Biliary System

Question 1

Which of the following is most likely to deem a cholangiocarcinoma irresectible?

A. Left hepatic artery invasion

B. PV branch to one lobe and hepatic artery to other lobe invaded

C. Right portal vein invasion

D. Size > 2cm

E. Biliary duct dilatation

Answer 1

B. PV branch to one lobe and hepatic artery to other lobe invaded

Irresectable tumours include those with main PV or main HA invasion, those with both right and left PV or both right and left HA involvement, or involvement of a PV branch to one lobe and a HA branch to other lobe

Question 2

Which of the following is not a feature of Mirrizzi sign?

A. Jaundice

B. Dilated Common Bile Duct (CBD) below level of impactedStone

C. Gall stone impacted in gall bladder neck

D. Dilatation of bile ducts above level of cystic duct

E. Smooth curved segmental stenosis of Common Hepatic Duct (CHD)

Answer 2

B. Dilated Common Bile Duct (CBD) below level of impactedStone

In Mirrizzi’s sign, the CBD below the level of the impacted gallstone is not dilated.

Question 3

Which of the following is a cause of non-visualisation of the gall bladder with trimethylbromo-im–indol acetic acid (TBIDA) and no bowel activity?

A. Acute cholecystitis

B. IV feeding

C. Biliary pancreatitis

D. Opiate usage

E. Severe diffuse hepatocellular disease

Answer 3

D. Opiate usage

Opiates, severe hepatitis and CBD obstruction are causes of non-visualisation and no bowel activity. Other cause bowel activity.

Question 4

1. A 64-year-old woman presents with jaundice. An abdominal ultrasound scan demonstrates the intrahepatic biliary ducts to be of similar calibre to the adjacent portal veins. The extrahepatic common bile duct measures 5 mm in diameter. No gallstones are seen. What is the most appropriate further imaging investigation?

A. CT of the abdomen

B. endoscopic ultrasound scan

C. MRCP

D. ERCP

E. no imaging indicated as normal findings

Answer 4

C. MRCP

Intrahepatic bile ducts are considered dilated when they exceed 40% of the diameter ofthe adjacent portal veins.

The upper limit of normal for the extrahepatic common bile duct is 5mm in adults (increasing after age 60 by approximately1mm /decade).

Appearances here are indicative of biliary obstruction at the level of the hilum, and MRCP is the investigation of choice after ultrasound scan in these circumstances.

MRCP reliably demonstrates the extent of ductal involvement, allowing planning of surgery or treatment; with malignant causes, it may provide further staging information.

CT is the investigation of choice when ultrasound scan indicates obstruction below the hilum.

If ultrasound scan demonstrates ductal stones, ERCP is the investigation of choice for confirmation and therapeutic intervention. Endoscopic ultrasound scan is particularly useful for detecting small ductal stones and periampullary tumours.

Percutaneous transhepatic cholangiography is reserved for cases when ERCP isnot possible.

Question 5

2. A 40-year-old woman undergoes abdominal ultrasound scan, which demonstrates three small, rounded, echogenic structures in relation to the anterior wall of the gallbladder. There is no posterior acoustic shadowing, and appearances remain constant with variation in patient position. The remainder of the gallbladder and biliary tree appear unremarkable. What is the most likely diagnosis?

A. gallstones

B. cholesterol polyps

C. adenomyomatosis

D. gallbladder carcinoma

E. strawberry gallbladder

Answer 5

B. cholesterol polyps

Cholesterolosis is a form of hyperplastic cholecystosis in which triglycerides, cholesterolprecursors and cholesterol esters accumulate within the lamina propria of the gallbladder wall.

Most cases are of the planar type, termed ‘strawberry gallbladder’ afterthe resemblance of the gallbladder mucosa to the surface of a strawberry, and produceno detectable ultrasound changes.

In a minority of cases, cholesterol polyps are formed, which are the commonest type of gallbladder polyp.

They are generally small, multiple echogenic lesions adjacent to the gallbladder wall.

Non-mobility and a lack of posterior acoustic shadowing helps to distinguish polyps from gallstones. Small size and multiplicity distinguish them from gallbladder malignancy, though, rarely, metastatic disease may produce multiple polypoid lesions, particularly malignant melanoma.

Adenomyomatosis, the other form of hyperplastic cholecystosis, results in mucosal hyperplasia and thickening of the muscular layer of the gallbladder. It is characterized bybright reflections and comet-tail artefacts from the gallbladder wall on ultrasound scan

Question 6

3. A 36-year-old man with ulcerative colitis develops progressive jaundice and pruritis. CT of the abdomen demonstrates multiple areas of dilatation and stenosis of tortuous intrahepatic bile ducts, with wall thickening and contrast enhancement of the extrahepatic bile ducts. What is the most likely diagnosis?

A. primary sclerosing cholangitis

B. choledocholithiasis

C. primary biliary cirrhosis

D. ascending cholangitis

E. chronic pancreatitis

Answer 6

A. primary sclerosing cholangitis

Primary sclerosing cholangitis is an idiopathic, progressive, fibrosing, inflammatory disorder of the biliary tree, causing multifocal strictures, cholestasis and biliary cirrhosis.

There is an association with inflammatory bowel disease and autoimmune conditions.

In most cases, both intra- and extrahepatic ducts are involved, and classic appearances oncholangiography are of a ‘string-of-beads’ appearance with alternating segments of dilatation and stenosis.

Biliary cirrhosis develops in up to 49% of cases, and there is an increased risk of cholangiocarcinoma.

In primary biliary cirrhosis, disease is limited tothe intrahepatic bile ducts.

In ascending cholangitis, there may be biliary dilatation and pneumobilia, but multifocal strictures are not a feature.

CT features of choledocholithiasis include biliary dilatation and visualization of a stone in the bile duct, but again strictures are not a feature.

Chronic pancreatitis may result in a smooth inflammatory stricture of the intrapancreatic portion of the common bile duct.

Question 7

4. In a 67-year-old female patient with jaundice and gallbladder wall thickening on ultrasound scan, which feature on CT favours a diagnosis of xanthogranulomatous cholecystitis rather than gallbladder carcinoma?

A. pericholecystic fat infiltration

B. intramural hypoattenuating nodules throughout the gallbladder

C. biliary obstruction

D. hepatic extension

E. regional lymphadenopathy

Answer 7

B. intramural hypoattenuating nodules throughout the gallbladder

Xanthogranulomatous cholecystitis (XGC) is an uncommon inflammatory disease of thegallbladder, which is characterized by multiple intramural nodules and proliferative fibrosis. It is thought to result from rupture and extravasation of bile and mucus following the occlusion of Rokitansky–Aschoff sinuses. There is considerable overlap between the clinical and radiological features of XGC and gallbladder carcinoma. Pericholecystic infiltration, biliary obstruction, regional lymphadenopathy and hepatic involvement may be seen in both conditions, and the difference in incidence between the two conditions is not statistically significant. Only the presence of multiple intramural hypoattenuating nodules (representing xanthogranulomas) occupying a large area of the thickened gallbladder wall allows a diagnosis of XGC to be made with anydegree of certainty. Similar hypoattenuating intramural nodules (representing Hge and necrosis) may be seen less commonly in gallbladder carcinoma, butthese tend to occupy a much smaller proportion of the thickened gallbladder wall.

Question 8

5. During MRCP, which substance may be administered to improve visualization of the pancreatic ducts?

A. glucagon

B. secretin

C. cholecystokinin

D. gastrin

E. Buscopan

Answer 8

B. secretin

Secretin is a hormone normally secreted by the duodenal mucosa in response to acid within the lumen. It has many physiological effects on the gastrointestinal tract, including stimulation of pancreatic secretions and a transient increase in tone of the sphincter of Oddi. When given intravenously immediately prior to imaging, it results in distension of the pancreatic ductal system and can significantly improve visualization of the pancreatic main and branch ducts on MRCP, as well as provide information about the secretory reserve capacity of the pancreas. Effects on the biliary tree are less pronounced and not usually appreciable on imaging. Side effects include abdominal pain, bloating and diarrhoea.

Glucagon increases bile flow and has been suggested to improve visualization of the biliary tree at MRCP.

Cholecystokinin stimulates gallbladder contraction, and is sometimes used in hepatobiliary scintigraphy.

Buscopan is widely used in imaging for its inhibition of intestinal motility.

Question 9

6. For relief of malignant biliary obstruction by percutaneous stenting, which factor is an advantage of using a metallic rather than a plastic stent?

A. higher long-term patency rates

B. lower cost

C. easily removed if infection develops

D. does not shorten following deployment

E. higher surface area

Answer 9

A. higher long-term patency rates

Percutaneous or endoscopic biliary stenting is usually performed to relieve jaundice inpatients with malignant biliary obstruction.

Metallic or plastic stents may be used. Metallic stents have a larger internal diameter and have higher long-term patency ratesthan plastic stents,

as well as a low surface area that reduces bacterial colonization and subsequent fibrous deposition.

However, metallic stents become incorporated into thebile duct mucosa and are not easily removed, which may present particular problems ifthe stent becomes infected.

They are also prone to shortening following deployment, and a long-segment obstruction may therefore require multiple stents.

In addition, thecost of metallic stents is approximately 10 times that of plastic stents.

Question 10

7. A 22-year-old woman with known medullary sponge kidney presents with recurrent upper abdominal pain and jaundice. Cholangiography demonstrates segmental saccular dilatation of the intrahepatic bile ducts and ectasia of the extrahepatic ducts. What is diagnosis?

A. choledochocele

B. choledochal cyst

C. primary sclerosing cholangitis

D. Caroli’s disease

E. polycystic liver disease

Answer 10

D. Caroli’s disease

Caroli’s disease is a rare congenital disorder characterized by multifocal segmental saccular dilatation of intrahepatic bile ducts. It presents in childhood and earlyadulthood with upper abdominal pain, fever and transient jaundice.

Up to 80% of patients have associated medullary sponge kidney.

Typical CT findings are of multiplecystic structures with a central enhancing ‘dot’, representing portal vein radicles surrounded by dilated ducts.

Cholangiography is diagnostic and demonstrates saccular dilatation of intrahepatic ducts of up to 5cm in diameter, with frequent associated ectasia of extrahepatic ducts.

Choledochal cysts primarily cause cystic dilatation of CBD, but there may be associated IHBD. A

choledochocele is a cystic dilatation of intraduodenal portion of CBD.

Primary sclerosing cholangitis classically causes multifocal strictures of I&EHBD, alternating with segments of dilatation.

In polycystic liver disease, there is no communication of cysts with biliary tree.

Question 11

A 40-year-old man is found to have abnormal liver function whilst undergoing routine blood tests prior to abdominal surgery. Subsequent imaging demonstrates a relatively normal liver parenchyma but there is irregularity of the bile ducts with beading and short segment strictures. What is the most likely diagnosis?

(a) Autoimmune liver disease

(b) Viral hepatitis

(c) Primary biliary cirrhosis

(d) Cholangiocarcinoma

(e) Primary sclerosing cholangitis

Answer 11

(e) Primary sclerosing cholangitis

Primary sclerosing cholangitis is a biliary condition of unknown etiology that is more common in men (2:1) and often presents under the age of 45 years. It is associated with ulcerative colitis, sicca complex and retroperitoneal fibrosis and patients are at increased risk of developing cholangiocarcinoma.

Question 12

A 47-year-old lady attends for an US of her biliary system. Three comet-tail artefacts are seen arising from the anterior wall, which is slightly thickened. The remainder of the examination was unremarkable. What is the most likely cause?

(a) Adenomyomatosis

(b) Cholesterolosis

(c) Gall stones

(d) Chronic cholecystitis

(e) Porcelain gallbladder

Answer 12

(a) Adenomyomatosis

Adenomyomatosis is caused by mucosal hyperplasia with herniations of mucosa in to the thickened muscular layer (Rokitansky-Asqhinoffsinuses). Cholesterol crystals deposited in these sinuses give rise to the hyperechoic comet-tail artefacts from the anterior wall, clearly visible against the hypoechoic bile.

Question 13

@# 30 A patient a pyrexia of unknown origin is referred for a radio-labelled white cell scan with Tc-99m HMPAO. At which time points should imaging of the abdomen be performed?

(a) 1 and 3 hours

(b) 1, 3 and 6 hours

(c) 1 and 6 hours

(d) 1, 3 and 24 hours

(e) 1, 6 and 24 hours

Answer 13

(a) 1 and 3 hours

99mTC-HAMPAO begins to break down by 4 hours as it is not as stable as 111In; thereafter, breakdown products may be seen within the bile as and intestines.

Question 14

@# 31 A patient is referred for the investigation of right upper quadrant pain. US has equivocal findings and a HIDA examination is requested. At 35 minutes, there is little uptake within the liver, but renal excretion is noted. What is the most likely cause for these findings?

(a) Poor liver function

(b) Acute cholecystitis

(c) Poor renal function

(d) Sphincter Of Oddi dysfunction

(e) Chronic cholecystitis

Answer 14

(a) Poor liver function

Liver uptake should be seen within 10 minutes. Thereafter, there is filling of the gallbladder and subsequent excretion to the bowel. Cholecystitis impairs uptake to the GB.

Question 15

46 A patient with a biopsy proven cholangiocarcinoma undergoes imaging which demonstrates that the tumour is confined to the bile duct. How would you classify this?

(a) Bismuth I

(b) Bismuth II

(c) Bismuth III

(d) Bismuth IV

(e) Bismuth V

Answer 15

(a) Bismuth I

A type II stricture extends in to the 1st order ducts. A type III stricture involves 2nd order ducts in either the right (IIIA) or left (IIIB) side, whilst type IV involve 2nd order ducts bilaterally. There is no type V. This classification is used to plan surgery.

Question 16

12 Which of the following is not considered to be a risk factor for the development of cholangiocarcinoma?

(a) Tobacco smoking

(b) Heavy alcohol consumption

(c) Hepatitis C virus

(d) Polyvinyl chloride exposure

(e) Caroli disease

Answer 16

(a) Tobacco smoking

Tobacco smoking is not associated with cholangiocarcinoma, but there are a large number of other associations, including viral agents (HIV, HBV, EBV), liver flukes, heptolithiasis, primary sclerosing cholangitis and biliary anomalies.

Question 17

32 A 47-year-old lady with right upper quadrant pain undergoes an US. This demonstrates gallbladder calculi and focal thickening of the wall at the fund us of the gallbladder. The patient undergoes an MRCP to further evaluate this which shows multiple foci of high signal within the wall of the GB on the T2 weighted images in addition to the calculi. What is the most likely diagnosis?

(a) Acute cholecystitis

(b) Chronic cholecystitis

(c) Gallbladder carcinoma

(d) Adenomyomatosis

(e) Xanthogranulomatouscholecystitis

Answer 17

(d) Adenomyomatosis

Adenomyomatosis of the gall bladder is characterised by deep, branching invaginations into the thickened GB wall. Seen in approximately 8% GB specimens, and associated with gallstones (90% cases), it is more common in women and often presents with RUQ pain. There are both diffuse and focal forms. The ‘string of beads’ sign in the GB wall is the hallmark of the disease on MRI and is said to be highly specific in differentiating it from carcinoma.

Question 18

38 A 35-year-old man undergoes abdominal US. The report reads: ‘ ‘The liver has a coarse echotexture and there appear to be multiple areas of saccular dilatation of the intrahepatic bile ducts, but no strictures. The CBD is normal. The spleen measures 16 cm. Note is also made of bilateral renal cysts.” What is the most likely diagnosis?

(a) Primary sclerosing cholangitis

(b) Primary biliary cirrhosis

(c) AIDS cholangiopathy

(d) Caroli’s disease

(e) Polycystic liver disease

Answer 18

(d) Caroli’s disease

These are the typical findings at US or MRI. Complications include biliary stasis, cholangitis and abscesses. The coarse echotexture would be in keeping with hepatic fibrosis (not a feature of polycystic disease), Whilst PSC and AIDS cholangiopathy have thickening of the bile ducts with strictures. Caroli’s disease is associated with renal cysts and medullary sponge kidney.

Question 19

54 A 56-year-old lady with jaundice undergoes an MRCP. This demonstrates a gallstone impacted in the neck of the gallbladder. The gallbladder wall is thickened and there is intrahepatic duct dilatation due to the gall bladder com pressing the common bile duct. What is the diagnosis?

(a) Caroli’s disease

(b) Klatskin syndrome

(c) Choledocholithiasis

(d) Mirizzi syndrome

(e) Cholangitis

Answer 19

(d) Mirizzi syndrome

This is Mirizzi syndrome. The inflamed gallbladder compresses the CBD to result in obstructive jaundice. Patients often have a low insertion of the cystic duct in the common bile duct.

Question 20

61 A 46-year-old woman is diagnosed with HIV cholangiopathy. What is the most likely causative organism?

(a) Cryptosporidium

(b) Clonorchis

(c) Ascaris

(d) E. coli

(e) Fasciolahepatis

Answer 20

(a) Cryptosporidium

HIV (or AIDS) cholangiopathy is due to opportunistic infection, most commonly with Cryptospordium, in patients with established HIV infection. Features include duct thickening, strictures and duct dilatation.

Question 21

74 An otherwise well 35-year-old man undergoes an US of the liver which shows a heterogeneous echotexture. Subsequent CT and MRI images demonstrate that the liver is normal in size and has a smooth contour, but that there are innumerable tiny lesions throughout measuring less than 5 mm in diameter. These are predominantly cystic in nature, although a small solid component is present, and return a high signal T2-weighted images. What is the most likely diagnosis?

(a) Polycystic liver disease

(b) Metastases

(c) Caroli disease

(d) Biliary hamartomas

(e) Primary sclerosing cholangitis

Answer 21

(d) Biliary hamartomas

These are the typical appearances of biliary hamartomas (von Meyenberg complexes), a benign abnormality of the ductal plate which may be misinterpreted as metastases.

Question 22

22. A 41 year old woman has an outpatient ultrasound scan for intermittent right upper quadrant pain. Five 5 mm gallstones and sludge are present. In addition, there is wall thickening of the gallbladder fundus with multiple foci of increased echogenicity within the wall, each associated with bright artefacts deep to them. Which one of the following is the most likely diagnosis?

a. Porcelain gallbladder

b. Emphysematous cholecystitis

c. Acute cholecystitis

d. Adenomyomatosis of the gallbladder

e. Gallbladder carcinoma

Answer 22

22. d. Adenomyomatosis of the gallbladder

The correct diagnosis is adenomyomatosis. This is an uncommon condition, more common in females, and is associated with gallstones in the majority of cases. It is characterised by generalised or focal mural thickening with intramural diverticula (Rokitansky–Aschoff sinuses). The ultrasound artefact from cholesterol crystals in the sinuses produces bright ‘comet-tail’ reverberation artefacts.

Question 23

23. A 32 year old man has an ultrasound scan for obstructive jaundice. Areas of intrahepatic duct dilatation are seen, with increased echogenicity of the portal triads. ERCP reveals alternating segments of dilatation and stenosis of both the intra- and extrahepatic ducts. Which one of the following diagnoses is most likely?

a. Primary sclerosing cholangitis

b. Primary biliary sclerosis

c. Ascending cholangitis

d. Choledochal cyst

e. Congenital hepatic fibrosis

Answer 23

23. a. Primary sclerosing cholangitis

These ultrasound and ERCP features are typical of primary sclerosing cholangitis, which is an idiopathic condition characterised by progressive fibrosis of the biliary tree. It primarily affects young men with inflammatory bowel disease (more common in ulcerative colitis than Crohn’s) although pancreatitis, liver cirrhosis and chronic active hepatitis are other associated conditions. Primary biliary cirrhosis may also cause scattered areas of focal intrahepatic duct dilatation, but this condition is much more common in females and the extrahepatic ducts are not involved.

Question 24

24. A neonate is investigated for obstructive jaundice and as part of the investigation has a hepatobiliary iminodiacetic acid (HIDA) nuclear medicine scan. This shows a photopaenic area within the liver and lack of visualisation of the small bowel. Which one of the following conditions would be most consistent with these findings?

a. Enteric duplication cyst

b. Biliary duct atresia

c. Choledochal cyst

d. Pancreatic pseudocyst

e. Hepatic cyst

Answer 24

24. c. Choledochal cyst

The only one of the listed diagnoses that would have both these features on HIDA scan is a choledochal cyst. This is a congenital condition characterised by dilatation of the common bile duct and common hepatic duct. Patients typically present in childhood with right upper quadrant pain, a mass and/or obstructive jaundice. Although the diagnosis is usually made with MRCP, HIDA scan can show typical features that include a photopaenic area in the liver representing the dilated CBD/CHD. Although a hepatic cyst would also show a photopaenic area within the liver, small bowel visualisation would be expected. Congenital biliary atresia would cause lack of small bowel visualisation, but the whole liver would take up HIDA and photopaenia would not be present.,

Question 25

A 71 year old female is admitted via A&E with abdominal pain, abdominal distension and vomiting. Plain abdominal film shows multiple dilated loops of small bowel. In addition there is gas projected over the liver shadow which is prominent centrally and has a branching appearance. Gas is not visible over the periphery of the liver. No other abnormality is seen on the plain film. Which of the following diagnoses is most likely? a. Small bowel perforation b. Small bowel infarction c. Gallstone ileus d. Emphysematous cholecystitis e. Pneumatosis intestinalis

Answer 25

c. Gallstone ileus Specific signs of gallstone ileus can be seen on the plain abdominal film in up to 40% of patients. Fifty per cent of patients have evidence of small bowel obstruction and up to 30% have gas in the biliary tree. Biliary tree gas is typically more prominent centrally and spares the periphery of the liver, whereas portal venous gas is more easily visualised in the periphery of the liver, which may be associated with small bowel infarction. The gallstone most frequently lodges in the terminal ileum, but is often not seen on the plain film. The presence of small bowel obstruction, pneumobilia and a visible stone are called Rigler’s triad.

Question 26

45. A 39 year old woman has an ultrasound scan for right upper quadrant pain and jaundice which reveals biliary ductal dilatation to the level of the common hepatic duct adjacent to a stone in the gallbladder neck. The gallbladder is thick-walled and tender. MRCP confirms these findings and excludes common duct stones. Which one of the following is the most likely diagnosis? a. Primary sclerosing cholangitis b. Mirizzi syndrome c. Caroli’s disease d. Fascioliasis e. Acute cholecystitis

Answer 26

45. b. Mirizzi syndrome Mirizzi syndrome is narrowing of the common hepatic duct caused by a gallstone impacted in the neck of the gallbladder or the cystic duct. The stricture is smooth and often concave to the right as seen on ERCP. Fistulae can develop between the gallbladder and the common duct, and the stone may pass into the common duct. It is associated with acute cholecystitis. Fascioliasis is caused by liver fluke infestation which may cause bile duct wall thickening and multiple hepatic abscesses. Caroli’s disease is a congenital disorder characterised by cystic dilatation of the intrahepatic bile ducts.

Question 27

60. A 60 year old male has an abdominal ultrasound for the investigation of deranged LFTs. A 2 cm hyperechoic mass is seen at the porta hepatis. There is dilatation of the right and left hepatic ducts but the common bile duct is of normal calibre. A PET-CT is performed which shows an FDG-avid lesion corresponding to the abnormality on ultrasound and no other findings. Which of the following is the most likely diagnosis? a. Caroli’s disease b. Klatskintumour c. Periampullary tumour d. Primary sclerosing cholangitis e. Biliary cystadenoma

Answer 27

60. b. Klatskintumour Klatskin tumours are the most common form of cholangiocarcinoma, representing tumour at the confluence of the hepatic ducts. The finding of a hyperechoic central porta hepatis mass at ultrasound is typical. Risk factors include inflammatory bowel disease, primary sclerosing cholangitis, Caroli’s disease and cholecystolithiasis. Cholangiocarcinomas have a very poor prognosis with a five-year survival of less than 2%. They are FDG-avid and PET-CT is typically performed in the pre-operative evaluation of these tumours.

Question 28

A 48-year-old woman is noted to have elevated liver enzymes on blood tests performed by her GP. She attends the radiology department and an abdominal ultrasound is performed. This demonstrates moderate diffuse fatty infiltration of the liver and thickening of the wall of the gallbladder fundus. Hyperechoic foci are seen in the gallbladder wall with ‘ring-down’ reverberation artefacts. There is no acoustic shadowing. What is the most likely diagnosis? A Adenomyomatosis B Chronic cholecystitis C Multiple gallstones with acute cholecystitis D Porcelain gallbladder E Xanthogranulomatous Cholecystitis

Answer 28

ANSWER: A Cholesterol crystals within Rokitansky-Aschoff sinuses produce the characteristic ‘comet tail’ or ring-down artefact seen in adenomyomatosis. Both gallbladder carcinoma and adenomyomatosis can cause focal wall thickening in the gallbladder, but the visualisation of hyperechoic sinuses is typical of the latter. A porcelain gallbladder is a complication of chronic cholecystitis causing mural calcification: the gallbladder wall appears hyperechoic with marked acoustic shadowing.

Question 29

@#e A 64-year-old woman presents to her GP with increasing discomfort in her upper abdomen and anorexia. There is a past medical history of gallstones. The GP requests an abdominal ultrasound and this demonstrates a 6 x 4 cm mixed echogenicity lesion in the gallbladder fossa, with the gallbladder not separately visualised. On CT, the gallbladder fossa mass demonstrates central low attenuation with peripheral enhancement and mild intrahepatic biliary dilatation. Low attenuation lymph nodes are present at the porta hepatis(measuring up to 1.5 cm short axis). Which diagnosis is most likely? A Adenomyomatosis B Gallbladder carcinoma C Hepatocellular carcinoma D Porcelain gallbladder E Xanthogranulomatous cholecystitis

Answer 29

B Gallbladder carcinoma A gallbladder fossa mass with little/no visible normal gallbladder and hilarbiliary obstruction is highly suggestive of gallbladder carcinoma.

Question 30

A 64-year-old man sees his GP with a 2-month history of unexplained weight loss. He has experienced right upper quadrant discomfort and blood tests show an elevated bilirubin and gamma glutamyltransferase (GGT) with grossly elevated alkaline phosphatase. An abdominal ultrasound performed 6 months ago was normal with no evidence of gallstones. Which factor would not increase this patient's risk of cholangiocarcinoma? A Caroli's disease B Clonorchissinensis infection C Exposure to iohexol15 years ago D Primary sclerosing cholangitis E Type 1 choledochal cyst

Answer 30

C Exposure to iohexol15 years ago Iohexol is a widely used low osmolar contrast medium and does notconfer increased risk of biliary tract malignancy. Previous exposure to Thorotrast (thorium dioxide) is a recognised risk factor, however.

Question 31

A 74-year-old man attends the Radiology Department for an abdominal ultrasound examination. He has a 2-month history of nausea and vomiting with unexplained weight loss. On ultrasound, there are linear structures of high reflectivity seen within liver segments 2-4. On turning into the left lateral decubitus position, similar hyperechoic structures become visible in the right lobe of liver. What additional medical history would explain these findings? A Autosomal dominant polycystic kidney disease B ERCP and sphincterotomy C Previous Pneumocystis jiroveci (carinii) infection D Right hemicolectomy for colorectal cancer E Wilson's disease

Answer 31

B ERCP and sphincterotomy The ultrasound findings are typical of pneumobilia. Other causes include an incompetent sphincter of Oddi (usually elderly patients) and a surgical procedure involving a Roux loop.

Question 32

A 49-year-old man is involved in a road traffic accident and sustains serious head and chest injuries. He is ventilated on the intensive care unit and his injuries are managed conservatively. Ten days later, he develops a temperature of 39.5°, becomes tachycardic and requires inotropic support to maintain his blood pressure. An abdominal ultrasound is performed and shows a cystic structure in the right upper quadrant measuring 12 x 8 cm in size. The mass has a 6-mm thick wall, contains a layer of echogenic material and is surrounded by a rim of fluid. What is the most likely diagnosis? A Acalculous cholecystitis B Acute cholangitis C Gallbladder haematoma D Traumatic hepatic artery pseudoaneurysm E Xanthogranulomatous cholecystitis

Answer 32

A Acalculous cholecystitis Acalculous cholecystitis should always be considered in the seriously ill patient who develops unexplained sepsis.

Question 33

QUESTION 50 A 38-year-old woman presents to her GP with a 3-month history of lethargy, nausea and itching. She was diagnosed with ulcerative colitis 8 years ago and has been treated with short courses of steroids and long-term oral mesalazine. Blood tests demonstrate an elevated serum bilirubin with markedly high alkaline phosphatase. MRCP demonstrates multiple biliary strictures with small diverticulae arising from the common duct. Which statement is true regarding the underlying diagnosis? A Ten to 20% of patients have inflammatory bowel disease. B Cessation of anti-inflammatory medication leads to normalisation of the liver function tests. C It is also known as the type 5 choledochal cyst. D Only the extrahepatic biliary ducts are involved. E There is a significant increased risk of cholangiocarcinoma

Answer 33

E There is a significant increased risk of cholangiocarcinoma Up to 10% of patients with primary sclerosing cholangitis will develop cholangiocarcinoma.

Question 34

10. A 65-year-old man presents with weight loss and obstructive jaundice. An ultrasound reveals dilatation of the intra- and extrahepatic biliary system. MRCP reveals a stricture in the distal common bile duct (CBD). The patient becomes septic and biliary drainage is required. Which is the most appropriate method for this? A. Percutaneous transhepatic cholangiography (PTC) and external drainage. B. PTC with internal/external drainage. C. ERCP with plastic stent insertion. D. ERCP with metal stent insertion. E. PTC/ERCP rendezvous procedure.

Answer 34

10. C. ERCP with plastic stent insertion. PTC is an appropriate approach, but biliary sepsis can cause bacteremia during PTC and thus ERCP is preferable in this case, if possible. Contraindications to PTC include prothrombin time greater than 2 seconds higher than control, platelet count less than 100,000, ascites, hydatid disease, and lack of access to surgical facilities. If an ERCP were to fail, the other options would be viable alternatives. Metal stent insertion at the first instance is inappropriate unless it is known that the biliary dilatation is due to inoperable malignancy. This is because metal stents cannot be removed, whereas the plastic variety can be removed, if necessary.

Question 35

17. A 72-year-old male patient presents to the surgical team with a 3-week history of increasing painless jaundice. He has a past medical history of gallstones, prostatic carcinoma, and ischaemic heart disease. There is no history of alcohol abuse. The LFTs are abnormal. Serum bilirubin is 346. He is referred for an ultrasound scan of the abdomen, which identifies grossly dilated intrahepatic bile ducts, but no evidence of a dilated CBD. The common hepatic duct (CHD) is not clearly visible due to an isoechoic mass in the region of the porta hepatis at the ductal confluence. A triple phase CT scan of the liver is carried out. The lesion is iso- to hypoattenuating. There is limited arterial enhancement, with some portal venous enhancement peripherally. On delayed images the lesion displays enhancement with mild peripheral washout. What is the most likely pathology? A. Cholangiocarcinoma. B. Portal metastasis. C. Hepatocellular carcinoma. D. Benign biliary stricture. E. Cavernous haemangioma.

Answer 35

17. A. Cholangiocarcinoma. Specifically, a Calfskin tumour, as it occurs at the porta hepatis. Cholangiocarcinoma can be iso- to hyperechoic on ultrasound. On CT and MRI, it shows delayed enhancement in 74%. Many conditions predispose to cholangiocarcinoma and gallstones are identified in 20–50% of patients with cholangiocarcinoma. Hepatocellular carcinoma would be the next most likely diagnosis. It can have a variable ultrasonographic appearance. Hepatocellular carcinoma usually demonstrates arterial phase enhancement (80%). Prostate does not commonly metastasize to the liver and would again demonstrate arterial phase enhancement classically. Whilst haemangiomas are classically hyperechoic on ultrasound, larger lesions can appear heterogeneously hypoechoic (40%).

Question 36

18. A patient is admitted with right upper quadrant (RUQ) pain to the surgical team and is referred for ultrasound. On the ultrasound there is a curvilinear echogenic line at the margin of the gallbladder and posterior acoustic shadowing in the gallbladder fossa. There is no evidence of peristalsis and the shadowing does not change on patient positioning. The sonographer states that the patient’s pain has settled and they are otherwise well. What is the most likely cause of this appearance? A. Bowel in the gallbladder fossa. B. Porcelain gallbladder. C. Gallstones. D. Emphysematous cholecystitis. E. Post-ERCP.

Answer 36

18. B. Porcelain gallbladder. It can sometimes be difficult to see a cause for this appearance, and a number of the given options could result in it. However, peristalsis should be seen in a healthy patient if the abnormality is due to bowel. With gallstones, the appearance should change on positioning. There is no mention of an ERCP in the history, and whilst air in the biliary tree is common after sphincterotomy, it is often only seen in the gallbladder immediately after the procedure. Patients with emphysematous cholecystitis are usually clinically unwell and are unlikely to be asymptomatic. Porcelain gallbladder is associated with gallstones in 90% of cases. It is a relevant finding to make as 10–20% of patients develop carcinoma of the gallbladder.

Question 37

26. A 45-year-old male presents with a history of jaundice and RUQ pain. An ultrasound of the abdomen demonstrates an impacted calculus in the gallbladder neck with dilatation of the intrahepatic ducts. An MRCP is requested to exclude Mirizzi syndrome. What additional features on MRCP confirm the diagnosis of Mirizzi syndrome? A. Dilated common hepatic duct. B. Dilated common hepatic and common bile ducts. C. Dilated common hepatic duct with normal common bile duct. D. Double duct sign. E. Normal ducts.

Answer 37

26. C. Dilated common hepatic duct with normal common bile duct. Mirizzi syndrome is a functional hepatic syndrome caused by extrinsic compression of the CHD by a calculus impacted in the gallbladder neck or cystic duct. Low insertion of the cystic duct into the CHD is a predisposing factor. Typical features at imaging include extrinsic compression of the CHD, a gallstone in the gallbladder neck or cystic duct, dilatation of the intrahepatic ducts and CHD proximally, and a normal CBD. Rarely, inflammation around an impacted calculus leads to a stricture formation mimicking a periductal infiltrating cholangiocarcinoma.

Question 38

27. A 60-year-old diabetic male presents with a history of fever and right upper quadrant pain. Ultrasound of the abdomen demonstrates curvilinear high-amplitude echoes in the gallbladder wall with reverberation artifact and multiple high-amplitude echoes in the gallbladder lumen. What is the diagnosis? A. Acute cholecystitis. B. Emphysematous cholecystitis. C. Adenomyomatosis. D. Chronic cholecystitis. E. Cholesterosis.

Answer 38

27. B. Emphysematous cholecystitis. This is a rare form of acute cholecystitis. The majority of patients are between 50 and 70 years of age. It is more common in men (male to female ratio of 2:1) and in those with diabetes and peripheral vascular disease. Emphysematous cholecystitis is a surgical emergency because there is an increased risk of gallbladder perforation and increased mortality rate. The definitive treatment is cholecystectomy, although in critically ill patients percutaneous cholecystostomy may be used as a temporary measure.

Question 39

34. A patient presents to A&E with severe upper abdominal pain 4 days following a barium enema. There is no free air under the diaphragm on the erect CXR. There is mild elevation of the inflammatory markers, but the surgeon is concerned with the degree of peritonism and requests a CT scan of abdomen. On this, the small bowel is dilated to 5 cm, but is not thick-walled. The vascular structures enhance normally. There is inflammatory change noted around the duodenum. Linear areas of low attenuation are noted extending from the porta hepatis into the liver parenchyma. These do not extend to the margin of the liver and are in general central in their location. The Hounsfield attenuation value of these areas is approximately–1500 HU. Barium in the rectum obscures the images of the pelvis. What is the most likely pathology? A. Cholecystoduodenal fistula. B. Mesenteric infarction. C. Acute bowel obstruction. D. Perforated duodenal ulcer. E. Complication of barium enema.

Answer 39

34. A. Cholecystoduodenal fistula. The other answers are all causes of portal air, whereas the salient description is for air in the biliary tree.

Question 40

57. A patient has an ultrasound scan carried out on a radiographer’s ultrasound list. The radiographer notices an unusual finding and asks you to check the images. The liver, kidneys, and spleen appear unremarkable. There are gallstones in the gallbladder, but also in the fundus of the gallbladder, and there is a reverberation artefact that gives a comet tail appearance. This finding is pathognomonic of a condition. Which of the following statements is true regarding this condition? A. Adenomyomatosis is caused by abnormal deposits of cholesterol esters in foam cells in the lamina propria. B. Cholesterolosis is caused by the rupture of Rokitansky–Aschoff sinuses with subsequent intramural leak of bile causing an inflammatory reaction. C. Xanthogranulomatous cholecystitis is characterized by an increase in the number and height of glandular elements in the gallbladder. D. Xanthogranulomatous cholecystitis is associated with gallbladder carcinoma in around10% of cases. E. Adenomyomatosis is associated with Cholesterolosis in up to a third of patients.

Answer 40

57. E. Adenomyomatosis is associated with cholesterolosis in up to a third of patients. Option A describes the cause of cholesterolosis. Option B describes the features of xanthogranulomatous cholecystitis (XGC). Option C describes the features of adenomyomatosis. Option D is true, but the ultrasound features described are not those of XGC, so this is not true regarding the condition described in the clinical scenario. Adenomyomatosis and cholesterolosisare both classed as types of hyperplastic cholecystosis. Adenomyomatosis has two pathognomonic descriptions. Firstly, the ‘pearl necklace’ appearance on oral cholecystogram (OCG) (the same appearance can be seen on MRCP). Secondly, comet tail artefact seen on ultrasound, caused by reverberation artefact between cholesterol crystals in Rokitansky–Ashcoff sinuses.

Question 41

64. A patient presents to the surgeons with a known history of gallstones, for which she underwent an ERCP 2 years earlier. She has had recurring pain and mildly elevated liver function tests. She underwent an MRCP/MRI liver prior to consideration for surgery. This showed a number of 8-mm filling defects in the CBD. Which of the following MRI sequences is likely to be the most helpful in trying to determine if these filling defects are due to pneumobilia, as opposed to retained calculi? A. Axial T2 steady-state GE. B. Coronal thick slab MRCP. C. Three-dimensional volume coronal MRCP. D. Two-dimensional coronal oblique thin (4mm) MRCP. E. Axial T1 in phase and out of phase GE.

Answer 41

64. A. Axial T2 steady-state GE. Axial imaging is generally going to be better than coronal imaging when trying to distinguish between pneumobilia and calculi within the CBD. The biliary air causes an air/fluid level of air lying on top of fluid in a non-dependent position in the CBD and this is more easily appreciated on an axial image. Calculi tend to lie dependently within the CBD. As fluid is hyperintense on T2WI and hypointense on T1WI, and both air and calculi are hypointense on both these sequences, then both will stand out as being more conspicuous on T2WI.

Question 42

75. A 50-year–old male is admitted under the surgical team having presented with upper abdominal pain and raised inflammatory markers. Suspecting acute cholecystitis, an ultrasound is requested, but due to large body habitus there is poor visualization of his gallbladder. To further evaluate hepatobiliary scintigraphy using 99mTc-labelled iminodiacetic acid is arranged. Which of the following findings are consistent with acute cholecystitis? A. Non-visualization of the gallbladder at 1 and 4 hours. B. Non-visualization of the gallbladder at 1 hour but seen at 4 hours. C. Visualization of the gallbladder at 1 hour. D. Visualization of the gallbladder at 30 minutes after morphine administration. E. Hepatobiliary scintigraphy is not appropriate for investigation of acute cholecystitis.

Answer 42

75. A. Non-visualization of the gallbladder at 1 and 4 hours. Hepatobiliary scintigraphy is most commonly used to evaluate suspected acute cholecystitis. A minimum of 2 hours fasting is required. Following prompt uptake by the liver, the radiotracer is excreted into the biliary system and drains into the small bowel. Activity should be demonstrated within the gallbladder by 1 hour. Morphine can be used during the scan to relax the sphincter of Oddi, thus pushing radiolabeled bile into the gallbladder. Acute cholecystitis is characterized by non-visualization of the gallbladder at both 1 and 4 hours or at 30 minutes following morphine administration. Non-visualization of the gallbladder at 1 hour, but seen at 4 hours, is indicative of chronic cholecystitis. A false-positive diagnosis of acute cholecystitis can occur with previous cholecystectomy, gallbladder agenesis, and tumour obstructing the cystic duct.

Question 43

3- An oral cholecystogram was requested for a patient who had suspected obstruction of the cystic duct. When reviewing patient's history what is the most definite contraindication to the technique that should be excluded? a) Peritonitis b) Serious liver disease c) Post-operative ileus d) Acute pancreatitis e) History of atopy

Answer 43

Answer B: Serious liver disease Peritonitis, post-operative ileus and acute pancreatitis are relative contraindications.

Question 44

50- Elective CT colonography was performed on an otherwise well 70-year-old gentleman to investigate a recent change in bowel habit and a history of weight loss. Fortunately, no evidence of a colorectal malignancy was identified but there was an incidental finding that the gallbladder was in an unusual position. Where is the most common position for an ectopic gallbladder to lie? a) Beneath the left lobe of liver b) Intrahepatic c) Retrohepatic d) Within falciform ligament e) Within interlobar fissure

Answer 44

Answer A: Beneath the left lobe of liver Most frequent locations in descending order are beneath left lobe of liver, intraheptic, retrohepatic, within the falciform ligament, within the interlobar fissure, suprahepatic, and within the anterior abdominal wall.

Question 45

51- A middle-aged female underwent an ultrasound for right upper quadrant pain. This showed multiple gallstones in a thin-walled gallbladder with no intrahepatic biliary duct dilatation. The common bile duct was not dilated and did not contain any gallstones. What is the likely composition of this patient's gallstones? a) Calcium b) Calcium bilirubinate c) Cholesterol d) Cysteine e) Urate

Answer 45

Answer C: Cholesterol Seventy per cent of gallstones are either made up completely or partly of cholesterol. Thirty per cent are black pigment stones made up of predominantly calcium bilirubinate.

Question 46

52- A fit 67-year-old female underwent an ultrasound to investigate right upper quadrant pain which demonstrated an abnormal gallbladder. Further imaging with CT confirmed a diagnosis of a porcelain gallbladder. What is the probability of a carcinoma developing in such patients? a) 1% b) 15% c) 50% d) 85% e) 99%

Answer 46

Answer B: 15 % Porcelain gallbladder is rare but is associated with chronic cholecystitis. The incidence of carcinoma has been reported at 10-30%, therefore cholecystectomy is often advised.

Question 47

53- A 40-year-old woman was admitted to the Neuro-ITU after a subarachnoid bleed and on day nine developed systemic inflammatory response syndrome (SIRS). She had, by this stage, been successfully weaned off the ventilator and her chest radiograph and urine cultures were normal. Blood cultures grew Salmonella. A limited portable transabdominal ultrasound showed free fluid in the upper abdomen. What is the most likely diagnosis? a) Acute pancreatitis b) Perforated peptic ulcer disease c) Portal vein thrombosis d) Acute cholecystitis e) Ruptured abdominal aortic aneurysm

Answer 47

d) Acute cholecystitis

Question 48

54- A 40-year-old woman underwent transabdominal ultrasound for investigation of right upper quadrant pain two days after an uncomplicated laparoscopic cholecystectomy. This showed a moderate volume of subhepatic free fluid, but a normal common bile duct (CBD). A diagnostic aspirate of this fluid showed it contained bile. What complication is she most likely to have suffered? a) Clipping of the CBD b) Transection of the CBD c) Liver haemorrhage d) Injury to the duct of Luschka e) Subhepatic abscess

Answer 48

Answer D: Injury to the duct of Luschka An accessory biliary duct can be injured despite good visualisation of the CBD.

Question 49

55- A patient presented unwell with abdominal pain and bilious vomiting. They had previously suffered from episodes of acute cholecystitis secondary to gallstones. On this occasion initial investigations showed abnormal liver function tests and a plain abdominal radiograph demonstrated an ileus. The surgical team requested a CT as they were concerned of the possibility of a biliary-enteric fistula. A contrast-enhanced abdominal CT was performed and pneumobilia was noted. What other feature would most support the diagnosis of a biliary-enteric fistula? a) Distended gallbladder with a thickened wall up to 5 mm b) Gallbladder totally collapsed around multiple small gallstones c) Shrunken gallbladder mimicking a diverticulum of the duodenal bulb d) Shrunken gallbladder with a thickened wall up to 5 mm e) Thick-walled gallbladder directly adjacent to the duodenal bulb

Answer 49

Answer C: Shrunken gallbladder mimicking a pseudodiverticulum of duodenal bulb. Ninety per cent of cholecystoduodenal fistulae are associated with perforation due to gallstones. Radiological appearances include pneumobilia and the presence of a shrunken gallbladder mimicking a diverticulum of the duodenal bulb.

Question 50

56- A 23-year-old female with a history of vague upper abdominal pain was investigated with an ultrasound which demonstrated multiple cystic structures converging towards the porta hepatis and communicating with the bile ducts. Cholangiography showed ectactic intrahepatic ducts extending to the periphery and the common bile duct was also dilated. What is the most likely diagnosis? a) Biliary hamartoma b) Caroli's disease c) Primary biliary cirrhosis d) Primary sclerosing cholangitis e) Pyogenic cholangitis

Answer 50

Answer B: Caroli's disease Caroli's disease is a rare congenital condition with multifocal segmental cystic dilatation of the large intrahepatic bile ducts, which communicates with the biliary tree.

Question 51

57- A previously well elderly male patient was admitted with painless obstructive jaundice. Upper abdominal ultrasound showed intrahepatic duct dilatation but normal-calibre extrahepatic ducts. Percutaneous transhepatic cholangiography with separate left and right duct system punctures demonstrated dilated but otherwise normal intrahepatic ducts. The central ducts were not opacified. What is diagnosis? a) Inflammatory biliary stricture b) Klatskintumour c) Pancreatic head tumour d) Primary biliary cirrhosis e) Primary sclerosing cholangitis

Answer 51

Answer B: Klatskintumour Hilar cholangiocarcinoma (Klatskintumour) is a common cause of biliary obstruction in older patients. Lack of communication between the lt and Rt-IHD and normal calibre extrahepatic ducts are typical findings. Apart from the ductal abnormalities CT findings may be subtle. The tumour mass is often isodense and may show delayed enhancement.

Question 52

58- A 40-year-old woman with a one-year history of symmetrical metacarpophalangeal joint arthritis and a dry mouth was admitted with abdominal distension. She underwent a contrast-enhanced CT of her liver which showed ascites, marked caudate hypertrophy and scattered dilated intrahepatic ducts. Her common bile duct measured 5 mm. What is the most likely diagnosis? a) Primary sclerosing cholangitis b) Obstructive cholangiolithiasis c) Primary biliary cirrhosis d) Alcoholic hepatitis e) Haemochromatosis

Answer 52

Answer C: Primary biliary cirrhosis This is a chronic non-supperative cholangitis and is associated with autoimmune disorders including rheumatoid arthritis, scleroderma, and Hashimoto's thyroiditis. Sixty-six to one hundred per cent have Sjogren's syndrome symptoms. CT signs include dilated intrahepatic ducts that do not appear to communicate with the main ducts and a hyperattenuating hypertrophied caudate lobe (in 98%) surrounded by hypoattenuating rind-like right lobe (pseudotumour) with a shrunken lateral left lobe.

Question 53

59- A 55-year-old man was investigated for weight loss and jaundice. A contrast enhanced CT showed dilated intrahepatic biliary ducts, a common bile duct of 12-mm and a pancreatic duct of 3-mm diameter. No causative mass was seen but an ampullary tumour was suspected. What is most sensitive technique for local staging? a) CT b) Endoscopic ultrasound c) ERCP d) MRCP e) Laparoscopy

Answer 53

Answer B: Endoscopic ultrasound 85 % staging accuracy.

Question 54

An 80-year-old man was admitted with epigastric pain. A transabdominal ultrasound revealed two large epigastric cysts which appeared simple, and a contrast-enhanced CT showed them to be intrahepatic cysts occupying the left lobe and associated with marked left lobar atrophy. There was right lobar intrahepatic duct dilatation but the common bile duct was of normal calibre. What should be the next appropriate step in his management? a No follow-up b Repeat transabdominal ultrasound in three months c Interval CT in six months d MRI liver e Diagnostic aspiration

Answer 54

Answer D: MRI liver Although these may be simple cysts, they should not cause left lobar atrophy or right lobar intrahepatic duct dilatation. There must be a concern of an isodense malignancy at the porta and MRI should be the next investigation.

Question 55

50- An overweight elderly female patient with a strong smoking history had an ultrasound of her abdomen and pelvis. Her gallbladder contained some small stones and the wall measured 2-mm thick except for an irregular focal area that was 6-mm thick. There was no acoustic shadowing from this thickened area. The gallbladder was of normal volume and the bile ducts were not dilated. What is the most likely diagnosis? a) Carcinoma of the gallbladder b) Hyperplastic cholecystoses c) Inflammatory polyp d) Metastases from malignant melanoma e) Wall-adherent gallstone

Answer 55

Answer A: Carcinoma of the gallbladder An irregular focal area of wall thickening is suggestive of gallbladder carcinoma. Risk factors include increased body mass, female gender, post-menopausal status and cigarette smoking. In up to 90% of gallbladder carcinomas cholelithiasis is present.

Question 56

51- A middle-aged male underwent an ultrasound of his abdomen which showed sludge within a thin walled gallbladder and no calculi. How likely is it that this patient will go on to develop gallstones? a) 0% b) 5-15% c) 30-45% d) 60-70% e) 95%

Answer 56

Answer B: 5-15 % Sludge on ultrasound is seen as dependent echoes that do not cause shadowing. Common causes are chronic fasting, total parental nutrition, critical illness, ceftriaxone therapy and pregnancy. Spontaneous resolution occurs in 50% of patients and 5-15% will go on to develop gallstones.

Question 57

52- An elderly gentleman was admitted with severe abdominal pain, jaundice and sepsis. He had a significant cardiac history, suffered from chronic airways disease and was a high anaesthetic risk. An ultrasound and CT confirmed severe calculus cholecystitis with a distended gallbladder but no common bile duct dilation. The patient was not responding well to intravenous antibiotic therapy and continued to deteriorate. What would be the most appropriate next step? a) ERCP b) Laparoscopic cholecystectomy c) MRCP d) Open cholecystectomy e) Percutaneous cholecystostomy

Answer 57

Answer E: Percutaneous cholecystostomy Percutaneous cholecystostomy can often be performed in poor surgical candidates or acutely unwell patients.

Question 58

53- A 75-year-old female had an abdominal radiograph as part of a work-up for chronic right upper quadrant pain. This showed a porcelain gallbladder. She subsequently has a transabdominal ultrasound which showed a fundal mass in the gallbladder, but no gallstones and gallbladder carcinoma was suspected. What is the most common mode of spread? a) Infiltration of liver b) Neural spread c) Lymphatic spread to cystic nodes d) Lymphatic spread to coeliac nodes e) Haematogenous

Answer 58

Answer A: Infiltration of liver Carcinoma of the gallbladder most commonly spreads by direct extension into the liver. Lymphatic spread and peritoneal seeding are also common. Neural spread tends to be associated with more aggressive tumours. Haematogenous spread is relatively rare.

Question 59

54- A 20-year-old woman presented with ongoing chronic vague abdominal pain. She was otherwise well and was taking the oral contraceptive pill. On examination there was a palpable mass in the right upper quadrant and her sclera appeared yellow. An urgent outpatient ultrasound was organised and a choledochocele was suspected. What ultrasound finding would support this diagnosis? a) Cystic change of the intrahepatic ducts b) Dilatation of the distal intramural portion of the common bile duct that protrudes in the duodenum c) Diverticular outpouching of the extrahepatic duct d) Fusiform dilatation of the extrahepatic duct e) Multifocal saccular dilatation of the intraheptic ducts with sparing of the extrahepatic ducts

Answer 59

Answer B: Dilatation of the distal intramural portion of the common bile duct that protrudes in the duodenum A choledochocele is cystic dilatation of the distal/intramural duodenal portion of the common bile duct with herniation of the duct into the duodenum.

Question 60

55- A patient presented with right upper quadrant pain, fever and jaundice. An ultrasound demonstrated a thick-walled gallbladder containing numerous gallstones and a stone impacted in the common bile duct. Which organism is most likely to be grown from their blood cultures? a) Pseudornonas b) Klebsiella c) Escherichia coli d) Haernophilusinfluenzae e) Clostridium difficile

Answer 60

Answer C: Escherichia coli Gram-negative enteric bacteria are the usual causative agent in ascending cholangitis, the commonest being E. coli.

Question 61

56- Following a long history of intermittent right upper quadrant pain a middle aged woman became jaundiced. She was referred for an ultrasound which showed a cystic lesion adjacent to the gallbladder. A CT confirmed the presence of a thin-walled lesion with a fluid attenuation centre. The intrahepatic ducts were normal in calibre. In view of her jaundice she then had an ERCP and a cholangiogram showed a tubular structure which communicated with the gallbladder and cystic duct. What is the most likely diagnosis? a) Biloma b) Caroli's disease c) Choledochal cyst d) Enteric duplication cyst e) Pancreatic pseudocyst

Answer 61

Answer C: Choledochal cyst Choledochal cysts are formed by cystic dilatation of the intra- or extrahepatic biliary ducts. The diagnosis is established at cholangiography. Caroli's disease affects only the intrahepatic ducts.

Question 62

57- A 23-year-old male presented with his third episode of right upper quadrant pain, fever and jaundice in six months. A contrast-enhanced CT showed multiple intrahepatic cysts, some of which showed strongly enhancing tiny central dots and focal calcification. There were also cystic foci in the renal parenchyma bilaterally. What is the most likely diagnosis? a) Polycystic liver disease b) Biliary haemangioma c) Primary sclerosing cholangitis d) Caroli's disease e) Ascending cholangitis

Answer 62

Answer D: Caroli's disease The best diagnostic clue is the `central dot' sign - strongly enhancing central tiny dots and the presence of renal tubular ectasia. Patients often present in their second to third decade with recurrent cholangitis. ERCP, MRCP and technetium colloid sulphur are most helpful.

Question 63

58- A 55-year-old man presented with painless jaundice and was diagnosed with extrahepatic cholangiocarcinoma. What is the most common mode of spread? a) Infiltration of liver b) Peritoneal seeding c) Lymphatic spread to cystic lymph nodes d) Lymphatic spread to coeliac lymph nodes e) Haematogenous

Answer 63

Answer C: Lymphatic spread to cystic lymph nodes Lymphatic spread to cystic nodes 32 %, infiltration of liver 23 %, lymphatic spread to coeliac nodes 16%, peritoneal seeding 9%, haematogenous spread is rare.

Question 64

59- A 40-year-old woman presented with right upper quadrant pain. A transabdominal ultrasound showed multiple gallstones in a thick-walled gallbladder with a trace of pericholecystic free fluid. She subsequently developed a biliary enteric fistula. What is the most likely site of communication with the gastrointestinal tract? a) Duodenum b) Colon c) Stomach d) jejunum e) Ileum

Answer 64

a) Duodenum

Question 65

60- A previously well 40-year-old woman was admitted with a one-week history of right upper quadrant pain and vomiting. An abdominal radiograph taken on admission showed dilated small bowel loops containing a number of lamellated calcific densities and pneumobilia. What is the most likely diagnosis? a) Acute cholecystitis b) Acute pancreatitis c) Cholangitis d) Gallstone ileus e) Gastric volvulus

Answer 65

d) Gallstone ileus

Question 66

61- A 30-year-old female smoker was investigated for general malaise and epigastric discomfort with a transabdominal ultrasound. This showed gallstones in a thin-walled gallbladder and echogenic soft tissue around the distal common bile duct and pancreatic head but no dilatation of any of the duct system. What is the most likely diagnosis? a) Pancreatic head carcinoma b) Chronic pancreatitis c) Impacted distal CBD stone d) Lymphoma e) Pancreatic metastasis

Answer 66

Answer D: Lymphoma This is a `soft' tumour, which does not usually obstruct ducts

Question 67

12- A patient presented three weeks after a laparoscopic cholecystectomy with increasing abdominal pain and raised inflammatory markers. An ultrasound showed an ill-defined low-reflectivity mass adjacent to the inferior surface of liver with no increased Doppler signal. What is best investigation to establish if the mass is a biloma? a) Triple-phase contrast-enhanced CT of the abdomen and pelvis b) Magnetic resonance cholangiopancreatography (MRCP) c) Radionuclide HIDA scan d) White cell labelled Tc scan e) Radionuclide bile salt malabsorption study

Answer 67

Answer C: Radionuclide HIDA scan White cell labelled radionuclide scans are used for the investigation of low-grade infection when no abnormality is seen on conventional imaging. MRCP is useful for imaging the biliary tree for strictures and stones but the length of time to acquire images and lack of functional imaging makes it unsuitable to diagnose a biloma. Although a collection on CT in the correct clinical setting will usually indicate a biloma a HIDA scan will demonstrate biliary excretion of Tc labelled IDA at 30 minutes and activity in the right paracolic space/peritoneum indicates a bile leak.

Question 68

38- A patient with shortness of breath underwent abdominal ultrasound which showed a thick-walled gallbladder but no gallstones. They were pain free and routine serum biochemical markers including C-reactive protein, albumin, eGFR and liver transaminases were normal. What is the most likely explanation for the gallbladder wall thickening? a) Cirrhosis b) Viral hepatitis c) Cardiac failure d) Renal failure e) Cholecystitis

Answer 68

Answer C: Cardiac failure

Question 69

49- A diabetic 70-year-old man was admitted with right upper quadrant pain. He became rapidly more unwell with evidence of sepsis and an urgent ultrasound of his abdomen was arranged. A previous ultrasound six months ago demonstrated stones within the gallbladder but little else. What feature on the more recent scan would suggest a diagnosis of the more unusual emphysematous cholecystitis over simple acute cholecystitis? a) Arc-like hyperechogenic areas outlining the gallbladder wall b) Gallbladder wall thickening over 5 mm c) Hazy delineation of the gallbladder d) Intramural gas e) The `halo sign'

Answer 69

Answer A: Arc-like hyperechogenic areas outlining the gallbladder wall Intramural gas can occur with any severe cholecystitis that causes gross inflammation and compromises the gallbladder wall. Arc-like echoes that outline the gallbladder wall represents gas within the gallbladder itself, which occurs in emphysematous cholecystitis and not simple acute cholecystitis. Emphysematous cholecystitis is associated with calculous and is more prevalent in diabetics. Complications include gallbladder gangrene and perforation. The halo sign is a threelayered configuration of the gallbladder wall

Question 70

50- A US abdomen of a 37-year-old lady with a one-month history of intermittent right upper quadrant pain showed an abnormality within the gallbladder. There was no further abnormality elsewhere. What feature on ultrasound would be more in keeping with sludge rather than a polyp? a) Hyper-reflective b) Non-shadowing and mobile c) Non-shadowing and non-mobile d) Shadowing and mobile e) Shadowing and non-mobile

Answer 70

Answer B: Non-shadowing and mobile

Question 71

51- A patient underwent an abdominal ultrasound on which it was difficult to identify her gallbladder but there was a large amount of pericholecystic fluid. The patient then had a contrast-enhanced CT which demonstrated pockets of air in the gallbladder wall and abnormal mucosal enhancement of the gallbladder wall with a small defect laterally. What is the most likely diagnosis? a) Acute acalculous cholecystitis b) Acute calculus cholecystitis c) Emphysematous cholecystitis d) Gangrenous cholecystitis e) Gallbladder perforation

Answer 71

Answer E: Gallbladder perforation Gallbladder perforation occurs in 5-10% of patients with acute cholecystitis. Localised disruption of the gallbladder wall is seen on ultrasound in less than 40% of cases and CT in 80%.

Question 72

52- A 50-year-old man with type 2 diabetes was diagnosed with acute cholecystitis. Transabdominal ultrasound showed gas artefact echoes outlining the gallbladder wall. What is the most likely causative organism? a) Clostridium difficile b) Clostridium perfringens c) Escherichia coli d) Staphylococcus aureus e) Staphylococcus epidermidis

Answer 72

Answer B: Clostridium perfringens Clostridium perfringens is the most common cause of emphysematous cholecystitis. There is an approximately 15% mortality.

Question 73

53- A 40-year-old woman was admitted with colicky right upper quadrant pain. An ultrasound showed a thick-walled gallbladder but no gallstones. Subsequently, scintigraphy was performed to assess the patency of her cystic duct. What is the most specific sign of an impacted cystic duct stone? a) Non-visualisation of the gallbladder by one hour b) Non-visualisation of the gallbladder by four hours c) Non-visualisation of the GB and CBD d) Pericholecystic rim sign e) Increased perfusion to gallbladder fossa during arterial phase

Answer 73

Answer B: Non-visualisation of the gallbladder by four hours (Ninety-nine per cent specific.)

Question 74

54- A 55-year-old male had been complaining of general malaise and weight loss for approximately six months. He had a past medical history of a total colectomy in early adulthood following a diagnosis of a familial adenomatous polyposis syndrome. CT and MRCP demonstrated double duct dilation. No other pathology was identified and an endoscopy was also unremarkable. What is the most likely diagnosis? a) Ampullary stricture b) Ampullary tumour c) Choledochocele d) Gallstone impaction at the ampulla e) Peri-ampullary tumour

Answer 74

Answer B: Ampullary tumour Ampullary tumours have an association with FAP syndrome. The tumour is often inconspicuous due to its small size. Peri-ampullary tumours are usually larger lesions with significant intraduodenal extension.

Question 75

55- A 45-year-old man presented with progressive jaundice and abnormal liver function tests. An ultrasound of his liver showed bright portal tracts and a filling defect in the common bile duct. An ERCP demonstrated multifocal strictures particularly at the bifurcations of the biliary ducts and a `string of beads' appearance. Small saccular outpouchings were also visible. What is the most likely diagnosis? a) Primary sclerosing cholangitis b) Cholangiocarcinoma c) Bacterial cholangitis d) Primary biliary cirrhosis e) Gallbladder perforation

Answer 75

Answer A: Primary sclerosing cholangitis (PSC) PSC is more common in males by approx 2:1. Usually presents by 45 years.

Question 76

56- A patient with known cholelithiasis developed jaundice and underwent ultrasound and subsequent MRCP which confirmed a diagnosis of Mirizzi's syndrome. What radiological features would be expected? a) Course of cystic duct perpendicular to common hepatic duct b) Dilatation of common bile duct to the ampulla c) Impacted gallstone in the pouch of Douglas d) Air in the intrahepatic ducts e) Fistulation between the gallbladder and common hepatic duct

Answer 76

Answer E: Fistulation between the gallbladder and common hepatic duct In Mirizzi's syndrome a gallstone impacts in the gallbladder neck or cystic duct and causes extrinsic compression of the common hepatic duct. It is frequently associated with the formation of a fistula between the gallbladder and common hepatic duct.

Question 77

57- A 36-year-old woman who was known to be HIV positive presented with right upper quadrant pain, jaundice and a fever. An admission USS liver showed dilated thick-walled bile ducts. She was diagnosed with an opportunistic infection. What is the most likely causative organism? a) Pneumocystis (PCP) b) Cryptococcus c) HIV d) Cytornegalovirus e) Escherichia coli

Answer 77

Answer D: Cytomegalovirus CMV and cryptococcus are the most common opportunistic infective organisms. HIV can also cause cholangitis but is not an opportunistic infection.

Question 78

58- A 55-year-old man presented with a three-month history of right upper quadrant pain and two stone weight loss. On examination there was a tender palpable mass. His serum bilirubin was 15 micro moll/L and his alkaline phosphatase 2001U/L. An ultrasound showed a hyperechoic 5-cm mass in the lateral right lobe of the liver and dilated bile ducts peripheral to this area. A CT showed this mass to be hypodense and early rim enhancement followed by marked homogeneous delayed enhancement was visible. What is the most likely diagnosis? a) Metastatic adenocarcinoma b) Metastatic leiomyosarcoma c) Intrahepatic cholangiocarcinoma d) Hepatocellular carcinoma e) Carcinoid

Answer 78

Answer C: Intrahepatic cholangiocarcinoma There is a predilection for the right lobe and this accounts for around 10% of all cholangiocarcinomas. Up to 20% are resectable. The peripheral washout sign and delayed enhancement on CT are suggestive.

Question 79

59- An 18-year-old woman was investigated for right upper quadrant pain and two episodes of jaundice. An ultrasound showed a large cyst below the porta hepatis, which was separate from gallbladder and communicated with the common hepatic duct. A HIDA scan showed only equivocal uptake. What is the most likely diagnosis? a) Hepatic cyst b) Intrahepatic gallbladder c) Pancreatic pseudocyst d) Biloma e) Choledochal cyst

Answer 79

Answer E: Choledochal cyst Communication to common hepatic/intrahepatic duct is vital for diagnosis. HIDA uptake is variable, but a positive result shows a photopenic area that fills in 60 minutes, with a paucity of contrast in the small bowel.

Question 80

60- A 55-year-old man had been diagnosed with ulcerative colitis aged 40 and had a total colectomy at 42 years old. He had been asymptomatic until presenting with a one-month history of right upper quadrant pain and jaundice. Transabdominal ultrasound showed prominent right intrahepatic ducts with echogenic walls. What is the most likely diagnosis? a) Portal vein thrombosis b) Primary biliary cirrhosis c) Intrahepatic cholangiocarcinoma d) Ascending cholangitis e) Viral hepatis

Answer 80

Answer C: Intrahepatic cholangiocarcinoma Increased risk in inflammatory bowel disease (by 10x) particularly ulcerative colitis and primary sclerosing cholangitis (PSC) with a latent period of approximately 15 years. Right lobar predilection. Poor prognosis.

Question 81

2. A 65-year-old woman is admitted with abdominal pain. ERCP shows generalized dilated intrahepatic and extrahepatic ducts with multifocal strictures and small diverticulae formation. The most likely diagnosis is? (a) Primary sclerosing cholangitis (b) Choledochocoele (c) Caroli’s syndrome (d) Cholangiocarcinoma (e) Primary biliary cirrhosis

Answer 81

2. (a) Primary sclerosing cholangitis These features are typically diagnostic of primary sclerosing cholangitis. Caroli’s disease is rare condition which manifests in childhood, adolescents and into the third decade. Appearances can be similar to primary sclerosing cholangitis. Choledochocoele is seen in young adults: there is a sac-like dilatation of the intramural segment of the common bile duct which prolapses into the duodenum; there are scattered dilated intrahepatic ducts with no apparent connection to main bile ducts. Caudate lobe hypertrophy is seen in primary biliary cirrhosis. Cholangiocarcinoma may be seen as mass lesion with focal duct dilatation; no generalised strictures and diverticulae are seen.

Question 82

24. A 50-year-old woman is admitted with right upper quadrant pain. Ultrasound shows a large gallstone within the lumen. The wall of the gallbladder is thickened and there are multiple echogenic intramural foci with ‘comet tail’ reverberation artefacts. The most likely cause of the reverberation artefacts is? (a) Adenomyomatosis (b) Gallbladder wall calcification (c) Gallbladder carcinoma in situ (d) Gallbladder papilloma (e) Gangrenous cholecystitis

Answer 82

24. (a) Adenomyomatosis There is an underlying increase in the number and height of mucosal folds in the gallbladder. This frequently exists with cholelithiasis. Cholesterol crystals precipitate in the bile and are trapped in Rokitansky–Aschoff sinuses, which gives the typical ‘comet tail’ reverberation artefacts on ultrasound.

Question 83

25. A 60-year-old diabetic man presents with pain in the right upper quadrant. A plain abdominal radiographs show multiple calcified gallstones and an air fluid level in the gallbladder. Ultrasound shows air in the gallbladder wall. The most likely diagnosis is? (a) Enteric fistula (b) Incompetent sphincter of Oddi (c) Emphysematous cholecystitis (d) Xanthogranulomatous cholecystitis (e) Adenomyomatosis

Answer 83

25. (c) Emphysematous cholecystitis This is a result of ischaemia of the gallbladder wall and infection with gas-producing organisms. It is common in patients who have diabetes and is associated with gallstones. Intramural gas and intraluminal gas is highly suggestive of this diagnosis.

Question 84

19. The following statements regarding primary sclerosing cholangitis are correct: (T/F) (a) The common bile duct is usually spared. (b) It affects only the intrahepatic bile ducts. (c) Echogenic portal triads are identified on ultrasound. (d) There is a 10-15 times increased risk of developing cholangiocarcinoma. (e) It is associated with positive antimitochondrial antibodies.

Answer 84

Answers: (a) Not correct (b) Not correct (c) Correct (d) Correct (e) Not correct Explanation: Primary biliary cirrhosis is associated with positive antimitochondrial antibodies. Primary sclerosing cholangitis affects intra-and extrahepatic bile ducts. Common bile duct is always involved.

Question 85

23. Which of the following are correct about Emphysematous cholecystitis: (T/F) (a) Gallstones are present in over 90% of cases. (b) The most common causative organism is staphylococcus aureus. (c) Is associated with diabetes in 5-10% of cases. (d) Intramural gas is characteristic. (e) Is usually successfully treated with antibiotics alone.

Answer 85

Answers: (a) Not correct (b) Not correct (c) Not correct (d) Correct (e) Not correct Explanation: Emphysematous cholecystitis is most commonly caused by clostridia and E.Coli species. It commonly affects order men and has association with diabetes mellitus in about 50% of the cases. Gallstones are present less frequently. It can rapidly lead to the perforation and septic shock. There is gas in the lumen of the gallbladder, in the wall or in the pericholecystic space in the absence of any fistula with the intestine.

Question 86

24. Which of the following are correct about Caroli’s disease: (T/F) (a) Is inherited as an autosomal dominant disorder. (b) Is associated with autosomal dominant polycystic kidney disease. (c) 70-80% have extrahepatic bile duct dilatation. (d) Is associated with ulcerative colitis. (e) Cholangiocarcinoma develops in 5-10%

Answer 86

Answers: (a) Not correct (b) Correct (c) Not correct (d) Not correct (e) Correct Explanation: Caroli’s disease is rare autosomal recessive disorder showing abnormal development of intrahepatic bile ducts. The differential diagnosis includes primary sclerosing cholangitis. The ductal dilatation in primary sclerosing cholangitis is a rarely saccular and is typically more isolated and fusiform. 70% of the patient’s with primary sclerosing cholangitis have co-existing inflammatory bowel disease. There are multiple intrahepatic cyst that communicate with the biliary tree with intrahepatic bile duct dilatation, irregular bile duct walls, strictures and stones in Caroli’s.

Question 87

25. Which of the following are correct about Choledochal cyst: (T/F) (a) Appears as a photointense area on 1-10 min HIDA scan images. (b) Recurrent pancreatitis affects 30-40% of patients. (c) The classic triad of intermittent obstructive jaundice, recurrent colicky right upper quadrant pain and palpable mass is seen in more than 50% of patients. (d) Portal hypertension is a known complication. (e) 90% affect the intrahepatic bile ducts.

Answer 87

Answers: (a) Not correct (b) Correct (c) Not correct (d) Correct (e) Not correct Explanation: Choledochal cyst is characterised by by balloon like dilatation of the extrahepatic bile ducts. It can be associated with intrahepatic bile duct dilatation in 15% of the cases. The classic triad of jaundice, recurrent colicky right upper quadrant pain and palpable mass is seen in 20-30% of the patients and bring the only images in a hilar scan shows a photopenic area. The cyst shows delayed filling which persists on delayed films. Large choledochal cysts may compresse the gallbladder leading to non visualisation.

Question 88

40. Regarding cholangiocarcinoma, which of the following are correct? (T/F) (a) Caroli’s disease is a predisposing factor. (b) The majority are squamous cell carcinomas. (c) It typically shows delayed enhancement on CT. (d) Duodenal obstruction is an early feature. (e) Tumours are low signal relative to liver on T2 weighted MRI.

Answer 88

Answers: (a) Correct (b) Not correct (c) Correct (d) Not correct (e) Not correct Explanation: Cholangiocarcinoma have varied appearance on T2-weighted imaging, from very high signal to mildly increased signal relative to liver. On T1 weighted images, and isointense to low signal relative to the liver. There is moderate enhancement after gadolinium administration. About 95% of the cholangiocarcinoma are adenocarcinoma. The tumour spreads by local invasion and may involve the portal vein and hepatic artery.