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Gastrointestinal > Bile ducts and gallbladder > Flashcards

Bile ducts and gallbladder Flashcards

1
Q

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

A

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

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2
Q

What are the cholangiographic features of PSC?

A

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

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3
Q

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

A

Cholcangiocarcinoma Suspect when there is a dominant stricture

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4
Q

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

A

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

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5
Q

What are the cholangiographic features of PBC? Early vs late

A

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

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6
Q

What are the bugs related to AIDS induced cholangiopathy?

A

Cryptosporidium and CMV

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7
Q

Intrahepatic ductal strictures with papillary stenosis?

A

AIDS cholangiopathy

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8
Q

What feature is unique to AIDS cholangiopathy?

A

Papillary stenosis

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9
Q

What is ascending cholangitis?

A

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

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10
Q

What is a common liver finding in ascending cholangitis?

A

Hepatic abscess

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11
Q

Cystic hepatic lesion communicating with biliary tree in septic patient?

A

Hepatic abscess complicating ascending cholangitis

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12
Q

What is the most common bug in ascending cholangitis?

A

E coli

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13
Q

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

A

Oriental cholangiohepatitis

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14
Q

What is the bug in oriental cholangiohepatitis

A

Clonorchis, Ascariasis, nutritional deficiency

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15
Q

What is the main difference between PSC and PBC?

A

PBC affects small bile ducts only

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16
Q

What is the target sign in relation to choledocholithiasis?

A

Ring of water attenuation around a stone

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17
Q

What is the crescent sign in relation to choledocholithiasis

A

Only a crescent of water surrounds the calculus

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18
Q

What are the 3 types of gallstone?

A

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

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19
Q

What is Admirand’s triangle

A

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

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20
Q

What is a pseudocalculus?

A

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

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21
Q

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

A

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.

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22
Q

Differentiate spasm of sphincter of oddi with Papillary stenosis?

A

Spasm will relax over time

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23
Q

What is a sign of fixed narrowing of the ampulla?

A

Upstream dilation of both the common bile and pancreatic.

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24
Q

What are the associations with ampullary carcinoma?

A

FAP, HNPCC

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25
Q

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

A

Mirrizzi syndrome

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26
Q

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

A

Hilar lymphadenopathy

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27
Q

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

A

Biliary papillomatosis

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28
Q

Are papillary adenomas premalignant?

A

Yes

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29
Q

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

A

Biliary cystadenoma

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30
Q

Differentiate cystadenoma from echinococcal and hepatic abscess

A

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

31
Q

What are signs of a biliary cystadenocarcinoma over cystadenoma?

A

Carcinoma: thick septae enhancing nodular components calcifications

32
Q

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

A

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

33
Q

What is the analogy to intraductal cholcangiocarcinoma?

A

IPMN pancreas

34
Q

Which cholangiocarcinoma has the best prognosis?

A

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

35
Q

What is a klatskin tumor?

A

Cholangiocarcinoma involving the upper common hepatic duct

36
Q

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

A

One hepatic lobe must be tumor free

37
Q

What is the enhancement pattern of a klatskin tumor?

A

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

38
Q

Why do scirrhous cholangiocarcinomas enhance on delayed imaging?

A

They incite a desmoplastic reaction

39
Q

What are the two types of cholangiocarcinoma?

A

Intra and extrahepatic

40
Q

What is the most common biliary tract anomaly?

A

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

41
Q

Are biliary leaks more common with laparoscopic or open cholecystectomy?

A

laparoscopic

42
Q

Name 3 associations with choledochal cysts

A

Biliary tract stenosis/atresia Congenital hepatic fibrosis Medullary sponge kidney

43
Q

What is the patholophysiology choledochal cysts

A

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

44
Q

choledochal cyst types

A

1 - fusiform

2 - pedunculated

3 - at ampulla, choledochocele

4 - intra and extrahepatic

5 - intrahepatic (carolis)

46
Q

What is a type 3 choledochal cyst?

A

Choledochocele

47
Q

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?

A

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

48
Q

What are the risks with carolis disease?

A

100x risk of adenocarcinoma

stone formation

recurrent cholangitis

liver abscess

49
Q

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

A

Caroli disease

50
Q

How does gangrenous cholecystitis present on US? CT?

A

Intramural edema or sloughing of the mucosa into GB lumen

Pericholecystic fluid collection due to perforation

51
Q

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

A

Clostridium perfringens

Diabetes 30%

52
Q

How does gas appear on US?

A

Dirty acoustic shadowing

vs. clean shadowing such as that seen with a calculus

53
Q

What are 6 causes of acalculous cholecystitis?

A

Hyperalimentation

Trauma

ICU setting

Infectious colitis

Vascular disease

Immunocompromised

54
Q

What is the cause of porcelain gallbladder?

A

Chronically obstructed cystic duct

Chronic cholecystitis

55
Q

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

A

25% incidence of gallbladder carcinoma

56
Q

What is the wall echo shadow sign?

A

Seen in a gallbladder full of stones

2 echogenic lines with an intervening sonolucent line

57
Q

What is milk of calcium bile?

A

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

58
Q

What is gallbladder sludge?

A

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

59
Q

What is tumefactive sludge?

A

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

60
Q

What makes up a cholesterol polyp?

A

Single layer of epithelium covering a core of cholesterol filled cells

61
Q

How does metastatic melanoma present in the gallbladder?

A

Multiple polypoid intraluminal masses

62
Q

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

A

Adenomyomatosis

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

63
Q

What is focal adenomyomatosis?

A

Can cause segmental narrowing and distort lumen with a masslike appearance

64
Q

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

A

25%

Infiltrating mass arising from gallbladder fossa extending into the liver

Blood flow on doppler will be seen with cancer

65
Q

What are the two types of gallbladder cancer

A

Schirrous - infiltrates liver from gallbladder

Polypoid - grows into GB lumen

66
Q

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

67
Q

What is a phrygian cap?

A

Congenital infolding of the gallbladder wall with no known clinical significance

68
Q

Differentiate between a phrygian cap and focal adenomyomatosis?

A

Phrygian cap will always be in the fundus and have a THIN membrane

Adenomyomatosis will be thicker and can be located anywhere

69
Q

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

A

3mm

Incomplete distension

Cholecystitis, adenomyomatosis, hepatitis, cirrhosis, portal hypertension, hypoproteinemia, CHF, renal failure, pancreatitis

70
Q

Cystic thickening of the gallbladder wall is seen with what?

A

Gallbladder varices

71
Q

Gallbladder varices should prompt a search for what?

A

Portal vein thrombosis

72
Q

Name 5 cystic duct variations

A

Low insertion onto CBD

Conjoined cystic and CBD

Absent cystic duct

Insertion into RHD

Insertion at bifurcation of CHD

73
Q

Name 3 intrahepatic ductal variations

A

Right posterior duct into the LHD

Right posterior into the CHD

Right posterior into the CHD bifurcation

Gastrointestinal (13 decks)

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