease

- sign of many possible underlying pathological processes the may occur

97
Q

Jaundice

A

-yellowish pigmentation of the skin, whites of the eyes and other mucous membranes

98
Q

Hyperbilirubinemia

A

-increased levels of bilirubin in blood and extracellular fluid

99
Q

What is hyperbilirubinemia caused by?

A

-hyperbilirubinemia

100
Q

How is bilirubin usually excreted?

A

-bile and urine

101
Q

Etiology of Jaundice

A
  • 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
Q

Symptoms of Jaundice

A
  • pruritis (itchiness)
  • fatigue
  • abd pain
  • weight loss
  • vomiting
103
Q

Signs of Jaundice

A
  • yellow skin and eyes
  • fever
  • pale stools
  • dark urine

Term 2 (19 decks)

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