Bile ducts

Question 1

What is Mirrizzi Syndrome?

Answer 1

Common duct obstruction due to gallstone in gallbladder neck or cystic duct.

Question 2

From anterior to posterior what is the order of Common duct, hepatic artery, portal vein?

Answer 2

Common Duct
right hepatic artery
Portal vein

Question 3

What are the US criteria for dilated intrahepatic ducts?

Answer 3

Larger than 2mm
More than 40% diameter of adjacent portal vein
Increased through transmission
Irregular, tortuous walls
Stellate configuration centrally
Lack of doppler signal

Question 4

What are US characteristics of choledocolithiasis? (4)

Answer 4

Hyper echoic
Shadowing ( 20% don’t shadow)
Intraductual structure
Not possible to show mobility

Question 5

What are some causes of intrahepatic duct stones?

Answer 5

Bile stasis
Bacterial infection
Recurrent pyogenic cholangitis (oriental choangiohepatitis)
Flukes - Clonorchis sinensis or ascaris lumbricoides

Question 6

What is a klatskin tumour?

Answer 6

Cholangiocarcinoma at the bifurcation of left and right main biliary ducts.

Question 7

What is the classic US appearance of cholangiocarcinoma?

Answer 7

Dilated duct that abruptly terminates
Poorly marginated mass
Mass isoechoic to liver parenchyma
Uncommonly focal thickening of bile duct wall

Question 8

What are causes of bile duct wall thickening? (9)

Answer 8

Sclerosing cholangitis
Common bile duct stones
Pancreatitis
Ascending cholangitis
AIDS cholangiopathy - CMV, cryptosporidium
Cholangiocarcinoma
Recurrent pyogenic cholangitis
Biliary stents
Intramural venous collaterals secondary to portal vein thrombosis

Question 9

What is PSC?

Answer 9

Idiopathic inflammatory condition affecting biliary tree resulting in multiple strictures and eventual cirrhosis.

Associated with IBD especially UC. Thus middle aged and young males.

Question 10

What is the classification of choledocal cysts?

Answer 10

Todani classification:

Type 1: fusiform
Type 2: Diverticulum from extra hepatic duct
Type 3: Choledochocoele - dilation of extra hepatic bile duct within duodenal wall
Type 4: Multifocal dilatations of intra and extra hepatic ducts
Type 5: Caroli Disease

Question 11

What is Caroli’s disease?

Answer 11

Multifocal cystic dilation of intrahepatic bile ducts. Commonly associated with medullary sponge kidney.

Complications - biliary stasis, ductal stones, cholangitis, liver abscess.

Question 12

What is the ddx for choledochal cysts? (7)

Answer 12

Duplication cyst of duodenum
Dilated cystic duct remnant
Omental or mesenteric cyst
Pancreatic pseudocyst
Right renal cyst
Hepatic cyst
Aneurysm/pseudoaneurysm