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Abdominal > Quiz 2 > Flashcards

Quiz 2 Flashcards

1
Q

what controls the flow of bile?

A

Valves of Heister

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2
Q

the extrahepatic CBD is _______ to the cystic duct and CHD

A

distal

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3
Q

what hormone stimulates the release of bile?

A

cholecystokinen

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4
Q

what aids in the digestion of fats? and how does it get to the digestive system?

A

bile enters the Ampulla of Vater along with enzymes from the pancreas through the duct of Wirsung

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5
Q

how are the gallbladder and cystic duct supplied by blood?

A

cystic artery (branch of right hepatic artery)

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6
Q

when scanning the biliary system, what else do we scan?

A

liver and pancreas

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7
Q

what is the normal total bilirubin?

A

0.3 to 1.1 /dL

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8
Q

what is the normal direct bilirubin?

A

0.1 to 0.4/dL

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9
Q

what is bilirubin?

A

a product from the breakdown of hemoglobin in old red blood cells

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10
Q

what does bilirubin reflect?

A

the balance between production and excretion of bile

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11
Q

what is the elevation of direct or conjugated bilirubin associated with?

A

obstruction,hepatitis,cirrhosis and liver metastases

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12
Q

what is elevation of indirect or unconjugated bilirubin associated with?

A

nonobstructive conditions ie-steatosis

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13
Q

what enzyme is produced primarily by liver, bone and placenta?

A

ALP

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14
Q

what is marked elevation of ALP associated with?

A

obstructive jaundice

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15
Q

what enzyme is used to assess jaundice?

A

ALT

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16
Q

what is elevation of ALT associated with?

A

cirrhosis,hepatitis and biliary obstruction

Mild elevation associated with liver metastases

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17
Q

what enzyme is released when cells are injured or damaged?

A

AST

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18
Q

what is elevation of AST associated with?

A

cirrhosis,hepatitis and mononucleosis

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19
Q

Cholelithiasis

A

gallstone disease

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20
Q

what are risk factors of Cholelithiasis?

A
  • increasing age
  • female
  • obesity
  • pregnancy
  • e.t.c
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21
Q

what are the complications of gallstone disease?

A
  • biliary colic

- acute cholecystitis

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22
Q

what is a key feature when diagnosing gallstone disease?

A

mobility

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23
Q

WES complex?

A

wall-echo-shadow

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24
Q

milk of calcium bile

A

GB is filled with semisolid calcium carbonate

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25
Q

what is milk if calcium bile caused by?

A

stasis

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26
Q

what can milk of calcium bile cause?

A

acute cholecystitis

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27
Q

how does biliary sludge appear?

A

amorphous low-level echoes with no acoustic shadowing

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28
Q

Tumefactive sludge

A

sludge balls

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29
Q

is biliary sludge vascular?

A

no

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30
Q

what are some predisposing factors for biliary sludge?

A
  • pregnancy
  • rapid weight loss
  • prolonged fasting
  • critical illness
  • bone marrow transplant
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31
Q

what are the symptoms of acute cholecystitis?

A
  • constant RUQ pain
  • Epigastric pain
  • RUQ tenderness
  • Nausea/vomiting
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32
Q

what is acute cholecystitis caused by?

A

stones

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33
Q

what does impaction of stones in cystic duct or GB neck cause?

A
  • obstruction of bile
  • ischemia
  • fever
  • leukocytosis
  • e.t.c
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34
Q

what is postitive murphy’s sign?

A

go sag in decub and ask to take a deep breath in. apply some pressure and if the patient experiences pain or discomfort then it is positive murphy’s sign

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35
Q

what are some sonographic signs of acute cholecystitis?

A
  • gallstones
  • thickening of GB wall
  • fluid collections
  • positive murphy’s sign
  • e.t.c
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36
Q

Gangrenous Cholecystitis

A

necrosis due to severe or prolonged acute cholecystitis

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37
Q

what are the sonographic findings of Gangrenous Cholecystitis?

A
  • wall becomes irregular

- small collections within wall

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38
Q

GB perforation

A

Focal defect in wall and deflation of GB

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39
Q

Emphysematous cholecystitis

A
  • Frequently acalculus

- Gas-forming bacteria after ischemic event appears as gas in lumen and wall

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40
Q

how does Emphysematous cholecystitis appear on ultrasound?

A

echogenic line with posterior dirty shadow or reverberation artifact “ring down artifact”

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41
Q

how is chronic cholecystitis different from acute cholecystitis?

A

1) gallbladder distension
2) positive murphy’s sign
3) hyperemia of the wall

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42
Q

where is acalculous cholecystitis common?

A

in the critically ill

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43
Q

what happens in torsion of GB?

A

twisting of cystic artery or duct occurs

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44
Q

what is the treatment of torsion of GB?

A

surgery

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45
Q

porcelain GB?

A

wall is thickly calcified with dense posterior acoustic shadowing

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46
Q

Adenomyomatosis

A

exaggeration of the normal invaginations of luminal epithelium

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47
Q

Rokitansky-Aschoff sinuses:

A

May appear as cystic spaces or echogenic foci with comet tail artifact

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48
Q

what is the key to diagnoses for Adenomyomatosis?

A

thickening of adjacent gallbladder wall

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49
Q

what does Adenomyomatosis look like on ultrasounfd?

A

-‘twinkling’ artifact on doppler
-focal or diffuse
focal-seen in fundus
hourglass appearance

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50
Q

are benign or malignant polypoid masses more common?

A

benign

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51
Q

benign polypoid masses

A
  • more common
  • may be multiple
  • do not change in size when followed
  • less than 10mm
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52
Q

malignant polypoid masses

A
  • singularity
  • gallstone disease
  • rapid change in size when followed
  • over 10mm
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53
Q

slide 44-50

A

don’t know why they are crossed out so go back

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54
Q

what are the indications for doing an ultrasound on the biliary tree?

A
  • increased LFT’s

- jaundice

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55
Q

what do we rule out for ultrasound of biliary tree?

A
  • stones
  • infection
  • neoplasms
  • extrinsic compression
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56
Q

Choledochal cysts

A
  • congenital disease
  • focal or diffuse dilation
  • most often seen in east Asia populations
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57
Q

type 1, 11, 111 Choledochal cysts

A

cystic dilation of CBD

58
Q

type 1V Choledochal cysts

A

involves intrahepatic ducts as well as cystic dilation of CBD

59
Q

type V Choledochal cysts

A

caroli’s disease (not a true Choledochal cyst)

60
Q

Caroli’s disease

A
  • rare, congenital disease
  • Type V
  • involves intrahepatic biliary tree
  • usually diffuse
61
Q

what are the complications of Caroli’s disease?

A
  • biliary stasis
  • cholangitis
  • stones and septis
  • hepatic fibrosis
  • portal hypertension
62
Q

Primary choledocholithiasis

A

Stones form within ducts related to diseases causing strictures or dilation of bile ducts resulting in stasis

63
Q

what are the causes of primary choledocholithiasis?

A
  • Sclerosing cholangitis
  • Caroli’s disease
  • Parasitic infections of liver
  • Chronic hemolytic disease (sickle cell -anemia)
  • Prior biliary surgery (enteric anastomosis)
64
Q

Secondary choledocholithiasis

A

migration of stones from gallbladder into CBD

65
Q

what are the sonographic signs of Secondary choledocholithiasis?

A
  • Dilated CBD proximal to stone
  • Intrahepatic ducts may also be dilated
  • Large stones shadow ,smaller stones may not shadow
  • GB distension
66
Q

where will majority of stones be in the CBD?

A

Majority of stones will be in distal CBD at the Ampulla of Vater

67
Q

when may CBD stones occur?

A

seen in patients post cholecystectomy

68
Q

what are the differential diagnosis for CBD stones?

A

-Blood clot-hemobilia
-Papillary tumor
-Biliary sludge
none of these shadow

69
Q

where is Intrahepatic bile duct stones seen?

A

seen in patients with cystic fibrosis

70
Q

mirizzi syndrome is a clinical syndrome of what?

A

painful jaundice
fever
obstruction of CHD

71
Q

Mirizzi syndrome

A

obstruction of cystic duct

  • Recurrent bouts of cholecystitis/impacted stone may erode into CHD
  • Results in fistula between the cystic and common hepatic ducts
  • Acute cholecystitis, cholangitis&pancreatitis may occur
72
Q

What is a Fistula?

A

abnormal connection between an organ, vessel, intestine, or other structure

73
Q

what is fistula usually the result of?

A
  • injury
  • surgery
  • infection
  • inflammation
74
Q

what are some causes of hemobilia?

A
  • Cholangitis/cholecystitis
  • Vascular malformations
  • Trauma
  • Malignancies
75
Q

what occurs with hemobilia?

A

pain, bleeding, increased bilirubin occurs

76
Q

what is hemobilia sonographically?

A

echogenic, mixed, echogenicity, conforms to shape of the duct

77
Q

how does pneumobilia look?

A
  • air within biliary tree appears as bright echogenic linear structures following portal triads
  • reverberation ringdown artifact
78
Q

what are the 3 entities that causes Pneumobilia?

A

1) emphysematous cholecystitis
2) choledochoduodenal fistula (caused by stone in CBD)
3) Cholecystoenteric fistula

79
Q

Gallstone ileus

A

paralysis of nerves

80
Q

how may stones pass from gallbladder into bowel?

A

cholecystoenteric fistula

81
Q

what are some causes of Acute bacterial cholangitis?

A
  • stricture due to trauma or surgery
  • choledochal cysts
  • partially obstructive tumors
82
Q

what is the clinical presentation of Acute bacterial cholangitis?

A

classic charcot’s triad

  • fever
  • RUQ pain
  • jaundice
  • leukocytosis
  • inc. ALP and bilirubin
  • gram-neg enteric bacteria in blood
83
Q

what are sonographic findings of Acute bacterial cholangitis?

A
  • Dilation of intrahepatic biliary tree
  • Choledocholithiasis-stone in distal CBD
  • CBD wall thickening
  • Hepatic abscess
  • Dilated CBD>6mm
  • Pneumobilia suggests a fistula–choledochoenteric
  • GB wall may be thickened
84
Q

Fascioliasis

A
  • Larvae travel through bowel wall -peritoneal cavity-liver capsule into liver parenchyma
  • Matures and produces eggs in the biliary tree
85
Q

what are the symptoms of Fascioliasis?

A
  • jaundice
  • fever
  • abscess
86
Q

what are the sonographic findings of Fascioliasis?

A
  • hepatomegaly

- hilar adenopathy

87
Q

fascioloasis lesions

A
  • hypoechoic or mixed echogenicity
  • present on 90% cases
  • flukes may be seen within ducts and GB
88
Q

what is the path of Clonorchiasis and Opisthorchiasis?

A
  • larvae migrate through the ampulla of Vater into CBD

- mature within the intrahepatic bile ducts

89
Q

what are the sonographic findings of Clonorchiasis and Opisthorchiasis?

A
  • diffuse dilation of peripheral intrahepatic ducts
  • periportal echoes-edema
  • floating echogenic foci in GB-flukes or debris
90
Q

Ascariasis

A
  • roundworm 20-30cm long
  • fecal-oral route
  • common in children
  • active in small bowel, enters biliary tree via ampulla of vater
91
Q

what is the sonographic appearance of Ascariasis?

A
  • appears as a tube or parallel echogenic lines within bile ducts or GB
  • movement of the worm during US facilities diagnosis
  • may be multiple
92
Q

Recurrent pyogenic cholangitis

A
  • chronic biliary obstruction, stasis, and stone formation

- leads to recurrent episodes

93
Q

what is the etiology of Recurrent pyogenic cholangitis?

A

unknown

94
Q

what are the sonographic findings of Recurrent pyogenic cholangitis?

A

-lateral left lobe most often affected
Acute complication=sepsis
chronic complication=biliary cirrhosis and cholangiocarcinoma

95
Q

Primary sclerosing cholangitis

A

-chronic inflammatory disease of entire biliary tree

96
Q

___________of patients however,have inflammatory bowel disease-colitis

A

80%

97
Q

what does primary sclerosing cholangitis lead to?

A
  • Biliary strictures
  • Cholestasis
  • Biliary cirrhosis
  • Portal hypertension
  • Hepatic failure
98
Q

what is the etiology of secondary sclerosing cholangitis?

A
  • AIDS cholangiopathy
  • Bile duct neoplasm
  • Biliary tract surgery
  • Trauma
  • Choledocholithiasis
  • Congenital anomalies
  • Ischemic stricturing of bile ducts
  • Toxic strictures-infusion of fluxuridine
  • Post treatment for hydatid cyst
  • Primary sclerosing cholangitis
99
Q

Cholangiocarcinoma

A

cancerous (malignant) growth in one of the ducts that carries bile from the liver to the small intestine

100
Q

what are the risk factors of Cholangiocarcinoma?

A
  • age
  • recurrent biliary infections
  • stone disease
101
Q

________ of Cholangiocarcinoma are adenocarcinoma

A

90%

102
Q

what are the classifications of Cholangiocarcinoma?

A
  • Hilar=60%
  • Distal=30% CBD
  • Intrahepatic=10%
103
Q

hilar in Cholangiocarcinoma is also called what?

A

Klatskin’s tumor

104
Q

intrahepatic is also called what?

A

peripheral

105
Q

what is the most common classification of Cholangiocarcinoma?

A

Hilar (Klatskins tumor)

106
Q

where is Klatskins tumor located?

A

porta hepatis

107
Q

what does Klatskins tumor cause?

A

fibrous tissue formation

108
Q

what are the symtoms of Klatskins tumor?

A
  • Jaundice
  • pruritic
  • increased LFTS
  • nodes
109
Q

what are seen frequently in Distal (CBD)cholangiocarcinoma?

A
  • polyploid masses

- jaundice

110
Q

what is the 2nd most common primary malignancy tumor?

A

Intrahepatic cholangiocarcinoma

111
Q

how does Intrahepatic cholangiocarcinoma occur?

A

increased numbers of liver cirrhosis and Hep C

112
Q

how does Intrahepatic cholangiocarcinoma appear on US?

A

large solid hypovascular mass with varying degrees of echogenicity

113
Q

how is Intrahepatic cholangiocarcinoma differentiated from HCC?

A

presence of ductal obstruction

114
Q

Intraductal cholangiocarcinoma

A

purely intraductal mass

115
Q

polypoidal

A

distends the affected ducts with mucin

116
Q

what mimics appearance of cholangiocarcinoma?

A

metastases to biliary tree

117
Q

what does metastases to biliary tree affect?

A

intrahepatic and extrahepatic ducts

118
Q

what are primary sites of metastases of biliary tree?

A
  • breast
  • colon
  • melanoma
119
Q

what is a HIDA scan?

A

most often done to evaluate the gallbladder and the bile

120
Q

why might a doctor preform a HIDA scan?

A

as part of a test to measure the rate at which bile is released from your gallbladder (gallbladder ejection fraction)

121
Q

what can HIDA tests diagnose?

A
  • Gallbladder inflammation (cholecystitis)
  • Bile duct obstruction
  • Congenital abnormalities in the bile ducts, such as biliary atresia
  • Postoperative complications, such as bile leaks and fistulas
  • Assessment of liver transplant
122
Q

what is another name for jaundice?

A

icterus

123
Q

what is jaundice?

A

itself is not a disease,but rather a sign of one of the many possible underlying pathological processes that may occur

124
Q

what is Hyperbilirubinemia?

A

increased levels of bilirubin in blood

125
Q

where else can high levels of bilirubin be?

A

extracellular fluid

126
Q

where is bilirubin excreted in?

A

bile and urine

127
Q

where is jaundice usually seen?

A 
liver disease (hepatitis and cirrhosis)
but could also be an obstruction in biliary tract
128
Q

what is elevation of direct or conjugated bilirubin associated with?

A

obstruction

  • hepatitis
  • cirrhosis
  • liver metastases
129
Q

what is elevation of indirect or unconjugated bilirubin associated with?

A

with nonobstructive conditions ie-steatosis

130
Q

what are the symptoms of jaundice?

A
  • pruritic (itchiness)
  • fatigue
  • abdominal pain
  • weight loss
  • vomiting
131
Q

what are the signs of jaundice?

A
  • yellow discolouration of skin and eyes
  • fever
  • pale stools, dark urine
132
Q

how does jaundice appear?

A

as a yellowish pigmentation of the skin,whites of the eyes and other mucous membranes

133
Q

what are 3 sonographic signs of a gallstone?

A
  • echogenic
  • mobility
  • shadowing
134
Q

what benign entity does sludge mimic?

A

polyp/neoplasm

135
Q

what can you do to differentiate between polyp and sludge?

A
  • change patient position

- use colour doppler

136
Q

what are the symptoms of a patient coming in with a suspended GB disease?

A
  • RUQ pain
  • nausea
  • vomiting
  • pain in back/shoulder
137
Q

what are the sonographic signs of adenomyomatosis?

A
  • GB wall thickening

- ringdown artifact from Rokitansky-Aschoff sinuses

138
Q

what does positive murphy’s sign imply?

A

acute cholecystitis

139
Q

what is the key sonographic sign of emphysematous cholecystitis?

A

gas within the wall/lumen of GB

140
Q

what is the key sonographic sign of gangrenous cholecystitis?

A

sloughing of the walls into the lumen

Abdominal (11 decks)

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