Hepatobiliary Flashcards
1
Q
What are the common post choleycystectomy complications?
A
Bile leak - from the wrong anatomy, gallbladder bed, duct clip may slip
Port site complications - during laparoscopy hitting the inferior epigastric vessels may cause abdominal wall bleeding
Fallen gallbladder stone - if a stone is dropped it may cause an abscess formation, which can be hard to see on CT
2
Q
What is the most common CBD anatomical varient?
A
Insertion into the posterior middle third of the hepatic duct
3
Q
What are the 3 types of biliary anatomical variants ?
A
Low insertion of a cystic duct
Aberrant right posterior duct
Long common channel ( union of the pancreatic duct and CBD occurs outside the duodenal wall )
4
Q
What is the papillary process with regards to the liver?
A
It is a medial projection of the Caudata lobe which can be mistaken for lymphadenopathy. Usually not a problem when using MPR.
5
Q
What are the causes of a diffusely hyperattenuating liver on CT ?
A
Haemochromatosis is the most common cause
Medications - amiodarone, gold, methotrexate
Wilson’s disease - copper
Glycogen excess
6
Q
If there is focal lesion with calcification within the liver , what are the main differentials ?
A
Mucin calcifies : adenomas produce mucin, therefore metasesis from e.g. Colon cancer
Fibrolamella HCC more common version of HCC that calcifies
7
Q
In a non-cirrhotic liver, what risk factor might increase someone’s risk of getting HCC ?
A
Hep B Infection
8
Q
What does the Hot quadrat sign represent ?
A
SVC obstruction
9
Q
Post liver transplant , what is the main blood supply to the liver ? What happens if there is a problem with this blood supply?
A
Hepatic artery, Issues result in billlary necrosis, and biliary abscess formation
10
Q
What is hereditary haemorrhagic telangectasia ?
A
Autosomal dominant condition - abnormal vessel formation in the skin / mucus/ other organs
11
Q
What is the most common cause of pancreatic insufficiency in children ?
A
CF.
Second most common - Shwachman diamond syndrome
12
Q
What is pancreatic lipomatosis ?
A
Fat accumulation within the pancreatic parenchyma
13
Q
What is pancreatic lipomatosis associated with ?
A
Obesity and aging
14
Q
With an annular pancreas - what complications are seen in
1) Kids
2) Adults
A
Kids - bowel obstruction
Adults - pancreatitis
15
Q
What are the 3 common congenital pathologies with regards to the pancreas ?
A
Annualar pancreas
Dorsal agenesis of the pancreas is
Pancreatic divisium
16
Q
Which cystic pancreatic lesion most common occurs in the tail of the pancreas.
A
Mucinous cyst adenomas - thought to be related to the descent of the ovary - they are closer together
17
Q
What two conditions would result in simple pancreatic cysts?
A
Von hippel lindaue syndrome
AD polycystic kidney disease
18
Q
what is the hot caudate sign ?
A
increased radioactivity in the caudate lobe due to bud-chiarir syndrome
19
Q
what are the classic features of a serous cystadenoma of the pancreas ?
A
bunch of grapes - lots of small cysts, separated by an enhancing septa.
usually found in the head of the pancreas
central stellate scar
20
Q
what are the US findings in an acute rejection ?
A
heterogenous enhancement, graft enlargement, dilated pancreatic duct
21
Q
which part of the bowel is most commonly affected by radiation enteritis ?
A
ileum
22
Q
what are the indications for using primovist in liver MRI
A
hepatic metastatic lesions (uptake exclude a met from non liver primary) and differentiation adenoma from focal nodular hyperplasia
23
Q
when is hepatic steatosis considered on contrast CT
A
when it is >25HU less than the spleen
24
Q
in hepatic steatosis where does focal fat tend to occur ?
A
gallbladder fossa, periportal and sub capsular
25
what are the primary organs of the RES system
liver, lung, spleen
26
what does hepatic iron overload look like on MRI
the liver is diffusely hypo intense - relative to the paraspinal muscles and show signal drop out on the in-phase imaging
27
what is primary hemochromatosis caused by ?
iron overload due to genetic defect causing increased iron absorption through the GI tract.
28
which organs are affected in primary haemochromatosis ?
liver
pancreas
myocardium
skin
joints
29
which organs are affected in secondary haemochromatosis ?
Liver
spleen
bone marrow
30
what causes secondary haemochromatosis ?
excess iron accumulates in the RES system - due to frequent blood transfusion or defective erthyrocyts
31
how does amyloid affect the liver ?
amyloid deposited in the liver causes focal/diffuse attenuation on CT
32
how does Wilsons disease affect the liver ?
increased copper in the liver causes hyperlattenuation liver on CT with nodueles
33
what causes a hyperlattenuation liver on CT
iron overload
medications - gold, amiodarone, methotrexate,
Wilsons disease
glycogen excess
34
which lobes hypertrophy in cirrhosis ?
1 and the leeft lobe 2 and 3
35
what are gamna-gandy bodies found in ?
portal hypertension resulting in microhaemorrahages in the spleen - leading to haemosiderin and calcium deposits - forming tiny hyperlattenuation foci
36
what are micro nodular cirrhotic nodules caused by
<3mm in size, assoicated with alcohol
37
where are macro nodular cirrhotic nodules caused by
>3mm caused by fulminant viral hepatitis
38
what is the most common hepatic malignancy?
hepatocellular carcinoma
39
what blood test is usually elevated in HCC?
AFP
40
what does HCC usually look like on CT or MRI
encapsulated mass which has arterial enhancement, washout on portal venous with an enhancing capsule
41
what is the reporting classification used for HCC ?
LI-RADS
42
in the LI-RADS what is the major criteria for a HCC ?
Atrial enhancement, non peripheral washout on PV, enhancing capsule , increased diameter >50% in 6 months
43
who does fibrolamellar carcinoma occur in >
young patients without cirrhosis
44
is AFP elevated in fibrolamellar carcinoma?
NO
45
what does fibrolamellar carcinoma look like ?
heterogenous mass
No capsule - but maybe pseudo capsule due to compressed tissue
Central fibrotic scar which doesn't enhance and is low on T1 and T2 imaging - may show calcification
capsular retraction
46
what does an intrahepatic cholangiocarcinoma look like
heterogenous mass with delayed enhnacement with upstream billary duct dilatation
47
which metastes are hypo vascular to the liver ?
breast
pancrease
liver
lung
48
which mets are hyper vascular in the liver
MRCT
Melanoma
Renal cell carcinoma
Carcinoid
Thyroid
49
which liver mets are calcified ?
mucinous cancers - ovary/colon/gastric
osteosarcoma
treated lymphoma
50
which liver mets are cystic?
ovarian cystuadenocarcinoma
gastrointestinal sarcoma
51
which is the most common cause of pseudo cirrhosis ?
treated breast cancer
52
what is a typical feature of a liver met on US
hypo echoic rim - producing a target sign
53
which lesions cause capsular retraction
fibrolamellar hcc
pseudo cirrhosis - treated mets
epithelioid haemangioma
mass-forming cholangiocarcinoma
54
what is an epithelioid haemngioendothelioma.
rare vascular malignancy, causing lots of rounded, subcapular masses which demonstrate a target appearance.
55
what is the classic appearance of a haemangioma
progressive peripheral nodular enhancement - matching the blood pool level with centripetal fill-in on later phases.
On MRI - light bulb lesions
56
what does focal nodular hyperplasia look like on MRI /
with primovist:
stealthy and then arterially enhancing with retained enhancements in the hepatobillary phase
Gad:
the central scar shows delayed enhancement
57
what is the classic doppler us finding of a FNH?
spoke wheel configuration
58
how does the HIDA scan differentiation between FNH and a hepatic adenoma ?
the presence of bilary ducts on an FNH
where has a hepatic adenoma doesn't contain bile ducts so will show poor uptake on HIDA
59
when would an incidental adenoma be resected ?
> 5cm
60
what are the 4 subtypes of an adenoma ?
inflammatory - highest bleeding risk
HNG-alpha-1 mutated - lots of them
beta-catenin mutated - steroid used
unclassified
61
how do adenomas tend to present
circumscribed mass with arterial enhancement and pV washout.
62
what is the classic ultrasound finding of acute hepatitis?
starry sky appearance with increased echogencity of the portal triad with gallbladder wall thickening
63
when do people develop hepatic pneumocystis jiroveci?
hepatic infection usually occurs when patients are using inhaled pentamidine as it is not absorbed so the infection gets to the liver
64
what is a hydatid cyst
a well-defined hypo enhancing cystic mass feature a characteristic floating membrane - known as a water-lily sign
65
what is hepatic echinococcosis and what is it treated with ?
caused by ingestion of echinococcus granulosus - in sheep
treated with albendazole or menbendazole
66
what are bilary harmatomas (von Meyenburg complexes)
small, benign cystic lesions which do not communicate with the bilary tree
67
what liver lesions are usually seen in VHL.
multiple. inumerable tiny cysts
68
in liver trauma how could you look for injury to the bilary tree ?
using a HIDA scan and looking for bile leak
using eovist with MRI
69
which criteria is used to assess for appropriateness for liver transplant >
milan criteria
one lesions < 5cm
or max 3 lesions < 3cm
no extrahepatic involvement
no major vascular involvement
70
what is post transplant lymphoproliferative disorder ?
lymphoma caused by EBV which arises in patients who have had a solid organ or bone marrow transplant. presents with a mass of variable and nonspecific appearance
71
what is Budd-chiari disease ?
hepatic venous outflow obstruction either thrombotic or non-thrombotic
72
how does acute Budd-chiari present >
hepatomegaly
ascitis
abdominal pain
73
what are the vascular findings in Budd-chiari
no flow in the hepatic veins
collateral vessels In a spider web pattern
thrombus in the hepatic veins and ivc
74
what are the ct features of Budd charier
thrombus in either the hepatic veins or ivc
caudate lobe hypertrophy
enlarged collateral vessels
heterogenous enhancement of the liver - nutmeg appearance
75
what is liver veno-occulsive disorder ?
destructive of the small hepatic vessels secondary to toxin exposure - the hepatic veins are patent
usually due to chemo
76
what image findings might indicate veno-occulsive disorder ?
narrowing of the hepatic veins
reversal of flow int he portal veins
NOT SPARING the caudate lobe
heterogenous enhancement
gallbladder wall thickening
76
what image findings might indicate veno-occulsive disorder ?
77
what is a normal portal vein doppler wave form ?
above base line ( doesn't go below zero)
RI 0.55-0.7
velocity rages from 16-40cm/s
78
when does graft vs host disease develop ?
3-12 months post transplant
79
what would candida look like post transplant in the liver ?
target lesions
80
which hepatitis virus - with a non cirrhotic liver is associated with HCC?
Hep B
81
what conditions are in MEN 1
parathyroid hyperplasia
pituitary gland tumours
pancreatic islet cell tumours (insulinomas, glucaonomas, gastrinomas)
82
what do pancreatic islet cell tumours look like on CT
when functioning ; small lesions with +++ arterial enhancement
83
what conditions are seen in MEN 2A
parathyroid hyperplasia
medullary thyroid carcinoma
phaeochromocytoma
84
which conditions are seen in MEN 2B
85
what is pseudomyoxa peritonei
where the peritoneal cavity fills with mucine due to the rupture of a muscus tumour. - such as an appendices mucocele.
86
how long after a transplant does veno-occulsive disease occur ?
20-30 days
87
what test investigates for accessory spleens ?
Tc99m - labelled RBC
88
what rate of flow in the portal vein would be seen in portal venous hypertension
<16cm/sec or reversal
89
what are the features of portal venous hypertension?
recanulisation of the umbilical vein (in the falciform ligament)
gamma gandy bodies in the spleen
portal varies
dilated portal vein >13mm
splenomegaly
90
what is the US follow up after a TIPS procedure ?
baseline
3 months for 1 year
then every 6-12 months
91
what velocity in the TIPS suggests stenosis ?
>190 or < 90
change of velocity > 50 from baseline
92
what causes increased hepatic vein pulsatility
right sided cardiac abnormality either right sided heart failure or tricuspid regurgitation
93
what causes decreased hepatic vein pulsatility ?
cirrhosis
budd-chiari
hepatic veno-occlusive disease
94
what is the treatment of acalculous cholecystitis
percutaneous choleycystostomy
95
what is adenomyomatosis ?
cholesterol deposition within the wall of the gallbladder - resulting in a comet tail artefact.
96
what is Caroli syndrome ?
Carol disease plus hepatic fibrosis
97
what is primary sclerosis cholangitis ?
idiopathic inflammation and destruction of the bile ducts.
98
what does PSC look like on MR
irregular beaded appearance of the CBD and intrahepatic bile ducts
99
what is PSC associated with ?
ulcerative colitis
100
what is primary biliary cholangitis ?
destruction of the smaller bile ducts
101
what does PBC look like on imaging ?
lace like fibrosis
halo sign - hypo density around the portis
lymphadenopathy
102
who does PBC occur in
women 40-50
103
what is recurrent pyogenic cholangitis caused by
the parasite clonorchis sinensis
104
which cancers can metastasis to the gallbladder ?
liver - by direct extension
melanoma
105
what are the risk factors for developing cholangioacarcinoma/
stone and inflammation
PSC
FAP
clonorchis sinuses infection - resulting in recurrent pyogenic cholangitis
106
what are the two morphological subtypes of pancreatitis ?
interstitial oedematous pancreatitis
necrotising pancreatitis
107
how long post pancreatitis would you see either walled off necrosis or a pseudocyst ?
after 4 weeks
108
what are the main causes of chronic pancreatitis ?
pancreatic divisum and alcohol
109
what is groove pancreatitis?
uncommon form of focal pancreatitis located in the groove between the head of the pancreas, duodenum and CBD
110
what are the solid pancreatic neoplasms
adenocarcinoma
acinar cell carcinoma
metastasis
111
what are the cystic pancreatic neoplasms
serous cystic
mucinsous cystic
solid peudopapillary tumour
intraductal papillary mucinsous neoplasm
112
what are the endocrine pancreatic neoplasms
insulinoma
gastrinoma
glucagonoma
VIPoma
somastostatinoma
cystic neuroendocrine
113
on CT what does a pancreatic adneocaricnoma look like ?
hypo enhancing
duct dilatation upstream
parenchymal atropphy
114
what is encasement of a vessel mean
the tumour encases a vessel more than 180 circumferential
115
what classic traid is seen in acinar cell carcinoma
acinar cell carcinoma is a large pancreatic mass
it secrets lipase leading to lipase hyper secretion syndrome which includes subcutaneous fat necrosis , bone infarcts and eosinophilia
116
what does a solid pseduopapillary tumour look like
usually in the tail of the pancrease
large solid and cystic mass with a capsule
may bleed
in younger women
117
what do mucinous cystic neoplasms tend to look like ?
mother lesion that occur in the tail of the pancreas
lots of larger cysts <6cysts > 2cms
also have a capsule
118
what doe serous cysadenomas look like
grandmother lesion occurring in the head of the pancreas,
lots of small tiny cysts.
usually have a central scar with stellate calcification
119
how doe most pancreatic neuroendocrine tumours loo ?
usually solid lesions which are hyper enhancing
120
what is the most common pancreatic endocrine tumour.
insulinoma
121
which metastatic lesions are usually seen In gastrinomas
liver metastasis
122
what causes hepatic capsular contraction?
lesions which cause fibrosis
- fibrolamellar hcc
- cholangiocarcinoma
- mets (breast, colon, carcinoid)
- IGG4
- Cirrhosis
-Iagtrogenic/ post trauma
123
what is the typical location for gastrinomas ?
within the gastrinoma triangle :
an area between the CBD/Cystic duct, the 2nd part of the duodenum and the pancreatic neck
124
how do patients with glucagonomas present ?
migratory rash, diabetes and glossitis
125
what organ does schwachman-diamond disorder affect ?
the pancreas- causing fatty replacement and subsequent exocrine insufficiency
126
what would a post traumatic pseudocyst look like ?
fibrous cystic walls - so may have calcification, there won't be any enhancement.
well circumscribed lesion with fluid density
127
what is associated with klippel-trenaunay-weber-syndrome
cutaneous haemangiomas - port wine stain
varicose veins
extremity hypertrophy
128
how do fungal abscess look like in the spleen?
multiple small hypo attenuating foci
129
which cancers may metastasis to the spleen
breast, lung, melanoma, ovarian
130
what is Erlenmeyer flask deformity and what condition is it linked too ?
where the femur looks like a connicle flask - the diaphsysi is thinner and the metaphysis is wider.
Associated with gauchers disease
131
what is gauchers disease
lyososmal storage disorder. resulting is abrnomal storage of lysosomes in the macrophages resulting in splenomegaly and bony findings
132
what is a grad 5 splenic injury
shattered spleen
133
what is a grade 4 splenic injury
when there is intravascular injury - such as a psueodaneurysm or av fistula
134
what does a flash hamangioma look like on Contrast enhanced ultrasound ?
immediate uniform enhancement which does not washes out
135
what does a malignant lesions look like on contrast enhanced us /
immediate uniform enahcmenet which then washes out
136
on barium swallow what does drug induced oesophagitis look like ?
at and area of construction - there is an ulcer
137
what is a key feature distinugishing gastric lymphoma from gastric carcinoma ?
gastric lymphoma crosses the pylorus and even though it maybe large, doesn't cause gastric outflow obstruction
138
what is the differential for low attenuating abdominal lymph nodes ?
whiplles disease
TB
necrotic metastatic lymph nodes
lymphoma
coeliac disease
139
which conditions predispose people to get small bowel lymphoma ?
coeliac
h.pylorid
aids
140
which can is useful to detect carcinoid tumours
octreotide scans
141
on barium , what is diagnostic of ectopic pancreatic tissue
an umbilicus, or central hole which fills with barium - this is meant to be where the duct would be
142
what is a schatzi ring ?
focal narrowing of the ring in the distal oesophagus making < 13mm
143
on floor what does reflux look like ?
thickened mucosal folds, mucosal granularity, strictures
144
what does eosinophilic esophagitis look like ?
concentric mucosal ring like strictures
145
what does a malignant stricture look like on barium swallow
irregular narrowing with shouldering (apple core)
146
what type of osesophageal strictures are seen post radiation and NG tube insertion?
long thin strictures
147
what is a primary contraction wave
a peristatitic wave initiated by swallowing
148
what is a secondary contraction wave
a peristaltic wave initiated by a bolus of food / fluid
149
what is achalasia caused by
inability of the distal oesphagus to relax
150
what disease can also lead to achalasia ?
chugs disease
151
how dose scleroderma affect the oesophagus ?
excess collagen causes lack of peristaltic in the distal 2/3 of the oesophagus, leading to dilatatin
152
what condition leads to a corkscrew oesophagus?
diffuse esophageal spasm
153
what is a feline oesophagus ?
normal variant characterised by multiple thin transverse echogenci folds.
154
what is zollinger-ellison syndrome
overproduction of gastrin from a gastrinoma
155
where do most benign ulcers occur
the lesser curvature of the stomach
156
what does Hamptons line represent ?
nonulcerated acid resistant mucosa surrounding the ulcer crater
157
what is the carman meniscus sign ?
pathagnomic for a malignant ulcer - splaying open of a large flat malignant ulcer when compression applied
158
what is the most common location for a GIST tumour ?
the stomach
159
what cells do GIST tumours arises from
the interstitial cells of cajal - the pacemakers that drive peristalsis
160
what is a krukenberg tumour
metastatic spread of a gastric carcinoma to the ovaries
161
what is the normal phi angle of a gastric band ?
4-58*
