Biliary System Flashcards
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
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
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)
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.
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
D. Opiate usage
Opiates, severe hepatitis and CBD obstruction are causes of non-visualisation and no bowel activity. Other cause bowel activity.
- 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
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.
- 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
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
- 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
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.
- 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
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.
- During MRCP, which substance may be administered to improve visualization of the pancreatic ducts?
A. glucagon
B. secretin
C. cholecystokinin
D. gastrin
E. Buscopan
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.
- 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
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.
- 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
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.
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
(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.
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
(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.
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
(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.
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
(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.
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
(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.
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
(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.
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
(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.
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
(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.
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
(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.
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
(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.
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
(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.
- 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
- 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.
- 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
- 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.
- 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
- 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.,
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
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.
- 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
- 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.
- 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
- 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.
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: 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.
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
B Gallbladder carcinoma
A gallbladder fossa mass with little/no visible normal gallbladder and hilarbiliary obstruction is highly suggestive of gallbladder carcinoma.
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
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.
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
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.
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
A Acalculous cholecystitis
Acalculous cholecystitis should always be considered in the seriously ill patient who develops unexplained sepsis.
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
E There is a significant increased risk of cholangiocarcinoma
Up to 10% of patients with primary sclerosing cholangitis will develop cholangiocarcinoma.
- 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.
- 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.
- 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.
- 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%).
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 B: Non-shadowing and mobile
