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FUNDAMENTALS OF BODY CT > Biliary Tree and Gallbladder > Flashcards

Biliary Tree and Gallbladder Flashcards

1
Q

Normal common duct size

A

<6 mm, increasing 1 mm per decade (Ex. 7 mm is normal for patients in their 70s)

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2
Q

CT of the bile ducts technique

A
  1. Water as oral contrast agent: (300 ml of water 15-20 min before exam)
  2. Multiphase CT (4 phases)
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3
Q

Biliary obstruction causes (in general) (6)

A
  1. Impacted Gallstones
  2. Bile duct stricture
  3. Malignancy
  4. Parasites
  5. AIDS related cholangiopathy
  6. Choledocal cysts
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4
Q

Biliary duct’s stricture causes (6)

A
  1. Trauma/surgery/instrumentation
  2. Chronic pancreatitis
  3. PSC
  4. Recurrent pyogenic cholangitis
  5. AIDS-associated cholangitis
  6. Benign tumors of the biliarty tract
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5
Q

Biliary obstruction main malignancies (5)

A
  1. Pancreas head carcinoma
  2. Duodenal/ampullary carcinoma
  3. Cholangiocarcinoma
  4. Gallbladder carcinoma
  5. Metastases
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6
Q

Mirizzi Syndrome

A

A gallbladder stone impected in the cystic duct induces cholangitis or erodes into the common duct to cause obstructive jaundice.

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7
Q

Clues to the cause of biliary obstruction

A
  1. Abrupt termination of a dilated CBD: Malignancy.
  2. Gradual tapering of a dilated duct: Benign.
  3. Choledocholithiasis: Might be difficult to recognize due to the wide variation in CT appearance of gallstones.
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8
Q

How many percent of gallstones are not visualized by CT?

A

15-25% of gallstones

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9
Q

Types of Gallstones to CT

A
  1. Calcific: Calcium billirubinate stones
  2. Soft-tissue: Mixed stones
  3. Fat: Cholesterol stones
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10
Q

Target or crescent sign

A

Stone as central density surrounded by a rim or crescent of lower-density bile

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11
Q

Rim sign

A

Low-attenuation stone may be defined by a higher attenuation outer rim

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12
Q

Cholangiocarcinoma growth patterns (4)

A
  1. Mass forming intrahepatic
  2. Periductal infiltrating
  3. Intraductal growing
  4. Extrahepatic
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13
Q

Cholangiocarcinoma localization %

A
  • Extrahepatic bile ducts (65%)
  • Hilum (25%)
  • Periphery of the liver (10%)
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14
Q

Intrahepatic mass forming CCA - CT findings

A
  • Homogeneous tumor, irregular borders, low attenuation
  • Arterial phase: Weak peripheral enhancement
  • Delayed phase: Central or diffuse enhancement
  • Bile ducts peripheral to the tumor obstructed and dilated
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15
Q

Periductal infiltrating CCA - CT findings

A
  • Bile ducts are invaded by lesions in an elongated and branching pattern
  • Tumor’s Bile ducts are narrowed with thick walls
  • Peripheral bile ducts are dilated with thin walls
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16
Q

Klatskin tumor

A

Periductal-infiltrating CCA at the confluence of the right and left hepatic bile ducts

17
Q

Intraductal CCA - CT findings

A
  • Polypoid or sessile papilary lesions that extend superficially along the bile duct mucosa
  • May produce mucin, which disproportionately dilates the biliary system
18
Q

Extrahepatic CCA - CT findings

A

May appear as:
-Duct obstructing polypoid tumor nodule 1-2 cm in diameter.
- Abrupt stricture with wall thickening up to 1 cm
- Single or multiple intraductal frond-like masses

19
Q

Cholangitis main causes (5)

A
  1. Primary schlerosing cholangitis
  2. Acute pyogenic cholangitis
  3. Recurrent pyogenic cholangitis (Oriental cholangitis)
  4. AIDS - Cholangiopathy
  5. Autoimmune pancreatitis-associated cholangitis
20
Q

Primary schlerosing cholangitis

A

Idiopathic inflammatory condition, causes progessive fibrosis of bile ducts leading to: obstruction, cholestasis and biliary cirrhosis
- 70% associated with ulcerative colitis and other inflammatory bowel diseases
- CT findings: Multiple segmental strictures thickening (2-5 mm) of bile ducts alternating with normal ones (Beaded appearance)

21
Q

Acute pyogenic cholangitis

A
  • Acute abdominal pain, feber, jaundice (Charcot Triad)
  • CT: Periductal edema, bile duct dilatation and inhomogeneous enhancement of the liver parenchyma
  • Complications: Liver abcess, sepsis
  • May produce pneumobilia
22
Q

Recurrent pyogenic cholangitis (Oriental cholangitis)

A
  • Recurrent episodes of cholangitis, associated with pigmented stones, multifocal biliary strictures and dilations
  • Causes: Clonorchis sinensis, ascaris lumbricoides, malnutrition and portal vein bacteremia
  • Endemic to southeast asia and china
  • CT: Marked dilation of CBD
  • Complications: Liver abscess, portal vein thrombosis, pneumobilia and CCA
23
Q

AIDS-Cholangiopathy

A
  • Opportunistic infection with criptosporidium or CMV
  • Intrahepatic bile ducts narrowing similar to PSC
  • KEYPOINT: Might generate obstruction of the distal part of CBD (near the ampula)
24
Q

Autoimmune pancreatitis-associated cholangitis

A
  • Autoimmune pancreatitis + involment of bile tree
  • Ig4-positive lymphocytes infiltrate the wall of intrahepatic and extrahepatic bile ducts
  • Thickening and enhancement of the wall of the bile ducts occurs in association with multiple strictures
  • The distal part of the CBD is most commonly affected
25
Q

Gas or contrast material in biliary tree causes (5)

A

By far the main cause is iatrogenic.

  1. Recent instrumentation of the biliary system (CPRE, percutaneous)
  2. Iatrogenic (Sphincterotomy, choledochojejunostomy, whipple procedure)
  3. Gallstone fistula (Cholecystoduodenal fistula)
  4. Perforated ulcer (Choledocoduodenal fistula)
  5. Carcinoma (Choledocoenteric fistula)
26
Q

Choledocal Cyst classification

A

Todani’s Classification (I-V)
- Type I (50-80%): Localized cystic dilation of CBD
- Type II (2%): Diverticulum of CBD o CHD
- Type III (1.4%-4.5%): Choledochocele at the intramural portion of the distal part of CBD, protrudes into the duodenum
- Type IV (15-35%): Type IV-A: Cystic dilation of intrahepatic bile duct and saccular dilation of CBD. Type IV-B: extremely rare, multiple cystic dilations of extrahepatic bile ducts with normal intrahepatic bile ducts
- Type V: Caroli disease

27
Q

Caroli Disease

A
  • Saccular dilation of the intrahepatic biliary tree, cholangitis and gallstone formation
  • Abscense of cirrhosis or portal hypertension
  • Increased risk of CCA (7% of patients)
  • CT findings: Dilation of the intrahepatic biliary tree with focal areas of tubular and saccular enlargement
28
Q

Caroli syndrome

A

Caroli disease + Congenital hepatic fibrosis

29
Q

Acute Cholecystitis types (3)

A
  1. Gangrenous cholecystitis: may lead to perforation, abscess, fistula and peritonitis
  2. Acalculous cholecystitis: critically ill patients after surgery, trauma, burns or hyperalimentation
  3. Emphysematous cholecystitis: severe form, occurs in eldery patients and diabetes
30
Q

Normal Gallbladder measurements

A

Size: 4-5 cm in diameter
Thickness: <3 mm

31
Q

Porcelain Gallbladder

A

Chronic cholecystitis, may develor gallbladder carcinoma in 5-7% of cases, cholecystectomi is advocated even if asymptomatic

32
Q

Gallbladder carcinoma

A
  • Most common malignancy of the biliary sistem
  • > 50 years old
  • RF: Gallstones and chronic cholecystitis
33
Q

Gallbladder carcinoma CT patterns (3)

A
  1. Polypoid soft tissue
  2. Focal o diffuse thickening of the gallbladder wall
  3. Mass contining gallstones
34
Q

Gallbladder Adenomyomatosis

A
  • Benign cause of thickening of walls
  • Hyperplasia o muscularis propia + proliferation of the epitelium, generating lines puches in the gallbladder
  • Infolds of thickened epithelium generates “rokitansky aschoff sinuses”
  • Gallbladder stones present in 25-75%
35
Q

Gallbladder Adenomyomatosis CT patterns (4)

A
  1. Diffuse.
  2. Localised.
  3. Segmental.
  4. Annular (hour glass shape).
36
Q

Klatskin tumor classificacion

A

Bismuth-Corlette classification:
I: CHD below the confluence
II: At the confluence of LHD and RHD
IIIa: Confluence and into LHD
IIIb: Confluence and into RHD
IV: Extension to LHD and RHD

FUNDAMENTALS OF BODY CT (8 decks)

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