GB & Biliary Pathology Flashcards by Sarah King

Clinical symptoms of GB pathology include…

RUQ epigastric pain (most classic symptom)
right shoulder pain
nausea and vomiting
jaundice

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GB wall thickening greater than ___ mm is abnormal.

3mm

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Sonographic appearance of sludge in GB…

non shadowing
homogeneous material which layers and shifts with patient position
sludge balls (tumefactive sludge)

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Normal wall thickness is under ___ mm

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Most common cause of gallbladder wall thickening is …

cholecystitis

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Inflammation of the GB that may have one of several forms. acute or chronic, acalculous, emphysematous, or gangenous

Cholecystitis

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Gallbladder wall inflammation is usually due to ________ obstruction by a gallstone.

cystic duct

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symptoms and findings of acute Cholecystitis…

acute RUQ pain, plus positive Murphy’s sign, fever, and leukocytosis
gallstones
enlarged GB (hydrops) even after a fatty meal
sludge

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_________ stimulates contraction of GB and releases the sphincter of Oddi

cholecystokinin

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Most common disease of the GB and may consist of a single large stone or hundreds of tiny stones.

Cholelithiasis

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factors that may lead to the development of gallstones include….

-pregnancy -diabetes, oral contraceptives -hemolytic disease -diet-induced weight loss and total parenteral nutrition

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sonographic criteria for Cholelithiasis included…

a mobile
strongly echogenic structure
with posterior acoustic clean shadowing

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When the gallbladder is completely filled with stones from chronic cholecystitis. only be able to image the anterior border of the GB. “wall echo shadow”. also called “the double arc”. You will see

wall
then echo
then shadow

“WES” sign

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The presence of both thickened bile and thin, watery bile can cause the appearance of __________

“floating gallstones”

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Complications of acute Cholecystitis

emphysematous cholecystitis
Gangrenous cholecystitis
Empyema (collection of pus in the pleural space)
Gallbladder perforation
Pericholecystic abscess
Pancreatitis

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Rare complication of acute cholecystitis due to GB wall ischemia and infection. More common in diabetic men due to neuropathy. Infection with presence of gas forming bacteria in GB wall and lumen with extension into the biliary ducts. comet-tail (reverberation) due to gas

Emphysematous Cholecystitis

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Tissue loss due to decreased blood supply. Serious and painful. Associated with perforation, focal areas of exudate, hemorrhage and necrosis

Gangrenous Cholecystitis

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sonographic findings of Gangrenous Cholecystitis…

presence of diffuse echogenic densities filling the GB lumen in the absence of bile duct obstruction
echogenic material with non-shadowing, not gravity dependent and does not show a layering effect
irregular GB wall (adematous pockets)

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gangrenous

tissue loss due to decreased blood supply

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signs suggestive of gangerous cholecystitis include:

assymetric wall, thickening, wall striations, pericholecystic fluid

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complication of acute cholecystitis;

localized fluid collection in the GB fossa, complications include: peritonitis, pericholecystic abscess, biliary fistula

Gallbladder Perforation

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purulent material within the gallbladder due to bacteria-containing bile associated with acute cholecystitis
initiated with obstruction of the cystic duct
same symptoms of acute + fever and leukocytosis

Empyema

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acute cholecystitis without the presence of gallstones
possibly due to decreased cystic artery blood flow or reflux of pancreatic enzymes into the GB
associated with conditions that produce depressed motility
- MURPHY’S SIGN

Acalculous

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rare condition found more in elderly women
symptoms of acute cholecystitis
massively inflamed and distended GB, possible twisting of the cystic artery and duct (twisting > 180 degrees increases risk for gangrenous GB)
surgical intervention for treatment

Torsion of the Gallbladder

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caused by transient obstruction of the GB neck or cystic duct by a stone. sonographic findings are -the same appearance as acute cholecystitis -thickened walls -sludge and an obstructing cystic duct stone may be present

Chronic Cholecystitis

- Rare - calcification of the GB wall - associated with cholelithiasis and chronic cholecystitis

Porcelain Gallbladder

higher incidence in older females, increased risk of cancer of the GB wall*** echogenic echo with posterior shadowing

Porcelain Gallbladder

differential diagnosis for porcelain gallbladder

WES sign

- sludge-like material with a high concentration of calcium * **associated with chronic cholecystitis and gallstone obstruction of the cystic duct - may be seen as a fluid layer that results in distal acoustic shadowing * "sludge that shadows"

Milk of the Calcium Bile

- small, non-shadowing intraluminal soft tissue masses | - fixed and do not change positions within the gallbladder

GB Polyps

- lipids are deposited in the gallbladder wall - also know as "strawberry gallbladder - vary in size and can be as large as 1cm - usually multiple, do not shadow, and are NOT mobile

Cholesterolois

- benign neoplasms of the GB with premalignant potential - usually occurs as a solitary lesion - homogenously hyperechoic

Adenoma

** comet-tail is associated with ______

Adenomyomatosis

- hyperplastic changes involving the GB wall causing overgrowth of the mucosa, thickening of the wall, and formation of diverticula - diverticula within the GB wall (Rockitansky-Aschoff sinuses or RAS) - comet-tail* (icicle look)

Adenomyomatosis

Hydrops of the GB is also known as ______

mucoclele of the GB

- round distended, non inflamed gallbladder due to obstruction of the cystic duct - bile is reabsorbed and the GB is filled with an anechoic secretion from the mucosa - asymptomatic and presenting as a palpable RUQ mass

Hydrops of the GB

Sonographic appearance of hydrops...

- obstructing stone noted in enlarge but non-tender gallbladder - Courvoisier GB (enlarged, non-diseased GB associated with a mechanical obstruction of the CBD of from an extrahepatic mass. ex. pancreatic cancer*

- associated with gallstones - increased risk with procelain GB - metastatic GB carcinoma (secondary to melanoma) - usually un-resectable due to late detection

Gallbladder Carcinoma

- congenital anomalies of the bile ducts consisting of cystic dilatation of the intra and extrahepatic bile ducts - caused by reflux of pancreatic secretions into the bile duct - may appear as true cyst in the RUQ with or without apparent communication with the biliary system.

choledochal cysts (aneurysm of the CBD)

classifications of choledochal cysts

- localized cystic dilation of the CBD - diverticulum from the common bile duct - invagination of the CBD into the duodenum - dilation of entire CBD and CHD

- rare congenital abnormality of segmental saccular cystic dilation of major intrahepatic bile ducts - found in younger adults or pediatrics - associated with renal disease or congenital hepatic fibrosis

Caroli's Disease (type V)

CHD is considered dilated above ____ mm

5 ways to differentiate intrahepatic bile ducts from portal veins

- alteration in normal appearance of the portal triad - irregular wall of dilated bile ducts - stellate confluence - acoustic enhancement behind dilated ducts - peripheral duct dilation

distal common bile duct obstruction...

the entire system distends including the gallbladder

common hepatic obstruction...

only proximal ducts will distend. the gallbladder will be contracted

Obstruction at the junction of the right and left hepatic ducts...

intrahepatic ducts dilate

most common level of obstruction...

cystic duct

with billiary obstruction what is elevated?

serum alkaline phosphate and conjugated or direct bilirubin levels are elevated

two most common causes of biliary obstruction?

gallstones and carcinoma of the head of the pancreas. other causes... -choledochaolithiasis -cholangiocarcinoma -cholanitis -Mirizzi syndrome -choledochal cysts -gallbladder carcinoma

Orginates within the large bile ducts- usually CHD or CBD

Cholangiocarcinoma (Bile duct carcinoma)

- type of cholangiocarcinoma, - located at the hepatic hilum (junction of the right and left bile duct) - results in intrahepatic but not extrahepatic biliary dilation

Klatskin's tumor

- extrahepatic biliary obstruction (due to impacted stone in the cystic duct causing ectrinsic mechanical compression of the common hepatic duct***) - painful jaundice

Mirizzi's syndrome

sonographic findings of Mirizzi's syndorme

- intrahepatic bile duct dilataion (above cystic duct) - a normal sized CBD - a large stone in the neck of the GB or cystic duct - a smooth curved segmental stenosis of CHD

- stones in the bile duct, ** most common cause of extrahepatic obstructive jaundice - *ductal stones especially if ductal dilatation is present

Choledocholithiasis

sonographic findings of choledocholithiasis

- echogenic structure in extrahepatic duct | - dilated biliary tree

air in the biliary tract

Pneumobilia

- infection and inflammation in the biliary ducts | - increase in alkaline phosphatase and conjugated or direct bilirubin

Cholangitis

more than 50% sclerosing cholangitis patients will have _______

ulcerative colitis

sonographic findings of cholangitis**

- wall of the intrahepatic bile ducts may be thickened in a smooth or irregular fashion - liver and bile ducts reveals localized irregular dilation of the intrahepatic bile ducts and unusual intraluminal soft-tissue protrusion into the bile ducts and portal radicals

- **absence of the extrahepatic biliary tree (from the hilum of the liver to the duodenum) - gallbladder is present 20% of the time - associated with polysplenia syndrome - sonographically seen as two-vessel portal triad (portal vein and hepatic artery)

Biliary atresia (seen in infants)

- **developmental congenital abnormality of the biliary tract characterized by multifocal segmental dilation of the intrahepatic bile ducts - type of choledochal cyst - findings include multiple cystic structures that converge toward the porta hepatis communicating with the bile ducts.

Caroli's Disease