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Abdominal and Pelvic Pathology > The Gallbladder and the Biliary System > Flashcards

The Gallbladder and the Biliary System Flashcards

1
Q

Sludge

A

Thickenedbile

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2
Q

Where does Sludge frequently occur from?

A

bilestasis

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3
Q

Sludge can be occasionally found in?

A

CBD

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4
Q

Sludge

Sonographicfinding?

A

AprominentGBcontaininglowlevel internalechoes

Particlescanbesmall

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5
Q

Sludge can also be seen in combination with?

A

cholelithiasis, cholecystitis,andother biliarydiseases

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6
Q

Wall Thickness causes of GB?

A
  • Cholecystitis
  • Adenomyomatosis
  • Cancer
  • Acquiredimmunodeficiencysyndrome
  • Cholangiopathy
  • Sclerosingcholangitis
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7
Q

Wall Thickness

Nonbiliarycauses?

A

–Diffuseliverdisease
–Pancreatitis
–Portalhypertension
–Heartfailure

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8
Q

Wallthickness

Sonographicfindings?

A

–Measuredwhenthetransducerisperpendiculartotheanterior GBwall
– TransverseplaneONLY
– Shouldclearlydemarcatetheanteriorwall
– Measuredfromoutertooutermargins

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9
Q

Cholecystitis?

A

AninflammationoftheGB

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10
Q

Types of Cholecystitis?

A 
– Acute 
– Chronic
– Acalculous
– Emphysematous
 – Gangrenous
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11
Q

Acute cholecystitis

A

Mostcommoncauseischolelithiasisthatcreatesacysticductobstruction
• Foundfrequentlyinfemales`

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12
Q

Clinicalsymptoms of Acute cholecystitis?

A

– AcuteRUQpain
– PositiveMurphy’ssign
– Fever
– Leukocytosis

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13
Q

Complications of Acute cholecystitis?

A

– Empyema
– Emphysematousorgangrenouscholecystitis
– Perforation

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14
Q

Acutecholecystitis

Sonographicfindings?

A

– AGBwithanirregularoutlineofathickenedwall – Asonolucentareamaybepresentwithinthe thickenedwall
–Occasionallyathickenedwallwillbeseeninanormal individual
• Relatedtothedegreeofcontraction

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15
Q

Chroniccholecystitis

A
  • MostcommonformofGB inflammation

* Endresultofnumerous attacksofacute cholecystitis

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16
Q

Chroniccholecystitis symptoms?

A

–MayhavetransientRUQpain

– Notenderness

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17
Q

Chroniccholecystitis

Sonographicfindings?

A

–Frequentlycholelithiasis

– ContractedGB –Coarsewallthickening – WESsign

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18
Q

Acalculouscholecystitis?

A

•AcuteinflammationoftheGBintheabsenceofcholelithiasis
• Mostlikelycausedbydecreasedbloodflow throughthecysticartery
– Trauma,burns,postoperativepatients
• Extrinsiccompressionofthecysticductbya massorlymphadenopathy
• PositiveMurphy’ssign

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19
Q

Acalculouscholecystitis

Sonographicfindings?

A

–ThickenedGBwall
•Greaterthan4–5 mm
–Echogenicsludge – DilatedGB
–Presenceofpericholecysticfluidwithinascitesand/or subserosaledema

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20
Q

Emphysematouscholecystitis

A
  • Rarecomplicationofacutecholecystitis
  • Associatedwiththepresenceofgasforming bacteriaintheGBwallandlumenwith extensionintothebiliaryducts
  • 50%ofpatientshavediabetes
  • Lessthan50%havegallstones
  • Gangrenewithassociatedperforationisa complication
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21
Q

Emphysematouscholecystitis

Sonographicfindings?

A

–Ifthegasisintraluminallookforaprominent brightechoalongthe anteriorwallwithring downorcomettail artifactdirectlyposterior totheechogenic structure

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22
Q

Gangrenouscholecystitis

A
  • Complicationofacutecholecystitis • Mayleadtoperforation
  • GBwallmaybethickenedandedematous withfocalareasofexudate,hemorrhage,and necrosis
  • Maybeulcerationsandperforationsresultinginpericholecysticabscessesorperitonitis
  • Stonesorfinegravelmayoccurin80‐95%of patients
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23
Q

Gangrenouscholecystitis

Sonographicfindings?

A

–PresenceofdiffusemediumtocoarseechogenicdensitiesfillingtheGB lumenintheabsenceofbileductobstruction
– Echogenicmaterialhasthreecharacteristics
• Doesnotshadow
• Isnotgravitydependent
• Doesnotshowalayeringeffect

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24
Q

ThemostcommondiseaseoftheGB?

A

Cholelithiasis

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25
Q

Cholelithiasis

A

Maybeasinglelargestoneorhundredsoftinystones • Tinystonesarethemostdangerous • Canenterthebileductsandobstructtheoutflowofbile

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26
Q

If a patient has Cholelithiasis, what happens after eating a fatty meal?

A

Physiology GBcontractsaftereatingafattymeal

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27
Q

What are the Clinicalpresentation of Cholelithiasis?

A 
5F’s
• Fat 
• Female 
• Forty 
• Fertile 
• Fair Skinned (Milky complexion)
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28
Q

What are other factors of Cholelithiasis?

A
  • Pregnancy
  • Diabetes
  • Oralcontraceptiveuse
  • Hemolyticdiseases
  • Diet-inducedweightloss
  • Totalparenteralnutrition
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29
Q

Symptoms of Cholelithiasis?

A
  • Patientsareasymptomaticuntilasmallstonelodgesinthecysticor commonduct
  • RUQpainwithradiationtotheshoulderafterahighfatmeal
  • Epigastricpain
  • Nausea&vomiting
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30
Q

Cholelithiasis

Sonographicfindings?

A

•Evaluatedforincreasedwallthickness,presenceofinternalreflectionswithinthelumenand posteriorshadowing
• Frequentlypatientshave adilatedGB
• Smallerstones(1‐2mm)aremoredifficultto distinguish
• WhentheGBiscompletely packedwithstonesyouwill onlybeabletoimagethe anteriorborder
- Wallechoshadowsign(WES)

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31
Q

Shiftpatientpositionto demonstratethepresenceof movement?

A
  • Supine
  • LLD
  • Erect
  • Stonesshouldshifttothemore dependentportionoftheGB
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32
Q

Why does Cholelithiasis cause acoustic shadowing?

A

Shadowfromagallstoneisattributedtoacoustic impedanceofthestones,refractionthroughthemor diffractionaroundthem
•Theirsize,location,andpositioninrelationtothefocusofthe beamandtheintensityofthebeam

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33
Q

What are the exceptions for a stone to cast acoustic shadowing?

A

Size of the stone is important

3mm or less may not shadow?

34
Q

Shadow is dependent on the relationship between what?

A

Stone and the sound beam

35
Q

Choledochalcysts

A

• May be the result of pancreatic juices refluxing into the bile duct because of an anomalous junction of the pancreatic duct into the distal common bile duct, causing a wall abnormality, weakness, and outpouching of the ductal walls

36
Q

Choledochalcysts?
Common or rare?
More commonly in?

A

Rare

More commonly found in females than males

37
Q

Choledochalcysts,

Clinical symptoms?

A
  • Abdominal mass
  • Pain
  • Fever
  • Jaundice
38
Q

Choledochalcysts

Sonographic findings?

A

•Appear as a true cyst in the RUQ with or without apparent communication with the biliary system

39
Q

Choledochalcysts
Sonographic findings,
Classified by anatomy?

A
  • Localized cystic dilation of the CBD
  • Diverticulum from the CBD
  • Invagination of the CBD into the duodenum
  • Dilation of the entire CBD and the CHD
40
Q

Hyperplastic cholecystitis?

A

•Represented by a variety of degenerative and proliferative changes of the GB

41
Q

Hyperplastic cholecystitis.

Characterized by?

A
  • Hyperconcentration
  • Hyperexcitablity
  • Hyperexcertion
42
Q

Hyperplastic cholecystitis,

More common in?

A

Females

43
Q

Hyperplastic cholecystitis,

How many types and what kind?

A

Two types
•Cholesterolosis
•Adenomyomatosis

44
Q

Cholesterolosis

A

A condition in which cholesterol is deposited within the lumina propria of the GB

45
Q

Cholesterolosis associated with?

A

Cholesterol stones

46
Q

Cholesterolosis,

Known as?

A
  • Known as a strawberry gallbladder

* The mucosa resembles the surface of a strawberry

47
Q

Cholesterolosis,

Conditions?

A
  • Most do not show thickening of the GB wall
  • A small percentage of patients with this condition will show cholesterol polyps
  • Polyps
    * Small well defined soft tissue projections from the GB wall
    * Cholesterol polyp is the most common pseudotumor of the GB
48
Q

Cholesterolosis

Sonographic finding?

A
  • Small smooth wall projections seen to arise from the GB wall
  • Usually multiple
  • Do not shadow
  • Remain fixed to the wall with changes in patient position
  • Comet‐tail artifact may be present
49
Q

Adenoma

A

•Benign neoplasms of the GB with a premalignant potential lower than colonic adenomas

50
Q

What does Adenoma usually occur as?

A

A solitary lesion

51
Q

Smaller lesions in Adenoma are?

A

smaller lesions are pedunculated

52
Q

Larger lesions in Adenoma may?

A

may contain foci of malignant transformation

53
Q

What should be suspected if the GB wall is thickened adjacent to the adenoma?

A

malignancy should be suspected

54
Q

Adenoma

Sonographic appearances?

A

•Thickening of the
GB wall making an hourglass appearance
•Twinkle artifact
without real vascularity

55
Q

Acutecholecystitis

Symptoms?

A

–Hydrops,

  • Sludge
  • PositiveMurphy’ssign
  • Presenceor absenceofpericholecysticfluid
56
Q

Adenomyomatosis

A
  • Hyperplastic change in the GB wall

* May be scattered over a large part of the mucosal surface of the GB

57
Q

Rokitansky‐Aschoff sinuses associated with?

A

Adenomyomatosis

58
Q

Rokitansky‐Aschoff Sinuses

A

–Small mucosal herniations into the muscular layer of the gallbladder

59
Q

Adenomyomatosis,

Sonographic findings?

A
  • Appear as small elevations in the GB lumen
  • Maintain their initial location during positional changes
  • Are the cause for a comet tail
  • No shadow is seen posterior
60
Q

Porcelain gallbladder

A

A rare occurrence, Calcium incrustation of the GB wall

61
Q

Porcelain gallbladder,

Associated with ______ in the majority of patients?

A

Gallstones

62
Q

Porcelain gallbladder, symptoms?

A

Asymptomatic

•25% will develop cancer of the GB wall

63
Q

How is Porcelain Gallbladder diagnosis made?

A

Diagnosis is made as an incidental finding or when a mass is found on physical examination

64
Q

Porcelain Gallbladder,

Sonographic findings?

A

•Bright echogenic echo is seen in the region of the GB
with posterior shadowing
•Differential will include WES sign

65
Q

Gallbladder carcinoma

A
  • Tumor infiltrates the GB and causes thickening and rigidity of the wall
  • A rapidly progressive disease
    * Occurs most frequently in women 60 yrs or older
66
Q

Gallbladder carcinoma, Mortality rate and is associated with?

A
  1. 100%

2. Associated with cholelithiasis in 80‐90%

67
Q

Gallbladder carcinoma, increases the risk of?

A
  • Increased incidence of GB cancer

* Twice as common as cancer of the bile ducts

68
Q

In Gallbladder carcinoma, adjacent liver is often invaded by?

A

by:

  1. direct continuity extending through tissue spaces,
  2. the ducts of Luschka,
  3. the lymph channels, or any combination
69
Q

In gallbladder carcinoma, obstruction of the cystic duct results from?

A

Direct extension of the tumor or extrinsic compression by involved lymph nodes
•Occurs early

70
Q

Gallbladder carcinoma,

Sonographic findings?

A
  • The global shape of malignant gallbladder masses is similar to that of the GB
  • Mass is heterogeneous solid or semisolid echo texture
  • GB wall is markedly abnormal and thickened
  • Adjacent liver tissue in the hilar area is often heterogeneous due to tumor spread
  • May be dilated biliary ducts within the liver parenchyma causing the “shotgun” sign
  • Almost never detected at a resectable stage
  • Obstruction of the cystic duct occurs early
  • Causes nonvisualization of the GB on oral cholecystogram
71
Q

Dilated biliary ducts

A
  1. Must be greater than 4mm
  2. Biliary ducts parallel the portal system
  3. Generally a duct more than 6 mm in diameter is considered borderline and more than 10 mm is considered dilated
72
Q

Dilated biliary ducts,

CHD has an internal diameter of?

A

= less than 4mm
•Duct diameter of 5 mm is borderline
•Duct diameter of 6 mm requires further investigation

73
Q

Biliary obstruction,

Three primary areas for obstruction?

A
  • Intrapancreatic
  • Suprapancreatic
  • Porta hepatic
74
Q

Extrahepatic biliary obstruction, the sonographer should?

A

localize the level and cause of the obstruction

75
Q

Biliary obstruction, Intrapancreatic, What are the three conditions that cause the majority of biliary obstruction at the level of the distal duct and cause extrahepatic duct to be entirely dilated?

A
  • Pancreatic carcinoma
  • Choledocolithiasis
  • Chronic pancreatitis with stricture formation
76
Q

Biliary obstruction, Suprapancreatic obstruction?

A

Obstruction originates between the pancreas and the porta hepatis
•Head of the pancreas, the intrapancreatic duct, and the pancreatic duct are normal with ultrasound

77
Q

Biliary obstruction, Suprapancreatic obstruction most common case is?

A

Most common cause is malignancy or adenopathy

78
Q

Biliary obstruction, Porta hepatic obstruction?

A
  • Usually due to a neoplasm
  • Ultrasound will show intrahepatic ductal dilation and a normal CBD
  • Hydrops of the GB may be present
79
Q

Biliary obstruction, Other causes of obstruction?

A
  • Cholangiocarcinoma originates within the larger bile ducts

* Klatskin’s tumor

80
Q

Klatskin’s tumor

A
  • Specific type of cholangiocarcinoma
  • Can occur at the bifurcation of the CHD
  • Involvement of both the central left and right duct
  • Most suggestive sonographic feature to indicate cholangiocarcinoma is isolated intrahepatic duct dilation
  • Obstructing mass may not be visualized, a nonunion of the Rt and Lt ducts is characteristic for a Klatskin’s tumor
81
Q

Mirizzi syndrome,

Cause?

A

Cause for extrahepatic biliary obstruction due to an impacted stone in the cystic duct

82
Q

Mirizzi syndrome,

Sonographic findings?

A

•Intrahepatic ductal dilation is seen with a normal size CBD and a large stone in the neck of the GB or cystic duct

Abdominal and Pelvic Pathology (1 decks)

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