Biliary Tree Flashcards
List the convergence of the bile ducts.
Intrahepatic > right and left hepatic ducts > CHD
Where is the GB located in the liver?
Inferior end of the the main lobar fissure
Which ducts make up the ampulla of Vater?
CBD and main pancreatic duct ( Duct of Wirsung)
What is the Mickey Mouse sign?
The portal triad
What is the spiral fold that controls bile flow in the cystic duct?
Valve of Heister’s
What is the abnormal sacculation of the neck of the GB?
Hartmann’s pouch
What is the phrygian cap?
Fold between the body and the funds of the GB
Where does the CBD pass in the liver?
Posterior to the first part of the duodenum and pancreatic head
What controls the ampulla of Vater emptying through the duodenal papilla?
Sphincter of Oddi
What are some causes of GB wall thickening?
Hypoalbuminemia Ascites Hepatitis CHF Pancreatitis
What are pre-hepatic causes of jaundice?
Increased bilirubin production (Hemolysis, Ineffective erythropoiesis, Absorption of large amounts of Hb)
What are hepatic causes of jaundice?
Acute liver inflammation Chronic liver disease Infiltrative liver disease Inflammation of bile ducts Genetic disorders
What are post-hepatic causes of jaundice?
Obstruction of the biliary tree
causes pale stool and dark urine
What is GB sludge?
Calcium bilirubinate granules and cholesterol
What is GB sludge associated with?
Biliary stasis secondary to prolonged fasting, TPN, hemolysis, cystic duct obstruction, cholecystitis.
What are gallstones made of?
Cholesterol
Calcium bilirubinate
Calcium carbonate
What is another name for WES?
Double Arc
What are complications of acute cholecystitis?
Empyema Gangrenous cholecystitis Perforation Pericholecystic abscess Bilioenteric fistula
What causes gas in the biliary system?
ERCP Sphincter of Oddi papillotomy Choledochojejunostomy GB fistula Emphysematous cholecystitis
What is emphysematous cholecystitis?
Acute cholecystitis due to GB wall ischemia and infection
What is empyema of the GB?
Purulent material within the GB due to bacteria-containing bile associated with acute cholecystitis
What are complications of a GB perforation?
Peritonitis
Pericholecystic abscess
Biliary fistula
What is acalculous cholecystitis?
Acute cholecystitis without presence of gallstones
What are causes of calculus cholecystitis?
Bile stasis
Decreased GB contraction
Infection
What is milk of calcium bile (Limy bile)?
Sludge-like material with high concentration of calcium
How does Limy bile appear on US?
Layering of sludge that results in distal acoustic shadowing
What is a porcelain GB?
Calcification of the GB wall associated with chronic cholecystitis
What is hydrops of the GB?
Mucocele of the GB from an over distended GB filled with mucoid or clear, watery contents
What size are noncancerous GB polyps?
<10 mm in diameter
What is cholesterolosis of the GB?
Lipids (cholesterol and TGs) deposited in the GB wall
What is a “strawberry GB”?
Cholesterolosis from the golden yellow lipid deposits against the red gallbladder mucosa
What are US findings of GB CA?
Intraluminal mass
Asymmetric wall thickening
Mass that fills GB (most common)
What is adenomyomatosis?
Hyperplastic changes involving the GB wall causing overgrowth of the mucosa, thickening of the wall, and formation of diverticula
What are the diverticula within the GB wall called?
Rokitansky-Aschoff sinuses
What causes the majority of biliary obstruction?
Pathology in the distal CBD
Gallstones
CA of head of pancreas
Where is the CHD routinely measured?
Point where the right hepatic artery courses between the portal vein and biliary duct
What is the “Parallel channel sign”?
“Shotgun sign” dilated hepatic duct adjacent to the portal vein
What vessels are more irregular and tortuous than the portal vein?
Bile ducts
How do bile ducts branch?
Stellate confluence - “star-shaped” configuration
Why do bile structures produce acoustic enhancement?
They attenuate sound less than blood
Which hormone causes gallbladder contraction?
Cholecystokinin
What is a negative result of the CBD with a fatty meal?
Unchanged or decreased size
Where do biliary tree obstructions occur?
Distal CBD (most common) Common hepatic obstruction Obstruction at the junction of the R and L hepatic ducts
What is choledocholithiasis?
Calculi in bile ducts (most common cause of extra hepatic obstructive jaundice)
What are complications of choledocholithiasis?
Biliary cirrhosis
Cholangitis
Pancreatitis
What is Mirizzi Syndrome?
Extrahepatic biliary obstruction due to an impacted stone in the cystic duct causing compression of the CHD
What are associated findings of Mirizzi Syndrome?
Intrahepatic duct dilatation
Cystic duct stone
Curved segmental stenosis of CHD
Cholecystocholedochal fistula
What is cholangiocarcinoma?
Bile duct adenoCA
What is cholangiocarcinoma located at the hepatic hilum called?
Klatskin tumor
What are some predisposing conditions for cholangiocarcinoma?
Primary sclerosing cholangitis (most common) Ulcerative colitis Caroli's disease Choledochal cyst Parasitic infestation Chemical toxins
How do cholangiocarcinoma patients present?
Jaundice
Weight loss
Abdominal pain
What is cholangitis?
Bacterial infxn superimposed on an obstruction of the biliary tree
What are common causes of cholangitis?
Choledocholithiasis
ERCP
Obstructive tumors
What is biliary atresia?
Absence of extrahepatic bile ducts
What is biliary atresia associated with?
Polysplenia syndrome
Absent IVC
Situs inversus
Cardiac anomalies
How is biliary atresia treated?
Kasai portoenterostomy within 90 days of life - surgical drainage
Liver transplant
What is pneumobilia?
Air in the biliary tract
What are choledochal cysts?
Congenital bile duct anomalies with cystic dilatation of intra or extra hepatic bile ducts - prevalent in Asia
What are choledochal cysts associated with?
Pancreatitis Cholangitis Hepatic abscesses Cirrhosis Portal HTN CholangioCA
What is Caroli’s disease?
Type V choledochal cyst - congenital anomaly of biliary tract with multifocal segmental dilatation of intrahepatic bile ducts
What is Caroli’s disease look like on US?
Multiple cystic structures that converge toward the portal hepatic communicating with bile ducts
What is the most common cause of malignancy obstructing the biliary tree?
Pancreatic adenoCA
What is a Courvoisier GB?
Enlarged, non-diseased GB due to mechanical obstruction of the CBD
What is primary sclerosing cholangitis?
Inflammation and fibrosis of the intrahepatic and extrahepatic bile ducts
What is sclerosing cholangitis associated with?
IBD
ERCP
Cholangiocarcinoma
How does sclerosing cholangitis look on US?
Thickening of the bile duct walls
Findings assoc with cirrhosis
What is primary biliary cirrhosis?
Chronic and progressive cholestasis due to obstruction of the small intrahepatic bile ducts leading to end-stage liver disease
What is bilirubin?
End product of Hb breakdown
Total bili = conj bili + unconj bili
What is the difference between conjugated and unconjugated bilirubin?
Conjugated bili has albumin removed from unconjugated bili that is needed for bilirubin disposal