Chapter 4: The Bile Ducts Flashcards
inflammation of the pancreas secondary to leakage of pancreatic enzymes from the acinar cells into the parenchyma of the organ
acute pancreatitis
the merging point of the pancreatic duct and common bile duct just before the Sphincter of Oddi; also referred to as the hepatopancreatic ampulla
ampullar of Vater
an infection of the small intestine that is caused by Ascaris lumbricoides, a parasitic roundworm
ascariasis
a congenital disease described as the narrowing or obliteration of all or part of the bilary tree
biliary atresia
pain secondary to a blockage of the biliary tree
biliary colic
a condition in which bile stagnant and allowed to develop into sludge or stones
biliary stasis
a yellowish pigment found in bile that is produced by the breakdown of old red blood cells by the liver
bilirubin
a green pigment found in bile
biliverdin
a congenital disorder characterized by segmental dilatation of the intrahepatic ducts
Caroli disease
the presence of echogenic dots in the nondependent part of the dilated duct representing small fibrovascular bundles; seen with caroli disease
central dot sign
fever, RUQ pain, and jaundice associated with cholangitis
Charcot triad
primary bile duct cancer
cholangiocarcinoma
a radiographic procedure in which contrast is injected into the bile ducts to assess for the presence of disease
cholangiography
inflammation of the bile ducts`
cholangitis
the recurring destruction of the pancreatic tissue that results in atrophy, fibrosis, scarring, and the development of calcifications within the gland
chronic pancreatitis
coexisting dilation of the common bile duct and pancreatic duct
double-duct sign
endoscopic procedure that utilizes fluoroscopy to evaluate the biliary tree and pancreas
endoscopic retrograde cholangiopancreatography
the level of the biliary tree where the common bile duct and the main pancreatic duct meet; may also be referred to as the ampulla of Vater
hepatopancreatic ampulla
the muscle that controls the emptying of bile and pancreatic juices into the duodenum; may also be referred to as the sphincter of Oddi
hepatopancreatic sphincter
chronic inflammation of all or part of the bowel
inflammatory bowel disease
a malignant biliary tumor located at the junction of te right and left hepatic ducts
Klaskin tumor
a clinical condition when the patient presents with jaundice, pain, and fever secondary to a lodged stone in the cystic duct causing compression of the common duct
Mirrizzi syndrome
the enlargement of the common duct to the size of the adjacent portal vein within the porta hepatis
parallel tube sign
air within the biliary tree
pneumoblia
severe itchiness of the skin
pruritus
a sign associated with biliary atresia in children where there is evidence of a cystic structure in the gallbladder fossa without the presence of an actual gallbladder
pseudogallbladder sign
the enlargement of the common duct to the size of the adjacent portal vein within the porta hepatis; also referred to as the parallel tube sign
shotgun sign
the muscle that controls the emptying of bile and pancreatic juices into the duodenum; also referred to as the hepatopancreatic sphincter
sphincter of Oddi
a sign associated with biliary atresia in children that is described as an avascular, echogenic, triangular, or tubular structure anterior to the portal vein, representing the replacement of the extrahepatic duct with fibrous tissue in the porta hepatis
triangular cord sign
an inflammatory bowel disease that leads to the development of ulcers within the bowel
ulcerative colitis
caused by bacterial accumulation secondary to obstruction; bacteria can be introduced during an ERCP for choledocholithiasis; pus may be noted within the bile ducts as low-level echoes
acute bacterial cholangitis
associated with advanced HIV and AIDS; most often results from infection with Cryptospordium or cytomegalovirus
AIDS cholangitis
endemic to Asia; seen in America because of immigration
Oriental cholangitis
characterize by fibrotic thickening of the bile ducts; most often affects young men; associated with inflammatory bowel disease or ulcerative colitis; increased risk for cholangiocarcinoma
sclerosing cholangitis
Charcot triad
fever, RUQ pain, jaundice
charcot triad, leukocytosis, elevated ALP, ALT, GGT, and bilirubin
clinical findings of cholangitis
biliary dilatation; biliary sludge or pus; choledocholithiasis; bile duct wall thickening
sonographic findings of cholangitis
recent biliary or gastric surgery; emphysematous or acute cholecystitis; fistula formation; symptoms of acute cholecystitis
clinical findings of pneumobilia
echogenic linear structures within the ducts that produce ring-down artifacts and dirty shadowing
sonographic findings of pneumobilia
may have symptoms of inflammation of the biliary tree, gallbladder, or pancreas
clinical findings of ascariasis
worm will be noted within the biliary duct as an echogenic linear structure in the sagittal plane; movement of the worm within the duct confirms the diagnosis
sonographic findings of ascariases
jaundice, pruritus, unexplained weight loss, abdominal pain, elevated bilirubin, elevated ALP
clinical findings of cholangiocarcinoma
dilated intrahepatic ducts that abruptly terminate at the level of the tumor; a solid mass may be noted within the liver or ducts
sonographic findings of cholangiocarcinoma
neonatal jaundice; elevated AST, ALT, and bilirubin
clinical findings of Biliary Atresia
absent biliary ducts, triangular cord sign, pseudogallbladder sign, sonographic signs of cirrhosis and portal hypertension
sonographic findings of biliary atresia
jaundice, pain, fever
clinical findings of choledochal cyst
cystic mass in the area of the porta hepatis; biliary dilatation
sonographic findings of a choledochal cyst
pain, fever, jaundice, signs of portal hypertension
clinical findings of caroli disease
segmental dilatation of the intrahepatic ducts; patient may also have cystic renal disease; central dot sign
sonographic findings of Caroli disease
vital digestive fluid
bile
Bile is produced by the:
liver
major component of bile
cholesterol
bile is made up of:
cholesterol
bilirubin
biliverdin
bile acids
Function of the biliary tree
provide a conduit for bile to drain from the liver into the small intestine
Bile first accumulates in the
small intrahepatic biliary radicles throughout the liver
The portal triads contain
hepatic artery
portal vein
intrahepatic ducts (biliary radicles)
From the biliary radicles, bile flows into either right or left _____
hepatic ducts
Bile is stored and concentrated in the:
gallbladder
attaches the gallbladder to the biliary tree
cystic duct
The point of attachment of the cystic duct to the gallbladder marks the proximal portion of the:
CBD
The cystic duct contains:
the spiral valves of Heister
prevent the cystic duct from collapsing or distending
the spiral valves of Heister
produced by the duodenum, makes the gallbladder contract and empty the bile
cholestokynin
also referred to as hepatopancreatic sphincter
Sphincter of Oddi
opening that allows bile and pancreatic juices to flow into duodenum
Spincter of Oddi
The fluid is mixed with chyme in the ______ and appropriate chemical reaction ensures
duodenum
A CBD diameter that exceeds __mm is abnormal
6
Intrahepatic ducts are considered dilated when they exceed __mm
2
describes enlargment of common duct to size of adjacent portal vein within porta hepatis
double barrel “shotgun sign” or “parallel tube sign”
coexisting dilation of CBD and pancreatic duct
“double-duct sign”
Most distal segment of biliary tree
CBD segment closest to pancreatic head
Biliary dilatation will occur _____ to level of obstruction
proximal
Extrahepatic parts of biliary tree
CBD
cystic duct
part of common hepatic duct
most common level for an obstruction to occur
distal CBD
Most common causes of biliary obstruction
choledocholithiasis
chronic pancreatitis
acute pancreatitis
pancreatic carcinoma
result of obstruction within the biliary tree; occurs as a consequence of bilirubin accumulation within tissues of the body
jaundice
Excessive bilirubin leads to elevated ______
serum bilirubin
presence of gallstones within the bile ducts
choledocholithiasis
Most common cause of obstructive jaundice
gallstones located within the CBD
Most gallstones in choledocholithiasis are located near the _____
ampulla of Vater
uncommon manifestation of choledocholithiasis; clinical condition in which the patient presents with jaundice, pain, and fever secondary to a lodged stone in the cystic duct with subsequent compression of the common duct
Mirizzi syndrome
inflammation of the biliary ducts
cholangitis
In cholangitis, the bile duct wall thickens to greater than __mm
5
Types of cholangitis
acute bacterial or ascending cholangitis
AIDS
oriental
sclerosing
Charcot triad
fever
RUQ pain
jaundice
sonographic findings of cholangitis
biliary dilatation
biliary sludge
bile duct thickening
Cholangitis can lead to _____ and _____
cirrhosis
portal hypertension
air within the biliary tree
pneumobilia
_______ may be associated with:
recent biliary or gastric surgery
emphysematous or prolonged acute cholecystitis
fistula formation
cholangitis
sonographic findings of pneumobilia
echogenic linear structures seen within the ducts; air will produce ring-down artifact and have dirty shadowing
infection of the small intestine that is caused by Ascaris lumbricoides, a parasitic roundworm that is transmitted fecal-oral route
ascariasis
In ascariasis, the roundworm develops in the _____ and makes its way to the biliary tree through the ______
small intestine
ampulla of Vater
primary biliary tree cancer
cholangiocarcinoma
most common risk factor for cholangiocarcinoma is
primary sclerosing cholangitis
most common manifestation of cholangiocarcinoma
Klastkin tumors
located at the junction of the right and left hepatic ducts
Klastkin tumors
dilated intrahepatic ducts that abruptly terminate at level of tumor; solid mass may be noted in the liver
cholangiocarcinoma
congenital disease that is thought to be caused by a viral infection at birth; although some think it is an inherited disorder
Biliary atresia
Narrowing or obliteration of all or a portion of the biliary tree
biliary atresia
sonographic findings of biliary atresia
absent ducts
gallbladder may be absent or small
triangular cord sign
pseudogallbladder sign
avascular, echogenic, triangular, or tubular structure anterior to portal vein, representing replacement of extrahepatic duct with fibrous tissue in the porta hepatis
triangular cord sign
cystic structure in the area of the gallbladder fossa without evidence of an actual gallbladder
pseudogallbladder sign
The most common type of ______ is described as the cystic dilatation of the CBD
choledochal cyst
signs and symptoms of choledochal cyst
abdominal mass
jaundice
pain
fever
Choledochal cysts can lead to:
cholangitis
portal hypertension
pancreatitis
liver failure
sonographic findings of choledochal cysts
fusiform cystic mass in the area of the porta hepatis and biliary dilatation
congenital disorder characterized by segmental dilatation of the intrahepatic ducts; often seen in association with cystic renal disease; may precede development of cholangiocarcinoma, hepatic abscess, cholangitis, and sepsis
Caroli disease
signs and symptoms of Caroli disease
pain
fever
jaundice
signs of portal hypertension
sonographic findings of Caroli disease
segmental dilatation of intrahepatic ducts; central dot sign
presence of echogenic dots in the nondependent part of the dilated duct represent small fibrovascular bundles
central dot sign
A congenital disease that is described as narrowing or obliteration of the bile ducts is referred to as:
Caroli disease
Ascariasis is caused by:
a parasitic roundworm
Primary biliary tree cancer is referred to as:
cholangiocarcinoma
Which of the following is associated with Charcot triad?
a. cholangitis
b. cholesterolosis
c. Klatskin tumor
d. choledochal cyst
a
The merging point of the pancreatic duct and common bile duct at the level of the duodenum is referred to as the:
ampulla of Vater
Which of the following would be the least helpful laboratory value to analyze in patients with suspected biliary tree disease?
a. ALT
b. ALP
c. GGT
d. creatinine
d
A gallstone located within the biliary tree is referred to as:
choledocholithiasis
Which of the following disorders is associated with the sonographic triangular cord sign?
a. cholangitis
b. choledocholithiasis
c. biliary atresia
d. ascariasis
c
The yellowish staining of the whites of the eyes and the skin secondary to a liver disorder or biliary obstruction is referred to as:
jaundice
The Klatskin tumor is located:
at the junction of the right and left hepatic ducts
Inflammation of the bile ducts is referred to as:
cholangitis
A patient presents with jaundice, pain, and fever secondary to an impacted stone in the cystic duct. This is referred to as:
Mirizzi syndrome
Air within the biliary tree is referred to as:
pneumobilia
The presence of an echogenic dot in the nondependent part of a dilated duct representing small fibrovascular bundles is seen with:
Caroli disease
The spiral valves of Heister are located within the:
cystic duct
Which of the following is characterized by fibrotic thickening of the bile ducts, found most often in young males, and is associated with inflammatory bowel disease or ulcerative colitis?
a. Ulcerative biliary atresia
b. oriental cholangitis
c. sclerosiing cholangitis
d. AIDS biliary atresia
c
If a gallstone, causing obstruction, is located with the distal common hepatic duct, which of the following would become dilated?
a. main pancreatic duct
b. gallbladder only
c. intrahepatic ducts
d. distal common bile duct
c
Which of the following is considered the most proximal portion of the biliary tree?
a. intrahepatic radicles
b. cystic duct
c. common hepatic duct
d. common bile duct
a
Pneumobilia will produce:
ring-down artifact
Which of the following would be the most distal portion of the biliary tree?
a. common bile duct
b. common hepatic duct
c. gallbladder
d. intrahepatic radicles
a
Which of the following could accidentally introduce bacteria into the biliary tree and thus cause cholangitis?
a. CT
b. ERCP
c. MRI
d. Radiography
b
If an obstructive biliary calculus is loacted in the distal common duct, which of the following could ultimately dilate?
a. common bile duct only
b. gallbladder and cystic duct
c. common hepatic duct and intrahepatic duct
d. common bile duct, gallbladder, common hepatic duct, and intrahepatic ducts
d
The muscle that controls the emptying of bile and pancreatic juices into the duodenum is:
sphincter of Oddi
The most common level for biliary obstruction to occur is the:
distal common bile duct
A 32 year old female presents to the sonography department with a history of fever, leukocytosis, and RUQ pain. Sonographically, you visualize dilated bile ducts that have thickened walls and contain sludge. What is the most likely diagnosis?
cholangitis
Sonographically, you visualize scattered echogenic linear structures within the liver parenchyma that produce ring-down artifact. What is the most likely diagnosis?
pneumobilia
A 64 year old man presents to the sonography department for a RUQ sonogram. He is complaining of abdominal pain, weight loss, and pruritus. Sonographically, you visualize an area of dilated ducts that abruptly end. What is the most likely diagnosis?
cholangiocarcinoma
An abdominal sonogram is ordered for an infant in the intensive care unit who is suffering from jaundice and fever. Sonographically, you visualize an anechoic mass within the common bile duct that is causing a focal enlargement. This is most suggestive of:
choledocal cyst
All of the following are clinical findings consistent with cholangiocarcinoma except:
a. pruritus
b. weight loss
c. elevated bilirubin
d. dilation of the intrahepatic ducts
d
Which of the following is not associated with the development of pneumobilia?
a. cholangiopneumonia
b. gastric surgery
c. acute cholecystitis
d. fistula formation
a
A Klastkin tumor is a manifestation of:
cholangiocarcinoma
The biliary duct wall should never measure more than:
5mm
Clinical findings of choledocholithiasis include all of the following except:
a. jaundice
b. elevated bilirubin
c. elevated blood urea of nitrogen
d. elevated ALP
c
Which segment of the biliary tree tends to dilate with obstruction?
extrahepatic
Which of the following is not a plausible cause of common bile duct obstruction in adults?
a. choledocholithiasis
b. chronic pancreatitis
c. choledochal cyst
d. pancreatic carcinoma
c
All of the following are forms of cholangitis except:
a. acute bacterial
b. AIDS
c. oriental
d. parabolic
d
The yellowish pigment found in bile that is produced by the breakdown of old red blood cells by the liver is:
bilirubin
Which of the following is typically found in pediatric patients and is described as the cystic dilation of the common bile duct?
a. biliary atresia
b. Mirizzi syndrome
c. Caroli disease
d. choledocal cyst
d
For patients older than 60 years, or those who have had a cholecystectomy, a maximum diameter of ____ may be considered normal.
1cm
Which of the following would be the most common cause of obstructive jaundice?
a. Klatskin tumor
b. cholangiocarcinoma
c. biliary atresia
d. choledocholithiasis
d
Which of the following is associated with the “pseudogallbladder” sign?
a. biliary strictures
b. charcot triad
c. pruritus
d. biliary atresia
d
Which of the following is a fluoroscopic procedure typically performed in ithe radiology department that involves an analysis of the biliary tree and pancreas?
a. MRCP
b. ERCP
c. Nuclear medicine cholangiography
d. Cholangiofluoroscopy
d
Which of the following is associated with a biliary obstruction?
a. posthepatic jaundice
b. prehepatic jaundice
c. hepatic jaundice
d. biliary jaundice
a
What is another name for the sphincter of Oddi?
hepatopancreatic sphincter
Among the following list. which of teh following is located just distal to the cystic duct?
a. right hepatic duct
b. common hepatic duct
c. Duct of Wirsung
d. Common bile duct
d
Severe itchiness of the skin is referred to as:
pruritus
Enlargement of the common bile duct and pancreatic duct is referred to as the:
double-duct sign
Which of the following is not a sonographic finding of cholangitis?
a. biliary dilatation
b. biliary sludge
c. choledocholithiasis
d. triangular cord sign
d
Which of the following is the most common risk factor for cholangiocarcinoma?
a. pruritus
b. biliary atresia
c. sclerosing cholangitis
d. choledocholithiasis
c
What is the most common location of choledocholithiasis?
near the ampulla of Vater
Which type of cholangitis is found in severely immunocompromisedpatients and results from infections caused by Cryptosporidium or cytomegalovirus?
AIDS cholangitis
What is the most common form of cholangitis?
adenocarcinoma
How is ascariasis transmitted?
fecal-oral route
Infants with biliary atresia often ultimately suffer from:
cirrhosis
Which of the following is the major component of bile?
cholesterol
