Chapter 11 Flashcards
What is the biliary system composed of?
Right and left hepatic ducts,
Common hepatic duct (CHD),
Common bile duct (CBD),
Pear-shaped gallbladder, and Cystic duct
True or False: The bile ducts follow the same course as the hepatic artery and portal vein.
True
Hepatic and bile ducts are enclosed in what?
Common collagenous sheath
Rt. and Lt. hepatic ducts join to form the?
CHD
Common hepatic duct and cystic duct join to form the?
CBD
How is each duct formed by?
By the union of bile canaliculi from the liver lobules
Normal size of CBD?
6mm or 1mm per decade of life
Proximal portion of the CBD is?
lateral to the hepatic artery and anterior to the portal vein
Distal portion of the CBD is?
in a grove on the posterior surface of the head of the panc.
Where does the CBD end?
by piercing the medial wall of the duodenum where it joins the main pancreatic duct
Define gallbladder and its divisions?
Pear-shaped sac in the anterior aspect of the RUQ, closely related to visceral surface of the liver
Divided into- fundus, body and neck
What is the normal size of the gallbladder?
Typically GB- 2.5-4 cm in diameter and 7-10 cm in length. Walls are less than 3 mm thick
Define hydrops
dilation of the gallbladder
Define Hartmanns Pouch
gallbladder is folded back on itself at the neck
Define Phrygian Cap
folding of the fundus
Function of the Gallbladder
Serves as a reservoir for bile
Has the ability to concentrate the bile
What is the function of the Heisters Valve?
Heister’s valve in the neck of the gallbladder help to prevent kinking of the duct
What can happen in the space between the liver and gallbladder?
infection or inflammation can occur
True or False: The gallbladder does not lie in various locations
False
Gallbladder has been found to lie in various ectopic locations, remember this if you are having a difficult time trying to locate the GB
Failure of the gallbladder to develop is?
agenesis of the gallbladder
These patients may still have the biliary ductal system, which can become inflamed and filled with stones
What is the vascular supply to the gallbladder?
arterial supply is from the cystic artery a branch of the rt. Hepatic artery. Cystic vein drain directly into the portal vein.
What are the primary functions of the extrahepatic biliary tract?
Transport bile from liver to intestines
Regulation of its flow
Liver secretes approximately 1-2 liters of bile/day
What happens in the fasting state?
Tone of the sphincter of Oddi increases, very little bile passes into the duodenum
Because of the increase in tone the pressure in the CBD increases and bile is forced into the GB
What happens in the non-fasting state?
When we eat the GB contracts and bile is passed into the duodenum
Tone of the sphincter of Oddi is decreased
Contracted gallbladder appears as a thick-walled structure with a slit of bile. Nearly impossible to see luminal or wall abnormalities in a contracted GB
Concentration of bile in the GB occurs in the ______state.
Fasting
What happens when the gallbladder is removed?
When the GB is removed the sphincter of Oddi loses tone and pressure within the CBD drops to that of the intraabdominal pressure
Bile is no longer retained in the bile ducts but is free flowing into the duodenum during fasting and digestive phases
Dilation of the extrahepatic bile ducts occurs after cholecystectomy—usually less than 1 cm
Products of steroid hormones, drugs and poisons are secreted in the bile
What is the main lobar fissure?
bright linear echo connecting portal vein and gallbladder fossa
What is the term used to define the removal of the gallbladder?
cholecystectomy
What kind of enzymes do bile salts activate?
intestinal and pancreatic enzymes
Bile is the principal medium for excreation of ____ and _____
bilirubin and cholesterol
What do bile salts stimulate from the intestine?
Bile salts from the intestine stimulate the liver to make more bile
what does Courvoisier’s sign indicate?
Courvoisier’s sign- indicates extrahepatic mass compressing CBD which can cause an enlarged GB. Thorough evaluation is important
The cause of the junctional fold is the indentation between the body and neck/Heister’s valve—called?
Phrygian cap
Define junctional fold
small septum within the gallbladder, usually arising from the posterior wall.
Powerpoint-
A small echogenic fold has been seen along the posterior wall of the GB at the junction of the body and where the GB narrows at the neck
Prominent GB may be normal secondary to what?
fasting state, diabetes, bedridden, pancreatitis, and patients taking anticholinergic drugs (inhibit transmission of parasympathetic nerve impulses, reducing spasms of smooth muscle)
obstruction vs. poorly functioning evaluation is needed when?
If GB fails to contract after a fatty meal or IV cholecystokinin
Where does the CBD lie?
CBD lies anterior and to the right of the portal vein in the region of the porta hepatis
Where does the hepatic artery lie?
Hepatic artery lies anterior and to the left of the portal vein
What is the Mickey Mouse sign?
Transverse image—CBD, hepatic artery, and portal vein can be identified “Mickey mouse sign”
How do you obtain a mickey mouse sign?
To obtain this the transducer should be in the oblique position from the left shoulder to the right hip
What angle should you roll the patient to better visualize the CBD?
45-90 degrees
Name the clinical symptoms of GB disease.
RUQ pain-usually after a greasy meal Rt. Shoulder blade pain Epigastric pain Positive Murphy’s sign N/V Jaundice Abnormal labs
define sludge
Thickened bile, frequently occurs from bile stasis
Sludge is predominantly pigment granules with lesser amounts of cholesterol crystals
Sludge is _____ dependent.
gravity
What kind of patients is sludge mostly seen with?
May be seen in patients with prolonged fasting, hyperalimentation therapy (nutrients given through IV), or obstructed GB
What can sludge be confused with?
GB full of sludge can be confused with liver because it is isoechoic
Why is sludge considered abnormal?
Considered abnormal because of an issue with the function or a pathologic abnormality (obstruction)
What is normal wall thickness?
less than 3mm
What are the causes of wall thickness?
Cholecystitis Adenomyomatosis Cancer AIDS Cholangiopathy (pathology of the duct) Sclerosing cholangitis
what are the nonbiliary causes?
Diffuse liver disease (cirrhosis and hepatitis)
Pancreatitis
Portal HTN
Heart failure
Define Cholecystitis
Cholecystitis- inflammation of the GB
Acute or chronic, acalculous, emphysematous, or gangrenous
What is the most common cause of acute cholecystitis?
Acute- most common cause—gallstones impacted in the cystic duct or neck
Results in –obstruction with distention of the lumen, ischemia, and infection with eventual necrosis of the GB
What are the clinical symptoms of acute cholecystitis?
Acute RUQ pain Positive Murphy’s sign Fever Leukocytosis Increase in serum bilirubin and alkaline phosphatase
What are the sonographic findings of acute cholecystitis?
Wall > 3mm Distended GB lumen > 4cm Gallstones Impacted stone- Hartmann’s pouch or cystic duct Positive Murphy’s sign Increased color Doppler flow Pericholecystic fluid collection Occasionally sonolucent area within the thickened wall because of edema
Define Cholelithiasis
Most common disease of the gallbladder
Single large stone or hundreds of tiny ones
Why are tiny stones more dangerous?
Tiny stones are the most dangerous because they can enter the bile ducts and obstruct the flow
What can gallstones consist of?
Gallstone can consist of-small crystals of bile salts or cholesterol
What are the Five F’s prone to gallstones?
fat, female, forty, fertile, and fair
After a fatty meal the GB contracts, if a stone is blocking the outflow, what can it result in?
pain
What are the symptoms of cholelithiasis
May be asymptomatic until a stone lodges in the cystic or common duct
RUQ pain with radiation to right shoulder pain after a fatty meal
Epigastric pain, N/V- normally when it becomes acute
What are ultrasound findings of cholelithiasis?
GB evaluated for increased size
Wall thickness
Presence of internal reflections within the lumen
Posterior shadowing
Wall echo shadow (WES sign)- GB packed full of stones
Anterior wall seen with stones casting distinct shadow
What is the WES sign?
wall echo shadow- happens when the gallbladder is packed with stones
What is Emphysematous Cholecystitis?
Rare complication of acute cholecystitis
Rapidly progressive and fatal in 15% of cases
Associated with gas forming bacteria in the gallbladder wall and lumen with extension into the ducts
What is a complication of Emphysematous Cholecystitis?
Gangrene with associated perforation is a complication
This condition is a surgical emergency
What are the ultrasound findings of emphysematous cholecystitis?
Depend on the amount of gas within the wall
If gas is intraluminal- look for prominent bright echo along anterior wall with ring down or comet-tail artifact
If large amount of gas is present it could looks similar to WES sign
