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KEVIN BURANT IV > Chapter 26 - Liver, Biliary Tree and Gallbladder (CHERI NOTES) > Flashcards

Chapter 26 - Liver, Biliary Tree and Gallbladder (CHERI NOTES) Flashcards

1
Q

__ is the current method of choice for most hepatic imaging.
(p.692)

A

DYNAMIC BOLUS CONTRAST-ENHANCED MDCT

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2
Q

___ is used as a screening method for patients with abdominal symptoms and suspected diffuse or focal liver disease. (p.692)

A

ULTRASOUND

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3
Q

___ are used to assess hepatic vessels and tumor vascularity.
(p.692)

A

COLOR FLOW and SPECTRAL DOPPLER

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4
Q

____ is used in the characterization of cavernous hemangiomas
and focal nodular hyperplasia. (p.692)

A

RADIONUCLIDE IMAGING

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5
Q

MDCT of the liver is performed using a ___ or ___ protocol

of multiple scans of the entire liver. (p.692)

A

THREE-PHASE or FOUR-PHASE

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6
Q

Maximum enhancement of the liver is attained during the ___ phase to demonstrate hypovascular lesions as low-attenuating masses on a background of brightly-enhanced parenchyma. (p.692)

A

PORTAL VENOUS phase

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7
Q

2/3 of the hepatic blood supply comes from the ____. (p.692)

A

PORTAL VEIN

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8
Q

maximum enhancement of the liver parenchyma occurs at
____ to ___ seconds following hepatic arterial enhancement.
(p.692)

A

60 to 120 seconds

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9
Q

Delayed images are obtained several minutes after contrast
injection to document late-contrast fill-in of _____ and
delayed enhancement of ____. (p.692)

A

HEMANGIOMA and CHOLANGIOCARCINOMA

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10
Q

Gadolinium-based contrast agent which is akin to

iodine-based contrast agents used in CT. (p.692)

A

Gadopentetate dimeglumine (Magnevist)

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11
Q

Liver-specific contrast agents such as ____ have conventional properties of the extracellular agents as well as being taken up by hepatocytes; which improves the detection and
characterization of small lesions. (p.692)

A

Gadoxetate disodium (Eovist)

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12
Q

_____ emerged as a method of hepatic lesion detection and
characterization in patients who cannot receive IV contrast.
(p.692)

A

DIFFUSION-WEIGHTED MR

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13
Q

____ is used for quantitation of liver fatty infiltration and other diffuse hepatic diseases. (p. 692)

A

MR spectroscopy

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14
Q

____ is used as a rapid screening modality to detect diseases
of the liver; biliary tree and gallbladder. (p.692)

A

ULTRASOUND

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15
Q

Radionuclide imaging of liver offers functional information

in characterizing lesions such as ____. (p.692)

A

FOCAL NODULAR HYPERPLASIA

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16
Q

_______ is very useful for definitive diagnosis of

cavernous hemangioma. (p.692)

A

RADIONUCLIDE BLOOD POOL IMAGING

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17
Q

Transient enhancement difference are seen during either
____ phase imaging or ____ phase imaging on MDCT and
dynamic MR. (p.694)

A

ARTERIAL phase imaging or

PORTAL VENOUS phase imaging

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18
Q

meaning of the acronyms THADs or THIDs (p.694)

A

TRANSIENT HEPATIC ATTENUATION DIFFERENCES or
TRANSIENT HEPATIC INTENSITY DIFFERENCES

-this results in focal areas of increased or decreased enhancement during the various phases of the parenchymal enhancement.

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19
Q

Portal venous flow may be altered by these three causes.

p.694

A
  1. PORTAL BLOCKADE BY TUMOR OR THROMBUS
  2. EXTRINSIC COMPRESSION CAUSED BY RIBS OR DIAPHRAGMATIC SLIPS; OR TUMORS OF THE LIVER CAPSULE
  3. THIRD INFLOW from systemic veins in the pericholecystic; parabiliary; and epigastric-paraumbilical venous systems.
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20
Q

Systemic venous blood drains into ___ altering normal intrahepatic blood flow. (p.694)

A

HEPATIC SINUSOIDS

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21
Q

On CT, the attenuation of normal liver parenchyma is ____ than the attenuation of normal spleen parenchyma on unenhanced images. (p.694)

A

EQUAL TO OR GREATER THAN

-following bolus IV contrast administration; the normal parenchymal enhancement is less than that of the spleen during arterial phase; and equal to or greater than that of the spleen during the portal venous phase.

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22
Q

On MR T1WI; the normal liver is slightly higher signal intensity than the ____; and most focal lesions appear as lower-intensity defects.

A

SPLEEN

  • with T2WI; the normal liver is less than or equal to the spleen in signal strength; and most lesions appear as high-intensity foci.
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23
Q

2 evidences of HEPATOMEGALY. (p.694)

A
  1. Rounding of the inferior border of the liver

2. Extension of the right lobe of the liver inferior to the lower pole of the right kidney.

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24
Q

A liver length greater than ___ cm; measured in the midclavicular line; is considered enlarged. (p. 694)

A

greater than 15.5 cm

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25
Q

______ is normal variant of hepatic shape found most often in women. It refers to an elongated inferior tip of the right lobe of the liver. (p.694)

A

REIDEL LOBE

  • When a Reidel lobe is present; the left lobe of the liver
    is respondingly smaller in size.
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26
Q

TRUE OR FALSE.

The left lobe of the liver may; as a normal variant; be elongated and surround a portion of the spleen.(p.694)

A

TRUE

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27
Q

___ is the most common abnormality demonstrated by hepatic imaging. (p.694)

A

FATTY LIVER (HEPATIC STEATOSIS)

  • 15% prevalent in the general population
  • in 50% of patients with hyperlipidemia
  • up to 75% of patients with severe obesity
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28
Q

2 most common causes of FATTY LIVER. (p. 694)

A
  1. ALCOHOLIC LIVER DISEASE
  2. NON-ALCOHOLIC FATTY LIVER DISEASE
    related to metabolic syndrome of insulin resistance; obesity; diabetes; hyperlipidemia and hypertension.
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29
Q

Give 6 other causes of fatty liver aside from alcoholic liver disease and non-alcoholic fatty liver disease. (p.694)

A
  1. VIRAL HEPATITIS
  2. DRUGS (esp.steroids and chemotherapy agents)
  3. NUTRITIONAL ABNORMALITIES
  4. RADIATION INJURY
  5. CYSTIC FIBROSIS
    - all conditions injure hepatocytes by altering hepatocellular lipid metabolism; with defects in free fatty acid metabolism resulting in accumulation of triglycerides within hepatocytes.
  6. STORAGE DISORDERS
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30
Q

Fatty liver is initially reversible but may progress to____ with further progression to cirrhosis. (p.694)

A

STEATOHEPATITIS

CELL INJURY; INFLAMMATION AND FIBROSIS

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31
Q

____ includes a continuum of liver disease that extends from simple fatty liver through non-alcoholic steatohepatitis (NASH) to cirrhosis. (p.694)

A

NON-ALCOHOLIC FATTY LIVER DISEASE (NASH)

- is diagnosed solely by liver biopsy showing inflammation and fibrosis in addition to hepatic steatosis.

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32
Q

On US, the normal liver parenchyma is equal to; or slightly more
echogenic; than the ___ and ____ parenchyma. (p.695)

A

RENAL CORTEX and SPLENIC PARENCHYMA

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33
Q

Three reliable US findings of fatty liver (p.695)

A
  1. LIVER ECHOGENICITY distinctly greater than that of the renal cortex
  2. LOSS OF VISUALIZATION of normal echogenic portal triads in the periphery of the liver.
  3. POOR SOUND penetration with loss of definition of the diaphragm.
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34
Q

On CT; fat infiltration lowers the attenuation of the hepatic parenchyma; and makes the liver appear ____ dense than the spleen. (p.695)

A

LESS

  • the liver normally has a slightly higher attenuation than the spleen or blood vessels.
  • differences in density between liver and spleen are most reliably judged on non-contrast images
  • on postcontrast images; the normal spleen enhances maximally 1 to 2 minutes before maximal liver enhancement and is thus transiently brighter than the normal liver.
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35
Q

Fatty liver enhances __ than normal liver. (p.695)

A

LESS

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36
Q

On unenhanced CT; fatty liver is diagnosed when the liver attenuation is __ H less than the spleen attenuation; or when the liver attenuation is less than ___ H. (p.695)

A

10 H; 40 H

  • when fatty liver is severe; blood vessels may appear brighter than the dark liver on unenhanced CT
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37
Q

Comparison of CT and US findings may yield the diagnostic ________ sign; with fatty liver being dark on CT and bright on US. (p.695)

A

FLIP-FLOP sign

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38
Q

___ is the MR method most sensitive to the diagnosis of fatty liver. (p.695)

A

GRADIENT ECHO IMAGING WITH FAT AND WATER MOLECULES IN-PHASE AND OUT-OF-PHASE

  • same technique used to characterize benign adrenal adenomas
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39
Q

On IN-PHASE images; the signal from water and fat molecules
are _____. (p.695)

A

ADDITIVE

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40
Q

ON OUT-PHASE images; the signals from water and fat _____.

p.695

A

CANCEL OUT EACH OTHER

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41
Q

A loss of signal intensity between in-phase and out-of-phase

images is indicative of ____. (p.695)

A

FATTY LIVER

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42
Q

This opposed-phase chemical shift GRE technique is more sensitive in the detection of _____ intracellular fat characteristic of fatty liver. (p.695)

A

MICROSCOPIC intracellular fat

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43
Q

Fat-saturation MR techniques, have greater sensitivity for __fat.
(p.695)

A

MACROSCOPIC fat

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44
Q

Iron deposition in the liver will also cause a ___ on out-of-phase
MR imaging and is a potential pitfall in MR diagnosis of fatty liver in patients with cirrhosis. (p.695)

A

LOSS OF SIGNAL

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45
Q

Characteristic features of fatty deposition include these TWO findings. (p.695)

A
  1. LACK OF MASS EFFECT (no bulging of the liver contour or displacement of intrahepatic blood vessels)
  2. ANGULATED GEOMETRIC BOUNDARIES between involved and uninvolved parenchyma.
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46
Q

Fatty changes can develop within __ weeks of hepatocyte insult and may resolve within __ days of removing the insult. (p.695)

A

3 weeks: 6 days

  • patterns of fatty infiltration are strongly related to hepatic blood flow.
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47
Q

____ fatty liver involving the entire liver is the most common pattern. (p.695)

A

DIFFUSE fatty liver

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48
Q

____ fatty liver involves a geographic or fan-shaped portion of the liver with the same imaging features as diffuse fat deposition.

A

FOCAL fatty liver

  • focal fat may simulate a liver tumor;
  • however the area of involvement has a density characteristic of fat.
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49
Q

Focal fat (in fatty liver); is most adjacent to the ___; ____ and ____. (p.695)

A

FALCIFORM LIGAMENT; GALLBLADDER FOSSA; AND PORTA HEPATIS

  • these are the areas prone to altered hepatic blood flow with systemic flow; and focal fat deposition may be related to higher concentrations of insulin in these areas.
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50
Q

______ in a diffusely fatty infiltrated liver may be the most confusing pattern becaused spared areas of normal parenchyma may convincingly simulate a liver tumor. (p.695)

A

FOCAL SPARING

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51
Q

Fat-spared areas are most commonly found in segment ___.

p.696

A

segment IV

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52
Q

The fat-spared area is hypoechoic relative to the rest of the liver on US and is of higher density than the rest of the liver on CT.
What is this RADIOLOGIC SIGN? (p.696)

A

FLIP-FLOP sign

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53
Q

___ fatty liver is an uncommon pattern of fat deposition throughout the liver in multiple atypical locations. (p.696)

A

MULTIFOCAL FATTY LIVER

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54
Q

____ fatty liver is seen as HALOS OF FAT surrounding the portal veins; hepatic veins or both. (p.696)

A

PERIVASCULAR fatty liver

  • unknown cause
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55
Q

____ fatty liver is seen only in patients with renal failure on peritoneal dialysis and only when INSULIN is added to the dialysate. (p.696)

A

SUBCAPSULAR fatty liver

  • high concentrations of INSULIN in the subcapsular liver leads to fat deposition
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56
Q 
\_\_\_\_\_ hepatitis most commonly causes no abnormalities on 
hepatic imaging (p.696)
A

ACUTE hepatitis

  • in some patients; diffuse edema lowers the parenchymal echogenicity and causes the portal venules to appear unusually bright on US.
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57
Q

In ____ hepatitis; areas of necrosis show ill-defined areas of low density on CT. (p.696)

A

ACUTE FULMINANT hepatitis

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58
Q

_____ hepatitis is characterized pathologically by portal and perilobular inflammation and fibrosis. (p.696)

A

CHRONIC hepatitis

  • causes include chronic viral infection; and hepatitis B and C.
  • perilymphatic lymph nodes are commonly visualized.
  • US may show a subtle coarse increase in hepatic echogenicity.
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59
Q

The primary role of imaging patients with chronic hepatitis is to detect ____. (p.696)

A

HEPATOCELLULAR CARCINOMA

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60
Q

____ is characterized pathologically by diffuse parenchymal destruction fibrosis with alteration of hepatic architecture; and innumerable regenerative nodules that replace normal liver parenchyma. (p.696)

A

CIRRHOSIS

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61
Q

Give 4 causes of cirrhosis. (p. 696)

A
  1. HEPATIC TOXINS
    (alcohol; drugs; and aflatoxin from a grain fungus)
  2. INFECTION (viral hepatitis; esp.types B and C)
  3. BILIARY OBSTRUCTION
  4. HEREDITARY (Wilson Disease)
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62
Q

In the U.S.: 75% of cirrhotic patients are ___.
In Asia and Africa: most cases of cirrhosis are due to ___.
(p.____)

A

CHRONIC ALCOHOLICS;

CHRONIC ACTIVE HEPATITIS

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63
Q

7 imaging findings of CIRRHOSIS? (p.696)

A
  1. HEPATOMEGALY (early)
  2. ATROPHY OR HYPERTROPHY of hepatic segments
  3. COARSENING OF HEPATIC PARENCHYMAL TEXTURE.
  4. NODULARITY OF THE PARENCHYMA; often most noticeable on the liver surface
  5. HYPERTROPHY OF THE CAUDATE LOBE with shrinkage
    of the right lobe
  6. REGENERATING NODULES
  7. ENLARGEMENT OF THE HILAR PERIPORTAL SPACE
    (>10 mm) reflecting parenchymal atrophy.
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64
Q

Extrahepatic signs of CIRRHOSIS include the presence of
_______ as evidence of portal hypertension; splenomegaly;
and ascites. (p.696-697)

A

PORTOSYSTEMIC COLLATERALS

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65
Q

TRUE OR FALSE.
The pathological changes of cirrhosis are irreversible; but disease progression can be limited or stopped by eliminating the causative agent. (stop drinking alcohol). (p.____)

A

TRUE

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66
Q

______ is an effective treatment for portal hypertension and
long-term control of esophageal variceal bleeding. (p.697)

A

TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS)

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67
Q

DIAGNOSIS?
US finding of heterogeneous parenchymal with coarsening of the echotexture and decreased visualization of the small portal triad structures. (p.697)

A

CIRRHOSIS

  • CT finding may be normal in the early stages or may reveal parenchymal inhomogeneity with patchy areas of increased and decreased attenuation.
  • MR shows heterogeneous parenchymal signal on T1WI and T2WI. High-signal fibrosis on T2WI is the predominant cause of the heterogeneous appearance.
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68
Q

_____ are conditions that cause diffuse hepatic nodularity or portal hypertension including pseudocirrhosis of treated breast CA metastases; miliary metastases; sarcoidosis; schistosomiasis; Budd-Chiari syndrome; nodular regenerative hyperplasia and idiopathic portal hypertension. (p.697)

A

MIMICS OF CIRRHOSIS

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69
Q

HCC may arise ____ or as a _______ process from a regenerative
nodule to low-grade dysplastic nodule to high-grade dysplastic nodule to small HCC to large HCC. (p.697)

A

DE NOVO or STEPWISE

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70
Q

_____ are the most common nodule and are a regular pathologic feature of cirrhosis due to attempted repair of hepatocyte injury. (p.697)

A

REGENERATIVE NODULES

  • composed primarily of hepatocytes that are surrounded by coarse fibrous septations.
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71
Q

Small regenerative nodules size? (p.___)

A

< 3 mm

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72
Q

Larger regenerative nodules (> __ mm) produce the macronodular pattern of cirrhosis. (p.697)

A

> 3 mm

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73
Q

Very large regenerative nodules (up to __ cm) can mimic

mass. (p.697)

A

up to 5 cm

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74
Q

Regenerative nodules are supplied by the _____ and thus show no enhancement on arterial phase postcontrast imaging. (p.____)

A

PORTAL VEIN

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75
Q

Regenerative nodules, because they consist of proliferating hepatocytes, are typically _____ on US; CT and MR imaging.
(p.697)

A

INDISTINCT

  • uncommonly; regenerative nodules are hyperintense to liver on T2WI; reflecting the accumulation of fat; protein or copper.
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76
Q

Regenerative nodules that accumulate iron (siderotic nodules) are ___ signal intensity on T1WI and T2WI. (p.697)

A

LOW

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77
Q

Infarction of regenerative nodules results in __ signal on T2WI.
(p.697)

A

HIGH

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78
Q

Regenerative nodules show ___ enhancement on arterial phase postcontrast CT and MR imaging. (p.697)

A

NO

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79
Q

____ nodules show foci of low-grade or high-grade dysplasia.

p.697

A

DYSPLASTIC

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80
Q

____ -grade dysplastic nodules show minimal atypia;

have no mitosis; and are not premalignant. (p.697)

A

LOW-grade dysplastic nodules

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81
Q

____ -grade dysplastic nodules shows moderate atypia; have occasional mitosis; may secrete alpha fetoprotein (AFP), but are not frankly malignant. (p.697)

A

HIGH-grade dysplastic nodules

  • they are however considered premalignant
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82
Q

TRUE OR FALSE.
Dysplastic nodules are almost never hyperintense on T2WI,
differentiating them from HCC. (p.697)

A

TRUE

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83
Q

Siderotic dysplastic nodules with iron accumulation are ___ signal on T1WI and T2WI. (p.698)

A

LOW

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84
Q

___ nodule is a radiologic term used to describe nodules that are high iron content and appear as low-signal nodules on both T1WI and T2WI. (p.698)

A

SIDEROTIC nodule

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85
Q

TRUE OR FALSE.
Dysplastic nodules may disappear on imaging follow-up.
(p.698)

A

TRUE

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86
Q

____ HCC; defined as less than 2 cm diameter; overlap the

appearance of high-grade dysplastic nodules. (p.698)

A

SMALL HCC

  • on T1WI: hypointense nodule with internal foci isointense to liver parenchyma
  • on T2WI: the nodules are of low intensity with foci of high-signal intensity.
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87
Q

TRUE OR FALSE.

High signal intensity on T2WI differentiates small HCC from dysplastic nodules. (p.699)

A

TRUE

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88
Q

___ content within the nodules raises the risk of HCC. (p.699)

A

FAT

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89
Q

Small HCCs shows the hallmark finding of ____ enhancement

on ____ phase dynamic MR. (p.699)

A

INTENSE; ARTERIAL

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90
Q

TRUE OR FALSE.
The American Association for the Study of Liver Diseases
(AALSD) no longer requires biopsy to diagnose HCC.
(p.___)

A

TRUE

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91
Q

Small nodules that are ________ on arterial phase postcontrast
CT or MR and show _____ of contrast on portal venous phase
are considered to be HCC. (p.699)

A

HYPERVASCULAR: WASHOUT

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92
Q

HCC developing within a dysplastic nodule may produce a characteristic _____ appearance seen as a high-signal focus within a low-intensity nodule. (p.699)

A

NODULE WITHIN A NODULE

  • high signal focus enhances avidly on arterial phase.
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93
Q

On US; ____ HCCs appear as a well-circumscribed hypoechoic mass in the cirrhotic liver. (p.699)

A

SMALL HCC

  • on T1WI: hypointense nodule with internal foci isointense to liver parenchyma
  • on T2WI: the nodules are of low intensity with foci of high-signal intensity.
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94
Q

3 MIMICS OF HCC? (p.699)

A
  1. NON-SPECIFIC ARTERIALLY ENHANCING LESIONS
  2. PSEUDOLESIONS
  3. THADs
  • lesions are features of cirrhosis related to arterio-portal shunts and fibrotic obstruction of the portal vein.
  • these non-specific lesions are usually isointense on delayed imaging; unlike in HCC which commonly becomes hypointense to the surrounding liver on delayed imaging.
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95
Q

_____ describes mass-like areas of fibrosis found in livers with
advanced cirrhosis. (p.699)

A

CONFLUENT FIBROSIS

  • extensive fibrosis produces a wedge
  • shaped mass radiating from the porta hepatis associated with parenchymal atrophy and flattening or retraction of the liver capsule.
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96
Q

Key feature of Confluent Liver Fibrosis. (p.699)

A

VOLUME LOSS OF THE AFFECTED PORTION OF THE LIVER.

*the central portion of the right hepatic lobe is most often involved.

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97
Q 
CT Imaging appearance of Confluent Liver Fibrosis in
A. Noncontrast-CT
B. Arterial phase contrast CT
C. Portal venous phase contrast CT
(p.699)
A

A. NECT: LOW ATTENUATION
B. Arterial phase CECT:
MOST LESIONS (60%) SHOW LITTLE TO NO ENHANCEMENT; WHEREAS THE REMAINDER ISOENHANCE WITH LIVER PARENCHYMA
C. Portal venous phase CECT:
MOST LESIONS ARE HYPODENSE OR ISODENSE TO LIVER PARENCHYMA; whereas 17% showed
hyperenhancement

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98
Q 
MR Imaging appearance of Confluent Liver Fibrosis in
A. On T1WI
B. On T2WI
C. Postcontrast MR
(p.\_\_\_\_)
A

A. T1WI: Hypointense
B. T2WI: ACUTE fibrosis
- has high fluid content and appears bright on T2WI
CHRONIC fibrosis
- is low in fluid content and appears bright on T2WI
C. Post-Contrast MR:
Negligible enhancement on arterial phase and late enhancement on delayed venous phase.

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99
Q

_____ is a pathological increase in portal venous pressure that results in the formation of portosystemic collateral vessels that divert blood flow away from the liver into the systemic circulation.
(p.699)

A

PORTAL HYPERTENSION

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100
Q

3 causes of PORTAL HYPERTENSION (p.699)

A
  1. PROGRESSIVE VASCULAR FIBROSIS ASSOCIATED WITH CHRONIC LIVER DISEASE
  2. PORTAL VEIN THROMBOSIS OR COMPRESSION
  3. PARASITIC INFECTIONS (SCHISTOSOMIASIS)
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101
Q

9 imaging signs of PORTAL HYPERTENSION (p.699)

A
  1. Visualization of portosystemic collaterals
    (coronary; gastroesophageal; splenorenal; paraumbilical; hemorrhoidal; and retroperitoneal)
  2. Increased portal vein diameter (>13mm)
  3. Increased superior mesenteric and splenic vein diameters (>10mm)
  4. Portal vein thrombosis
  5. Calcifications in the portal and mesenteric veins
  6. Edema in the mesentery; omentum and retroperitoneum
  7. Splenomegaly due to vascular congestion
  8. Ascites
  9. Reversal of flow in any portion of the portal venous system (hepatofugal flow)
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102
Q

_______ may occur as a complication of cirrhosis; or may be caused by portal vein invasion or compression by tumor; hypercoagulable states; or inflammation (pancreatitis). (p.699)

A

PORTAL VEIN THROMBOSIS

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103
Q

On CT and US; the _____ is seen as a hypodense plug within the portal vein. (p.699)

A

THROMBUS

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104
Q

TRUE OF FALSE.

Malignant thrombus in the portal vein is contiguous with and extends from the primary tumor. (p.699-700)

A

TRUE

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105
Q

TRUE OF FALSE.
Cavernous transformation of the portal vein develops when small collateral veins adjacent to the portal vein expand and replace the obliterated portal vein. (p.700)

A

TRUE

  • These collateral veins appear as a tangle of small vessels surrounding the thrombosed portal vein
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106
Q

_____ refers to a group of disorders characterized by obstruction to hepatic venous outflow involving one or more hepatic veins. (p.700).

A

BUDD-CHIARI SYNDROME

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107
Q

TRUE OR FALSE.
Hepatic venous obstruction causes increased pressure in the hepatic sinusoids; resulting in liver congestion; portal hypertension and decreased hepatic perfusion. (p.700)

A

TRUE

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108
Q

Three causes of Budd-Chiari syndrome (p.700)

A
  1. COAGULATION DISORDERS
  2. MEMBRANOUS WEBS OBSTRUCTING
    THE HEPATIC VEINS OR IVC (most common in Asian countries)
  3. MALIGNANT TUMOR INVASION OF THE HEPATIC VEINS
  • CAUDATE lobe is spared because of its venous drainage to the IVC.
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109
Q

COMMA SIGN is seen in what syndrome? (Comma-shaped intrahepatic collateral vessels may be seen on CT or MR.
(p.700)

A

BUDD-CHIARI SYNDROME

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110
Q

In BUDD-CHIARI SYNDROME; blood flow to the right and left hepatic lobes is severely impaired resulting in a characteristic _______ pattern on contrast-enhanced CT. (p.700)

A

FLIP-FLOP pattern

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111
Q

_______ is a common complication of congestive heart failure and constrictive pericarditis. (p.700)

A

PASSIVE HEPATIC CONGESTION

  • Hepatic venous drainage is impaired and the liver becomes becomes engorged and swollen.
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112
Q

4 Imaging findings in PASSIVE HEPATIC CONGESTION (p.700)

A
  1. DISTENTION OF THE HEPATIC VEINS AND IVC
  2. REFLUX OF IV CONTRAST INTO THE HEPATIC VEINS
    AND IVC
  3. INCREASED PULSATILITY OF THE PORTAL VEIN
  4. INHOMOGENEOUS CONTRAST ENHANCEMENT OF THE LIVER.
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113
Q

4 Secondary findings in PASSIVE HEPATIC CONGESTION

p.700

A
  1. Hepatomegaly
  2. Cardiomegaly
  3. Pleural effusions
  4. Ascites
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114
Q

_____ may be primarily resulting from a hereditary disorder that increases dietary iron absorption or secondary due to excessive iron intake usually from multiple blood transfusions or chronic
disease including cirrhosis; myelodysplastic syndrome and certain anemias. (p.700)

A

HEMOCHROMATOSIS

  • the susceptibility effect of iron; best appreciated on T2* images; causes loss of signal in tissues with excessive iron accumulation.
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115
Q

The ____ pattern of iron deposition is seen with increased iron absorption of primary hemochromatosis and with secondary hemochromatosis caused by chronic anemias. (p.700)

A

PARENCHYMAL

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116
Q

The ____ pattern of iron deposition is seen in secondary hemochromatosis; with iron overload caused by blood transfusions. (p. 700)

A

RETICULOENDOTHELIAL

  • excess iron accumulation occurs in reticuloendothelial
    cells in the liver; spleen; and bone marrow
  • MR shows diffuse decreased signal in all three areas.
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117
Q

The ___ pattern of iron deposition is rare but dramatic;

occuring only in patients with intravascular hemolysis caused by mechanical heart valves. (p.700)

A

RENAL

  • excess iron deposition occurs in the proximal convoluted tubules of the renal cortex; causing a loss of cortical signal. On T1WI and T2WI; and thus reverse in the normal corticomedullary differentiation pattern.
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118
Q

Gas in the _____ may be an ominous imaging sign associated with bowel ischemia in adults and necrotizing enterocolitis in infants. (p.701)

A

gas in the PORTAL VENOUS SYSTEM

  • CT reveals air in branching tubular structures extending to the liver capsule.
  • Air is commonly evident within the mesenteric and central portal veins
  • conventional radiographs show streaks of low density in the periphery of the liver.
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119
Q

GAS IN THE PORTAL VENOUS SYSTEM versus AIR IN BILIARY TREE? (p.701)

A

In distinction; AIR IN THE BILIARY TREE is more central;

not extending to within 2 cm from the liver capsule.

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120
Q

In normal liver; the most common hypervascular lesions are ____ (GIVE 4). (p.701)

A
  1. HEMANGIOMA;
  2. FOCAL NODULAR HYPERPLASIA;
  3. HEPATIC ADENOMA
  4. HYPERVASCULAR METASTASES
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121
Q

In cirrhosis; the most common hypervascular lesions are __ and ___.
(p.701)

A

HCC and DYSPLASTIC NODULES

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122
Q

____ are the most common MALIGNANT masses in the liver.

p.701

A

METASTASES

  • 20 times more common than primary liver malignancies
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123
Q

Hepatic metastases most commonly originate from the __; __ and __. GIVE 3. (p.701)

A

GI TRACT; BREAST and LUNG

MNEMONIC: Liver Mets BLoG

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124
Q

The most characteristic feature of Liver Metastases is ______ enhancement; creating a ______ on post-contrast CT and MR images. (p. 701)

A

BAND-LIKE PERIPHERAL enhancement;

TARGET LESION

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125
Q

TRUE OR FALSE. Metastatic disease must be considered in the

differential diagnosis of virtually all hepatic masses. (p.701)

A

TRUE

  • multiplicity of lesions favors metastatic disease
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126
Q

On CT; hypovascular metastases are most apparent on _____ phase images when the background liver is maximally enhanced and the metastatic lesions are of low attenuation. (p.701)

A

PORTAL VENOUS phase

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127
Q

The most common HYPOVASCULAR LIVER METASTASES are___ (GIVE 5). (p.702)

A
  1. COLORECTAL
  2. LUNG
  3. PROSTATE
  4. GASTRIC
  5. UROEPITHELIAL CARCINOMAS
    Mnemonic: Check PLUG
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128
Q

TRUE OR FALSE. HYPERvascular metastases overlap the appearance of HCC. (p.702)

A

TRUE

  • MR and CT show arterial phase enhancement with rapid washout on portal venous and delayed images.
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129
Q

HYPERVASCULAR METASTASES are associated with ____

GIVE 6). (p.702

A 
1. PRIMARY NEUROENDOCRINE TUMORS
(pancreatic islet tumors; carcinoid tumor;and pheochromocytoma).
2. RENAL CELL CARCINOMA
3. THYROID CARCINOMA
4. MELANOMA
5. SOME SARCOMAS
6. CHORIOCARCINOMA
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130
Q

_____ is second only to metastases as the common cause of a liver mass. (p.702)

A

CAVERNOUS HEMANGIOMA

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131
Q

What is the most common benign liver neoplasm?;

found in 7% to 20% of the population and more commonly in women.(p.702)

A

CAVERNOUS HEMANGIOMA

  • this tumor consists of large; thin-walled; blood-filled vascular spaces separated by fibrous septa.
  • blood flow through the maze of vascular spaces is extremely slow; resulting in characteristic imaging findings.
  • thrombosis within the vascular channels may result in central fibrosis and calcification
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132
Q

Larger lesions; GIANT HEMANGIOMAS (> ____ cm); occasionally causes symptoms. (p.702)

A

> 5 cm

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133
Q

TRUE OR FALSE. The size of most cavernous hemangiomas is stable over time. (p.702)

A

TRUE

  • enlargement of cavernous hemangiomas is a cause for reassessment.
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134
Q

US feature of a cavernous hemangioma. (p. 702)

A

Well-defined; uniformly hyperechoic mass in 80% of patients

  • no Doppler signal is obtained from most cavernous hemangiomas because the flow is too slow.
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135
Q

CT feature of a cavernous hemangioma. (P. 702)

A

Well-defined; hypodense mass on unenhanced scans

  • because the lesion consists mostly of blood;attenuation of the hemangioma is similar to that of blood vessels within the liver.
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136
Q

What is the characteristic pattern of enhancement with bolus IV contrast in cavernous hemangiomas? (p.702)

A

DISCONTINUOUS NODULAR ENHANCEMENT FROM THE PERIPHERY OF THE LESION THAT GRADUALLY BECOMES ISODENSE OR HYPERDENSE COMPARED TO THE LIVER PARENCHYMA.

  • the degree of contrast enhancement parallels that of hepatic blood vessels during all postcontrast phases.
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137
Q

The contrast enhancement in cavernous hemangiomas persists

for __ to __ minutes following injection because of slow flow within the lesion. (p. 702)

A

20 to 30 minutes

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138
Q

Areas of fibrosis remain ____ in all image sequences. (p. 702)

A

DARK

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139
Q

MR contrast enhancement pattern of cavernous hemangiomas.

p.702

A

Well-marginated mass with discontinuous peripheral nodular enhancement; leading to progressive fill-in of the lesion
on delayed imaging (>5 minutes).

  • brightness of enhancement parallels the blood pool
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140
Q

Central areas of fibrosis,usually seen in ___ hemangiomas (>5 cm); do not enhance. (p.702)

A

GIANT

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141
Q

_____ hemangiomas (< 1.5 cm) fill in more rapidly; and the peripheral nodular enhancement may not be evident depending upon the timing of the images. (p.703)

A

SMALL CAPILLARY hemangiomas

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142
Q

FLASH hemangiomas ____ contrast on delayed images;
whereas other small early phase-enhancing lesions; such as
HCC and hypervascular metastases; show early and progressive
_____. (p.703)

A

RETAIN; CONTRAST-WASHOUT

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143
Q

Radionuclide scanning using _____ as a blood pool agent is extremely accurate in the diagnosis of cavernous hemangioma. (p. 703)

A

TECHNETIUM-LABELED RED BLOOD CELLS

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144
Q

____ is the most common primary malignancy of the liver.

p.703

A

HEPATOCELLULAR CARCINOMA

  • 5th most common tumor in the world and the 3rd most common cause of cancer-related death (following lung and gastric cancer).
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145
Q

Give 3 risk factors of HEPATOCELLULAR CARCINOMA. (p.703)

A
  1. CIRRHOSIS
  2. CHRONIC HEPATITIS
  3. VARIETY OF CARCINOGENS
    (sex hormones; aflatoxin; and thorotrast)
    Mnemonic: 3 C’s of HCC
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146
Q

In asia; most HCCs are found in patients with _____. (p.703)

A

CHRONIC ACTIVE VIRAL HEPATITIS

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147
Q

___ is the most sensitive imaging modality for the detection of HCC at 81% (p.703)

A

MR

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148
Q

Elevation in serum ______ is found in 90% of patients and is strongly suggestive of hepatoma in patients with cirrhosis.
(p.703)

A

ALPHA FETOPROTEIN

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149
Q

Three major growth patterns of hepatomas that affect their imaging appearance. (p.703-704)

A
  1. SOLITARY MASSIVE
  2. MULTINODULAR
  3. DIFFUSE INFILTRATIVE
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150
Q

_____ HCC growth pattern which appears as a single large mass with or without satellite nodules. (p.704)

A

SOLITARY MASSIVE HCC

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151
Q

____ HCC growth pattern which appears as multiple discrete nodules involving a large area of the liver. (p.704)

A

MULTINODULAR HCC

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152
Q

_____ HCC growth pattern which manifests as innumerable tiny indistinct nodules throughout the liver distorting the parenchyma but not causing a discrete mass. (p.704)

A

DIFFUSE HCC

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153
Q

High intensity on T1WI reflects the accumulation of __; ___ or ____ within the tumor (HCC). (p.704)

A

FAT; GLYCOGEN; or COPPER

  • fat shows signal loss on opposed-phase or fat saturation images.
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154
Q

Moderate high signal on T2WI is quite specific for HCC as dysplastic nodules are not high signal unless ____. (p.704)

A

INFARCTED

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155
Q

Arterial phase enhancement in HCC reflects ____ with supply from the ____ artery. (p.704)

  • This is considered an essential characteristic for diagnosis.
A

NEOANGIOGENESIS; HEPATIC artery

  • enhancement is HOMOGENOUS in small lesions and HETEROGENOUS in large lesions.
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156
Q

The classic and most common appearance of HCC on MR is

___ signal on T1WI; __ signal on T2WI; with ____ enhancement and venous _____. (p.704)

A

LOW; HIGH; ARTERIAL ENHANCEMENT;VENOUS WASHOUT

  • delayed images commonly show late enhancement of an outer rim or capsule; a feature highly sensitive and specific.
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157
Q

6 imaging characteristics of large HCCs (p.704)

A
  1. MOSAIC PATTERN (80 to 90% with HCC)
    of confluent small nodules separated by thin septations and necrotic areas; best seen on T2WI
  2. DISTINCT TUMOR CAPSULE
  3. EXTRACAPSULAR EXTENSION (40% to 80%)
    of tumor with satellite lesions or tumor projection through the capsule
  4. VASCULAR INVASION (25%) of tumor into portal veins or; less commonly hepatic veins
  5. EXTRAHEPATIC DISSEMINATION to abdominal lymph nodes; bones; lungs; and adrenals
  6. PATTERN OF CONTRAST ENHANCEMENT
    - heterogeneous enhancement during arterial phase with rapid washout of contrast during portal venous and equilibrium phase.
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158
Q

Washout to become hypointense on delayed postcontrast images is a feature of ____; not seen with regenerative or dysplastic nodules. (p.705)

A

HCC

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159
Q

_______ is a common finding related to portal vein compression
or occlusion by the tumor with compensatory increase in hepatic arterial supply. (p.____)

A

PERITUMORAL ARTERIAL PHASE ENHANCEMENT

  • peritumoral enhancement is commonly wedge-shaped and confined to the segment of the liver with compromised portal venous supply. (p.705)
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160
Q

Approximately 24% of liver tumors are surrounded by a fibrous capsule or pseudocapsule. This encapsulated HCC; a variant of the solitary massive form; is found more frequently seen in ____ populations and has a ___ prognosis.(p.____)

A

ASIAN; BETTER

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161
Q

___ metamorphosis is a common histologic finding in HCC and hepatic adenomas.(p.705)

A

FATTY metamorphosis

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162
Q

_____ shunting is seen as early or prolonged enhancement of the portal vein; or as a wedge-shaped area of parenchymal enhancement adjacent to the tumor.(p.705)

A

ARTERIOPORTAL shunting

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163
Q

Abundant copper binding protein in cancer cells may lead to _____ within the tumor. (p.705)

A

EXCESSIVE COPPER ACCUMULATION

  • high copper concentration causes the tumor to appear hyperdense on noncontrast CT and hyperintense (due to T1 shortening effect) on T1WI on MR.
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164
Q

____ HCC (approximately 13% of cases) appears as a heterogeneous permeative extensive tumor difficult to differentiate from the distorted parenchyma or cirrhosis.

A

DIFFUSE HCC

  • Vascular invasion and portal vein thrombosis is a prominent clue to the diagnosis.
  • hypointensity on delayed images is highly indicative of diffuse tumor.
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165
Q

______ is as benign solid mass consisting of abnormally arranged hepatocytes, bile ducts and Kupffer cells. (p.705)
- second to hemangioma as the most common benign liver tumor

A

FOCAL NODULAR HYPERPLASIA (FNH)

  • most tumors are diagnosed in women of childbearing age.
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166
Q

Liver lesion that is mostly solitary; less than 5 cm in diameter;
and are hypervascular with a CENTRAL FIBROUS SCAR containing thick-walled blood vessels.
- Lesions are lobulated and well-circumscribed but lack a capsule.
(p.705)

A

FOCAL NODULAR HYPERPLASIA (FNH)

  • benign lesions that do not require treatment but must be differentiated from hepatic adenoma and fibrolamellar carcinoma.
  • found most commonly in women
  • twice as common as hepatic adenoma and is not related to oral contraceptive use
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167
Q

Because of the presence of ___ cells, most (50% to 70%) FNH will show normal or increased radionuclide activity on technetium sulfur colloid liver-spleen scans. (p. 705)

A

KUPFFER CELLS

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168
Q

DIAGNOSIS?
US finding of slight bulge in the liver contour or subtle alteration of parenchymal echogenicity may be the only clues to the presence
of a lesion. Color Doppler may show its central vascularity.
(p.705)

A

FOCAL NODULAR HYPERPLASIA(FNH)

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169
Q

DIAGNOSIS?
CT FINDING of a subtle; slightly hypoattenuating lesion on unenhanced images.
Post-contrast shows characteristic intense homogeneous enhancement in arterial phase sometimes with visualization of the large feeding vessels.
Contrast washes out early on portal venous phase.
The lesion is isointense and commonly near invisible on delayed-phase equilibrium images. (p.705)

A

FOCAL NODULAR HYPERPLASIA (FNH)

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170
Q

MR key diagnosis to recognize Focal Nodular Hyperplasia?

p.705

A

FNH is near isointense to liver parenchyma on all precontrast MR sequences
- central scar is hypointense on T1WI and isointense to slightly hyperintense on T2WI

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171
Q

______ are rare; benign liver tumor that carry a risk of life threatening hemorrhage and potential for malignant degeneration.(p.705)

A

HEPATIC ADENOMAS

  • surgical removal of the tumor is advocated
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172
Q

Liver tumor found most commonly in women on long-term oral contraceptives. (p.705)

A

HEPATIC ADENOMAS

  • additional risk factors include androgen steroid intake and glycogen storage disease
  • tumor size is commonly 8 to 15 cm but may be up to 30 cm size.
173
Q

Hepatic adenomas appear as ____ on technetium sulfur colloid

radionuclide scans; allowing differentiation from FNH. (p. 706)

A

COLD DEFECTS

174
Q

________ is considered a separate clinical entity characterized by the presence of multiple adenomas (>10) in an otherwise normal liver in patients (usually young women) without risk factors for hepatic adenomas. (p.706)

A

LIVER ADENOMATOSIS

175
Q

DIAGNOSIS? (LIVER TUMOR)
US finding shows a well-circumscribed tumor that is usually
heterogeneous depending on content of fat; necrosis; hemorrhage;
or rarely calcification. High fat content or intratumoral hemorrhage
makes the lesions appear hyperechoic.

A

LIVER ADENOMATOSIS

176
Q

DIAGNOSIS? (LIVER TUMOR)
CT finding shows well-circumscribed tumors that are often
low in attenuation because of internal fat; necrosis; or old hemorrhage.
Calcifications in areas of old hemorrhage or necrosis are present in 15%.
Post-contrast scans show intense homogeneous enhancement during arterial phase that becomes isodense with liver on portal venous and
delayed-phase scans. (p.706)

A

LIVER ADENOMATOSIS

177
Q

With hepatocyte-specific contrast administration; adenomas

appear _____ to liver parenchyma on delayed images obtained 1 to 3 hours.(p.706)

A

HYPOINTENSE

178
Q

_______ is a hepatocellular malignancy with clinical and pathologic features that are distinct from HCC.
- typically present as a large liver mass in an adolescent or young adult (mean age, 23 years) with none of the risk factors for HCC;
and without elevation of alpha fetoprotein levels. (p.706)

A

FIBROLAMELLAR CARCINOMA

  • cords of tumors are surrounded by prominent fibrous bands
    that emanate from a central fibrotic scar.
179
Q

Liver tumor with a characteristic appearance of a large; lobulated hepatic mass with central scar and calcifications.
(p.706)

A

FIBROLAMELLAR CARCINOMA

  • the central scar with radiating septa mimics the appearance of FNH
180
Q

TRUE OR FALSE.
LYMPHOMA involving the liver is usually diffusely infiltrative and
undetectable by imaging methods. (P.707)

181
Q

HEMATOMAS show the evolution and breakdown of blood products.
Subacute hematomas are bright on T1WI (effect of _____ ).
(p.707)

A

METHEMOGLOBIN

182
Q

Chronic hematomas are dark on T2WI (effect of _____). (p.707)

A

HEMOSIDERIN

183
Q

Postcontrast images of hematomas shows no evidence of

___ enhancement. (p. 707)

184
Q

_____ is an autosomal dominant disorder of fibrovascular dysplasia; resulting in multiple telangiectasias and arteriovenous malformations.(p._____)

A

HEREDITARY HEMORRHAGIC TELANGIECTASIA

OSLER-WEBER-RENDU SYNDROME

185
Q

______ are thin-walled dilated vascular channels that appear on the skin and mucous membranes as well as throughout the body on multiple organs. (p. 707)

A

TELANGIECTASIAS

  • patient present with epistaxis and intestinal bleeding
186
Q

Nodular transformation of the liver parenchyma without fibrosis is called ______. (p. 707)

A

PSEUDOCIRRHOSIS

187
Q

_____ appear as hypervascular rounded masses resembling an

asterisk; usually a few millimeters in size. (p.____)

A

TELANGIECTASIAS

188
Q

_____ is a rare disorder associated with chronic wasting from cancer or tuberculosis; or associated with the use of oral contraceptives or anabolic steroids. (p. 707)

A

PELIOSIS HEPATIS

  • cystic dilatation of the hepatic sinusoids and multiple small (1 to 3 mm) blood-filled spaces characterize the lesions.
  • postcontrast images show no significant arterial phase enhancement with progressive delayed enhancement on portal venous and delayed-phase images.
189
Q

_____ is a common hepatic mass; found in 5% of the population.
(p.707)

A

BENIGN HEPATIC CYST

  • cysts range in size from microscopic to 20 cm
190
Q

TRUE OR FALSE.

Hepatic cysts do not communicate with the biliary tree. (p.____)

191
Q

TRUE OF FALSE.

Tiny cysts are responsible for many of the HYPOATTENUATING LESIONS TOO SMALL TO CHARACTERIZE seen on MDCT. (p.707)

192
Q

_____ confirms the fluid nature of benign hepatic cysts.(p. 708)

A

POSTERIOR ACOUSTIC ENHANCEMENT

193
Q

TRUE OR FALSE

Benign hepatic cysts do not enhance following contrast administration.(p.____)

194
Q

______ is in the spectrum of autosomal dominant polycystic disease and ocassionally occurs in the absence of polycystic kidneys. (p.708)

A

POLYCYSTIC LIVER DISEASE

  • The number and size of cysts increase over time and may eventually result in massive hepatomegaly and affect hepatic function.
  • Cysts are prone to hemorrhage and infection
195
Q

____ are small benign neoplasms consisting of dilated cystic branching bile ducts embedded within fibrous tissue. (p.708)

A

BILE DUCT HAMARTOMAS (von Meyenburg Complexes)

  • appear as multiple tiny (<1cm) cystic lesions throughout the liver; best recognized on MR.
  • low signal on T1WI and high signal on T2WI
  • show peripheral enhancement on postcontrast
196
Q

___ is a rare cystic neoplasm of the biliary epithelium. (p.708)

A

BILIARY CYSTADENOMA/CYSTADENOCARCINOMA

197
Q

____ are premalignant and on a continuum of disease with

adenocarcinomas. (p.708)

A

CYSTADENOMAS

  • tumors typically contain mucin and appear as large (up to 35 cm) multiloculated cystic mass
  • fine septations are seen in cystadenomas
  • presence of thick; coarse calcifications suggest malignancy
  • differentiation from malignant lesions by imaging may not be possible.
198
Q

US features of BILIARY CYSTADENOMA/CYSTADENOCARCINOMA? (p.708)

A

LARGE MULTICYSTIC MASS; SEPTATIONS AND MURAL NODULES AND PAPILLARY PROJECTIONS IF PRESENT.

  • CT shows enhancement of the wall and any solid components
  • Calcifications are well shown by CT and favor cystadenocarcinoma
  • MR depicts the mass as multiseptated cystic with low signal on T1WI and high signal on T2WI
199
Q

PYOGENIC LIVER ABSCESS is usually caused by _____ (GIVE 4)

p.709

A

Escherichia coli; Staphylococcus aureus; Streptococcus or Anaerobic bacteria

  • destruction of liver results in a solitary cavity or a tight group of individual loculated abscesses
  • lesion may be echogenic and appear solid on US
  • a peripheral rim enhances with contrast
  • gas is present within the lesion in 20% of cases.
200
Q

Diagnosis of PYOGENIC LIVER ABSCESSES is confirmed by

________. (p.709)

A

PERCUTANEOUS ASPIRATION

  • catheter or surgical drainage is indicated in pyogenic liver abscesses
201
Q

_______ is usually solitary with thick nodular walls.(p.709)

A

AMEBIC ABSCESS

  • The lesion may be indistinguishable from pyogenic abscess; however; the patient is often more acutely ill and resides in or has
    travelled to endemic areas (India; Africa; the Far East; and Central and South America).
202
Q

Amebic abscesses commonly occur in the ___ lobe of the liver
causing elevation of the right hemidiaphragm and may rupture
through the diaphragm into the pleural space. (p.709)

A

RIGHT lobe of the liver

203
Q

In the United States (AMEBIC LIVER ABSCESS);
the diagnosis is typically confirmed by ______ and the patient is
treated with metronidazole. (p.709)

204
Q

In the endemic areas (AMEBIC LIVER ABSCESS); the diagnosis is confirmed by aspiration of _____ material. (p.709)

A

ANCHOVY PASTE

205
Q

the diagnosis of AMEBIC ABSCESS is typically confirmed by ______ and the patient is treated by ______. (p.709)

A

ASPIRATION OF ANCHOVY PASTE MATERIAL;

REPEATED ASPIRATION or CATHETER DRAINAGE

206
Q

______ cyst is due to infestation with Echinococcus granulosus or E. multilocularis tapeworm. (p. 709)

A

HYDATID CYST

  • parasite is endemic in central and northern Europe;
    the Mediterranean; northern Asia; China; Japan; Turkey; and parts of North America
  • single or multiple cystic masses usually have well-defined walls that commonly calcify (50%)
  • daughter cysts may be visualized within the parent cyst (75%).
207
Q

The ___ is the most common organ affected (95%) by hydatid cysts. (p.709)

208
Q

TRUE OR FALSE. Diagnostic aspiration of HYDATID CYSTS

carries a risk of anaphylactic reaction. (p.709)

A

TRUE

  • treatment is mebendazole or surgical
    excision
209
Q

______tumor must always be considered for atypical cystic liver masses. (p. 709)

A

CYSTIC/NECROTIC tumor

  • METASTASES may be necrotic or predominantly cystic
  • HCC is ocassionally cystic
  • Undifferentiated embryonal sarcomas are seen in older children; adolescents;and young adults.
210
Q

TRUE OR FALSE.
TINY HYPOATTENUATING LESIONS on MDCT are detected with increased frequency related to thinner collimation; improved resolution; and rapid multiphase postcontrast scanning (p.709)

A

TRUE

- lesions smaller than 1 cm are difficult
 to characterize and often too small to
biopsy.
- differential diagnoses include cysts;
hemangiomas and metastases
211
Q

DIAGNOSIS? (LIVER TUMOR)
- MR finding is variable fat content and internal hemorrhage;
both of which produce bright foci on T1WI.
- On T2WI; most are hyperintense to liver and are commonly
heterogeneous because of hemorrhage or necrosis.
- Postcontrast arterial phase images show heterogeneous
enhancement; not as avid as FNH
- Delayed contrast washout is typical. (p.706)

A

LIVER ADENOMATOSIS

212
Q

_____ preferred screening method for biliary obstruction because of its low cost, high accuracy in detecting biliary dilatation and convenience. (p.710)

A

ULTRASOUND

213
Q

______ has a reported sensitivity of 88%

in detection of stones in the CBD. (p.710)

A

UNENHANCED HELICAL CT

  • MR can also demonstrate biliary dilation and appears more effective than CT or US in demonstrating associated tumors.
214
Q

_____ provides excellent visualization of
the biliary tree by taking advantage of the
high water content of bile and its
relative stasis compared to the
flowing blood. (p.710)

A

MR cholangiopancreatography
(MRCP)

  • performed using heavily
    T2-weighted sequences with acquisition times slower
    than moving blood; producing high
    signal in the biliary tree and signal
    voids in the nearby blood vessels. - extreme T2-weighting demonstrates bright bile ducts
    with bright surrounding soft tissues
215
Q 
TRUE OR FALSE.
However; any static fluid will also be bright
on MRCP images; so ascites; hepatic
and renal cysts; and fluid in the 
bowel may obscure the biliary tree.
(p.710)
216
Q

_____ MRCP uses slice thickness of
40 to 60 mm with fat saturation to improve
visualization of the biliary tree. (p.710)

A

THICK SLAB MRCP

217
Q

____ and ___ images produce
impressive displays of the entire biliary
tree. (p.710)

A

HIGH-RESOLUTION 3D ACQUISITIONS
and MAXIMUM INTENSITY
PROJECTION (MIP) images

218
Q

____ is now used primarily to guide
therapy such as stent placement
for biliary strictures; stone extraction
or sphincterotomy. (p.710)

A

ENDOSCOPIC RETROGADE
CHOLANGIOGRAPHY
(ERCP)

219
Q

Direct contrast injection of the biliary tree during ERCP produces ____ resolution images than MRCP; but duct visualization is limited to the ducts that can be filled retrograde.
(p.710)

A

HIGHER RESOLUTION

  • ducts proximal to a high-grade
    obstruction are not visualized.
220
Q

____ is mainly used to guide
therapy when the biliary tree cannot be
accessed endoscopically such as when patients have had a choledojejunostomy.
(p.710)

A

PERCUTANEOUS TRANSHEPATIC
CHOLANGIOGRAPHY
(PTC)

221
Q 
Operative cholangiography is used to 
visualize non palpable bile duct stones
at surgery and \_\_\_\_\_\_\_ is used to visualize
common duct stones following surgery. 
(p.710)
A

T-TUBE CHOLANGIOGRAPHY

222
Q 
Radionuclide imaging; utilizing
\_\_\_\_; is useful for showing the patency
of biliary-enteric anastomoses
and for demonstrating bile leaks
and fistulae. (p.710)
A

TECHNETIUM-99m-IMINODIACETIC

ACID

223
Q

______is performed using agents such as
iopanoic acid formerly used for
oral cholecystography. (p.710)

A

CT CHOLANGIOGRAPHY

224
Q

____ causes swelling of hepatocytes;
which blocks biliary capillaries and causes
and intrahepatic cholestasis without
surgical obstruction. (p.711)

225
Q

4 imaging signs of biliary dilation

p.711

A 
1. Multiple branching tubular;
round or oval structures
that course toward the porta hepatis
2. diameter of IHBDs larger than
40% of the diameter
of the adjacent portal vein
3. Dilation of the common duct
greater than 6 mm
4. gallbladder diameter greater 
than 5cm; when obstruction is 
distal to the cystic duct.
226
Q

____ sign refers to dilatation of both the
CBD and the pancreatic duct in the head of
the pancreas. (p.711)

A

DOUBLE DUCT sign

  • dilation of both the ducts is usually
    caused by a tumor at the ampulla
227
Q

TRUE OR FALSE.
Benign disease is responsible for
approximately 75% of cases of obstructive
jaundice in the adult; whereas malignant
disease causes the remainder. (p.711)

228
Q

GRADUAL TAPERING of a dilated common bile

duct suggests ___-. (p.711)

A

BENIGN STRICTURE

  • gallstones may be identified in the bile
    duct surrounded by a crescent of bile.
229
Q

ABRUPT TERMINATION of a dilated
common bile duct is characteristic
of a ____ process. (p.711)

230
Q

____ is responsible for approximately
20% of cases of obstructive jaundice
in the adult. (p.711)

A

CHOLEDOCHOLITHIASIS

  • 1% to 3% of patients with choledocholithiasis will have
    no stones in the gallbladder.
  • the sensitivity of US for stones in the bile ducts ranges
    from 20% to 80%
  • stone detection by US is much improved when the CBD
    is dilated and the pancreatic head is well-visualized.
231
Q

CT sensitivity for choledocholithiasis
is __% to __ %; with stones appearing
as intraluminal masses of varying attenuation. (p.711)

A

70 % to 80 %

232
Q

____ and ____ have the highest
sensitivity for stone detection (95% to 99%)
- choledocholithiasis. (p.711)

A

CONTRAST STUDIES and MRCP

  • they demonstrate stones as dark-filling
    defects within the bright bile.
233
Q

MRCP may miss stones smaller than
___ mm because they are lost within
high-signal fluid. (p.711)

A

smaller than 3 mm

234
Q

Three imaging signs of stones
within the bile ducts include ___
(p.712)

A
  1. Stone layer dependently within;
    allowing a crescent of bile to outline the
    anterior portion of the stone
    (the CRESCENT SIGN)
  2. Stones are usually geometric or
    angulated in shape and lamellated in appearance
  3. Periductal edema and thickening and
    enhancement of the wall of the bile duct occur with impacted stones
    or infection.
  • Wall thickening and enhancement is also seen with tumors
235
Q

______ is the cause of 40% to 45% of
obstructive jaundice in the adult.
(p.712)

A

BENIGN STRICTURE

236
Q

7 CAUSES OF BENIGN STRICTURE

p.712

A
  1. TRAUMA
  2. SURGERY
  3. PRIOR BILIARY INTERVENTIONAL PROCEDURES
  4. RECURRENT CHOLANGITIS
  5. PREVIOUS PASSAGE OF STONES
    THROUGH THE BILE DUCTS
  6. RADIATION THERAPY
  7. PERFORATED DUODENAL ULCERS
237
Q

The wall of the involved CBD
enhanced minimally with
_____ strictures. (p.712)

A

BENIGN strictures

238
Q

Hyperenhancement of the CBD during
portal venous phase is evidence of
_____ stricture. (p.712)

A

MALIGNANT stricture

239
Q

___ is responsible for approx.
8% of cases of biliary obstruction.
(p.712)

A

PANCREATITIS

-Inflammation; fibrosis; and
inflammatory masses narrow the bile ducts

240
Q

___ is associated with a history
of ulcerative colitis (50% to 70% of cases).
- an idiopathic; fibrosing; chronic
inflammatory disease characterized by
insidious onset of jaundice; with progressive
disease affecting both IHBD and EHBD.
(p.712)

A

PRIMARY SCLEROSING CHOLANGITIS

PSC

241
Q

3 imaging findings found in PSC.
PRIMARY SCLEROSING CHOLANGITIS.
(p.712)

A
  1. IHBD dilatation
  2. IHBD strictures
  3. EHBD wall thickening and stenosis
242
Q

Key diagnostic finding of PSC.

p.712

A

Alternating dilation and stenosis
produces a characteristic BEADED pattern
of intrahepatic ducts.

  • small saccular outpouching (duct diverticula)
    ; demonstrated on cholangiography; are also
    considered to be pathognomonic
  • complications include biliary cirrhosis (50%)
    and cholangiocarcinoma
243
Q

___ is characterized by thickening
of the walls of the bile ducts and the
gallbladder due to inflammation
and edema. (p.712)

A

HIV-ASSOCICATED CHOLANGITIS

  • infection by opportunistic organisms;
    most commonly Cytomegalovirus and
    Cryptosporidium; as well as reaction
    to the HIV itself
244
Q

____ occurs in the settng of biliary
obstruction and is life-threatening
with mortality as high as 65%. (p.713)

A

ACUTE BACTERIAL CHOLANGITIS

245
Q

Components of CHARCOT TRIAD (p.713)

A
  1. FEVER
  2. PAIN
  3. JAUNDICE
    Mnemonic: FPJ
    - infection is usually polymicrobial with
    gram-negative rods predominating
246
Q

Imaging finding of ACUTE

BACTERIAL CHOLANGITIS. (p.713)

A

BILIARY DILATATION; USUALLY CAUSED
BY A STONE IN THE DUCT; ASSOCIATED
WITH PERIBILIARY CONTRAST
ENHANCEMENT AND EDEMA

247
Q

____ has in the past been called
ORIENTAL CHOLANGIOHEPATITIS
because it is an endemic disease in
Southeast Asia. (p.713)

A

RECURRENT PYOGENIC CHOLANGITIS

- characterized by recurrent attacks of 
jaundice; abdominal pain; fever and 
chills
- Intrahepatic and EHBDs are dilated
and filled with soft pigmented stones 
and pus
248
Q 
TRUE OR FALSE.
RECURRENT PYOGENIC CHOLANGITIS 
is associated with parasitic
infestation and nutritional deficiency. 
(p.713)
A

TRUE

- findings include intraductal stones;
severe extrahepatic biliary dilation;
focal strictures; pneumobilia and 
straightening and rigidity of the 
intrahepatic ducts
249
Q

5 complications of RECURRENT
PYOGENIC CHOLANGITIS
(p.713)

A
  1. LIVER ABSCESS
  2. BILOMA
  3. PANCREATITIS
  4. CHOLANGIOCARCINOMA
  5. ATROPHY
250
Q

____ is an uncommon congenital anomaly of the biliary tract characterized by saccular ectasia of the IHBD
without biliary obstruction. (p.713)

A

CAROLI DISEASE (Type V)

  • only one hepatic lobe or segment;
    or the entire liver; may be affected
  • EHBD are spared in 50% of cases

Todani Classification:

  • Type I: most common, EHBD
  • Type II: True DIVERTICULUM from EHBD
  • Type III: within the DUODENAL WALL
  • Type IV: next most common, both IHBD and EHBD
  • Type V: Caroli disease, multiple dilatations/cysts of IHBD only
251
Q 
5 imaging findings of 
CAROLI DISEASE (p.713)
A
  1. SACCULAR DILATATION OF IHBD
  2. ENHANCING FIBROVASCULAR BUNDLES
  3. SEGMENTAL DISTRIBUTION OF THE BILE
    DUCT ABNORMALITY WITH NORMAL APPEARANCE
    UNAFFECTED LIVER SEGMENTS
  4. CHOLANGIOGRAPHY shows a characteristic pattern
    of focal biliary narrowing and saccular dilatation
  5. DILATATION of the CBD (10 to 30 mm) in half the cases
252
Q

Imaging sign found in CAROLI DISEASE;
wherein enhancing fibrovascular bundles
are seen centrally within many of the dilated
ducts producing this sign.(p.713)

A

CENTRAL DOT SIGN

253
Q

___ are uncommon congenital
anomalies of the biliary tree
characterized by cystic
dilation of the bile ducts. (p.713)

A

CHOLEDOCHAL CYSTS

254
Q

Most common choledochal cyst
type (Todani Classification)?
(p.713)

A

TYPE I

  • 80% to 90%
  • confined to the EHBD
  • appear as fusiform saccular dilatations of
    the CHD; CBD; or segments of each.
255
Q

Choledochal Cyst type seen as a
diverticula of the CBD attached by a
narrow stalk. (p.713)

256
Q 
Choledochal cyst type termed 
CHOLEDOCHOCELES and are focal
dilatations of the intraduodenal 
portion of the CBD closely resembling
ureteroceles.
257
Q

Choledochal cyst type defined as
multiple focal dilatations of the
IHBD and EHBD usually with a focal
large cystic dilatation of the CBD.(p.714)

A

TYPE IV (next most common)

258
Q 
Choledochal cyst type
referred to CAROLI DISEASE; which is
more appropriately classified
as a disease separate from choledochal
cyst. (p.714)
259
Q

______ and ___ carcinomas are the cause
of 20% to 25% of cases of biliary
obstruction in the adult. (p.714)

A

PANCREATIC and AMPULLARY

carcinomas

260
Q 
\_\_\_\_ may present as intraductal 
filling defects.
- Colorectal cancers are the most common
primary tumors associated with intraluminal 
biliary metastases. (p.714)
A

METASTASES

261
Q

Findings that favor metastases
over cholangiocarcinoma are the
__ and __. (p.714).

A 
1. presence of a contiguous 
parenchymal mass
2. expansion of the duct at 
the site of the intraluminal
mass in a patient with known
colorectal cancer
262
Q

__ is the second most common
malignant primary hepatic
tumor. (p.714)

A

CHOLANGIOCARCINOMA

- tumors arise from the 
epithelium of the bile ducts
 and are usually adenocarcinomas 
(90%)
- growth patterns include 
mass-forming; periductal infiltrating;
and intraductal polypoid
-poor prognosis
263
Q 
\_\_\_\_\_ cholangioCA (10%)
presents as an intrahepatic
hypodense mass sometimes
(25%) causing peripheral biliary
dilatation.(p.714)
A

PERIPHERAL CholangioCA

- MDCT demonstrates a homogeneous
low-attenuation mass with delayed;
mild; thin; incomplete; rim-like
enhancement.
- additional findings may include
capsular retraction and satellite
nodules
264
Q

____ cholangioCA (____ tumor)
(25%) occurs near the junction
of the right and left bile ducts.
(p.714)

A

HILAR cholangioCA
(Klatskin tumor)

- tumor is usually small; poorly
differentiated; aggressive;
and causes obstruction of 
both ductal systems
- surgical resection is the only hope for cure.
265
Q 
\_\_\_\_ cholangioCA (65%) causes
stenosis or obstruction of the CBD in most cases (95%) and 
presents as an intraductal
polypoid mass in 5%.(p.714)
A

EXTRAHEPATIC cholangioCA

- shows thickening of the wall of
the involved bile duct with 
hyperenhancement during 
arterial phase
- abrupt stricture with thickening
duct wall may be the only findings.
266
Q

5 predisposing conditions
of EXTRAHEPATIC
CHOLANGIOCARCINOMA
(p.715)

A
  1. CHOLEDOCHAL CYST
  2. ULCERATIVE COLITIS
  3. CAROLI DISEASE
  4. CLONORCHIS SINENSIS
    INFECTION
  5. PSC
267
Q 
\_\_\_ tumor of the bile ducts
may produce a large amount 
of mucin that markedly dilates
the billiary tree and impairs 
the flow of bile. (p.715)
A

INTRADUCTAL PAPILLARY
MUCINOUS TUMOR

  • tumors are intraductal;
    polypoid;and characterized by
    innumerable frondlike papillary
    projections
268
Q 
\_\_\_\_ (\_\_\_) is most commonly
encountered in the patient
with a surgically created biliary-
enteric anastomosis; or who
has had a sphincterotomy
to facilitate stone passage.
(p.715)
A

GAS IN THE BILIARY TRACT

PNEUMOBILIA

269
Q

___ fistula is most commonly
due to the erosion of a gallstone
through the gallbladder and
into the duodenum (p.715)

A

CHOLECYSTODUODENAL
FISTULA

- most common in women
because of the higher incidence
of gallstones
- when the gallstone is large;
it may cause small bowel obstruction
270
Q

___ fistula is caused by a
penetrating peptic ulcer
eroding ino the CBD.
(p.715)

A

CHOLEDOCHODUODENAL

FISTULA

271
Q

____ is the imaging method
of choice for the gallbladder.
(p.715)

A

ULTRASOUND

272
Q

____ has sensitivity and
specificity comparable to US
for the diagnosis of acute
cholecystitis. (p.715)

A

CHOLESCINTIGRAPHY utilizing

technetium-99m-iminodiaceticacid

273
Q 
Approx. 85% of gallstone
 are predominantly \_\_\_\_\_;
whereas 15% are pred. \_\_\_\_
(pigment stones) related to
hemolytic anemia. (p. 715)
A

CHOLESTEROL;
BILIRUBIN

- approx. 10% of stones are 
sufficiently radioopaque
to be detected by conventional
radiographs as laminated or
faceted calcifications.
274
Q 
Fissure within gallstones
may contain nitrogen gas
that appears on radiographs
as branching linear lucencies
resembling a \_\_\_\_\_.
(p.715)
A

CROW’S FOOT

275
Q

5 conditions where

gallstones are common. (p.715)

A
  1. Women (female:male = 4:1)
  2. Patients with hemolytic
    anemia
  3. Diseases of the Ileum
  4. Cirrhosis
  5. Diabetes Mellitus
276
Q

__ detects 95% of all gallstones;
whereas __ detects only 80
to 85%. (p.715)

A

ULTRASOUND; CT

  • gallstones vary in CT
    attenuation from fat density
    to calcium density
277
Q 
TRUE OR FALSE.
Up to 20% of gallstones are
ISODENSE with bile and not 
detected by CT;
whereas some gallstones are 
missed because of their small
size or volume averaging with
the adjacent bowel. 
(p.715-716)
278
Q 
Contrast studies; MRCP and T2
-weighted MR demonstrate
\_\_\_\_ as "filling defects"; rounded
 or faceted dark objects within 
the high-density bile.
(p.716)
A

GALLSTONES

279
Q

Give 5 Differential considerations
for lesions in the GB that may be
mistaken for gallstones
(p.716)

A 
1. Sludge balls or tumefactive
biliary sludge
2. Cholesterol polyps
3. Adenomatous polyps
4. Gallbladder CA
5. Adenomyomatosis
280
Q 
\_\_\_\_ result from biliary stasis.
Bile thickens and forms layers 
of bile and mobile masses that
move with changes in patient 
position. (p.716)
A

SLUDGE BALLS or
TUMEFACTIVE BILIARY SLUDGE

  • the presence of sludge indicates
    indicates lack of bile turnover; which
    may occur because of obstruction;
    or simply lack of oral food intake.
281
Q 
\_\_\_\_ polyps are common 
(4% to 7% of the population)
benign; polypoid masses that result 
from accumulation of
triglycerides and cholesterol
in macrophages in the GB wall.
(p.716)
A

CHOLESTEROL polyps
(p.716)

  • polyps 5mm and smaller
    are routinely dismissed as
    benign cholesterol polyps
282
Q

TRUE OR FALSE.
Adenomatous polyps are
potentially premalignant.
(p.716)

283
Q

__ carcinoma may present
as a polypoid GB mass
(p.716)

A

GALLBLADDER CARCINOMA

- GB polyps larger than 10 mm 
should be considered for 
surgical removal because of 
the risk of cancer
- gallstones are usually present
284
Q

___ may be focal and present
as a polypoid mass fixed to
the GB wall. (p.716)

A

ADENOMYOMATOSIS

285
Q

Refers to acute inflammation
of the GB caused by gallstones
obstructing the cystic duct in
90% of cases. (p. 716)

A

ACUTE CHOLECYSTITIS

286
Q

Confident US diagnosis of
acute cholecystitis requires the
presence of these 3 findings.
(p.716)

A
  1. CHOLELITHIASIS
  2. EDEMA OF THE GB WALL
    seen as a band of echolucency
    in the wall
  3. POSITIVE SONOGRAPHIC
    MURPHY SIGN
287
Q

Scintigraphic diagnosis of
acute cholecystitis is based on
___ and ____. (p.716)

A
  1. Obstruction of the cystic duct
  2. Non-vizualization of the GB
- The normal GB demonstrates
progressive accumulation of radionuclide 
activity over 30 minutes to 1 hour ff
injection of technetium-99m
-iminodiacetic acid. 
- delayed visualization of the GB
may be seen in patients with 
biliary stasis due to fasting or 
hyperalimentation.
288
Q 
Diagnosis? CT demonstrates
gallstones; distended GB;
thickened GB wall; subserosal 
edema; high-density bile; 
intraluminal sloughed
membranes; inflammatory
stranding in pericholecystic fat;
pericholecystic fluid; blurring 
of the interface between GB 
and liver; and prominent arterial
phase enhancement of the liver
adjacent to the gallbladder.
(p.716)
A

ACUTE CHOLECYSTITIS

  • MR Findings are similar:
    1. gallstones; often impacted
    in the neck
    2. wall thickening (> 3mm) with edema
    3. distended GB
    4. pericholecystic fluid
289
Q

___ cholecystitis causes
special problems in diagnosis
because the cystic duct is often
not obstructed. (p.717)

A

ACALCULOUS Cholecystitis

  • inflammation may be due to
    GB wall ischemia or direct
    bacterial infection
290
Q

5 conditions wherein patient is
at risk for acalculous
cholecystitis (p.717)

A 
1. Biliary stasis due to lack of 
oral intake
2. Posttrauma
3. Post-burn
4. Postsurgery
5. Total parenteral nutrition
291
Q

Diagnosis? US demonstrates
a distended tender GB with
thickened wall but without stones. (p.717)

A

ACALCULOUS CHOLECYSTITIS

  • many patients are too ill to elicit a reliable sonographic
    Murphy sign
292
Q 
\_\_\_\_ is the term used to 
describe the presence of 
thick particulate matter
in highly concentrated bile.
(p.717)
A

SLUDGE

- calcium bilirubinate and 
cholesterol crystals precipitate
in the bile when biliary stasis is 
prolonged because of a lack of  
oral intake or biliary obstruction
293
Q

Causes of dense bile; give 4.

p.717

A
  1. Sludge
  2. Pus
  3. Blood
  4. Milk of Calcium
294
Q

Give 5 complications of
ACUTE Cholecystitis
(p.717)

A
  1. Gallbladder Empyema
  2. Gangrenous Cholecystitis
  3. Perforation of the GB
  4. Emphysematous cholecystitis
  5. Mirizzi syndrome
295
Q 
\_\_\_\_\_ desbribes the GB
distended with pus
in a patient; often diabetic;
with rapid progression of 
symptoms suggesting an
abdominal abscess. (p.717)
A

GALLBLADDER EMPYEMA

296
Q

____ indicates the presence of

necrosis of the GB wall. (p.717)

A

GANGRENOUS CHOLECYSTITIS

- the patient is at risk for GB
perforation.
- findings include mucosal 
irregularity and asymmetric thickening
of the GB wall with multiple lucent
layers; indicating mucosal ulceration
and reactive edema.
297
Q 
TRUE OR FALSE.
Perforation of the GB 
is a life-threatening condition
seen in 5% to 10% of cases.
(p.717)
A

TRUE

- a focal pericholecystic fluid 
collection suggests 
pericholecystic abscess
- gas is often present within the
GB lumen if the perforation 
extends into the bowel.
298
Q 
\_\_\_\_\_\_\_ results from infection
of the gallbladder with
gas-forming organisms;
usually E.coli or Clostridium 
perfringens
-approx. 40% are diabetic 
(p.717)
A

EMPHYSEMATOUS CHOLECYSTITIS

- gallstones may or may not be
present.
-gas is demonstrated within 
the wall or within the lumen of 
the gallbladder by conventional
radiography or CT.
- on US; intramural gas has an
arc-like configuration difficult
to differentiate from calcification
and porcelain gallbladder.
299
Q 
\_\_\_\_\_ refers to the condition
of biliary obstruction resulting
from a gallstone in the 
cystic duct eroding into the adjacent 
common duct and causing an inflammatory 
mass that obstructs the 
common duct. (p.717)
A

MIRIZZI SYNDROME

- visualization of a stone
at the junction of the cystic 
duct and the common hepatic 
duct in a patient with biliary 
obstruction and gallbadder
inflammation suggests the
diagnosis.
300
Q 
\_\_\_\_\_ includes a spectrum of 
pathology that shares the 
presence of gallstones and
chronic gallbladder 
inflammation. (p.717)
A

CHRONIC CHOLECYSTITIS

- patients with chronic
cholecystitis complain of 
recurrent attacks of RUQ 
abdominal pain and biliary
colic
301
Q

5 imaging findings of
Chronic Cholecystitis
(p.717)

A
  1. Gallstones
  2. Thickening of the GB wall
  3. contraction of the GB lumen
  4. Delayed visualization
    of the GB on cholescintigraphy
  5. Poor contractility
302
Q

Give 3 variants of
Chronic Cholecystitis
(p.717)

A
  1. Porcelain Gallbladder
  2. Milk of Calcium bile
  3. Xanthogranulomatous
    Cholecystitis
303
Q

____ describes the presence
of dystrophic calcification
in the wall of an obstructed and chronically inflammed GB.
(p.717)

A

PORCELAIN GALLBLADDER

- the condition is associated with 
gallstones in 90% of cases.
- carries a 10% to 20% risk of
GB carcinoma
- Cholecystectomy is usually
indicated.
304
Q

______ (____) is associated
with an obstructed cystic duct;
chronic cholecystitis; and
gallstones

A

MILK OF CALCIUM
(LIMY BILE)

  • the bile is extremely echogenic
    on US and gallstones may be
    visualized within it.
305
Q 
\_\_\_\_\_\_\_ is an uncommon
variant of chronic cholecystitis
characterized by nodular depostis
of lipid-laden macrophages
in the gallbladder wall 
and proliferative fibrosis. 
(p.717)
A

XANTHOGRANULOMATOUS

CHOLECYSTITIS

306
Q 
Diagnosis? Imaging findings 
include marked GB wall
thickening of about 2 cm; 
fat density nodules in the 
wall; narrowing of the lumen.
(p.717)
A

XANTHOGRANULOMATOUS
CHOLECYSTITIS

- Cholelithiasis is frequently 
present
- the condition is difficult to
differentiate from GB
carcinoma
- preservation of linear 
enhancement of the mucosa 
on post-contrast MR favors
xanthogranulomatous
cholecystitis over carcinoma
307
Q 
Thickening of the GB wall
 is present when the wall
 thickness measured on the 
hepatic aspect of the GB
exceeds \_\_ mm in patients
who have fasted at least
8 hours. (p.718)
A

exceeds 3 mm

308
Q

7 conditions associated
with GB wall thickening.
(p.718)

A 
1. Acute and Chronic 
Cholecystitis
2. Hepatitis
3. Portal venous HTN
and Congestive Heart 
Failure
4. AIDS
5. Hypoalbuminemia
6. Gallbladder CA
7. Adenomyomatosis
309
Q 
Hepatitis causes \_\_\_\_; 
which results in reduced
GB volume and thickening
of the GB wall in approx.half
of the patients (p.718)
A

REDUCTION IN BILE FLOW

310
Q

Portal venous HTN and
CHF may cause GB wall
thickening by ___. (p.718)

A

PASSIVE VENOUS CONGESTION

311
Q

GB carcinoma usually presents
as a focal mass but may cause
only ___ GB wall thickening.
(p.718)

A

FOCAL GB wall thickening

312
Q 
\_\_\_\_ is the most frequent 
benign condition of the GB
and is characterized by 
hyperplasia of the mucosa 
and smooth muscle
A

ADENOMYOMATOSIS

- it may be localized; usually in the 
fundus; segmental or diffuse 
involving the entire GB
- coexisting gallstones are 
commonly present
313
Q

Outpouchings of GB mucosa
into or through the muscularis
form characteristic ____.
(p.718)

A

ROKITANSKY-ASCHOFF SINUSES

314
Q

TRUE OR FALSE.
Adenomyomatosis has no
malignant potential. (p.718)

315
Q 
DIAGNOSIS? US shows 
"comet-tail" reverberation
artifacts emanating from inspissated
bile within these sinuses in the 
thickened GB wall.
A

ADENOMYOMATOSIS

316
Q 
DIAGNOSIS? MRCP shows
a "pearl necklace" appearance
of the GB wall caused
by bright fluid within the sinuses.
(p.718)
A

ADENOMYOMATOSIS

317
Q

DIAGNOSIS? CT shows GB wall
thickening with tiny cystic
spaces. (p.718)

A

ADENOMYOMATOSIS

318
Q 
TRUE OR FALSE.
The presence of gallstones
in 70% to 80% of cases masks
the findings of cancer;
esp. with US examination. (p.718)
A

TRUE

  • GB Carcinoma is a tumor
    of elderly women (>60 years;
    female:male=4;1)
319
Q

TRUE OR FALSE.
Calcification of the GB wall
(porcelain GB) is a risk factor
for GB carcinoma. (p.718)

320
Q

7 imaging findings of

GB carcinoma. (p.718)

A
  1. Intraluminal soft tissue mass
  2. Focal or diffuse GB wall thickening
  3. Soft tissue mass replacing the GB
  4. Gallstones
  5. Extension of the tumor into the liver;
    bile ducts and adjacent bowel
  6. dilated bile ducts
  7. metastases to periportal and
    peripancreatic lymph nodes of the
    liver
  • most tumors are unresectable at discovery
321
Q

__ is the preferred screening method for;
biliary obstruction because of its low cost;
high accuracy in detecting biliary dilatation;
and convenience. (p.710)

A

ULTRASOUND

  • limited by incosistent
    visualization of the distal common
    bile duct (CBD) and low sensitivity for
    determining the cause of obstruction.
322
Q

______ has a reported sensitivity of 88%

detection of stones in the CBD. (p.710)

A

UNENHANCED HELICAL CT

  • MR can also demonstrate
    biliary dilation and appears more
    effective than CT or US in demonstrating associated tumors.
323
Q

_____ provides excellent visualization of
the biliary tree by taking advantage of the
high water content of bile and its
relative stasis compared to the
flowing blood. (p.710)

A

MR cholangiopancreatography
(MRCP)

  • performed using heavily
    T2-weighted sequences with acquisitiion times slower
    than moving blood; producing high
    signal in the biliary tree and signal
    voids in the nearby blood vessels. - extreme T2-weighting demonstrates bright bile ducts
    with bright surrounding soft tissues
324
Q 
TRUE OR FALSE.
However; any static fluid will also be bright
on MRCP images; so ascites; hepatic
and renal cysts; and fluid in the 
bowel may obscure the biliary tree.
(p.710)
325
Q

_____ MRCP uses slice thickness of
40 to 60 mm with fat saturation to improve
visualization of the biliary tree. (p.710)

A

THICK SLAB MRCP

326
Q

____ and ___ images produce
impressive displays of the entire biliary
tree. (p.710)

A

HIGH-RESOLUTION 3D ACQUISITIONS
and MAXIMUM INTENSITY
PROJECTION (MIP) images

327
Q

____ is now used primarily to guide
therapy such as stent placement
for biliary strictures; stone extraction
or sphincterotomy. (p.710)

A

ENDOSCOPIC RETROGADE
CHOLANGIOGRAPHY
(ERCP)

328
Q 
Direct contrast injection of the biliary
tree during ERCP produces \_\_\_\_
resolution images than MRCP;
but duct visualization is limited to the 
ducts that can be filled retrograde.
(p.710)
A

HIGHER RESOLUTION

  • ducts proximal to a high-grade
    obstruction are not visualized.
329
Q

____ is mainly used to guide
therapy when the biliary tree cannot be
accessed endoscopically such as when patients have had a choledojejunostomy.
(p.710)

A

PERCUTANEOUS TRANSHEPATIC
CHOLANGIOGRAPHY
(PTC)

330
Q 
Operative cholangiography is used to 
visualize non palpable bile duct stones
at surgery and \_\_\_\_\_\_\_ is used to visualize
common duct stones following surgery. 
(p.710)
A

T-TUBE CHOLANGIOGRAPHY

331
Q 
Radionuclide imaging; utilizing
\_\_\_\_; is useful for showing the patency
of biliary-enteric anastomoses
and for demonstrating bile leaks
and fistulae. (p.710)
A

TECHNETIUM-99m-IMINODIACETIC

ACID

332
Q

______is performed using agents such as
iopanoic acid formerly used for
oral cholecystography. (p.710)

A

CT CHOLANGIOGRAPHY

333
Q

____ causes swelling of hepatocytes;
which blocks biliary capillaries and causes intrahepatic cholestasis without
surgical obstruction. (p.711)

334
Q

4 signs of imaging signs of biliary dilation

p.711

A 
1. Multiple branching tubular;
round or oval structures
that course toward the porta hepatis
2. diameter of IHBDs larger than
40% of the diameter
of the adjacent portal vein
3. Dilation of the common duct
greater than 6 mm
4. gallbladder diameter greater 
than 5cm; when obstruction is 
distal to the cystic duct.
335
Q

____ sign refers to dilatation of both the
CBD and the pancreatic duct in the head of
the pancreas. (p.711)

A

DOUBLE DUCT sign

  • dilation of both the ducts is usually
    caused by a tumor at the ampulla
336
Q

TRUE OR FALSE.
Benign disease is responsible for
approximately 75% of cases of obstructive
jaundice in the adult; whereas malignant
disease causes the remainder. (p.711)

337
Q

GRADUAL TAPERING of a dilated common bile

duct suggests ___. (p.711)

A

BENIGN STRICTURE

  • gallstones may be identified in the bile
    duct surrounded by a crescent of bile.
338
Q

ABRUPT TERMINATION of a dilated
common bile duct is characteristic
of a ____ process. (p.711)

339
Q

____ is responsible for approximately
20% of cases of obstructive jaundice
in the adult. (p.711)

A

CHOLEDOCHOLITHIASIS

  • 1% to 3% of patients with choledocholithiasis will have
    no stones in the gallbladder.
  • the sensitivity of US for stones in the bile ducts ranges
    from 20% to 80%
  • stone detection by US is much improved when the CBD
    is dilated and the pancreatic head is well-visualized.
340
Q

CT sensitivity for choledocholithiasis
is __% to __ %; with stones appearing
as intraluminal masses of varying attenuation. (p.711)

A

70 % to 80 %

341
Q

____ and __ have the highest
sensitivity for stone detection (95% to 99%)
- choledocholithiasis. (p.711)

A

CONTRAST STUDIES and MRCP

  • they demonstrate stones as dark-filling
    defects within the bright bile.
342
Q

MRCP may miss stones smaller than
___ mm because they are lost within
high-signal fluid. (p.711)

A

smaller than 3 mm

343
Q

Three imaging signs of stones
within the bile ducts include ___
(p.712)

A
  1. Stone layer dependently within;
    allowing a crescent of bile to outline the
    anterior portion of the stone
    (the CRESCENT SIGN)
  2. Stones are usually geometric or
    angulated in shape and lamellated in appearance
  3. Periductal edema and thickening and
    enhancement of the wall of the bile duct occur with impacted stones
    or infection.
  • Wall thickening and enhancement is also seen with tumors
344
Q

______ is the cause of 40% to 45% of
obstructive jaundice in the adult.
(p.712)

A

BENIGN STRICTURE

345
Q

7 CAUSES OF BENIGN STRICTURE

p.712

A
  1. TRAUMA
  2. SURGERY
  3. PRIOR BILIARY INTERVENTIONAL PROCEDURES
  4. RECURRENT CHOLANGITIS
  5. PREVIOUS PASSAGE OF STONES
    THROUGH THE BILE DUCTS
  6. RADIATION THERAPY
  7. PERFORATED DUODENAL ULCERS
346
Q

The wall of the involved CBD
enhanced minimally with
_____ strictures. (p.712)

A

BENIGN strictures

347
Q

Hyperenhancement of the CBD during
portal venous phase is evidence of
_____ stricture. (p.712)

A

MALIGNANT stricture

348
Q

___ is responsible for approx.
8% of cases of biliary obstruction.
(p.712)

A

PANCREATITIS

-Inflammation; fibrosis; and
inflammatory masses narrow the bile ducts

349
Q

___ is associated with a history
of ulcerative colitis (50% to 70% of cases).
- an idiopathic; fibrosing; chronic
inflammatory disease characterized by
insidious onset of jaundice; with progressive
disease affecting both IHBD and EHBD.
(p.712)

A

PRIMARY SCLEROSING CHOLANGITIS

PSC

350
Q

3 imaging findings found in PSC.
PRIMARY SCLEROSING CHOLANGITIS.
(p.712)

A
  1. IHBD dilatation
  2. IHBD strictures
  3. EHBD wall thickening
    and stenosis
351
Q

Key diagnostic finding of PSC.

p.712

A

Alternating dilation and stenosis
produces a characteristic beaded pattern
of intrahepatic ducts.

  • small saccular outpouching (duct diverticula)
    ; demonstrated on cholangiography; are also
    considered to be pathognomonic
  • complications include biliary cirrhosis (50%)
    and cholangiocarcinoma
352
Q

___ is characterized by thickening
of the walls of the bile ducts and the
gallbladder due to inflammation
and edema. (p.712)

A

HIV-ASSOCICATED CHOLANGITIS

  • infection by oppurtunistic organisms;
    most commonly cytomegalovirus and
    Cryptosporidium; as well as reaction
    to the HIV itself
353
Q

____ occurs in the settng of biliary
obstruction and is life-threatening
with mortality as high as 65%. (p.713)

A

ACUTE BACTERIAL CHOLANGITIS

354
Q

Components of CHARCOT TRIAD

A
  1. FEVER
  2. PAIN
  3. JAUNDICE
  • infection is usually polymicrobial with
    gram-negative rods predominanting
355
Q

Imaging finding of ACUTE

BACTERIAL CHOLANGITIS. (p.713)

A

BILIARY DILATATION; USUALLY CAUSED
BY A STONE IN THE DUCT; ASSOCIATED
WITH PERIBILIARY CONTRAST
ENHANCEMENT AND EDEMA

356
Q

____ has in the past been called
ORIENTAL CHOLANGIOHEPATITIS
because it is an endemic disease in
Southeast Asia. (p.713)

A

RECURRENT PYOGENIC CHOLANGITIS

- characterized by recurrent attacks of 
jaundice; abdominal pain; fever and 
chills
- Intrahepatic and EHBDs are dilated
and filled with soft pigmented stones 
and pus
357
Q 
TRUE OR FALSE.
RECURRENT PYOGENIC CHOLANGITIS 
is associated with parasitic
infestation and nutritional deficiency. 
(p.713)
A

TRUE

- findings include intraductal stones;
severe extrahepatic biliary dilation;
focal strictures; pneumobilia and 
straightening and rigidity of the 
intrahepatic ducts
358
Q

5 complications of RECURRENT
PYOGENIC CHOLANGITIS
(p.713)

A
  1. LIVER ABSCESS
  2. BILOMA
  3. PANCREATITIS
  4. CHOLANGIOCARCINOMA
  5. ATROPHY
359
Q

____ is an uncommon anomaly congenital anomaly of the biliary tract characterized
by saccular ectasia of the IHBD
without biliary obstruction. (p.713)

A

CAROLI DISEASE

  • only one hepatic lobe or segment;
    or the entire liver; may be affected
  • EHBD are spared in 50% of cases
360
Q 
5 imaging findings of 
CAROLI DISEASE (p.713)
A
  1. SACCULAR DILATATION OF IHBD
  2. ENHANCING FIBROVASCULAR BUNDLES
  3. SEGMENTAL DISTRIBUTION OF THE BILE
    DUCT ABNORMALITY WITH NORMAL APPEARANCE
    UNAFFECTED LIVER SEGMENTS
  4. CHOLANGIOGRAPHY shows a characteristic pattern
    of focal biliary narrowing and saccular dilatation
  5. DILATATION of the CBD (10 to 30 mm) in half the cases
361
Q

Imaging sign found in CAROLI DISEASE;
wherein enhancing fibrovascular bundles
are seen centrally within many of the dilated
ducts producing this sign.(p.713)

A

CENTRAL DOT SIGN

362
Q

___ are uncommon congenital
anomalies of the biliary tree
characterized by cystic
dilation of the bile ducts. (p.713)

A

CHOLEDOCHAL CYSTS

363
Q

Most common choledochal cyst
type (Todani Classification)?
(p.713)

A

TYPE I

  • 80% to 90%
  • confined to the EHBD
  • appear as fusiform saccular dilatationsof
    the CHD; CBD; or segments of each.
364
Q

Choledochal Cyst type seen as a
diverticula of the CBD attached by a
narrow stalk. (p.713)

365
Q 
Choledochal cyst type termed 
CHOLEDOCHOCELES and are focal
dilatations of the intraduodenal 
portion of the CBD closely resembling
ureteroceles.
366
Q

Choledochal cyst type defined as
multiple focal dilatations of the
IHBD and EHBD usually with a focal
large cystic dilatation of the CBD.(p.714)

367
Q 
Choledochal cyst type
referred to CAROLI DISEASE; which is
more appropriately classified
as a disease separate from choledochal
cyst. (p.714)
368
Q

______ and ___ carcinomas are the cause
of 20% to 25% of cases of biliary
obstruction in the adult. (p.714)

A

PANCREATIC and AMPULLARY

carcinomas

369
Q 
\_\_\_\_ may present as intraductal 
filling defects.
- Colorectal cancers are the most common
primary tumors associated with intraluminal 
biliary metastases. (p.714)
A

METASTASES

370
Q

Findings that favor metastases
over cholangiocarcinoma are the
__ and __. (p.714).

A 
1. presence of a contiguous 
parenchymal mass
2. expansion of the duct at 
the site of the intraluminal
mass in a patient with known
colorectal cancer
371
Q

__ is the second most common
malignant primary hepatic
tumor. (p.714)

A

CHOLANGIOCARCINOMA

- tumors arise from the 
epithelium of the bile ducts
 and are usually adenocarcinomas 
(90%)
- growth patterns include 
mass-forming; periductal infiltrating;
and intraductal polypoid
-poor prognosis
372
Q 
\_\_\_\_\_ cholangioCA (10%)
presents as an intrahepatic
hypodense mass sometimes
(25%) causing peripheral biliary
dilatation.(p.714)
A

PERIPHERAL CholangioCA

- MDCT demonstrates a homogeneous
low-attenuation mass with delayed;
mild; thin; incomplete; rim-like
enhancement.
- additional findings may include
capsular retraction and satellite
nodules
373
Q

____ cholangioCA (____ tumor)
(25%) occurs near the junction
of the right and left bile ducts.
(p.714)

A

HILAR cholangioCA
(Klatskin tumor)

- tumor is usually small; poorly
differentiated; aggressive;
and causes obstruction of 
both ductal systems
- surgical resection is the only hope for cure.
374
Q 
\_\_\_\_ cholangioCA (65%) causes
stenosis or obstruction of the CBD in most cases (95%) and 
presents as an intraductal
polypoid mass in 5%.(p.714)
A

EXTRAHEPATIC cholangioCA

- shows thickening of the wall of
the involved bile duct with 
hyperenhancement during 
arterial phase
- abrupt stricture with thickening
duct wall may be the only findings.
375
Q

5 predisposing conditions
of EXTRAHEPATIC
CHOLANGIOCARCINOMA
(p.715)

A
  1. CHOLEDOCHAL CYST
  2. ULCERATIVE COLITIS
  3. CAROLI DISEASE
  4. CLONORCHIS SINENSIS
    INFECTION
  5. PSC
376
Q 
\_\_\_ tumor of the bile ducts
may produce a large amount 
of mucin that markedly dilates
the billiary tree and impairs 
the flow of bile. (p.715)
A

INTRADUCTAL PAPILLARY
MUCINOUS TUMOR

  • tumors are intraductal;
    polypoid;and characterized by
    innumerable frondlike papillary
    projections
377
Q 
\_\_\_\_ (\_\_\_) is most commonly
encountered in the patient
with a surgically created biliary-
enteric anastomosis; or who
has had a sphincterotomy
to facilitate stone passage.
(p.715)
A

GAS IN THE BILIARY TRACT

PNEUMOBILIA

378
Q

___ fistula is most commonly
due to the erosion of a gallstone
through the gallbladder and
into the duodenum (p.715)

A

CHOLECYSTODUODENAL
FISTULA

- most common in women
because of the higher incidence
of gallstones
- when the gallstone is large;
it may cause small bowel obstruction
379
Q

___ fistula is caused by a
penetrating peptic ulcer
eroding ino the CBD.
(p.715)

A

CHOLEDOCHODUODENAL

FISTULA

380
Q

____ is the imaging method
of choice for the gallbladder.
(p.715)

A

ULTRASOUND

381
Q

____ has sensitivity and
specificity comparable to US
for the diagnosis of acute
cholecystitis. (p.715)

A

CHOLESCINTIGRAPHY utilizing

technetium-99m-iminodiaceticacid

382
Q 
Approx. 85% of gallstone
 are predominantly \_\_\_\_\_;
whereas 15% are pred. \_\_\_\_
(pigment stones) related to
hemolytic anemia. (p. 715)
A

CHOLESTEROL;
BILIRUBIN

- approx. 10% of stones are 
sufficiently radioopaque
to be detected by conventional
radiographs as laminated or
faceted calcifications.
383
Q 
Fissure within gallstones
may contain nitrogen gas
that appears on radiographs
as branching linear lucencies
resembling a \_\_\_\_\_.
(p.715)
A

CROW’S FOOT

384
Q

5 conditions where

gallstones are common. (p.715)

A
  1. Women (female:male = 4:1)
  2. Patients with hemolytic
    anemia
  3. Diseases of the Ileum
  4. Cirrhosis
  5. Diabetes Mellitus
385
Q

__ detects 95% of all gallstones;
whereas __ detects only 80
to 85%. (p.715)

A

ULTRASOUND; CT

  • gallstones vary in CT
    attenuation from fat density
    to calcium density
386
Q 
TRUE OR FALSE.
Up to 20% of gallstones are
ISODENSE with bile and not 
detected by CT;
whereas some gallstones are 
missed because of their small
size or volume averaging with
the adjacent bowel. 
(p.715-716)
387
Q 
Contrast studies; MRCP and T2
-weighted MR demonstrate
\_\_\_\_ as "filling defects"; rounded
 or faceted dark objects within 
the high-density bile.
(p.716)
A

GALLSTONES

388
Q

Give 5 Differential considerations
for lesions in the GB that may be
mistaken for gallstones
(p.716)

A 
1. Sludge balls or tumefactive
biliary sludge
2. Cholesterol polyps
3. Adenomatous polyps
4. Gallbladder CA
5. Adenomyomatosis
389
Q 
\_\_\_\_ result from biliary stasis.
Bile thickens and forms layers 
of bile and mobile masses that
move with changes in patient 
position. (p.716)
A

SLUDGE BALLS or
TUMEFACTIVE BILIARY SLUDGE

  • the presence of sludge indicates
    indicates lack of bile turnover; which
    may occur because of obstruction;
    or simply lack of oral food intake.
390
Q 
\_\_\_\_ polyps are common 
(4% to 7% of the population)
benign; polypoid masses that result 
from accumulation of
triglycerides and cholesterol
in macrophages in the GB wall.
(p.716)
A

CHOLESTEROL polyps
(p.716)

  • polyps 5mm and smaller
    are routinely dismissed as
    benign cholesterol polyps
391
Q

TRUE OR FALSE.
Adenomatous polyps are
potentially premalignant.
(p.716)

392
Q

__ carcinoma may present
as a polypoid GB mass
(p.716)

A

GALLBLADDER CARCINOMA

- GB polyps larger than 10 mm 
should be considered for 
surgical removal because of 
the risk of cancer
- gallstones are usually present
393
Q

___ may be focal and present
as a polypoid mass fixed to
the GB wall. (p.716)

A

ADENOMYOMATOSIS

394
Q

Refers to acute inflammation
of the GB caused by gallstones
obstructing the cystic duct in
90% of cases. (p. 716)

A

ACUTE CHOLECYSTITIS

395
Q

Confident US diagnosis of
acute cholecystitis requires the
presence of these 3 findings.
(p.716)

A
  1. CHOLELITHIASIS
  2. EDEMA OF THE GB WALL
    seen as a band of echolucency
    in the wall
  3. POSITIVE SONOGRAPHIC
    MURPHY SIGN
396
Q

Scintigraphic diagnosis of
acute cholecystitis is based on
___ and ____. (p.716)

A
  1. Obstruction of the cystic duct
  2. Non-vizualization of the GB
- The normal GB demonstrates
progressive accumulation of radionuclide 
activity over 30 minutes to 1 hour ff
injection of technetium-99m
-iminodiacetic acid. 
- delayed visualization of the GB
may be seen in patients with 
biliary stasis due to fasting or 
hyperalimentation.
397
Q 
Diagnosis? CT demonstrates
gallstones; distended GB;
thickened GB wall; subserosal 
edema; high-density bile; 
intraluminal sloughed
membranes; inflammatory
stranding in pericholecystic fat;
pericholecystic fluid; blurring 
of the interface between GB 
and liver; and prominent arterial
phase enhancement of the liver
adjacent to the gallbladder.
(p.716)
A

ACUTE CHOLECYSTITIS

  • MR Findings are similar:
    1. gallstones; often impacted
    in the neck
    2. wall thickening (> 3mm) with edema
    3. distended GB
    4. pericholecystic fluid
398
Q

___ cholecystitis causes
special problems in diagnosis
because the cystic duct is often
not obstructed. (p.717)

A

ACALCULOUS Cholecystitis

  • inflammation may be due to
    GB wall ischemia or direct
    bacterial infection
399
Q

5 conditions wherein patient is
at risk for acalculous
cholecystitis (p.717)

A 
1. Biliary stasis due to lack of 
oral intake
2. Posttrauma
3. Post-burn
4. Postsurgery
5. Total parenteral nutrition
400
Q

Diagnosis? US demonstrates
a distended tender GB with
thickened wall but without stones. (p.717)

A

ACALCULOUS CHOLECYSTITIS

  • many patients are too ill to elicit
    to elicit a reliable sonographic
    Murphy sign
401
Q 
\_\_\_\_ is the term used to 
describe the presence of 
thick particulate matter
in highly concentrated bile.
(p.717)
A

SLUDGE

- calcium bilirubinate and 
cholesterol crystals precipitate
in the bile when biliary stasis is 
prolonged because of a lack of  
oral intake or biliary obstruction
402
Q

Causes of dense bile; give 4.

p.717

A
  1. Sludge
  2. Pus
  3. Blood
  4. Milk of Calcium
403
Q

Give 5 complications of
ACUTE Cholecystitis
(p.717)

A
  1. Gallbladder Empyema
  2. Gangrenous Cholecystitis
  3. Perforation of the GB
  4. Emphysematous cholecystitis
  5. Mirizzi syndrome
404
Q 
\_\_\_\_\_ desbribes the GB
distended with pus
in a patient; often diabetic;
with rapid progression of 
symptoms suggesting an
abdominal abscess. (p.717)
A

GALLBLADDER EMPYEMA

405
Q

____ indicates the presence of

necrosis of the GB wall. (p.717)

A

GANGRENOUS CHOLECYSTITIS

- the patient is at risk for GB
perforation.
- findings include mucosal 
irregularity and asymmetric thickening
of the GB wall with multiple lucent
layers; indicating mucosal ulceration
and reactive edema.
406
Q 
TRUE OR FALSE.
Perforation of the GB 
is a life-threatening condition
seen in 5% to 10% of cases.
(p.717)
A

TRUE

- a focal pericholecystic fluid 
collection suggests 
pericholecystic abscess
- gas is often present within the
GB lumen if the perforation 
extends into the bowel.
407
Q 
\_\_\_\_\_\_\_ results from infection
of the gallbladder with
gas-forming organisms;
usually E.coli or Clostridium 
perfringens
-approx. 40% are diabetic 
(p.717)
A

EMPHYSEMATOUS CHOLECYSTITIS

- gallstones may or may not be
present.
-gas is demonstrated within 
the wall or within the lumen of 
the gallbladder by conventional
radiography or CT.
- on US; intramural gas has an
arc-like configuration difficult
to differentiate from calcification
and porcelain gallbladder.
408
Q 
\_\_\_\_\_ refers to the condition
of biliary obstruction resulting
from a gallstone in the 
cystic duct eroding into the adjacent 
common duct and causing an inflammatory 
mass that obstructs the 
common duct. (p.717)
A

MIRIZZI SYNDROME

- visualization of a stone
at the junction of the cystic 
duct and the common hepatic 
duct in a patient with biliary 
obstruction and gallbadder
inflammation suggests the
diagnosis.
409
Q 
\_\_\_\_\_ includes a spectrum of 
pathology that shares the 
presence of gallstones and
chronic gallbladder 
inflammation. (p.717)
A

CHRONIC CHOLECYSTITIS

- patients with chronic
cholecystitis complain of 
recurrent attacks of RUQ 
abdominal pain and biliary
colic
410
Q

5 imaging findings of
Chronic Cholecystitis
(p.717)

A
  1. Gallstones
  2. Thickening of the GB wall
  3. contraction of the GB lumen
  4. Delayed visualization
    of the GB on cholescintigraphy
  5. Poor contractility
411
Q

Give 3 variants of
Chronic Cholecystitis
(p.717)

A
  1. Porcelain Gallbladder
  2. Milk of Calcium bile
  3. Xanthogranulomatous
    Cholecystitis
412
Q

____ describes the presence
of dystrophic calcification
in the wall of an obstructed and chronically inflammed GB.
(p.717)

A

PORCELAIN GALLBLADDER

- the condition is associated with 
gallstones in 90% of cases.
- carries a 10% to 20% risk of
GB carcinoma
- Cholecystectomy is usually
indicated.
413
Q

______ (____) is associated
with an obstructed cystic duct;
chronic cholecystitis; and
gallstones

A

MILK OF CALCIUM
(LIMY BILE)

  • the bile is extremely echogenic
    on US and gallstones may be
    visualized within it.
414
Q 
\_\_\_\_\_\_\_ is an uncommon
variant of chronic cholecystitis
characterized by nodular depostis
of lipid-laded macrophages
in the gallbladder wall 
and proliferative fibrosis. 
(p.717)
A

XANTHOGRANULOMATOUS

CHOLECYSTITIS

415
Q 
Diagnosis? Imaging findings 
include marked GB wall
thickening of about 2 cm; 
fat density nodules in the 
wall; narrowing of the lumen.
(p.717)
A

XANTHOGRANULOMATOUS
CHOLECYSTITIS

- Cholelithiasis is frequently 
present
- the condition is difficult to
differentiate from GB
carcinoma
- preservation of linear 
enhancement of the mucosa 
on post-contrast MR favors
xanthogranulomatous
cholecystitis over carcinoma
416
Q 
Thickening of the GB wall
 is present when the wall
 thickness measured on the 
hepatic aspect of the GB
exceeds \_\_ mm in patients
who have fasted at least
8 hours. (p.718)
A

exceeds 3 mm

417
Q

7 conditions associated
with GB wall thickening.
(p.718)

A 
1. Acute and Chronic 
Cholecystitis
2. Hepatitis
3. Portal venous HTN
and Congestive Heart 
Failure
4. AIDS
5. Hypoalbuminemia
6. Gallbladder CA
7. Adenomyomatosis
418
Q 
Hepatitis causes \_\_\_\_; 
which results in reduced
GB volume and thickening
of the GB wall in approx.half
of the patients (p.718)
A

REDUCTION IN BILE FLOW

419
Q

Portal venous HTN and
CHF may cause GB wall
thickening by ___. (p.718)

A

PASSIVE VENOUS CONGESTION

420
Q

GB carcinoma usually presents
as a focal mass but may cause
only ___ GB wall thickening.
(p.718)

A

FOCAL GB wall thickening

421
Q 
\_\_\_\_ is the most frequent 
benign condition of the GB
and is characterized by 
hyperplasia of the mucosa 
and smooth muscle
A

ADENOMYOMATOSIS

- it may be localized; usually in the 
fundus; segmental or diffuse 
involving the entire GB
- coexisting gallstones are 
commonly present
422
Q

Outpouchings of GB mucosa
into or through the muscularis
form characteristic ____.
(p.718)

A

ROKITANSKY-ASCHOFF SINUSES

423
Q

TRUE OR FALSE.
Adenomyomatosis has no
malignant potential. (p.718)

424
Q 
DIAGNOSIS? US shows 
"comet-tail" reverberation
artifacts emanating from inspissated
bile within these sinuses in the 
thickened GB wall.
A

ADENOMYOMATOSIS

425
Q 
DIAGNOSIS? MRCP shows
a "pearl necklace" appearance
of the GB wall caused
by bright fluid within the sinuses.
(p.718)
A

ADENOMYOMATOSIS

426
Q

DIAGNOSIS? CT shows GB wall
thickening with tiny cystic
spaces. (p.718)

A

ADENOMYOMATOSIS

427
Q 
TRUE OR FALSE.
The presence of gallstones
in 70% to 80% of cases masks
the findings of cancer;
esp. with US examination. (p.718)
A

TRUE

  • GB Carcinoma is a tumor
    of elderly women (>60 years;
    female:male=4;1)
428
Q

TRUE OR FALSE.
Calcification of the GB wall
(porcelain GB) is a risk factor
for GB carcinoma. (p.718)

429
Q

7 imaging findings of

GB carcinoma. (p.718)

A
  1. Intraluminal soft tissue mass
  2. Focal or diffuse GB wall thickening
  3. Soft tissue mass replacing the GB
  4. Gallstones
  5. Extension of the tumor into the liver;
    bile ducts and adjacent bowel
  6. dilated bile ducts
  7. metastases to periportal and
    peripancreatic lymph nodes of the
    liver
  • most tumors are unresectable at discovery

KEVIN BURANT IV (20 decks)

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