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Abdominal Sonography > Biliary Tract > Flashcards

Biliary Tract Flashcards

1
Q

____ converges to form the RT and LT hepatic duct?

A

Intrahepatic Bile Duct

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2
Q

The RT and LT hepatic ducts join to form the _____

A

Common Hepatic Duct (CHD)

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3
Q

Where is the GB located?

A

Inferior end of Main lobar fissure

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4
Q

The GB neck tapers to form the ___ ?

A

Cystic duct

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5
Q

The cystic duct joins with what?

A

CHD

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6
Q

What Cystic duct and the CHD form the ___ ?

A

CBD

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7
Q

What CBD and the main panc duct form the ___?

A

Ampulla of vater

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8
Q

What is another name for the pancreatic duct?

A

Duct of Wirsung

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9
Q

What does the Portal triad consist of ?

A

MPV, CHD, PHA.

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10
Q

What do sonographers refer to the portal triad as?

A

Mickey mouse

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11
Q

What supplies the GB?

A

Cystic artery

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12
Q

Where does the cystic artery branch from?

A

RHA

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13
Q

What is the GB divided into?

A

Neck, Body, Fundus.

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14
Q

What is a spiral fold which controls bile flow in the cystic duct.

A

Valve of Heister’s

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15
Q

What is an ABNL sacculation (diverticulum) of the neck of the GB?

A

Hartmann’s pouch

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16
Q

Where is the phrygian cap located?

A

A fold between the body and fundus of the GB

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17
Q

Where is a junctional fold in the GB?

A

Between the body and the neck (infundibulum) of the GB

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18
Q

The GB passes posterior to the ___ and ___ and then joins the main ___ at the ___.

A

Duodenum and Panc Head
Panc duct at the ampulla of vater

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19
Q

Where does the Ampilla of vater empties through and is what is it controlled by?

A

Duodenal papilla
Sphincter of Oddi

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20
Q

What is a NL wall thickness?

A

<3mm

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21
Q

What can cause GB wall thickening?

A

Cholecystitis
Hypoalbuminemia
Ascities
Hepatitis
CHF
Pancreatitis

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22
Q

What are the 3 types of jaundice?

A

Pre hepatic, Hepatic, Post Hepatic

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23
Q

What is Pre-Hepaic jaundice caused by?

A

Excessive red cell breakdown

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24
Q

What happens if the liver excessively breaks down red cells?

A

The liver becomes overwhelmed and the liver cant conjugate bilirubin = unconjugated hyperbilirubinemia

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25
Q

What is Hepatic jaundice caused by?

A

There is a dysfunction in the liver itself. The liver cant conjugate bilirubin

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26
Q

What is Post-Hepatic jaundice?

A

Obstruction of the biliary tree

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27
Q

What does an obstruction in the biliary tree cause?
- what does that result in?

A

Conjugated hyperbilirubinemia
- pale stool and dark urine

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28
Q

What are examples of biliary obstruction?

A

Choledocholithiasis
Choledochal cyst
Cholangiocarcinoma
Biliary atresia
Panc carcinoma
GB carcinoma
Carolis dz
Mirizzi syndrome

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29
Q

What is calcium bilirubinate granules and cholesterol crystals?

A

Sludge

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30
Q

What is non shadowing, echogenic material which layers shift with patient position?

A

Sludge

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31
Q

Sludge is associated with what ?

A

Biliary stasis

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32
Q

What is sludge is secondary associated to?

A

Cholecystitis
Cystic duct obst.
Prolonged fasting
Parenteral nutrition (intravenous feeding)
Hemolysis

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33
Q

What does long term parenteral nutrition (TPN) cause ?

A

GB stasis-> sludge, milk of calcium or stones

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34
Q

What is tumefactive sludge?

A

Thick sludge that appears as an intraluminal GB mass

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35
Q

What is cholelithiasis?

A

GB stone

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36
Q

What is a GB filled with stones and may be seen as a strong shadow in the RUQ?

A

WES- wall echo shadow
or
Double arc

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37
Q

What is Acute cholecystitis?

A

Inflammation of the GB due to obst of the cystic duct

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38
Q

What is the murphy’s sign?

A

Tenderness d/t transducer pressure over GB area

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39
Q

What are complications of acute cholecystitis?

A

Empyema
Gangrenous cholecystitis
Perforation
Pericholecystic abscess

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40
Q

What is chronic cholecystitis?

A

Reoccurring symptoms of biliary colic d/t multiple episodes of acute cholecystitis

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41
Q

what is the difference sonographicly of an acute vs chronic cholecystitis?

A

Does not appear different

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42
Q

What is emphysematous cholecystitis ?

A

Acute cholecystitis d/t GB wall ischemia and infection

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43
Q

Emphysematous cholecystitis occurs more commonly in what kind of patients?

A

Diabetic patients

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44
Q

What is gas produced by in emphysematous cholecystitis?

A

Anerobic bacteria (clostridium E. coil)

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45
Q

What does gas look like in the GB?

A

Comet tail or ring down artifact

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46
Q

What is referred to as the champagne sign?

A

Gas bubbles to the nondependent wall of the GB

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47
Q

What does gangrenous cholecystitis result in?

A

Pneumoperitoneum peritonitis and sepsis

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48
Q

What causes gas in the biliary system?

A

Emphysematous cholecystitis
GB fistula
Choledochojejunostomy
Sphincter of Odii papilotomy
ERCP

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49
Q

What is a choledochojejunostomy?

A

Creating an anastomosis of the CBD to the jejunum to relieve biliary obst.

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50
Q

What is empyema of the GB?

A

The GB fills with purulent material (pus)

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51
Q

GB perforation is a ____ and ____ complication of acute cholecystitis

A

Rare
Life threating

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52
Q

What are complications of a perforated GB?

A

Peritonitis
Pericholecystitis
Biliary fistula

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53
Q

What is acalculous cholecystitis

A

Acute cholecystitis without gallstones

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54
Q

Sonographic findings:
in the GB you see wall thickening, Murphy sign, and pericholecystic fluid

A

Acalculous cholecystitis

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55
Q

What is Milk of calcium bile (limy bile)

A

Sludge like material with high concentration of calcium

56
Q

What is milk of calcium bile associated with?

A

Chronic cholecystitis and GB obst. of the cystic duct

57
Q

What is a porcelain GB?

A

Calcification of the GB wall

58
Q

What is Porcelain GB associated with?

A

Chronic Cholecystitis

59
Q

A porcelain GB is linked with what?

60
Q

What is a hydrops of the GB?
- what is another name for this?

A

Overdistended GB
Mucocele of the GB

61
Q

What is the measurement for a hydropic GB?

A

> 5cm in Trans

62
Q

What is hydropic GB associated with ?

A

Kawasaki dz
Acute febrile illness-> multiorgan vasculitis

63
Q

What measurement is unlikely to be cancerous in a GB polyp?

64
Q

What measurement is likely to be cancerous in a GB polyp?

65
Q

What is the malignancy rate for a GB poylp?

A

Between 37% - 88%

66
Q

What is cholesterolosis?

A

Lipis are deposited in the GB wall

67
Q

Cholesterolosis can sonographicly look like what?

68
Q

What is another name for cholesterolosis?

A

Strawberry GB

69
Q

What are the clinical symptoms of cholesterolosis

A

Usually silent but can cause colicky ABD pain

70
Q

What is the survival rate of GB carcinoma?
- how is it found?

A

5year less than 5%
usually diagnosed post cholecystectomy. <50% preoperatively

71
Q

What is adenomyomatosis?

A

Hyperplastic changes in the GB wall causing overgrowth of the mucosa

72
Q

Sonographic finding:
GB: hyperechoic foci with thickened GB wall (comet tail artifact)

A

Adenomyomatosis

73
Q

Where are the majority of biliary Obst. located?

A

Distal CBD

74
Q

What are the most common reasons for Biliary Obst?

A

GB and Carcinoma of the Panc head

75
Q

What is the NL, equivocal, and Dilated measurements for the CBD?

A

NL <5 mm
Equivocal 6 to 7mm
Dilated >8 mm

76
Q

What is the CBD measurement rule with age?

A

1 mm per decade
Increases with age
10mm upper limites

77
Q

What is the normal measurement for a post cholecystectomy patient?

A

Up to 10mm

78
Q

Wha is the parallel channel sign or shotgun sign of the liver?

A

Dilated intrahepatic ducts

79
Q

What is cholecystokinin ?

A

Hormone that is released into the blood by the ingestion of fatty foods -> causes the GB to contract

80
Q

With a fatty meal what is a negative and positive sign of the duct?

A

Neg- duct unchange or decreases
Post- duct increases

81
Q

Where is a distal CBD Obst?

A

Outside usually a stone
it includes the GB

82
Q

Where is a common hepatic Obst?

A

Only the common Hepatic ducts and intrahepatic ducts with dilate. GB will be contracted

83
Q

Where is a Obst at the Junc Hepatic ducts?

A

At the junc of the RT and LT hepatic ducts
GB will be contracted

84
Q

What is choledocholithiasis ?

A

Gallstones in the bile ducts

85
Q

What are symptoms of choledocholithiasis?

A

Biliary colic (RUQ pain) and jaundice

86
Q

What lab values are increased with choledocholithiasis?

A

ALP, Conjugated bilirubin, GGT

87
Q

What is Mirizzi syndrome?

A

Extrahepatic biliary Obst. from and impacted stone in the cystic duct causing extrinsic mechanical compression of the CHD

88
Q

Mirizzi syndrome is associated with what findings?

A

Intrahepatic duct dilatation, cystic duct stone, curved seg stenosis of CHD, Cholecystocholedochal fistula

89
Q

What is Cholangiocarcinoma?

A

Bile duct adenocarcinomas

90
Q

Where is Cholangiocarcinoma usually found?

A

Extrahepatic bile ducts (CHD or CBD)

91
Q

What is Klatskin tumor?
- where is it located?

A

Cholangiocarcinoma
hepatic hilum (RT and LT intrahepatic duct) but not extrahepatic biliary dilation

92
Q

What is Biliary ascariasis ?
- what can it block?

A

Parasitic roundworm Ascaris Lumbricoides
ampulla vater or main panc duct

93
Q

Where is Ascariasis commonly encountered?

A

South East Asian countries

94
Q

What is cholangitis

A

Inflammation of the biliary tree.

95
Q

What is the classical triad of cholangitis?

A

RUQ pain, Fever, and Jaundice

96
Q

What are the types of cholangitis?

A

Acute bacterial cholangitis
AIDS cholangitis
Recurrent pyogenic cholangitis
Sclerosing cholangitis

97
Q

What is the most common cause of cholangitis?

A

Choedocholithiasis

98
Q

What lab work is increased with cholangitis?

A

COnjugated bilirubin
ALP
GGT
Amylase and Lipase
White blood cells (leukocytosis)

99
Q

When is biliary atresia suspected?

A

Jaundice (hyperbilirubinemia) last longer than 14 days

100
Q

What ducts arent affected with biliary atresia?

A

Absence of extrahepatic bile ducts (CBD and CHD)

101
Q

What is biliary atresia associated with sonographicaly?

A

Triangular cord sign

102
Q

What is the triangular cord sign?

A

Echogenic triangular structure anterior to the PV

103
Q

Polyspenia **, absent IVC, sinus inversus/ambiguous, cardiac anomalies (ASD/VSD) is associated with what?

A

Biliary Atresia

104
Q

What is the treatment for Biliary Atresia?

A

Kasai portoenterostomy (KPE)
If done within 90 days of life.

105
Q

What is Pneumobilia?

A

Air in the biliary tract

106
Q

Pneumobilia is associated with what?

A

ERCP ( endosopic retrograde cholangiopancreatogram)

107
Q

What causes pneumobilia?

A

ERCP
Sphincter of Oddi papillotomy
CHoledochojejunostomy
GB fistula
Emphysematous cholecystitis

108
Q

What causes choledochal cyst?

A

Congenital bile duct cystic dilation of the ectrahepatic ducts

109
Q

Sonographic findings
Bile duct has two cystic structure in the RUQ (GB and dilated CBD) intrahepatic bile duct dilatation

A

Chholedochal cyst

110
Q

Where is choledochal cyst more prevent in?

A

Asia
-before the age 10.

111
Q

What is Caroli DZ/ Caroli syndrome?

A

Congenital anomaly of the intrahepatic ducts that have multi segment dilation

112
Q

How do you get caroli dz/syndrome?
- associated with?

A

Generally inherited
- Congenital fibrosis, Auto Recessive Poly Kid dz, Portal HTN

113
Q

Sonographic findings:
in the bile ducts you see multi cystic structures from the porta hepatis to bile ducts. May see sludge and calculi in the ectatic ducts that can cause acoustic shadowing

A

Caroli DZ/syndrome

114
Q

Pancreatic adenocarcinoma can cause what to the bile duct and GB?

A

Obst. of the biliary tree
Ciurvoiser GB

115
Q

What is the double duct sign?
- casue

A

Dilation of the CBD, Duct of wursung.
Panc carcinoma

116
Q

What is primary Sclerosing Cholangitis (PSC)

A

Inflammation and fibrosis of the intra and extra hepatic bile ducts

117
Q

PSC can lead to __ of the liver?

118
Q

What lab vaules are incresed with PSC?

A

ALP, GGT, ALT/AST, Conjugated

119
Q

Sonogrpahic findings:
The bile duct walls are thick and the PT has Cirrhosis?

120
Q

What is Primary Biliary Cholangitis (PBC)?

A

Autoimmune disorder resulting in cholestasis due to destruction of the small intrahepatic ducts leading to cirrhosis

121
Q

what lab values are increased with PBC?

A

ALT, AST, APLP, GGT, AMAs

122
Q

What is done to rule out blockage of the bile ducts?

A

Ultrasound

123
Q

What is the end product of hemoglobin breakdown?

124
Q

What is total bilirubin?

A

Conjugated + unconjugated bilirubin

125
Q

What is conjugated bilirubin?

A

Process of removing protein (albumin) from unconjugated bilirubin making it soluble.

126
Q

What is important for bilirubin disposal?

A

Conjugation

127
Q

What is unconjugated hyperbilirubinemia resulted from?

A

Impaired hepatic bilirubin uptake
Impaired conjugation bilirubin
Increase bilirubin production

128
Q

What are is Impaired hepatic bilirubin?

A

CHF, liver varices, TIPS, drugs, Contrast agents

129
Q

What is Impaired conjugation bilirubin

A

Gilbert syndrome
Crigler-Najjae syndrome type I and II

130
Q

What is Increase bilirubin production?

A

Hemolysis/ ineffective erythropoiesis

131
Q

Do the kidneys filter conjugated or unconjugated bilirubin?

A

Conjugated
NOT unconjugated bc its bound to albumin

132
Q

What does conjugated Hyperbilirubinemia result from?

A

Direct bile outflow

133
Q

What is Alkaline Phosphate ALP

A

An enzyme that is concentrated in the bile ducts (also bone, liver, placenta)

134
Q

ALP increases with what pathology?

A

Bile duct obst. ANY BILE OBST.
(bone growth and pregnancy)

Abdominal Sonography (9 decks)

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