Quiz 2 Flashcards
1
Q
what controls the flow of bile?
A
Valves of Heister
2
Q
the extrahepatic CBD is _______ to the cystic duct and CHD
A
distal
3
Q
what hormone stimulates the release of bile?
A
cholecystokinen
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
5
Q
how are the gallbladder and cystic duct supplied by blood?
A
cystic artery (branch of right hepatic artery)
6
Q
when scanning the biliary system, what else do we scan?
A
liver and pancreas
7
Q
what is the normal total bilirubin?
A
0.3 to 1.1 /dL
8
Q
what is the normal direct bilirubin?
A
0.1 to 0.4/dL
9
Q
what is bilirubin?
A
a product from the breakdown of hemoglobin in old red blood cells
10
Q
what does bilirubin reflect?
A
the balance between production and excretion of bile
11
Q
what is the elevation of direct or conjugated bilirubin associated with?
A
obstruction,hepatitis,cirrhosis and liver metastases
12
Q
what is elevation of indirect or unconjugated bilirubin associated with?
A
nonobstructive conditions ie-steatosis
13
Q
what enzyme is produced primarily by liver, bone and placenta?
A
ALP
14
Q
what is marked elevation of ALP associated with?
A
obstructive jaundice
15
Q
what enzyme is used to assess jaundice?
A
ALT
16
Q
what is elevation of ALT associated with?
A
cirrhosis,hepatitis and biliary obstruction
Mild elevation associated with liver metastases
17
Q
what enzyme is released when cells are injured or damaged?
A
AST
18
Q
what is elevation of AST associated with?
A
cirrhosis,hepatitis and mononucleosis
19
Q
Cholelithiasis
A
gallstone disease
20
Q
what are risk factors of Cholelithiasis?
A
- increasing age
- female
- obesity
- pregnancy
- e.t.c
21
Q
what are the complications of gallstone disease?
A
- biliary colic
- acute cholecystitis
22
Q
what is a key feature when diagnosing gallstone disease?
A
mobility
23
Q
WES complex?
A
wall-echo-shadow
24
Q
milk of calcium bile
A
GB is filled with semisolid calcium carbonate
25
what is milk if calcium bile caused by?
stasis
26
what can milk of calcium bile cause?
acute cholecystitis
27
how does biliary sludge appear?
amorphous low-level echoes with no acoustic shadowing
28
Tumefactive sludge
sludge balls
29
is biliary sludge vascular?
no
30
what are some predisposing factors for biliary sludge?
- pregnancy
- rapid weight loss
- prolonged fasting
- critical illness
- bone marrow transplant
31
what are the symptoms of acute cholecystitis?
- constant RUQ pain
- Epigastric pain
- RUQ tenderness
- Nausea/vomiting
32
what is acute cholecystitis caused by?
stones
33
what does impaction of stones in cystic duct or GB neck cause?
- obstruction of bile
- ischemia
- fever
- leukocytosis
- e.t.c
34
what is postitive murphy's sign?
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
35
what are some sonographic signs of acute cholecystitis?
- gallstones
- thickening of GB wall
- fluid collections
- positive murphy's sign
- e.t.c
36
Gangrenous Cholecystitis
necrosis due to severe or prolonged acute cholecystitis
37
what are the sonographic findings of Gangrenous Cholecystitis?
- wall becomes irregular
| - small collections within wall
38
GB perforation
Focal defect in wall and deflation of GB
39
Emphysematous cholecystitis
- Frequently acalculus
| - Gas-forming bacteria after ischemic event appears as gas in lumen and wall
40
how does Emphysematous cholecystitis appear on ultrasound?
echogenic line with posterior dirty shadow or reverberation artifact "ring down artifact"
41
how is chronic cholecystitis different from acute cholecystitis?
1) gallbladder distension
2) positive murphy's sign
3) hyperemia of the wall
42
where is acalculous cholecystitis common?
in the critically ill
43
what happens in torsion of GB?
twisting of cystic artery or duct occurs
44
what is the treatment of torsion of GB?
surgery
45
porcelain GB?
wall is thickly calcified with dense posterior acoustic shadowing
46
Adenomyomatosis
exaggeration of the normal invaginations of luminal epithelium
47
Rokitansky-Aschoff sinuses:
May appear as cystic spaces or echogenic foci with comet tail artifact
48
what is the key to diagnoses for Adenomyomatosis?
thickening of adjacent gallbladder wall
49
what does Adenomyomatosis look like on ultrasounfd?
-'twinkling' artifact on doppler
-focal or diffuse
focal-seen in fundus
hourglass appearance
50
are benign or malignant polypoid masses more common?
benign
51
benign polypoid masses
- more common
- may be multiple
- do not change in size when followed
- less than 10mm
52
malignant polypoid masses
- singularity
- gallstone disease
- rapid change in size when followed
- over 10mm
53
slide 44-50
don't know why they are crossed out so go back
54
what are the indications for doing an ultrasound on the biliary tree?
- increased LFT's
| - jaundice
55
what do we rule out for ultrasound of biliary tree?
- stones
- infection
- neoplasms
- extrinsic compression
56
Choledochal cysts
- congenital disease
- focal or diffuse dilation
- most often seen in east Asia populations
57
type 1, 11, 111 Choledochal cysts
cystic dilation of CBD
58
type 1V Choledochal cysts
involves intrahepatic ducts as well as cystic dilation of CBD
59
type V Choledochal cysts
caroli's disease (not a true Choledochal cyst)
60
Caroli’s disease
- rare, congenital disease
- Type V
- involves intrahepatic biliary tree
- usually diffuse
61
what are the complications of Caroli’s disease?
- biliary stasis
- cholangitis
- stones and septis
- hepatic fibrosis
- portal hypertension
62
Primary choledocholithiasis
Stones form within ducts related to diseases causing strictures or dilation of bile ducts resulting in stasis
63
what are the causes of primary choledocholithiasis?
- Sclerosing cholangitis
- Caroli’s disease
- Parasitic infections of liver
- Chronic hemolytic disease (sickle cell -anemia)
- Prior biliary surgery (enteric anastomosis)
64
Secondary choledocholithiasis
migration of stones from gallbladder into CBD
65
what are the sonographic signs of Secondary choledocholithiasis?
- Dilated CBD proximal to stone
- Intrahepatic ducts may also be dilated
- Large stones shadow ,smaller stones may not shadow
- GB distension
66
where will majority of stones be in the CBD?
Majority of stones will be in distal CBD at the Ampulla of Vater
67
when may CBD stones occur?
seen in patients post cholecystectomy
68
what are the differential diagnosis for CBD stones?
-Blood clot-hemobilia
-Papillary tumor
-Biliary sludge
none of these shadow
69
where is Intrahepatic bile duct stones seen?
seen in patients with cystic fibrosis
70
mirizzi syndrome is a clinical syndrome of what?
painful jaundice
fever
obstruction of CHD
71
Mirizzi syndrome
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
What is a Fistula?
abnormal connection between an organ, vessel, intestine, or other structure
73
what is fistula usually the result of?
- injury
- surgery
- infection
- inflammation
74
what are some causes of hemobilia?
- Cholangitis/cholecystitis
- Vascular malformations
- Trauma
- Malignancies
75
what occurs with hemobilia?
pain, bleeding, increased bilirubin occurs
76
what is hemobilia sonographically?
echogenic, mixed, echogenicity, conforms to shape of the duct
77
how does pneumobilia look?
- air within biliary tree appears as bright echogenic linear structures following portal triads
- reverberation ringdown artifact
78
what are the 3 entities that causes Pneumobilia?
1) emphysematous cholecystitis
2) choledochoduodenal fistula (caused by stone in CBD)
3) Cholecystoenteric fistula
79
Gallstone ileus
paralysis of nerves
80
how may stones pass from gallbladder into bowel?
cholecystoenteric fistula
81
what are some causes of Acute bacterial cholangitis?
- stricture due to trauma or surgery
- choledochal cysts
- partially obstructive tumors
82
what is the clinical presentation of Acute bacterial cholangitis?
classic charcot's triad
- fever
- RUQ pain
- jaundice
- leukocytosis
- inc. ALP and bilirubin
- gram-neg enteric bacteria in blood
83
what are sonographic findings of Acute bacterial cholangitis?
- 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
Fascioliasis
- Larvae travel through bowel wall -peritoneal cavity-liver capsule into liver parenchyma
- Matures and produces eggs in the biliary tree
85
what are the symptoms of Fascioliasis?
- jaundice
- fever
- abscess
86
what are the sonographic findings of Fascioliasis?
- hepatomegaly
| - hilar adenopathy
87
fascioloasis lesions
- hypoechoic or mixed echogenicity
- present on 90% cases
- flukes may be seen within ducts and GB
88
what is the path of Clonorchiasis and Opisthorchiasis?
- larvae migrate through the ampulla of Vater into CBD
| - mature within the intrahepatic bile ducts
89
what are the sonographic findings of Clonorchiasis and Opisthorchiasis?
- diffuse dilation of peripheral intrahepatic ducts
- periportal echoes-edema
- floating echogenic foci in GB-flukes or debris
90
Ascariasis
- roundworm 20-30cm long
- fecal-oral route
- common in children
- active in small bowel, enters biliary tree via ampulla of vater
91
what is the sonographic appearance of Ascariasis?
- 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
Recurrent pyogenic cholangitis
- chronic biliary obstruction, stasis, and stone formation
| - leads to recurrent episodes
93
what is the etiology of Recurrent pyogenic cholangitis?
unknown
94
what are the sonographic findings of Recurrent pyogenic cholangitis?
-lateral left lobe most often affected
Acute complication=sepsis
chronic complication=biliary cirrhosis and cholangiocarcinoma
95
Primary sclerosing cholangitis
-chronic inflammatory disease of entire biliary tree
96
___________of patients however,have inflammatory bowel disease-colitis
80%
97
what does primary sclerosing cholangitis lead to?
- Biliary strictures
- Cholestasis
- Biliary cirrhosis
- Portal hypertension
- Hepatic failure
98
what is the etiology of secondary sclerosing cholangitis?
- 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
Cholangiocarcinoma
cancerous (malignant) growth in one of the ducts that carries bile from the liver to the small intestine
100
what are the risk factors of Cholangiocarcinoma?
- age
- recurrent biliary infections
- stone disease
101
________ of Cholangiocarcinoma are adenocarcinoma
90%
102
what are the classifications of Cholangiocarcinoma?
- Hilar=60%
- Distal=30% CBD
- Intrahepatic=10%
103
hilar in Cholangiocarcinoma is also called what?
Klatskin's tumor
104
intrahepatic is also called what?
peripheral
105
what is the most common classification of Cholangiocarcinoma?
Hilar (Klatskins tumor)
106
where is Klatskins tumor located?
porta hepatis
107
what does Klatskins tumor cause?
fibrous tissue formation
108
what are the symtoms of Klatskins tumor?
- Jaundice
- pruritic
- increased LFTS
- nodes
109
what are seen frequently in Distal (CBD)cholangiocarcinoma?
- polyploid masses
| - jaundice
110
what is the 2nd most common primary malignancy tumor?
Intrahepatic cholangiocarcinoma
111
how does Intrahepatic cholangiocarcinoma occur?
increased numbers of liver cirrhosis and Hep C
112
how does Intrahepatic cholangiocarcinoma appear on US?
large solid hypovascular mass with varying degrees of echogenicity
113
how is Intrahepatic cholangiocarcinoma differentiated from HCC?
presence of ductal obstruction
114
Intraductal cholangiocarcinoma
purely intraductal mass
115
polypoidal
distends the affected ducts with mucin
116
what mimics appearance of cholangiocarcinoma?
metastases to biliary tree
117
what does metastases to biliary tree affect?
intrahepatic and extrahepatic ducts
118
what are primary sites of metastases of biliary tree?
- breast
- colon
- melanoma
119
what is a HIDA scan?
most often done to evaluate the gallbladder and the bile
120
why might a doctor preform a HIDA scan?
as part of a test to measure the rate at which bile is released from your gallbladder (gallbladder ejection fraction)
121
what can HIDA tests diagnose?
- 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
what is another name for jaundice?
icterus
123
what is jaundice?
itself is not a disease,but rather a sign of one of the many possible underlying pathological processes that may occur
124
what is Hyperbilirubinemia?
increased levels of bilirubin in blood
125
where else can high levels of bilirubin be?
extracellular fluid
126
where is bilirubin excreted in?
bile and urine
127
where is jaundice usually seen?
```
liver disease (hepatitis and cirrhosis)
but could also be an obstruction in biliary tract
```
128
what is elevation of direct or conjugated bilirubin associated with?
obstruction
- hepatitis
- cirrhosis
- liver metastases
129
what is elevation of indirect or unconjugated bilirubin associated with?
with nonobstructive conditions ie-steatosis
130
what are the symptoms of jaundice?
- pruritic (itchiness)
- fatigue
- abdominal pain
- weight loss
- vomiting
131
what are the signs of jaundice?
- yellow discolouration of skin and eyes
- fever
- pale stools, dark urine
132
how does jaundice appear?
as a yellowish pigmentation of the skin,whites of the eyes and other mucous membranes
133
what are 3 sonographic signs of a gallstone?
- echogenic
- mobility
- shadowing
134
what benign entity does sludge mimic?
polyp/neoplasm
135
what can you do to differentiate between polyp and sludge?
- change patient position
| - use colour doppler
136
what are the symptoms of a patient coming in with a suspended GB disease?
- RUQ pain
- nausea
- vomiting
- pain in back/shoulder
137
what are the sonographic signs of adenomyomatosis?
- GB wall thickening
| - ringdown artifact from Rokitansky-Aschoff sinuses
138
what does positive murphy's sign imply?
acute cholecystitis
139
what is the key sonographic sign of emphysematous cholecystitis?
gas within the wall/lumen of GB
140
what is the key sonographic sign of gangrenous cholecystitis?
sloughing of the walls into the lumen
