Bile ducts and gallbladder

Question 1

What is the pathology behind PSC? What is the natural history? What is the median survival?

Answer 1

Fibrosing inflammation Chronic progression from initial cholangitis to periportal hepatitis to septal fibrosis to bridging necrosis to cirrhosis 12 years

Question 2

What are the cholangiographic features of PSC?

Answer 2

Band strictures (beaded appearance) Nonuniform, segmental strictures Pruned tree appearance of intrahepatic ducts Diverticular outpouching Mural irregularity

Question 3

What is the feared complication with PSC? When is is suspected?

Answer 3

Cholcangiocarcinoma Suspect when there is a dominant stricture

Question 4

What is the mechanism for PBC? What diseases is it associated with? What is the marker? What is the pathophysiology

Answer 4

T-cell mediated immune response RA, Sjogrens, Hashimotos Antimitochondrial antibody Small duct destruction with inflammatory cellular infiltrate

Question 5

What are the cholangiographic features of PBC? Early vs late

Answer 5

Early - may be normal Late - Cirrhosis, crowding, tortuosity and deformity of the bile ducts. Enlarged benign reactive lymph nodes in the hepatic portal

Question 6

What are the bugs related to AIDS induced cholangiopathy?

Answer 6

Cryptosporidium and CMV

Question 7

Intrahepatic ductal strictures with papillary stenosis?

Answer 7

AIDS cholangiopathy

Question 8

What feature is unique to AIDS cholangiopathy?

Answer 8

Papillary stenosis

Question 9

What is ascending cholangitis?

Answer 9

Obstruction of the biliary tree with bacterial infection of the bile.

Question 10

What is a common liver finding in ascending cholangitis?

Answer 10

Hepatic abscess

Question 11

Cystic hepatic lesion communicating with biliary tree in septic patient?

Answer 11

Hepatic abscess complicating ascending cholangitis

Question 12

What is the most common bug in ascending cholangitis?

Answer 12

E coli

Question 13

Bile duct stones Ductal dilation and focal strictures Acute peripheral tapering Decreased arborization of intrahepatic ducts

Answer 13

Oriental cholangiohepatitis

Question 14

What is the bug in oriental cholangiohepatitis

Answer 14

Clonorchis, Ascariasis, nutritional deficiency

Question 15

What is the main difference between PSC and PBC?

Answer 15

PBC affects small bile ducts only

Question 16

What is the target sign in relation to choledocholithiasis?

Answer 16

Ring of water attenuation around a stone

Question 17

What is the crescent sign in relation to choledocholithiasis

Answer 17

Only a crescent of water surrounds the calculus

Question 18

What are the 3 types of gallstone?

Answer 18

1) cholesterol 75% 2) pigmented 20% - crystallization of calcium bilirubinate, can be black (blood, sickle cell) or brown (bile, infection) 3) Mixed

Question 19

What is Admirand’s triangle

Answer 19

Balance of cholesterol, bile acids, and lecithin (phospholipid) in the gallbladder

Question 20

What is a pseudocalculus?

Answer 20

Apparent filling defect within the ampulla due to sphincter of oddi spasm

Question 21

What is a helpful sign to differentiate pseudocalculus from real stone?

Answer 21

Pseudocalculus will only have a crescent along the superior aspect that disappears with time/glucagon Real stone will have a crescent along the inferior aspect as well.

Question 22

Differentiate spasm of sphincter of oddi with Papillary stenosis?

Answer 22

Spasm will relax over time

Question 23

What is a sign of fixed narrowing of the ampulla?

Answer 23

Upstream dilation of both the common bile and pancreatic.

Question 24

What are the associations with ampullary carcinoma?

Answer 24

FAP, HNPCC

Question 25

Inflammatory stricture of the common hepatic or common bile duct due to impacted stone in the cystic duct or neck of the gallbladder.

Answer 25

Mirrizzi syndrome

Question 26

What is the most common cause of common hepatic duct narrowing?

Answer 26

Hilar lymphadenopathy

Question 27

Multiple and recurrent papillary adenomas in the biliary tract. US - multiple solid filling defects attached to the wall of a dilated extrahepatic duct extremely rare

Answer 27

Biliary papillomatosis

Question 28

Are papillary adenomas premalignant?

Answer 28

Yes

Question 29

Multiloculated cystic lesion along the biliary tree with well defined thick capsule? Seen in middle aged white women

Answer 29

Biliary cystadenoma

Question 30

Differentiate cystadenoma from echinococcal and hepatic abscess

Answer 30

Echinococcal - peripheral intracystic cysts and wall calcification and history of travel to endemic area Abscess - multiple well defined cystic masses with rim hyperenhancement and fevers/leukocytosis

Question 31

What are signs of a biliary cystadenocarcinoma over cystadenoma?

Answer 31

Carcinoma: thick septae enhancing nodular components calcifications

Question 32

What are the two types are biliary cystadenocarcinoma\> which one has a better prognosis?

Answer 32

Those that contain ovarian stroma and those that do not Ovarian stroma favors better prognosis

Question 33

What is the analogy to intraductal cholcangiocarcinoma?

Answer 33

IPMN pancreas

Question 34

Which cholangiocarcinoma has the best prognosis?

Answer 34

Those growing in the CBD (ie extrahepatic) have easier chance for resection

Question 35

What is a klatskin tumor?

Answer 35

Cholangiocarcinoma involving the upper common hepatic duct

Question 36

What is a limiting factor for removal of a klatskin tumor?

Answer 36

One hepatic lobe must be tumor free

Question 37

What is the enhancement pattern of a klatskin tumor?

Answer 37

Hypo/isoattenuating compared to liver during arterial and portal venous phase Enhances on delayed phase

Question 38

Why do scirrhous cholangiocarcinomas enhance on delayed imaging?

Answer 38

They incite a desmoplastic reaction

Question 39

What are the two types of cholangiocarcinoma?

Answer 39

Intra and extrahepatic

Question 40

What is the most common biliary tract anomaly?

Answer 40

Aberrant intrahepatic duct draining into a contralateral main or common hepatic duct.

Question 41

Are biliary leaks more common with laparoscopic or open cholecystectomy?

Answer 41

laparoscopic

Question 42

Name 3 associations with choledochal cysts

Answer 42

Biliary tract stenosis/atresia Congenital hepatic fibrosis Medullary sponge kidney

Question 43

What is the patholophysiology choledochal cysts

Answer 43

Anomalous connection between pancreatic duct and biliary system allows pancreatic secretions to weaken the wall of the duct

Question 44

choledochal cyst types

Answer 44

1 - fusiform 2 - pedunculated 3 - at ampulla, choledochocele 4 - intra and extrahepatic 5 - intrahepatic (carolis)

Question 46

What is a type 3 choledochal cyst?

Answer 46

Choledochocele

Question 47

What is carolis disease? is it AR or AD? How does it present radiographically? What are the associations? What is a good differentiating feature between carolis and PSC?

Answer 47

Autosomal recessive disease, results in alternating regions of narrowing and saccular/fusiform dilatation within the intrahepatic ducts Associated with renal diseases (medullary sponge kidney, polycystic kidney disease, medullary cystic disease) PSC is rarely saccular

Question 48

What are the risks with carolis disease?

Answer 48

100x risk of adenocarcinoma stone formation recurrent cholangitis liver abscess

Question 49

What biliary disease does renal tubular ectasia have an association with?

Answer 49

Caroli disease

Question 50

How does gangrenous cholecystitis present on US? CT?

Answer 50

Intramural edema or sloughing of the mucosa into GB lumen Pericholecystic fluid collection due to perforation

Question 51

What bug is associated with emphysematous cholecystitis? What disease is associated and what percentage of patients have it?

Answer 51

Clostridium perfringens Diabetes 30%

Question 52

How does gas appear on US?

Answer 52

Dirty acoustic shadowing vs. clean shadowing such as that seen with a calculus

Question 53

What are 6 causes of acalculous cholecystitis?

Answer 53

Hyperalimentation Trauma ICU setting Infectious colitis Vascular disease Immunocompromised

Question 54

What is the cause of porcelain gallbladder?

Answer 54

Chronically obstructed cystic duct Chronic cholecystitis

Question 55

What is the risk and percentage of that risk associated with porcelain gallbladder

Answer 55

25% incidence of gallbladder carcinoma

Question 56

What is the wall echo shadow sign?

Answer 56

Seen in a gallbladder full of stones 2 echogenic lines with an intervening sonolucent line

Question 57

What is milk of calcium bile?

Answer 57

Calcium carbonate/phosphate/bilirubinate that is highly concentrated within the GB due to cystic duct obstruction

Question 58

What is gallbladder sludge?

Answer 58

Concentrated, echogenic bile containing particulate material consisting of cholesterol crystals and calcium bilirubinate granules

Question 59

What is tumefactive sludge?

Answer 59

Ball of sludge, can mimic mass but wont have posterior shadowing

Question 60

What makes up a cholesterol polyp?

Answer 60

Single layer of epithelium covering a core of cholesterol filled cells

Question 61

How does metastatic melanoma present in the gallbladder?

Answer 61

Multiple polypoid intraluminal masses

Question 62

Echogenic foci within a thickened gallbladder wall with comet down artifact suggests what? What is the pathology behind it?

Answer 62

Adenomyomatosis Convoluted infoldings of the normal gallbladder mucosa (rokitansky aschoff sinuses) with smooth muscle proliferation

Question 63

What is focal adenomyomatosis?

Answer 63

Can cause segmental narrowing and distort lumen with a masslike appearance

Question 64

How many gallbladder carcinomas present as polypoid lesions? What is the most common manifestation? How are the differentiated from sludge on US?

Answer 64

25% Infiltrating mass arising from gallbladder fossa extending into the liver Blood flow on doppler will be seen with cancer

Question 65

What are the two types of gallbladder cancer

Answer 65

Schirrous - infiltrates liver from gallbladder Polypoid - grows into GB lumen

Question 66

What is the most common tumor to metastasize to the gallbladder?

Answer 66

MElanoma

Question 67

What is a phrygian cap?

Answer 67

Congenital infolding of the gallbladder wall with no known clinical significance

Question 68

Differentiate between a phrygian cap and focal adenomyomatosis?

Answer 68

Phrygian cap will always be in the fundus and have a THIN membrane Adenomyomatosis will be thicker and can be located anywhere

Question 69

What is the cutoff for a normal gallbladder wall thickness? What are some causes?

Answer 69

3mm Incomplete distension Cholecystitis, adenomyomatosis, hepatitis, cirrhosis, portal hypertension, hypoproteinemia, CHF, renal failure, pancreatitis

Question 70

Cystic thickening of the gallbladder wall is seen with what?

Answer 70

Gallbladder varices

Question 71

Gallbladder varices should prompt a search for what?

Answer 71

Portal vein thrombosis

Question 72

Name 5 cystic duct variations

Answer 72

Low insertion onto CBD Conjoined cystic and CBD Absent cystic duct Insertion into RHD Insertion at bifurcation of CHD

Question 73

Name 3 intrahepatic ductal variations

Answer 73

Right posterior duct into the LHD Right posterior into the CHD Right posterior into the CHD bifurcation