Biliary Tract Patho Flashcards
Most common cause of GB wall thickening?
Cholecystitis
Besides cholecystitis, other causes of GB wall thickening (5)
hypoalbuminemia ascites hepatitis CHF pancreatitis
Prehepatic cause of jaundice
increased bilirubin production
Hepatic causes of jaundice (5)
acute liver inflammation chronic liver disease infiltrative liver disease inflammation of bile ducts genetic disorders
prehepatic jaundice occurs if there is increased bilirubin production, which may be due to (3)
hemolysis - breakdown of RBC
ineffective erythropoiesis - overproduction of hemoglobin
absorption of large amounts of hemoglobin - internal bleeding
Acute liver inflammation is one cause of hepatic jaundice because it….
reduces the liver’s ability to conjugate
Hepatic related jaundice occurs with infiltrative liver diseases such as (4)
metastatic liver disease
hemochromatosis (inc iron absorption)
Alpha 1 antitryspin deficiency
Wilson’s disease (inc Copper absorption)
Inflammation of the bile ducts is a hepatic related cause of jaundice that may be due to (2)
primary biliary cholangitis
sclerosing cholangitis
genetic disorders that can cause hepatic jaundice include (2)
Gilbert’s syndrome
Crigler-Najjar syndrome (dec enzyme for conjugation)
Post hepatic cause of jaundice is due to an
obstruction of biliary tree, anything that blocs the bile ducts
obstruction that blocks the ducts causes pale _____ and dark _____, which is a post hepatic cause of janudice.
pale stool
dark urine
9 examples of biliary obstruction
choledocholithiasis Mirizzi syndrome cholangiocarcinoma cholangitis biliary atresia choledochal cyst Caroli's disease pancreatic adenocarcinoma GB carcinoma
Long-term total parenteral nutrition (TPN) induces GB stasis, which may create (3)
sludge
milk of calcium bile
gallstones
_____ appears as nonshadowing, echogenic material which layers and shifts with patient position.
sludge
calcium bilirubinate granules and cholesterol crystals
sludge
What sonographic finding distinguishes tumefactive sludge from gallstones?
no shadowing with tumefactive sludge
causes of biliary stasis that may result in sludge (5)
prolonged fasting TPN - intravenous feeding hemolysis cystic duct obstruction cholecystitis
cholelithiasis
gallstones
WES or double arc sign
Wall-Echo-Shadow seen with a GB filled with stones
Sonographic criteria for cholethiasis (3)
mobile
strongly echogenic
acoustic shadowing
Gallstones are composed of
cholesterol
calcium bilirubinate
calcium carbonate
Cholelithiasis may obstruct the cystic duct resulting in ______ _______ and possible complications such as (4)
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
Signs and symptoms of acute cholecystitis
RUQ pain
fever
leukocytosis
Sonographic features of acute cholecystitis (5)
gallstones Murphy's sign diffuse wall thickening GB dilation sludge
Murphy’s sign
intense point of tenderness transducer pressure directly on the GB
90% sensitive and specific
Obstruction at the level of the ampulla of Vater is suggested if _____ is elevated.
amylase
Complications of acute cholecystitis include (5)
empyema gangrenous cholecystitis perforation pericholecystic abscess bilioenteric fistula
Acute cholecystitis
Diffuse GB wall thickening due to cystic duct obstruction by a gallstone
Following initial stages of acute cholecystitis (obstruction, ischemia), _______ _______ may follow.
bacterial infection
Chronic cholecystitis (chronic GB disease) is characterized by recurring symptoms of ______ _____ due to multiple episodes of acute cholecystitis.
biliary colic
T/F - sonographically the findings for chronic cholecystitis are different from acute.
F - does not appear different
may include thick-wall, contracted GB, sludge, obstructing cystic duct stone
Emphysematous cholecystitis
due to acute cholecystitis with wall ischemia and infection
-thought to be a different pathogenesis than calculous cholecystitis
Emphysematous cholecystitis occurs more commonly in
diabetic men
Emphysematous cholecystitis has a higher rate of _______ and ________.
gangrene and perforation
With gangrenous cholecystitis, perforation is inevitable, resulting in ____________ and _________.
pneumoperitoneum and peritonitis
What five things can casue gas in the biliary system?
post ERCP post sphincter of Oddi papilotomy choledochojejunostomy gallbladder (biliary) fistula emphysematous cholecystitis
Choledochjejunostomy
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
empyema of the GB
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
GB perforation
- 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
Complications from GB perforation (3)
peritonitis
pericholecystic abscess
biliary fistula
acalculous cholecystitis
acute cholecystitis without gallstones
- caused by: bile stasis, dec. GB contraction, infection (secondary event)
- sonographic: wall thickening, Murphy sign, pericholecystic fluid
Acalculous cholecystitis is typically a secondary event in critically ill patients and is associated with (8)
parenteral (intravenous) nutrtion (>3 months) post operative abd surgery severe trauma severe burns sepsis HIV/AIDS blood transfusion reaction high-does opiod anagesics
increased hypoalbuminemia casuing ascites and CHF are other casues of _____ _____ _______
GB wall thickening
Milk of calcium bile is aka
limey bile
What is limey bile?
sludge-liek material with a high concentration of calcium
_______ _______ is associated with chronic cholecystitis and GB obtsruction of cystic duct
Limey bile
sonographic appearance of milk of calcium bile
may be seen as layering of sludge that results in distal acoustic shadowing
What is porcelain GB
calcification of the GB wall assocaited with chronic cholecystitis
Hydrops of the GB
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)
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?
possible mucocele
T/F - GB polyps that are greater than 10mm and demonstrate growth are most likely to be malignant
True
cholesterolosis
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
T/F - GB carcinoma is not realted to porcelain GB.
False
Adenomyomatosis
hyperplastic changes of the GB wall, overgrowth of mucosa, thickening of wall, and formation of diverticula
diverticula in the GB wall accumulate stones or sludge and is aka
rokitansky-aschoff sinuses or RAS
Adenomyomatosis is sonographically seen as hyperechoic foci within a thickened wall that casue what kind of artifact?
comet-tail (reverberation) artifact
Adenomyomatosis is sonographically seen as hyperechoic foci within a thickened wall that casue what kind of artifact?
comet-tail (reverberation) artifact
In the majority of patients, biliary obstruction is due to pathology in the _____ _____.
distal CBD
Two most common lesions associated with biliary obstruction
gallstones
carcinoma of the head of the pancreas
lab values associated with distal biliary obstruction
alp (alkaline phosphatase)
conjugated bilirubin/direct
gamma glutamyl transpeptidase (GGT)
Distal biliary obtsruction results in progressive dilatation of the ________ and _______ biliary tree.
extrahepatic to intrahepatic (distal to proximal)
causes of biliary obstruction
choledochalithiasis mirizzi syndrome cholangiocarcinoma cholangitis biliary atresia choledochal cyst caroli's disease pancreatic adenocarcinoma GB carcinoma
How can you distinguish dilated intrahepatic ducts from portal veins?
“parallel channel sign” or “shotgun sign” which refers to the dilated intrahepatic ducts adjacent to the portal vein
Cause of intrahepatic bile duct dilitation only (4)
cholangiocarcinoma (Klatskin tumor)
intrahepatic choledocholithiasis
recurrent pyogenic cholangitis
Caroli’s disease
choledocholithiasis is the presence of ______ in the bile ducts and is the most common casue of ________ obstructive jaundice.
calculi
extrahepatic obstructive jaundice
Symptoms associated with choledocholithiasis?
biliary colic (RUQ pain( jaundice
Lab values that increase with choledocholithiasis?
ALP
conjugated bilirubin
GGT
Complication associted with choledocholithiasis
biliary cirrhosis
cholangitis
pancreatitis
Mirizzi syndrome
extrahepatic biliary obtsruction due to an impacted stone in the cystic duct casuing extrinisc mechanical compression of the CHD
findings associated with mirizzi syndrome
intrahepatic duct dilitation
cystic duct stone
curved segmental stenosis of CHD
cholecystocholedochal fistual
Symptoms associated with cholangiocarcinoma (bile duct carcinoma)
jaundice
weight loss
abdominal pain
Klatskin Tumor
cholangiocarcinoma located at the hepatic hilum (junction of RT/LT hepatic ducts)
-results in intrahepatic dilitation, not extrahepatic
______ _____ _____ is the most common predisposing condition for bile duct carcinoma and dilatation of the _____ bile ducts is the most common finding
primary sclerosing cholangitis
intrahepatic
Biliary Ascariasis
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
cholangitis
bacterial infection sueprimposed on a biliary tree obstruction
A history of choledocholithiasis or recent biliary tract manipulation associated with fever (chills, rigors), RUQ pain, jaundice - The charcot triad - is highly suggestive of ______.
cholangitis
Cuases of cholangitis?
choledocholithiasis* ERCP obstructive tumor (panc head)
cholangitis result in in increased:
ALP conjugated bili GGT amylase and lipase WBC
biliary atresia
absence of extrahepatic ducts (CHD and CBD)
suspected when janudice (hyperbilirubinemia) persists beyond 14 days of age
Biliary atresia is associated with
polysplenia syndrome
absent IVC
situs inversus, situs ambiguous
cardiac abnormalites (ASD, VSD)
Pneumobilia
air in the biliary tract
echogenic foci in the intrahepatic bile ducts, comet-tail reverberation artifact
Causes of pneumobilia
ERCP sphincter of Oddi papilliotomy choledochojejunostomy GB fistula emphysematous cholecystitis
choledochal cysts
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
sonographic findings associated with choledochal cysts involving the CBD
2 cystic structures in the RUQ (dilated CBD and GB)
inrahepatic bile duct dilatation
Choledochal cysts are ore prevalent in _____.
Asia, more than 33% of reported cases are from Japan
-symptoms usually occur before age 10
Choledochal cysts are associated with (6)
pancreatitis cholangitis heaptic abscesses cirrhosis portal HTN cholangiocarcinoma
A congenital anomaly of the biliary tract charcterized by multifocal segmental dilatation of the intrahepatic bile ducts.
Caroli’s Disease/Syndrome
Caroli’s Disease is associated with (3)
congenital hepatic fibrosis
portal HTN
polycystic kidney disease
Sonographic appearance of Caroli’s Disease/Syndrome?
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
Most common cause of malignant neoplasm obstructing the biliary tree?
Pancreatic adenocarcinoma
Pancreatic adenocarcinoma at the head of the pancreas typically causes _______ _______.
Courvoisier gallbladder
Enlarged, non-diseased gallbladder due to a mechanical obstruction of the CBD.
Courvoisier GB
The _____ ______ sign refers to the dilatation of the CBD and the duct of Wursung.
Double Duct Sign
Common causes of the Double Duct Sign include (3)
carcinoma of the head of the pancreas (Panc adenocarcinoma)
ampullary tumors
stone at the ampulla of Vater
_______ ______ ______ is an inflammation and fibrosis of the intrahepatic and extrahepatic bile ducts.
Primary Sclerosing Cholangitis
Sonographic findings associated with Primary Sclerosing Cholangitis
thickening of the bile duct walls
findings associated with cirrhosis
Labs associated with Primary Sclerosisng Cholangitis (4)
ALP
GGT
ALT/AST
Conjugated Bilirubin
Primary Sclerosing Cholangitis is associated with
inflammatory bowel diease (ulcerative colitis)
ERCP
Cholangiocarcinoma
- thought be autoimmune but the casue is unknown
- ERCP for diagnosis
- results in liver failure
________ ________ __________ is a chronic and progressive cholestasis due to destruction of the small intrahepatic bile ducts leading to end-stage liver disease.
Primary Biliary Cirrhosis
- Dx with liver biopsy
- etiology unknown, presumed to be autoimmune in nature
Labs associated with primary biliary cirrhosis
ALT/AST
ALP
GGT
Antimitochondrial antibodies (AMAs)*
Ultrasound findings associated with primary biliary cirrhosis
nonspecific
increased liver echogenicity
findings associated with cirrhosis and portal HTN
-F/U every 6m for HCC
stones, mobile, shadowing
cholelithiasis
move the patient!
non-shadowing, mobile, layering
sludge
thick, poetntially non-mobile and mass like
tumefactive sludge
thick wall with “seperating” layers
acute cholecystitis, edema in the wall
contracted, thick wall
chronic cholecystitis
echogenic foci protruding into GB, stalk, comet-tail artifact
GB Polyp
optimize for resolution (highest frequency, SonoCT/Harm off)
echogenic foci in the wall, “strawberry”, cholesterol deposits
adenomymatosis vs cholesterolosis
broad based projections into GB with blood flow
GB carcinoma
optimize Color because not NML vessels and won’t be fast (gain up, sm box, etc)
dilated GB with intrinsic obstruction
hydrops
hydrops GB w/ acute painless jaundice, extrinsic compression
Courvoisier’s GB
WES
Porcelain GB
sludge containing microcal deposits
Milk of Ca
dirty shadowing in the GB
Emphysematous cholecystitis
saccular dilatation, intra or extra
Caroli’s Disease
should communicate with duct unlike choledochal cysts
stone in the duct
choledochalithiasis
-have been reports of intrahepatic stones
liver like mass at porta hepatis, intra-hepatic dilatation
Klatskin’s Tumor
non-specific unless klatskin’s
cholangiocarcinoma
inflammation of the biliary ducts
primary sclerosing cholangitis
