Ch. 11- Gallbladder Flashcards
1
Q
Hyperplastic Cholecystisis Characterized by
A
Hyperconcentration: increase amt. of concentrated bile Hyperexcitability: ______ Hyperexcertion: too much bile
2
Q
Types of Hyperplastic Cholecystitis
A
Cholesterolosis Adenomyomatosis
3
Q
Cholesterolosis
A
condition in which cholesterol is deposited w/in lumina propria of GB
4
Q
Adenoma
A
Benign neoplasms w/ a potential to become malignant
5
Q
Adenoma occurs
A
as a solitary lesion Small: pedunculated Large: contain foci malignant transformation
6
Q
Adenoma Sonographic Appearance
A
Homogenously hyperechoic - as grow in size will become heterogenous - thick wall= hourglass appearance
7
Q
Adenomyomatosis
A
Hyperplastic change in the GB wall
8
Q
How do papillomas occur?
A
Singularly or in groups
9
Q
Where may adenomyomatosis be found?
A
May be scattered over a large part of the mucosal surface of the GB
10
Q
What is adenomyomatosis associated w/?
A
Rokitansky- Aschoff Sinuses
11
Q
What are Rokitanksy-Aschoff sinuses?
A
Small mucosal herniations into the muscular layer of the GB
12
Q
Rokitanksy-Aschoff sinuses appear- if filled w/bile
A
Cystic
13
Q
Rokitanksy-Aschoff- if filled w/cholesterol deposits
A
Echogenic foci w/v-shaped reverberation artifact
14
Q
Adenomyomatosis Sonographic Appearance
A
small elevelations in lumen of the GB Maintain their initial location during positional changes
15
Q
What type of artifact does adenomyomatosis cause?
A
Comet tail artifact
16
Q
Porcelain
A
Calcium incrustation of GB wall
17
Q
What is Porcelain gallbladder associated with?
A
gallstones
18
Q
What are the symptoms of a porcelain gallbladder?
A
asymptomatic
19
Q
How is a diagnosis made for Porcelain gallbladder
A
- incidental finding - mass is found on physical examination
20
Q
Can porcelain gallbladder develop into cancer?
A
Yes; 25%
21
Q
Porcelain Sonographic Findings
A
Bright echogenic echo region of GB w/posterior shadowing (can’t see a wall majority of the time)
22
Q
Gallbladder Carcinoma -characteristics
A
Rare & rapidly progressive 100% mortality rate 2X as common as cancer of the bile ducts
23
Q
What is GB carcinoma associated w/?
A
cholelithiasis 80-90%
24
Q
What increases the chance of developing GB carcinoma?
A
Cholelithiasis- presence of stones in the GB
25
GB carcinoma occurs most frequently in?
Women over 60 yrs
26
Where may GB carcinoma tumor arise from?
-body of the GB - cystic duct (rare)
27
Effects of GB carcinoma tumor
- infiltrate the GB -causes thickening and rigidity of the wall
28
What or how do you differentiate between a benign or malignant tumor of the GB
Put color doppler - Malignant= GB carcinoma = hypervascularity will show
29
How does GB carcinoma affect the liver?
Liver is invaded by direct continuity extending through tissue spaces= Ducts of Lushka - lymph channels - or any combination
30
How does obstruction of the cystic ducts occur in relation to GB carcinoma?
- Direct extenstion of the tumor - Extrinsic compression by involved lymph nodes
31
GB carcinoma sonographic findings
global shape of malignant GB masses- looks similar to GB -heterogenous solid or semi-solid mass
32
GB carcinoma sonographic findings
adjacent liver tissue in hilar area ( main-lobar fissure& pv- where it inserts into the liver) is heterogenous due to tumor spread - Shotgun sign= dilated biliary ducts w/in liver -cause non-visualization of gb on oral cholecystogram
33
Dilated Biliary Ducts - what is the measurement to be considered dilated?
- greater than 4 mm
34
What are the biliary ducts parallel to?
Portal sytem
35
What is the internal diameter of the CHD?
- less than 4 mm
36
What is the borderline measurement for the duct diameter?
- 5mm
37
What does the it mean if the duct diameter 6mm
- requires further investigation
38
What may look normal but still have a distal obstruction
normal size hepatic duct ( \<4mm)
39
The distal duct is often obscured by what?
- gas
40
CBD internal diameter?
- slightly greater than the hepatic duct
41
What measurement of the duct is considered dilated?
10 mm
42
What is the most common cause of a biliary obstruction?
- tumor or thrombus w/in the ductal system
43
Where may a biliary obstruction be found?
- extrahepatic ductal pathway - intrahepatic ductal pathway
44
What is seen as a sign when intrahepatic ducts are dilated?
- to many tubes - shotgun sign
45
How do bile ducts expand?
centrifugally- from the point of obstruction
46
When does extrahepatic dilation occur?
before intrahepatic \*\*\*if obstruction is extrahepatic!
47
What are the three primary areas for Extrahepatic obstruction?
- Intrapancreatic - Suprapancreatic - Porta hepatic (portal triad)
48
What are the three intrapancreatic conditions?
- pancreatic carcinoma - choledocolithiasis - chronic pancreatitis w/stricture formation
49
What is intrapancreatic obstruction?
- Extrahepatic - obstruction at the level of the distal duct
50
What is suprapancreatic obstruction? Where does it originate?
- Extrahepatic obstruction -originates b/w head of pancreas
51
What structures appear normal on ultrasound in a suprapancreatic obstruction?
- head of pancreas - intrapancreatic duct - pancreatic duct
52
What is the most common cause of suprapancreatic obstruction?
Malignancy or adenopathy
53
Porta hepatic obstruction usually occurs due to what?
Neoplasm
54
What will appear on an ultrasound of a porta hepatic obstruction?
- intrahepatic ductal dilation - Normal CBD - possibly GB hydrop
55
Where does cholangiocarcinoma originate from?
w/in the larger bile ducts = CBD or CHD
56
Specific type of cholangiocarcinoma?
- Klatskin's tumor
57
Where can the Klatskin's tumor occur?
- bifurcation of the CHD (involves all parts- central, left & right)
58
What sonographic feature suggests Klatskin's tumor?
Non-union of the rt. & lt. ducts
59
What sonographic features indicates cholagiocarcinoma?
- isolated intrahepatic duct dilation
60
What should be down to confirm Klatskins tumor?
- contrast & color doppler
61
Mirizzi Syndrome is caused by?
Extrahepatic biliary obstruction due to an impacted stone in the cystic duct
62
If a stone is penetrated into the CHD or gut what disease could this indicate?
Mirizzi syndrome
63
Cholecystobiliary or cholecystenteric fistula is a result of what? & associated w/ what?
- stone penetrated into the CHD or gut - Mirizzi Syndrome
64
What allows Mirizzi syndrome to occur?
cystic duct inserts unusually low into the CHD & 2 ducts have parallel alignment
65
Mirizzi Syndrome- Sonographic Findings
- intrahepatic ductal dilation - normal CBD - large stone in neck or cystic duct
66
What type of tumors will have the same sonographic appearance as pancreatic tumors?
- Tumors arising from GB - Ampullar carcinoma
67
What indicates cancer of the biliary convergence?
- ducal wall w/out bulging outside
68
What indicates ampulloma?
- specific pattern - bulge inside dilated CBD
69
Cancer of the hepatic duct usually infiltrates what?
- the ducal wall w/out bulging outside
70
Extrahepatic biliary obstruction - sonographic findings
- minimal dilation in patients w/ 1.)NON-jaundice w/ a.) gallstones [OR] b.) pancreatitis 2.) Jaundice w/ a.) common duct stone [OR] b.) tumor
71
A diameter \>11 mm suggests an obstruction by what?
- stone - tumor of the a.) duct b.) pancreas c.) other source
72
What causes intermittent obstruction resulting from a ball-valve effect?
Biliary obstruction involving - 1 HD - early obstruction 2nd to carcinoma/ gallstones
73
Extra obs.- What is found in Non-jaundice dilate ducts?
Biliary obstruction involving - 1 HD - early obstruction 2nd to carcinoma/ gallstones
74
What characteristics traditionally distinguish bile ducts from other intrahepatic structures?
1.) alteration in pattern adjacent to RMPV segment & bifurcation 2.) irregular walls of dilated ducts 3.) stellate confluence of dilated ducts 4.) acoustic enhancement by DD 5.) peripheral duct dilation
75
Intrahepatic biliary ducts occur...
2nd to extrahepatic bile duct obstruction
76
Cystadenoma & cystadenocarcinoma are rare and primarily limited diseases that may occassionally occur from?
- intrahepatic lesions--\> changes in the duct
77
Intrahepatic biliary neoplasms frequently found in
- middle aged women
78
Clinical Presentation of Intrahepatic biliary neoplasms
- abd. pain - abd. mass - jaundice - dilated intra ducts
79
Abd. mass near the porta hepatis will cause
- jaundice
80
What pattern variations may show in an intrahepatic biliary neoplasm mass
- uniocular - calcifies - multiple
81
What are the differential diagnoses of an intrahepatic biliary neoplasm
- hemorrhagic cyst - infection -echinococcal cysts - abscess - cystic metastasis
82
What is cholangitis
- inflammation of the bile ducts
83
What are the clinical symptoms of cholangitis
- malaise (can't localize pain) - Fever - sweating & shivering - Lethargic -Prostrate - in shock
84
Cholangitis is caused by the dependence on the type of disease; but obstruction may include
- ductal strictures - parasitic infestation - bacterial infection - stones - neoplasm
85
How is cholangitis identified?
- oriental sclerosing cholangitis -AIDS "" - acute obstructive suppurative ""
86
What does cholangitis cause?
- increased pressure on biliary tree w/pus accumulation
87
What lab values are associated w/ cholangitis?
- increase in a.) alk phos b.) bilirubin
88
Which two cholangitis diseases have identical ultrasonic intrahepatic biliary changes?
- sclerosing - aids
89
Decompression of what is necessary in cholangitis
- decompression of CBD
90
What are the sonographic findings of cholangitis?
- smooth/irregular wall thickening of CBD - CBD wall so thin- diff. to recognize
91
Choledocholithiasis
- stones in the CBD
92
The majority of stones in the CBD have migrated from where?
GB
93
Choledocholithiasis is usually associated w/ what other GB disease?
- calculous cholecystitis
94
Choledocholithiasis- sonographic findings
- impacted @ ampulla of Vater - hyperechoic density w/in CBD producing shadowing
95
Causes of shadowing
- calcifications of small vascular structures - air/gas in duodenum= dirty - Intrabiliary gas= pneumobilia
96
Which biliary diesease is congenital?
- Caroli's disease
97
What is Caroli's disease?
- communicating cavernous ectasia of intrahepatic ducts= dilated or extended ducts
98
How is Caroli's disease described?
- congenital segmental saccular cystic dilation of major intrahepatic bile ducts
99
What is the the Caroli's disease common in whom?
- younger adults - pediatric
100
Caroli's Disease- Symptoms
- reoccurring cramp-like upper abd. pain
101
How does milk of calcium bile occur?
- GB becomes filled w/ pasty semi-solid substance
102
What is milk of calcium bile mostly made up of?
- calcium carbonate
103
Milk of calcium bile is often associated w/
- bile stasis
104
What other GB disease may milk of calcium bile cause?
- acute cholecystitis - migrate into bile ducts
105
Milk of Calcium bile- sonographic appearance
- highly echogenic material - posterior acoustic shadowing
106
Posterior acoustic shadowing forming a level w/ different patient positioning may indicate what?
- milk of calcium bile
107
What does sludge occur from?
Bile Stasis
108
What is bile stasis?
When bile cannot flow from liver to duodenum; GB is not contracting
109
Sludge may be seen in patients w/?
- prolonged fasting - hyperalimentation - obstruction of GB
110
Alimenation, what is it?
admin. of nutrients by IV feeding
111
Where is sludge usually found in?
CBD
112
Sludge- Sonographic Findings
- low level internal echoes
113
What other disease may sludge be seen in?
- cholelithiasis - Cholecystitis etc.
114
What disease occurred from bile stasis will mimic polypoid tumors?
- Tumefactive sludge
115
What is it called when sludge in GB is isoechoic w/liver?
Hepatization
116
Adenomyomatosis- definition
small polypoid projections from the GB wall
117
Causes of GB wall thickening
- cholecystitis - adenomyomatosis - AIDS - Cholangiopathy - Sclerosing cholangitis
118
What is Sclerosing cholangitis
bile dues narrow
119
What is cholangiopathy
any disease of the bile ducts
120
Which diseases are an inflammation of the GB?
- Acute & Chronic Cholecystitis - Acalculous - Emphysematous - Gangrenous
121
Unique about Acalculous?
- w/out a stone
122
Unique about Emphysematous
- Gas in GB--\> ring down artifact
123
Which inflammatory disease creates usually creates a cystic duct obstruction?
- Acute cholecystitis
124
Acute Cholecystitis- Symptoms
- acute RUQ pain - + murphy's sign - Fever - Leukocytosis
125
Acute -cystisis complications =
- Empyema - Emphysematous - Gangrenous - Perforation
126
Murphy's sign definition:
+ sign implies tenderness over GB area upon palpation (touched)
127
What is empyema?
- collection of pus
128
Acute Cholecystisis - Sonographic findings
- irregular GB wall - sonolucent area w/ thick wall - Hydrop - + Murphy sign - Pericholecystic fluid ( can be there or not)
129
Sludge definiton:
low- level echoes found along posterior margin of GB
130
Hydrop definition:
enlargment of GB
131
Describe the presence of pericholecystic fluid
- inflammed wall & swelling w/leakage into pericholecystic space--\> space surrounding GB
132
What is perforation
- hole; piercing; aperature; could be row of small holes - Whole/opening in the GB wall
133
What feeds the GB?
- cystic artery
134
What non-biliary diseases may sludge be found in?
- hepatitis - severe hypoalbuminec states
135
What disease is the most common form of inflammation?
- chronic cholecystitis
136
What is chronic- cystitis
- end result of acute -cystitis
137
Chronic -cystitis -- sonographic findings
- cholelithiasis- found in contracted GB w/ coarse GB wall thickening - WES
138
WES- definition:
Sonographic pattern found when GB packed w/stones
139
What is acalculous - cystitis
- acute infl. w/out stones (cholelithiasis)
140
What type of patients would most likely have a decrease in blood flow of the cystic artery? What GB disease could they develop?
- Trauma - Burn - Post OP \*\*\* Acalculous -cystitis
141
What is the measurment of an acalculous- cystitis wall?
4-5mm
142
Which inflammatory GB disease is rapidly progressive and fatal?
Emphysematous -cystitis
143
50 % of patients have this GB disease
Emphysematous Cholecystitis
144
Which inflammatory GB disease may lead to perforation?
Gangrenous -cystitis
145
Gangrenous -cystitis caused by?
- prolonged infection
146
What are other clinical factors of cholelithiasis
- pregnancy -diabetes -oral contraceptive use -diet induced weight loss - total parenteral nutrition (coma pts)
147
When do patients w/-lithiasis start to experience symptoms
- small stone lodges in the cystic or common duct
148
What portion of the GB should stones shift after changing patient positions
- dependent portion of the GB (closest to earth)
149
Which type of reflections affect shadowing the most?
- specular reflection
150
What is the shadow of the gallstone from
- acoustic impedance - Refraction through them or diffraction around them
151
What type of stones will not cast an acoustic shadow?
- \<3mm
152
Shadow is dependent on what/
- relationship b/w stone & sound beam
153
Which biliary disease causes wall abnormality, weakness, & outpouching of the ductal walls?
Choledochal cysts
154
Choledocal cysts cause?
pancreatic juices refluxing into bile duct
155
What would cause pancreatic juices to reflux into the bile duct? What GB disease is this?
- b/c an anomalous junction of pancreatic duct into distal CBD - Choledochal cysts
156
Choledochal cysts may be associated w/?
- stones - pancreatitis - cirrhosis
157
How are -dochal cysts classified?
- localize cystic dilation of CBD - sac from CBD (diverti) -invag (outpouch) CBD into duo - dilation of entire CBD &CHD
