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ABD > Biliary Tract Patho > Flashcards

Biliary Tract Patho Flashcards

1
Q

Most common cause of GB wall thickening?

A

Cholecystitis

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2
Q

Besides cholecystitis, other causes of GB wall thickening (5)

A 
hypoalbuminemia
ascites
hepatitis
CHF
pancreatitis
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3
Q

Prehepatic cause of jaundice

A

increased bilirubin production

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4
Q

Hepatic causes of jaundice (5)

A 
acute liver inflammation
chronic liver disease
infiltrative liver disease
inflammation of bile ducts
genetic disorders
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5
Q

prehepatic jaundice occurs if there is increased bilirubin production, which may be due to (3)

A

hemolysis - breakdown of RBC
ineffective erythropoiesis - overproduction of hemoglobin
absorption of large amounts of hemoglobin - internal bleeding

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6
Q

Acute liver inflammation is one cause of hepatic jaundice because it….

A

reduces the liver’s ability to conjugate

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7
Q

Hepatic related jaundice occurs with infiltrative liver diseases such as (4)

A

metastatic liver disease
hemochromatosis (inc iron absorption)
Alpha 1 antitryspin deficiency
Wilson’s disease (inc Copper absorption)

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8
Q

Inflammation of the bile ducts is a hepatic related cause of jaundice that may be due to (2)

A

primary biliary cholangitis

sclerosing cholangitis

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9
Q

genetic disorders that can cause hepatic jaundice include (2)

A

Gilbert’s syndrome

Crigler-Najjar syndrome (dec enzyme for conjugation)

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10
Q

Post hepatic cause of jaundice is due to an

A

obstruction of biliary tree, anything that blocs the bile ducts

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11
Q

obstruction that blocks the ducts causes pale _____ and dark _____, which is a post hepatic cause of janudice.

A

pale stool

dark urine

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12
Q

9 examples of biliary obstruction

A 
choledocholithiasis
Mirizzi syndrome
cholangiocarcinoma
cholangitis
biliary atresia
choledochal cyst
Caroli's disease
pancreatic adenocarcinoma
GB carcinoma
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13
Q

Long-term total parenteral nutrition (TPN) induces GB stasis, which may create (3)

A

sludge
milk of calcium bile
gallstones

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14
Q

_____ appears as nonshadowing, echogenic material which layers and shifts with patient position.

A

sludge

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15
Q

calcium bilirubinate granules and cholesterol crystals

A

sludge

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16
Q

What sonographic finding distinguishes tumefactive sludge from gallstones?

A

no shadowing with tumefactive sludge

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17
Q

causes of biliary stasis that may result in sludge (5)

A 
prolonged fasting
TPN - intravenous feeding
hemolysis
cystic duct obstruction
cholecystitis
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18
Q

cholelithiasis

A

gallstones

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19
Q

WES or double arc sign

A

Wall-Echo-Shadow seen with a GB filled with stones

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20
Q

Sonographic criteria for cholethiasis (3)

A

mobile
strongly echogenic
acoustic shadowing

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21
Q

Gallstones are composed of

A

cholesterol
calcium bilirubinate
calcium carbonate

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22
Q

Cholelithiasis may obstruct the cystic duct resulting in ______ _______ and possible complications such as (4)

A

acute cholecystitis

  • empyema - collection of pus in the pleural space
  • GB perforation
  • pericholecystic abscess
  • bile peritonitis - secondary to perforation/rupture of the GB, duct, GI
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23
Q

Signs and symptoms of acute cholecystitis

A

RUQ pain
fever
leukocytosis

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24
Q

Sonographic features of acute cholecystitis (5)

A 
gallstones
Murphy's sign
diffuse wall thickening
GB dilation
sludge
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25
Q

Murphy’s sign

A

intense point of tenderness transducer pressure directly on the GB
90% sensitive and specific

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26
Q

Obstruction at the level of the ampulla of Vater is suggested if _____ is elevated.

A

amylase

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27
Q

Complications of acute cholecystitis include (5)

A 
empyema
gangrenous cholecystitis
perforation
pericholecystic abscess
bilioenteric fistula
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28
Q

Acute cholecystitis

A

Diffuse GB wall thickening due to cystic duct obstruction by a gallstone

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29
Q

Following initial stages of acute cholecystitis (obstruction, ischemia), _______ _______ may follow.

A

bacterial infection

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30
Q

Chronic cholecystitis (chronic GB disease) is characterized by recurring symptoms of ______ _____ due to multiple episodes of acute cholecystitis.

A

biliary colic

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31
Q

T/F - sonographically the findings for chronic cholecystitis are different from acute.

A

F - does not appear different

may include thick-wall, contracted GB, sludge, obstructing cystic duct stone

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32
Q

Emphysematous cholecystitis

A

due to acute cholecystitis with wall ischemia and infection

-thought to be a different pathogenesis than calculous cholecystitis

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33
Q

Emphysematous cholecystitis occurs more commonly in

A

diabetic men

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34
Q

Emphysematous cholecystitis has a higher rate of _______ and ________.

A

gangrene and perforation

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35
Q

With gangrenous cholecystitis, perforation is inevitable, resulting in ____________ and _________.

A

pneumoperitoneum and peritonitis

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36
Q

What five things can casue gas in the biliary system?

A 
post ERCP
post sphincter of Oddi papilotomy
choledochojejunostomy
gallbladder (biliary) fistula
emphysematous cholecystitis
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37
Q

Choledochjejunostomy

A

procedure for creating an anastomosis of the CBD to the jejunum, performed to relieve symptoms of biliary obstruction and restore continuity to the biliary tract

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38
Q

empyema of the GB

A

acute cholecystitis in the presence of bacteria-containing bile progressing to infection where the GB fills with purulent material (atypical bile echoes)

  • initiated by cystic duct obstruction
  • symptoms the same as acute but with fever
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39
Q

GB perforation

A
  • complication of acute cholecystitis
  • fundus is most common part
  • localized fluid collection in GB fossa
  • Dx difficult, delayed treatment results in higher morbidity and mortality rates
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40
Q

Complications from GB perforation (3)

A

peritonitis
pericholecystic abscess
biliary fistula

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41
Q

acalculous cholecystitis

A

acute cholecystitis without gallstones

  • caused by: bile stasis, dec. GB contraction, infection (secondary event)
  • sonographic: wall thickening, Murphy sign, pericholecystic fluid
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42
Q

Acalculous cholecystitis is typically a secondary event in critically ill patients and is associated with (8)

A 
parenteral (intravenous) nutrtion (>3 months)
post operative abd surgery
severe trauma
severe burns
sepsis
HIV/AIDS
blood transfusion reaction
high-does opiod anagesics
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43
Q

increased hypoalbuminemia casuing ascites and CHF are other casues of _____ _____ _______

A

GB wall thickening

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44
Q

Milk of calcium bile is aka

A

limey bile

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45
Q

What is limey bile?

A

sludge-liek material with a high concentration of calcium

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46
Q

_______ _______ is associated with chronic cholecystitis and GB obtsruction of cystic duct

A

Limey bile

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47
Q

sonographic appearance of milk of calcium bile

A

may be seen as layering of sludge that results in distal acoustic shadowing

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48
Q

What is porcelain GB

A

calcification of the GB wall assocaited with chronic cholecystitis

49
Q

Hydrops of the GB

A

aka mucocele of the GB

  • overdistended GB filled with mucoid or clear and watery content
  • usually noninflammatory
  • results from outlet obstrcution of the GB (commnly impacted stone in the neck of the GB or in the cystic duct)
50
Q

What is suggested if a grossly distended, thin-walled GB, measuring >5cm x 11cm, an impacted stone in the infundibulum or neck of the GB or in the cystic duct, and clear fluid content?

A

possible mucocele

51
Q

T/F - GB polyps that are greater than 10mm and demonstrate growth are most likely to be malignant

A

True

52
Q

cholesterolosis

A

aka strawberry GB

  • lipids are depositied into the wall, appearing like polyps of differnt sizes (can be as large as 1cm)
  • usually clinically silent but can be the casue of colicky abdominal pain
53
Q

T/F - GB carcinoma is not realted to porcelain GB.

A

False

54
Q

Adenomyomatosis

A

hyperplastic changes of the GB wall, overgrowth of mucosa, thickening of wall, and formation of diverticula

55
Q

diverticula in the GB wall accumulate stones or sludge and is aka

A

rokitansky-aschoff sinuses or RAS

56
Q

Adenomyomatosis is sonographically seen as hyperechoic foci within a thickened wall that casue what kind of artifact?

A

comet-tail (reverberation) artifact

57
Q

Adenomyomatosis is sonographically seen as hyperechoic foci within a thickened wall that casue what kind of artifact?

A

comet-tail (reverberation) artifact

58
Q

In the majority of patients, biliary obstruction is due to pathology in the _____ _____.

A

distal CBD

59
Q

Two most common lesions associated with biliary obstruction

A

gallstones

carcinoma of the head of the pancreas

60
Q

lab values associated with distal biliary obstruction

A

alp (alkaline phosphatase)
conjugated bilirubin/direct
gamma glutamyl transpeptidase (GGT)

61
Q

Distal biliary obtsruction results in progressive dilatation of the ________ and _______ biliary tree.

A

extrahepatic to intrahepatic (distal to proximal)

62
Q

causes of biliary obstruction

A 
choledochalithiasis
mirizzi syndrome
cholangiocarcinoma
cholangitis
biliary atresia
choledochal cyst
caroli's disease
pancreatic adenocarcinoma
GB carcinoma
63
Q

How can you distinguish dilated intrahepatic ducts from portal veins?

A

“parallel channel sign” or “shotgun sign” which refers to the dilated intrahepatic ducts adjacent to the portal vein

64
Q

Cause of intrahepatic bile duct dilitation only (4)

A

cholangiocarcinoma (Klatskin tumor)
intrahepatic choledocholithiasis
recurrent pyogenic cholangitis
Caroli’s disease

65
Q

choledocholithiasis is the presence of ______ in the bile ducts and is the most common casue of ________ obstructive jaundice.

A

calculi

extrahepatic obstructive jaundice

66
Q

Symptoms associated with choledocholithiasis?

A 
biliary colic (RUQ pain(
jaundice
67
Q

Lab values that increase with choledocholithiasis?

A

ALP
conjugated bilirubin
GGT

68
Q

Complication associted with choledocholithiasis

A

biliary cirrhosis
cholangitis
pancreatitis

69
Q

Mirizzi syndrome

A

extrahepatic biliary obtsruction due to an impacted stone in the cystic duct casuing extrinisc mechanical compression of the CHD

70
Q

findings associated with mirizzi syndrome

A

intrahepatic duct dilitation
cystic duct stone
curved segmental stenosis of CHD
cholecystocholedochal fistual

71
Q

Symptoms associated with cholangiocarcinoma (bile duct carcinoma)

A

jaundice
weight loss
abdominal pain

72
Q

Klatskin Tumor

A

cholangiocarcinoma located at the hepatic hilum (junction of RT/LT hepatic ducts)
-results in intrahepatic dilitation, not extrahepatic

73
Q

______ _____ _____ is the most common predisposing condition for bile duct carcinoma and dilatation of the _____ bile ducts is the most common finding

A

primary sclerosing cholangitis

intrahepatic

74
Q

Biliary Ascariasis

A

casued by parasitic roundworm that blocks the ampulla of vater or the main pancreatic duct resulting in acute pancreatitis (inc. amylase and lipase)
-can also travel into the biliary tree casuing ductal dilation with increased levels of conjugated bilirubin resulting in acute cholangitis or acute cholecystitis

75
Q

cholangitis

A

bacterial infection sueprimposed on a biliary tree obstruction

76
Q

A history of choledocholithiasis or recent biliary tract manipulation associated with fever (chills, rigors), RUQ pain, jaundice - The charcot triad - is highly suggestive of ______.

A

cholangitis

77
Q

Cuases of cholangitis?

A 
choledocholithiasis*
ERCP
obstructive tumor (panc head)
78
Q

cholangitis result in in increased:

A 
ALP
conjugated bili
GGT
amylase and lipase
WBC
79
Q

biliary atresia

A

absence of extrahepatic ducts (CHD and CBD)

suspected when janudice (hyperbilirubinemia) persists beyond 14 days of age

80
Q

Biliary atresia is associated with

A

polysplenia syndrome
absent IVC
situs inversus, situs ambiguous
cardiac abnormalites (ASD, VSD)

81
Q

Pneumobilia

A

air in the biliary tract

echogenic foci in the intrahepatic bile ducts, comet-tail reverberation artifact

82
Q

Causes of pneumobilia

A 
ERCP
sphincter of Oddi papilliotomy
choledochojejunostomy
GB fistula
emphysematous cholecystitis
83
Q

choledochal cysts

A

congenital bile duct anomaly consisteing of cystic dilatation of the intra or extrahepatic bile ducts.
-five classes of cysts, most common involves dilatation of the CBD, aneurysmal

84
Q

sonographic findings associated with choledochal cysts involving the CBD

A

2 cystic structures in the RUQ (dilated CBD and GB)

inrahepatic bile duct dilatation

85
Q

Choledochal cysts are ore prevalent in _____.

A

Asia, more than 33% of reported cases are from Japan

-symptoms usually occur before age 10

86
Q

Choledochal cysts are associated with (6)

A 
pancreatitis
cholangitis
heaptic abscesses
cirrhosis
portal HTN
cholangiocarcinoma
87
Q

A congenital anomaly of the biliary tract charcterized by multifocal segmental dilatation of the intrahepatic bile ducts.

A

Caroli’s Disease/Syndrome

88
Q

Caroli’s Disease is associated with (3)

A

congenital hepatic fibrosis
portal HTN
polycystic kidney disease

89
Q

Sonographic appearance of Caroli’s Disease/Syndrome?

A

multiple cystic structures that converge toward the porta hepatis communicating with the bile ducts
-sludge and calculi may accumulate in these ectatic ducts reuslting in posterior acoustic shadowing

90
Q

Most common cause of malignant neoplasm obstructing the biliary tree?

A

Pancreatic adenocarcinoma

91
Q

Pancreatic adenocarcinoma at the head of the pancreas typically causes _______ _______.

A

Courvoisier gallbladder

92
Q

Enlarged, non-diseased gallbladder due to a mechanical obstruction of the CBD.

A

Courvoisier GB

93
Q

The _____ ______ sign refers to the dilatation of the CBD and the duct of Wursung.

A

Double Duct Sign

94
Q

Common causes of the Double Duct Sign include (3)

A

carcinoma of the head of the pancreas (Panc adenocarcinoma)
ampullary tumors
stone at the ampulla of Vater

95
Q

_______ ______ ______ is an inflammation and fibrosis of the intrahepatic and extrahepatic bile ducts.

A

Primary Sclerosing Cholangitis

96
Q

Sonographic findings associated with Primary Sclerosing Cholangitis

A

thickening of the bile duct walls

findings associated with cirrhosis

97
Q

Labs associated with Primary Sclerosisng Cholangitis (4)

A

ALP
GGT
ALT/AST
Conjugated Bilirubin

98
Q

Primary Sclerosing Cholangitis is associated with

A

inflammatory bowel diease (ulcerative colitis)
ERCP
Cholangiocarcinoma

  • thought be autoimmune but the casue is unknown
  • ERCP for diagnosis
  • results in liver failure
99
Q

________ ________ __________ is a chronic and progressive cholestasis due to destruction of the small intrahepatic bile ducts leading to end-stage liver disease.

A

Primary Biliary Cirrhosis

  • Dx with liver biopsy
  • etiology unknown, presumed to be autoimmune in nature
100
Q

Labs associated with primary biliary cirrhosis

A

ALT/AST
ALP
GGT
Antimitochondrial antibodies (AMAs)*

101
Q

Ultrasound findings associated with primary biliary cirrhosis

A

nonspecific
increased liver echogenicity
findings associated with cirrhosis and portal HTN
-F/U every 6m for HCC

102
Q

stones, mobile, shadowing

A

cholelithiasis

move the patient!

103
Q

non-shadowing, mobile, layering

A

sludge

104
Q

thick, poetntially non-mobile and mass like

A

tumefactive sludge

105
Q

thick wall with “seperating” layers

A

acute cholecystitis, edema in the wall

106
Q

contracted, thick wall

A

chronic cholecystitis

107
Q

echogenic foci protruding into GB, stalk, comet-tail artifact

A

GB Polyp

optimize for resolution (highest frequency, SonoCT/Harm off)

108
Q

echogenic foci in the wall, “strawberry”, cholesterol deposits

A

adenomymatosis vs cholesterolosis

109
Q

broad based projections into GB with blood flow

A

GB carcinoma

optimize Color because not NML vessels and won’t be fast (gain up, sm box, etc)

110
Q

dilated GB with intrinsic obstruction

A

hydrops

111
Q

hydrops GB w/ acute painless jaundice, extrinsic compression

A

Courvoisier’s GB

112
Q

WES

A

Porcelain GB

113
Q

sludge containing microcal deposits

A

Milk of Ca

114
Q

dirty shadowing in the GB

A

Emphysematous cholecystitis

115
Q

saccular dilatation, intra or extra

A

Caroli’s Disease

should communicate with duct unlike choledochal cysts

116
Q

stone in the duct

A

choledochalithiasis

-have been reports of intrahepatic stones

117
Q

liver like mass at porta hepatis, intra-hepatic dilatation

A

Klatskin’s Tumor

118
Q

non-specific unless klatskin’s

A

cholangiocarcinoma

119
Q

inflammation of the biliary ducts

A

primary sclerosing cholangitis

ABD (20 decks)

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