Biliary Tree Flashcards
The GB and cystic duct form from the cranial/caudal portion of the bud on the fore/mid/hindgut in the 4th or 5th week of life.
caudal, fore
T/F? Agenesis of the GB is a serious birth defect that needs immediate treatment.
False.
Duplication of the GB often occurs with the ___and may be diagnosed prenatally.
cystic duct
Bile is a…
digestive liquid produced by the liver.
When bile is stored in the GB it becomes more ___ and therefore more ___.
concentrated, potent
The ingestion of food casuses the release of a hormone called…
cholecystokinin (CKK)
CKK signals the relaxation of the ___ and the contraction of the ___ which squirts the bile into the small intestine.
sphincter of Oddi (the valve at the end of the CBD); GB
___ form when bile salts and cholesterol get out of balance in the bile.
Gallstones
The two major functions of bile in the body are…
1) to break down fats
2) to remove toxins from the liver
The GB derives its blood supply from the ___ artery which arises from the ___ artery.
cystic, right hepatic
T/F? The cystic vein drains directly into the portal vein.
True.
What are the three parts of the GB?
neck, body, and fundus
This area of the neck is a common location for impaction of gallstones.
Hartmann’s pouch aka infundibulum aka that angulated portion of the neck
When the GB fundus folds onto the body, it’s known as a…
phrygian cap.
When the GB has two or more compartments divided by a thin septa, it’s known as a…
septate GB.
When the GB has a thick septa separating the components, it’s known as a…
hourglass GB.
The GB neck tapers to form the ___ duct which joins with the ___ duct to form the ___ duct.
cystic, common hepatic, common bile
The ___ duct and the ___ duct join to form the ampulla of vater.
common bile, main pancreatic
These valves are small mucsal folds and control the bile flow in the cystic duct.
spiral valves of heister
GB’s normal size is less than…
4 cm trans, 10 cm sag
GB’s normal wall thickness is less than…
3 mm.
Because food consumption stimulates the GB to contract, a GB exam should be performed after…
a minimum of 6 hrs fasting.
The proximal portion of the CBD is ___ to the proper hepatic artery and ___ to the main portal vein.
lateral, anterior
The common risk factors for gallstones are…
5 F’s:
- forty something
- female
- fat
- fertile
- fair-skinned
Recurrent episodes of abd pain are called…
biliary colic.
What do the letters of the ‘WES’ sign stand for?
Wall
Echo
Shadowing
This is the presence of a gallstone in the CBD.
Choledocholithiasis
This is a rare condition in which the GB becomes filled with a pasty semi-solid substance made mostly of calcium carbonate.
Milk of calcium bile aka limey bile
This is a a residue of particles that remain in the GB after the bile is ejected which can solidify, forming gallstones.
Sludge aka biliary sand aka microlithiasis
The common risk factors for GB slude are…
pregnancy rapid weight loss prolonged fasting critical illness bone marrow transplant biliary stasis cystic duct obstruction cholecystitis
Sonographically, this appears as an amorphous material in the lumen of the GB with low level echoes in the dependent position with no shadowing.
sludge
Sonographically, this appears as a highly echogenic material in the GB lumen with posterior acoustic shadowing.
Milke of calcium bile
Sonographically, this appears as a mobile echogenic foci with shadowing in the GB lumen.
gallstones
Sludge that moves but doesn’t shadow and mimics polypoid tumors is called…
tumefactive sludge aka ‘sludge balls’
When sludge has the same echotexture of the liver and camouflages the GB it’s referred to as…
the ‘hepatization’ of the GB.
This is a tumor or tumor-like projection arising from the GB mucosa.
GB polyp
Sonographically, this appears as a non-mobile, non-shadowing echogenic foci within the GB lumen.
GB polyp
This is an impaction of a stone in the cystic duct or the GB neck, associated with RUQ pain, fever, and leukocytosis.
Acute cholecystitis
Sonographically, this appears as a distended GB with a thickened hyperemic wall, stones in the lumen or the duct, fluid collections, and a positive Murphy’s sign.
Acute cholecystitis
Amylase elevation suggests…
obstruction at the level of the ampulla of vater.
This is when the GB wall necroses due to decreased blood supply.
Gangrenous cholecystitis
Sonographically, this appears as a GB with wall striations, intraluminal membranes, and pericholecystic fluid.
gangrenous cholecystitis
This is when GB wall ischemia and infections lead to acute cholecystitis.
emphysematous cholecystitis (occurs more commonly in diabetic men)
Sonographically, this appears as a comet tail or reverberation artifact due to the presence of gas within the GB lumen.
emphysematous cholecystitis
This is when the GB contains purulent material due to bacteria-containing bile, initiated with obstruction of the cystic duct.
empyema
Sonographically, this appears as atypical bile echoes within the GB of patients with RUQ pain, fever, and leukocytosis.
empyema
Sonographically, this appears as a localized fluid collection in the GB fossa.
GB perforation
This is acute cholecystitis without the presence of gallstones.
acalculous cholecystitis
Prolonged use of TPN, abd surgery, trauma, severe burns, sepsis, and AIDS are associated with…
acalculous cholecystitis
Sonographically, this appears as a massively distended and inflamed GB lying in an unusual horizontal position.
Torsion (volvulus) of the GB
This presents as acute cholecystitis requiring emergency surgery, often seen in elderly females.
torsion of the GB
This is characterized by recurring symptoms of biliary colic due to multiple previous episodes of acute cholecystitis.
chronic cholecystitis
Sonographically, this appears the same as acute cholecystitis, but a thick-walled fibrotic contracted GB with sludge/stone in the cystic duct may be present.
chronic cholecystitis
This is an unusual variant of chronic cholecystits that resembles carcinoma of the GB.
xanthogranulomatous cholecystitis
Sonographically, this appears as a thickened irregular GB with extensions of inflammation to adjacent organs and hypoechoic intramural nodules.
xanthogranulomatous cholecystitis
T/F? GB wall thickness is > 3 mm and the most common cause is cholecystitis.
true
T/F? Once the GB is removed, bile is retained in the bile ducts and is not free to flow into the duodenum during fasting and digestive phases.
false, post-GB removal the bile flows freely.
T/F? Dilation of the extrahepatic bile duct occurs after GB removal.
true
This is a calcification of the GB wall.
porcelain GB
Porcelain GB occurs in association with gallstone ___ and may represent some form of ___ cholecystitis.
disease, chronic
What determines the sonographic appearance of porcelain GB?
the degree and pattern of calcification
When the entire GB wall is thickly calcified, a ___echoic ___lunar line with dense ___ is noted.
hyper, semi, posterior acoustic shadowing
When the GB wall is only mildly calcified, an ___ line with variable degrees of ___ is observed.
echogenic, posterior acoustic shadowing
In a porcelain GB, the luminal contents may be visible with…
interrupted clumps of calcium appearing as echogenic foci w/ posterior shadowing.
Why is the WES sign absent in a porcelain GB?
Because the calcification occur in the GB wall.
This is a benign condition in which diverticula within the GB wall accumulate stones or sludge within them.
adenomyomatosis
Adenomyomatosis is also known as…
rokitansky-aschoff sinuses.
T/F? Adenomyomatosis can be focal or diffuse.
true
Sonographically, this appears as tiny echogenic foci in the GB wall that create comet-tail, ringdown, or twinkling artifacts.
adenomyomatosis
If an echogenic foci in the GB wall does NOT create an ___ or DOES have internal ___ further investigation in needed to rule out ___.
artifact, vasularity, neoplasm
What are the different types of polypoid masses in the GB?
- cholesterol polyps (50-60%)
- inflammatory polyps (5-10%)
- adenoma (<5%)
- focal adenomyomatosis
- adenocarcinoma
- metastases (esp melanoma)
Differentiation of benign and malignant GB polyps is very important b/c the former are ___ and the latter require ___.
very common; early intervention to improve outcome
What are the most frequently used criteria for GB polyps being benign?
multiplicity and size less than 10 mm
Malignancy has been documented in 37-88% of resected GB polyps that were…
10 mm or more.
Besides size, how else might you tell if a GB polyp was malignant?
- older than 60
- single lesion
- gallstone disease
- rapid change in size
- sessile morphology (no stalk)
Approximately half of all GB polyps are…
cholesterol polyps.
Cholesterol polyps represent the ___ form of GB cholesterolosis, a common non-neoplastic condition.
focal
Cholesterolosis results in the ___ of lipids in the GB ___.
accumulation, wall
How do you tell a gallstone from a GB polyp?
Polyps don’t roll and don’t produce posterior shadowing.
If the focal form of cholesterolosis is the polyp, what is the diffuse form called?
Strawberry GB
T/F? Cholesterolosis is usually asymptomatic or presents with colicky abdominal pain.
True.
Sonographically, this appears as tiny echogenic foci in the GB lumen (but without comet tail reverberation).
Cholesterolosis
The two most common lesions that cause biliary obstruction are…
gallstones and carcinoma of the pancreas head.
T/F? AFP and bilirubin are typically elevated/associated with biliary obstruction.
False. Serum alk phos and bilirubin.
Obstruction of the distal CBD results in progressive dilation of the…
intra- and extrahepatic biliary tree.
Besides gallstones and pancreatic head cancer, what else could cause a biliary obstruction?
choledocholithiasis pancreatic carcinoma cholangiocarcinoma cholangitis mirizzi syndrome choledochol cyst GB carcinoma
The ‘parallel channel’, ‘shotgun’, ‘star-shaped’ sign is indicative of what condition?
Dilated intrahepatic ducts
Sonographically, these appear as irregular tortuous ducts in the liver that create lots of posterior acoustic enhancement.
dilated intrahepatic ducts
What happens when the obstruction is in the distal CBD?
The entire system including the GB distends.
What happens when the obstruction is in the CHD?
The proximal ducts distend, and the GB contracts.
What happens when the obstruction is in the right and left hepatic ducts?
The intrahepatic ducts dilate.
Here’s a list of some biliary tract abnormalities…
choledochal cysts caroli's disease mirizzi syndrome hemobilia pneumobilia acute (bacterial) cholangitis recurrent pyogenic cholangitis ascariasis HIV cholangiopathy primary sclerosing cholangitis cholangiocarcinoma metastases
This is a congenital bile duct abnormality that consists of cystic dilation of the intra or extra hepatic bile ducts and is classified into five groups.
choledochal cysts
Which type of choledochal cyst is the most common, a fusiform dilation of the CBD resulting in a long channel between distal CBD and MPV.
Type I
Which type of choledochal cyst is confined to the intraduodenal portion of the CBD outside the liver, called ‘choledochoceles’?
Type III
Which type of choledochal cyst presents with multiple intra and extra hepatic biliary dilations?
Type IVa
Which type of choledochal cyst presents with multiple dilations ONLY in the extra hepatic ducts?
Type IVb
Which type of choledochal cyst is called Caroli’s disease?
Type V
Sonographically, this appears as a cystic structure in the bile duct which may contain internal sludge, stones, or even solid neoplasm.
choledochal cyst
Because of the risk of cholangiocarcinoma with all choledochal cysts…
surgical resection is advocated
ERCP is necessary to ensure that ___ especially in the case of Type I choledochal cysts.
the dilation isn’t the result of a distal neoplasm
This is a rare congenital anomaly of the biliary tract characterized by multi-focal segmental dilations of the INTRAhepatic bile ducts.
Caroli’s disease
Sonographically, this appears as multiple cystic structures that converge toward the porta hepatis communicating with the bile ducts. Sludge and calculi accumulate in the ectatic ducts resulting in posterior acoustic shadowing.
Caroli’s disease
This condition presents with jaundice, pain, and fever resulting from an impacted stone in the cystic duct that compresses the CHD.
Mirizzi syndrome
This condition is characterized by a blood clot in the biliary tree.
hemobilia
This condition results from previous biliary intervention and is characterized by air in the biliary tree.
pneumobilia
Sonographically, this appears as intrahepatic linear echogenic regions that produce dirty shadowing and reverberation artifacts.
pneumobilia
Pneumobilia is best diagnosed by seeing the air bubbles move within the bile ducts. This phenomena can be produced by…
changing the patient’s position.
This condition presents with leukocytosis, elevated alkaline phosphatase and bilirubin, and Charcot’s triad (fever, ruq pain, jaundice).
acute (bacterial) cholangitis
What is an essential component of bacterial cholangitis along with CBD stones?
antecedent (precursor) biliary obstruction
What kind of bile is most commonly affected by acute cholangitis?
bile infected by gram-negative enteric bacteria, as shown by blood cultures
Sonographically, this appears as a dialation of the biliary tree, choledocholithiasis and possibly sludge, bile duct wall thickening, and hepatic abscesses.
acute (bacterial) cholangitis
This condition is an inflammation process affecting the biliary tree in the advanced stages of HIV infection.
HIV cholangiopathy aka AIDS cholangitis
Patients with this condition present with severe RUQ or epigastic pain, markedly elevated alk phos but NORMAL bilirubin levels.
HIV cholangiopathy aka AIDS cholangitis
Sonographically, this appears as bile duct wall thickening, intra & extra hepatic focal structures and dilations, CBD dilations, and diffuse GB wall thickening.
HIV cholangiopathy aka AIDS cholangitis
This condition is a chronic disease process that affects the entire bliary tree, frequently seen in middle aged men, particularly if they have concomitant inflammatory bowel disease, usually ulcerative colitis.
primary sclerosing cholangitis
Sonographically, this appears as irregular circumferential bile duct wall thickening of varying degrees, encroaching on and narrowing the lumen, with focal strictures and dilations of the bile ducts.
primary sclerosing cholangitis
This develops in 7-30% of patients with primary sclerosing cholangitis.
cholangiocarcinoma
T/F? Primary sclerosing cholangitis is not seen in extrahepatic ducts.
False, it’s seen in both intra- and extrahepatic ducts.
In this condition, roundworms spread by the fecal-oral route that are active in the small bowel may enter the biliary tree through the ampulaa of vater and cause a biliary obstruction.
ascariasis
Sonographically, this appears as a tube or parallel echogenic line within the bile ducts like a stent or, transversely, as a ‘target’ surrounded by bile ducts.
ascariasis
This condition is associated with gallstones, chronic gallstone disease, and resultant dysplasia.
GB carcinoma
Sonographically, this can appear a a mass arising in the GB fossa, obliterating the GB and invading the adjacent liver.
GB carcinoma
Sonographically, this can appear as a focal or diffuse, markedly abnormal and irregular wall thickening.
GB carcinoma
Sonographically, this can appear as an intraluminal polypoid mass.
GB carcinoma
What are the two patterns of GB carcinoma tumor spread?
contiguous hepatic spread**(most common)
lympatic spread
Contiguous hepatic spread of GB carcinoma is the most common pattern because…
the GB wall is thin and so little connective tissue separates it from the liver parenchyma.
How does GB carcinoma mimic hilar cholangiocarcinoma?
by extending up the cystic duct into the porta hepatis
This pattern of GB carcinoma spread may occur even in the absence of invasion of adjacent organs.
lympatic spread
Where are the first nodes to be affected in the lymphatic spread of GB carcinoma?
the hilar region
Sonographically, small masses of ___ in the GB fossa may be difficult to appreciate because they blend into the liver.
GB carcinoma spread
The absence of a normal appearing GB with no history of cholecystectomy should raise suspicion of…
GB carcinoma spread
Sonographically, this may appear as a polypoid mass in the GB.
primary GB adenocarcinoma
Sonographically, this appears as multiple hyperechoic broad based polyps.
primary GB adenocarcinoma
This condition is an uncommon neoplasm that may arise from any portion of the biliary tree.
cholangiocarcinoma
The two types of cholangiocarcinoma are…
intra- and extrahepatic
This is the least common (but second most common) primary malignancy of the liver.
intrahepatic cholangiocarcinoma
Sonographically, this appears as a large hepatic mass, hypovascular, solid with heterogeneous echotexture.
intrahepatic cholangiocarcinoma
Primary sclerosing cholangitis**(most common) and chronic biliary stasis and inflammation are the risk factors for…
intrahepatic cholangiocarcinoma
Hilar intrahepatic cholangiocarcinoma is also known as…
klatskins.
Klatskins staging and tumor growth patterns begin where?
in either the right or left bile ducts and extend proximally (into the higher order branches) and distally (into the CHD and contralateral bile ducts).
T/F? Klatskin tumors can extend outside of the bile ducts into the adjacent portal vein and arteries.
True
T/F? Klatskin tumor usually do not metastasize to the liver.
False
T/F? In klatskins, nodal disease often begins at the porta hepatis.
True
This condition mimics the different appearances of cholangiocarcinoma and affects both intra and extra hepatic ducts.
metastases
These sites constitute the majority of primary metastases to the biliary tree.
breast, colon, and melanoma
This condition is the most common malignant neoplasm that obstructs the biliary tree.
pancreatic adenocarcinoma
Sonographically, this appears as an enlarged, often palpable, GB in a patient pancreatic head carcinoma. It is associated with jaundice due to obstruction of the CBD.
Courvoisier GB
