Gallbladder And Biliary system Flashcards
Where do the right and left hepatic ducts emerge?
The right and left hepatic ducts emerge from the right lobe of the liver in the porta hepatis.
What do the right and left hepatic ducts form?
They unite to form the common hepatic duct.
What is the diameter of the common hepatic duct?
The common hepatic duct is approximately 4 mm in diameter.
What does the common hepatic duct join to form?
It is joined by the cystic duct to form the common bile duct.
What is the primary function of the gallbladder?
Transportation and storage of bile.
What triggers the release of bile from the gallbladder?
Release is triggered by cholecystokinin (CCK).
What is the normal size of the common bile duct (CBD)?
Up to 6 mm is within normal limits.
What is Calot’s triangle?
A location between the cystic duct and common hepatic duct, used for lymphatic drainage.
Loss of tone in CBD & Sphincter
Cholecystectomy
Labs for GB
Bilirubin
Alkaline Phosphatase
What are common clinical symptoms of gallbladder issues?
Fat intolerance, midepigastric pain, right shoulder pain, RUQ pain, nausea, vomiting, jaundice, chills, and fever.
What is sludge in the gallbladder?
Sludge consists of calcium, bilirubin, or cholesterol precipitates that are gravity dependent.
What are the causes of biliary stasis?
Prolonged fasting, TPN, hemolysis, cystic duct obstruction, cholecystitis.
What is acute cholecystitis?
Acute cholecystitis is inflammation of the gallbladder usually caused by a stone obstructing the cystic duct.
Common causes of Cholecystitis
Gallbladder perforation
Sepsis
Hyperplastic cholecystosis
Gallbladder carcinoma
AIDS cholangiography
Sclerosing cholangitis
What are the sonographic findings of acute cholecystitis?
Gallbladder wall >3 mm, distended gallbladder lumen >4 cm, gallstones, positive Murphy’s sign.
Chronic cholecystitis signs
Repeated acute attacks or asymptomatic
Transient RUQ pain; no tenderness; fatty food intolerance
Even thickened, fibrous wall; stones; WES sign (differentiate from porcelain GB), contracted around stones
Abnormal conjugated bilirubin can indicate
- obstructive jaundice (hepatitis)
- intrahepatic cholestasis
- biliary tree obstruction
If unconjugated (indirect) bilirubin is abnormal could indicate
- hepatocellular disease
- hemolytic anemia
If bilirubin elevates what other lab values could be affected?
↑ Alkaline phosphatase
↑ WBC
↑ LDH, ALT
3 causes of jaundice
- Hepatic/ Hepatocellular disease (liver disease):
hepatitis, cirrhosis - Pre-hepatic/ Hemolytic disease (↑ bilirubin production but not due to liver disease):
sickle cell anemia - Post-hepatic/ Surgical jaundice (biliary obstruction):
Choledocholith, choleangiocarcinoma, pancreatic disease
Can cause pale stool and dark urine
What is emphysematous cholecystitis?
A rare complication of acute cholecystitis characterized by gas in the gallbladder wall.
Emphysematous cholecystitis affects more..
Men than women up to 50% of patients are diabetic
Gangrenous GB is resolved by?
Surgical emergency
Acalculous cholecystitis will h
(+) Murphy’s sign; wall thickening; sludge; pericholecystic fluid; edema, absence of stones
What is the most common disease of the gallbladder?
Cholelithiasis, which involves inflammation and stones within the gallbladder.
Patients with cholelithiasis falls under what category?
“five Fs”: fat, female, forty, fertile, and fair.
What is milk of calcium bile?
A fluid-fluid level in the gallbladder that produces shadowing due to high concentrations of calcium.
What is GB hydrops?
An enlarged gallbladder due to total obstruction of the cystic duct.
What are the benign neoplasms of the gallbladder?
Adenoma (pre malignant potential), cholesterolosis (“strawberry GB”), adenomyomatosis (comet tail), and porcelain gallbladder (bright linear echo) .
Some patients with Porcelain gallbladder will develop..
25% of these patients will develop cancer on the gallbladder wall.
Porcelain GB is defined as..
calcium incrustation of the gallbladder wall
Gallbladder carcinoma is associated with which other pathology?
Cholelithiasis
Mortality rate of GB carcinoma..
near 100%
What is adenomyomatosis?
A hyperplastic change in the gallbladder wall
This condition involves Rokitansky-Aschoff sinuses and cholesterol crystal formation.
What are Rokitansky-Aschoff sinuses?
Sinuses that penetrate into the muscular wall of the gallbladder
They are associated with adenomyomatosis.
What forms in trapped bile during adenomyomatosis?
Cholesterol crystals
These crystals contribute to the thickening of the gallbladder wall.
What imaging artifact is associated with adenomyomatosis?
Comet-tail artifact
This artifact is related to the thickened wall of the gallbladder.
How may papillomas appear in the gallbladder?
Singly or in groups, scattered over a large part of the mucosal surface
Papillomas are benign and not precursors to cancer.
Are papillomas in the gallbladder precursors to cancer?
No
Papillomas do not indicate a higher risk of cancer.
What observation is made when compressing the gallbladder in adenomyomatosis?
The lesion is immobile
Various patient positions can be used to demonstrate this immobility.
Is adenomyomatosis a common condition?
Yes
It is frequently encountered in clinical practice.
What is the gender predominance for adenomyomatosis?
Female predominance
More females are affected compared to males.
What are choledochal cysts?
Congenital, focal, or diffuse cystic dilation of the biliary tree.
Choledochal cysts can lead to complications if not diagnosed and treated.
What may cause choledochal cysts?
Pancreatic juices refluxing into the bile duct due to an anomalous junction of the pancreatic duct into the distal common bile duct.
This reflux can cause duct wall abnormality, weakness, and outpouching of the ductal walls.
How common are choledochal cysts?
Rare.
They are more prevalent in certain demographics.
What are the two cyst-like structures found in the right upper quadrant (RUQ)?
Gallbladder (GB) and dilated common bile duct (CBD).
These structures can indicate the presence of choledochal cysts.
What is a notable feature in imaging of choledochal cysts?
Dilated intrahepatic ducts.
This finding is significant in diagnosing choledochal cysts.
In which gender are choledochal cysts more common?
Women, with a ratio of 4:1 compared to men.
This prevalence may vary by ethnicity.
In which demographic group is the incidence of choledochal cysts increased?
Asian women, especially of Japanese descent.
This highlights the importance of considering ethnicity in diagnosis.
What conditions may be associated with choledochal cysts?
- Gallstones
- Pancreatitis
- Cirrhosis
These associations can complicate the clinical picture.
What are common symptoms of choledochal cysts?
- Abdominal mass
- Pain
- Fever
- Jaundice
Symptoms can vary in severity and presentation.
What diagnostic method may confirm choledochal cysts?
Nuclear medicine hepatobiliary scan.
This imaging technique is useful in evaluating biliary tree abnormalities.
What is Caroli’s Disease?
Rare congenital abnormality most likely inherited in an autosomal recessive fashion
Characterized by communicating cavernous ectasia of the intrahepatic ducts.
What characterizes Caroli’s Disease?
Congenital segmental saccular cystic dilation of major intrahepatic bile ducts
Also involves multi-focal segmental dilatation of intrahepatic bile ducts.
In which population is Caroli’s Disease commonly found?
Young adult or pediatric population
May be associated with renal disease or congenital hepatic fibrosis.
What may be present in Caroli’s Disease?
Sludge or calculi may be present
Indicates possible complications in the bile ducts.
What conditions are associated with Caroli’s Disease?
- Infantile PKD
- Congenital hepatic fibrosis
- Choledochal cysts
These conditions can co-exist with Caroli’s Disease.
What is cholangiocarcinoma?
Rare cancer of bile ducts
Predisposing conditions include ulcerative colitis, Caroli’s disease, choledochal cyst, and parasitic infections.
Where is cholangiocarcinoma commonly located?
At the CHD/CBD junction
This is a key location for the development of cholangiocarcinoma.
What is Klatskin’s tumor?
Occurs at the bifurcation of the hepatic duct
Causes isolated intrahepatic duct dilation without extrahepatic dilation.
What does the nonunion of right/left hepatic ducts suggest?
Cholangiocarcinoma
This finding is significant in the diagnosis of biliary tract cancers.
What should ultrasound determine in cases of biliary obstruction?
The level and cause of obstruction
Essential for guiding further management.
What is sclerosing cholangitis?
Inflammation of bile duct with pus
Can complicate the biliary system and is associated with various conditions.
What are the most common tumor sites that can spread to the biliary system?
- Breast
- Colon
- Melanoma
These cancers frequently metastasize to the biliary tree.
How do metastases to the biliary tree appear on sonography?
Similar to that of cholangiocarcinoma
This can complicate the diagnosis.
What is Choledocholithiasis?
Stones that migrate from the gallbladder affecting the ampulla of Vater and project into the duodenum
Associated with increased bilirubin, alkaline phosphatase, and leukocytosis; echogenic structures in dilated ducts.
What lab values are elevated in Choledocholithiasis?
- Alkaline phosphatase
- Direct bilirubin
- Gamma-glutamyl transpeptidase
Elevated lab values indicate biliary obstruction.
What is the most common cause of biliary obstruction?
The presence of a tumor, thrombus, or stone within the ductal system
Can occur in both extrahepatic and intrahepatic ductal pathways.
How is obstruction of the biliary ductal system diagnosed?
By ultrasound detecting ductal dilation
This finding is known as ‘too many tubes’, ‘shotgun’, or ‘parallel channel’ sign.
Describe the appearance of dilated ducts in biliary obstruction.
- Irregular path compared to portal veins
- Stellate or star-shaped configuration
- Acoustic enhancement of ducts
If obstruction is at the CHD or higher, the gallbladder will be contracted.
What is Courvoisier’s gallbladder?
Palpable, non-tender enlargement of gallbladder due to progressive obstruction of CBD from an external mass
Usually associated with adenocarcinoma of the pancreatic head.
What is the most common cause of a malignant neoplasm obstructing the biliary tree?
Pancreatic adenocarcinoma
This type of cancer is particularly aggressive and often leads to biliary obstruction.
What is pneumobilia?
Air within the biliary tree secondary to biliary intervention, biliary-enteric anastomoses, or common bile duct stents
Commonly seen after ERCP.
What artifact is commonly associated with pneumobilia?
Comet-tail artifact
Frequently seen in the liver hilum and may indicate previous biliary interventions.
What are some causes of pneumobilia in a patient with an acute abdomen?
- Emphysematous cholecystitis
- Inflammation from impacted stone in CBD
- Prolonged acute cholecystitis leading to bowel erosion
- Incompetence of Sphincter of Oddi
- GB wall erosion or ulcer in CBD
- Other interventions
These conditions can introduce air into the biliary system.
What is cholangitis?
Inflammation of the bile ducts
May present as Oriental sclerosing cholangitis or other forms such as AIDS cholangitis.
What symptoms are associated with cholangitis?
- Malaise
- Fever
- Sweating and shivering
- Right upper quadrant pain
- Jaundice
Severe cases can lead to lethargy, prostration, and shock.
What laboratory findings are expected in cholangitis?
- Leukocytosis
- Elevated serum alkaline phosphatase
- Elevated bilirubin
These findings help confirm the diagnosis.
What tests are used to diagnose cholangitis?
Picon test and ERCP
These tests help visualize the bile ducts and confirm inflammation.
What can severe cholangitis lead to?
The need for liver transplant
Severe cases can result in significant liver damage and dysfunction.
What is Biliary Atresia?
Most common type of obstructive biliary disease in infants and young children
Biliary Atresia involves the obstruction of bile flow due to the absence or malformation of bile ducts.
What is absent in Biliary Atresia?
Absence of CHD/CBD (Extrahepatic ducts)
CHD stands for cystic duct and CBD stands for common bile duct.
When is Biliary Atresia suspected?
When jaundice persists beyond 14 days of age
Jaundice is a yellowing of the skin and eyes due to high levels of bilirubin.
What are the surgical treatments for Biliary Atresia?
Surgical drainage w/ Kasai portoenterostomy or liver transplant
The Kasai procedure involves connecting the small intestine directly to the liver to allow bile drainage.
