Pathology Flashcards
What is an important question to ask the patient before scanning the GB?
The last time they have had anything by mouth
Clinical symptoms of GB disease…
RUQ pain especially after fatty meals Nausea & vomiting Right shoulder & midepigastric pain Jaundice Chills & fever
What is sludge?
Concentrated bile - soft echoes layered in dependent part of GB that will change with patient position
Gravity dependent
Asymptomatic or with associated GB disease
What causes sludge?
Thickened bile Bile stasis (doesn't move) Prolonged fasting or hyper alimentation therapy (feeding tube)
What can resemble a mass or psuedo tumor when related to sludge?
Tumefactive sludge - use color Doppler - long standing biliary obstruction
Describe a sludge ball…
Medium level echogenic masses
What is the normal thickness of the GB wall?
Less than 3 mm
Where do you measure the thickness of the GB wall?
Anterior wall
What is Cholelithiasis?
GB stones; can be large or small
Tiny stones are dangerous because they can obstruct the bile flow in the ducts
Cholelithiasis etiology…
Abnormal bile composition
Stasis
Infection
Stages of gallstone formation…
Saturation of bile
Nucleation (forming a blob)
Growth
Gallstone composition…
Cholesterol
Calcium bilirubinate
Calcium carbonate
What is the most common GB disease?
Cholelithiasis
Cholelithiasis clinically…list the “F’s”
Fat Female Forty Fertile Fair Flatulent
Causes of Cholelithiasis…
Obesity Diabetes Pregnancy Oral contraceptives Estrogen replacement Pancreatitis Biliary infection Alcohol cirrhosis Diet induced Rapid weight loss program Feeding tube
What % of Cholelithiasis evokes no clinical manifestations?
80%
What is a serious consequence in obstruction of the cystic duct or CBD?
GB hydrops - getting bigger from fluid build up
What is Bouveret?
Gastric outlet obstruction caused by gallstone in the pylorus or proximal duodenum
Cholelithiasis sonographically…
Gallstones Increased GB size Decubitus Acoustic shadowing Acoustic impedance of gallstones WES sign
What is the WES sign?
Completely filled with gallstones
No lumen…all shadow
Wall Echogenic Shadowing
When will you see floating gallstones?
Prolonged fasting, air, oral cholecystogram
What do you need to make sure your not confusing for gallstones?
GB valves
What is cholecystitis?
Inflammation of the GB
What are the 5 forms of cholecystitis?
Acute Chronic Acalculous Emphysematous Gangrenous
What is a Murphy’s sign?
A hypersensitivity with deep palpitation in the sub costal area when a patient takes in a deep breath that may produce inspiratory arrest
Describe acute cholecystitis…
Cholelithiasis Cystic duct obstruction or neck of GB obstruction (Hartmann's Pouch) Females \+ Murphy's Fever Leukocytosis Abn LFTs Pancreatic reflux
The most common cause of acute cholecystitis is ___________.
Gallstones - impacted & extrinsic pressure
Acute cholecystitis sonographically…
Thickened wall
Edema-halo
Enlarged (greater than 5 cm trans)
Pericholecystic fluid
Describe chronic cholecystitis…
Contraction of GB
Coarse wall thickening
WES sign
What is the most common form of GB inflammation?
Chronic cholecystitis
Clinical symptoms for cholecystitis…
Intermittent RUQ pain
Intolerance to fatty, fried food
Intermittent nausea and vomiting
Acute inflammation of the GB is ___________.
Acalculous cholecystitis
Acalculous cholecystitis is absent of ___________.
Gallstones - Cholelithiasis
Clinical workup of acalculous cholecystitis…
+ Murphy’s
Abn LFTs
Increased amylase
Increased WBC
Acalculous cholecystitis sonographically…
Decreased blood flow in the cystic artery
Extrinsic compression of the cystic duct by a mass
GB wall thickened
Sludge
Pericholecystic fluid
Describe emphysematous cholecystitis…
Acute cholecystitis
Gas forming bacteria in wall and lumen into ducts
Relationship to diabetes
May lead to gangrene with associated perforation
Surgical emergency
Fever, pain, infection
Emphysematous cholecystitis sonographically…
Prominent bright echo along the anterior wall
Ring down or comet tail artifact
Gangrenous cholecystitis sonographically…
Absent blood supply - necrosis
Thickened and edematous wall
Hemorrhage
Gallstones or fine gravel
Describe gangrenous cholecystitis…
May lead to perforation Abn LFTs Ulcerations Pericholecystitis abscesses Peritonitis Painful complications
Gangrenous cholecystitis has a medium to coarse echogenic densities which means not ___________, not ___________, not ___________.
Shadowing
Gravity dependent
Layering
Name 3 types of benign neoplasm.
Adenoma
Cholesterolosis
Adenomyomatosis
Describe cholesterolosis…
Cholesterol deposited in the GB wall STRAWBERRY GB Polyps (most common psuedo tumor of GB) Attached with a stalk Less than 10 mm Do not shadow
Describe adenomyomatosis…
Hyperplastic change
Papillomas
Over the mucosal surface
Adenomyomatosis is a ___________ change in the GB wall.
Hyperplastic
With adenomyomatosis, ___________ may occur singly or in groups and may be scattered over a large part of the mucosal surface of the GB.
Papillomas
Papillomas are not a precursor to ___________.
Cancer
With adenomyomatosis, various patient positions and compressions show the ___________ to be ___________ in the GB.
Lesion
Immobile
Adenomyomatosis sonographically…
Ring down or comet tail
W shaped reverberation between diverticula Rokitanski-Aschoff sinuses
Describe porcelain gallbladder…
RARE GB wall calcified Calcium incrustation Gallstones Asymptomatic 25% progress to CA**
Primary GB CA is ___________.
Rare
What is the mortality rate if GB CA infiltrates other organs?
Near 100%
What is GB CA?
Obstruction of the cystic duct from compression
Metastatic may occur from melanoma
GB CA sonographically…
Heterogenous solid mass
Dilated ducts
Most common biliary malignancy
Describe metastatic disease…
Primary of stomach, pancreas, & ducts
Focal thickening of the duct
Intraluminal
Most common tumor sites that can spread to the biliary system are from the ___________, ___________, & ___________.
Breast
Colon
Melanoma
Metastases can affect the ___________ and ___________ ductal system.
Intrahepatic
Extrahepatic
On sonography, the appearance of metastases is similar to that of ___________.
Cholangiocarcinoma
___________ is the second most common primary malignancy of the GB.
Cholangiocarcinoma
*poor prognosis
With cholangiocarcinoma, cancer is within the ___________.
Ducts
What 2 liver diseases are associated with cholangiocarcinoma?
Liver cirrhosis
Hepatitis C
Generally a biliary duct measures ___________. A dilated duct measures ___________.
Greater than 6 mm
Greater than 10 mm
What is courvoisier?
Obstruction of the CBD due to pancreatic mass
Enlargement of the GB
What is cholecystomegaly?
Hydropic GB
Enlarged GB without wall thickening
Obstruction of duct
What are the 3 extra hepatic obstruction? Describe.
Intrapancreatic - pancreatic ca, choledocholthiasis, chronic pancreatitis
Suprapancreatic - between pancreatic & porta hepatis, head of pancreas & duct are normal
Porta hepatic - neoplasm, hydrops of the GB
___________ is a specific cholangiocarcinoma at the junction of the right and left hepatic duct.
Klatskin’s tumor
___________ is when there is an impacted stone in the cystic duct or GB neck.
Mirizzi Syndrome
What will you see in a parasagital scan when there is an obstruction?
Alteration at PV Irregular walls of the ducts Stellate confluence Acoustic enhancement Peripheral ductal dilatation
___________ is an inflammation of the bile ducts.
Cholangitis
*increased pressure in the biliary tree with pus
Clinical symptoms of cholangitis…
Fever
Malaise
Sweating and shivering
Can lead to shock
3 types of cholangitis…
Oriental sclerosing cholangitis
AIDS cholangitis
Acute obstructive suppurative cholangitis
Lab values and sonographical appearance of cholangitis…
Increased Alk Phos and bili
Thickened ductal wall
What is ERCP?
(Post) endoscopic retrograde cholangiopancreatopgraphy - this procedure can give you an inflection (cholangitis)
___________ is a disease caused by the parasitic roundworm, which uses a fecal-oral route of transmission.
Ascariasis
With ascariasis, the worm grows in the ___________ before entering the biliary tree though the ___________. This will cause ___________.
Small bowel
Ampulla of Vater
Acute biliary obstruction
Describe choledocholthiasis…
Stones in CBD
Associated with acalculous cholecystitis
Impacted stones in the ampulla of Vater
Elevated direct bili and Alk Phos
___________ is when there is blood in the biliary tree.
Hemobilia
The main cause of hemobilia is ___________.
Biliary trauma
___________ is air within the biliary tree.
Pneumobilia
Pneumobilia may be caused by what 2 things?
Emphysematous cholecystitis
Inflammation from an impacted stone in the CBD
Describe choledocholthiasis cysts…
CONGENITAL conditions involving cystic dilatation of bile ducts
Pancreatic juices refluxing into the bile ducts
Rare
Females - infants to 10 years
“Outpouching of the GB”
What is choledochal cysts associated with?
Gallstones
Pancreatitis
Cirrhosis
Clinical symptoms of choledochal cysts…
ABD mass Pain Fever Jaundice Confirmed with nuc med scan
How many classification types of choledochal cysts are there?
6 types
What is choledochal cysts type V?
Cysts have been classified as Caroli’s disease
Choledochal cysts in the RUQ:
_________ of the CBD
_________ from the CBD
_________ of the CBD
Dilatation
Diverticulum
Invagination
_________ is a rare congenital disorder that classically causes saccular ductal dilatation.
Caroli’s disease
_________ will have multiple cystic structures in the are of the ductal system towards the _________.
Caroli’s disease
Porta hepatis
Caroli’s disease sonographically…
Ducts may show a BEADED appearance as they extend into the periphery of the liver
Describe biliary atresia…
Ducts are obliterated
Congenital
Neonatal
_________ cause thickening of the GB wall from inside the GB…“chole-“ will be attached to explanation.
_________ cause thickening of the GB wall from outside the GB…other organs involved.
Intrinsic - cholecystitis
Extrinsic - hepatitis & cirrhosis
What can cause GB wall diffuse thickening…
Normal contracted GB Ascites Acute hepatitis, cirrhosis CHF Renal disease AIDS Pancreatitis
What can cause GB wall focal thickening…
Adenomyomatosis Polyp Adenoma Carcinoma Metastatic
