URR 25 Flashcards
1
Q
In gallbladder carcinoma, ____ is common due to the thin layer of tissues that make up the GB wall
A
hepatic invasion
2
Q
_____ in the liver hilum are the first to be affected with lymphatic involvement in gallbladder carcinoma
A
lymph nodes
3
Q
diffuse of focally thickened, irregular gallbladder wall; solid may in lumen that may extend into the ducts
A
gallbladder carcinoma
4
Q
most commonly presents as a diffusely thickened gb wall with stones
A
gallbladder carcinoma
5
Q
In gallbladder carcinoma, there is a loss of differentation between the gb wall and liver interface due to:
A
tumor invasion
6
Q
How to evaluate the extent of gb carcinoma
A
assess biliary tree for dilatation
check the porta hepatis area for enlarged lymph nodes
evaluate the liver for metastasis
7
Q
rare malignant tumor growth in the intrahepatic or extrahepatic biliary tree
A
cholangiocarcinoma
8
Q
Cholangiocarcinoma arises from the:
A
epithelium
9
Q
Cholangiocarcinoma is classifed as ____, ____, and ____
A
intrahepatic
hilar (Klatskin)
extrahepatic
10
Q
Extrahepatic involvement of cholangiocarcinoma most commonly occurs in the:
A
extrahepatic duct segments (CBD or CHD)
11
Q
Focal thickening of the ductal wall with surrounding mass invasion into the liver
A
cholangiocarcinoma
12
Q
Clinical symptoms of cholangiocarcinoma
A
RUQ pain
weight loss
obstructive jaundice
palpable gallbladder
13
Q
Lab testing associated with cholangiocarcinoma
A
increased bilirubin, alkaline phosphatase, alpha-fetoprotein
14
Q
Risk factors for cholangiocarcinoma
A
primary sclerosing cholangitis (#1)
parasitic infections
colitis
choledochal cysts
Caroli disease
15
Q
Cholangiocarcinoma can obstruct ___ and/or ____
A
ducts
portal veins
16
Q
Cholangiocarcinoma can cause:
A
lobar atrophy of affected liver lobe (s)
17
Q
In cholangiocarcinoma evaluate for associated lymphadenopathy at the ____, ___, and around the _____ in the midline abdomen
A
liver hilum
pancreas
vascular structures
18
Q
____ may be used as part of the treatment in cholangiocarcinoma to relieve obstructive jaundice
A
Biliary stent placement
19
Q
Biliary stents are made of ____ or ____
A
plastic
metal
20
Q
Causes of malignant obstructive jaundice
A
pancreatic cancer
cholangiocarcinoma
metastatic disease
21
Q
Causes of benign obstructive jaundice
A
acute and chronic pancreatitis
choledocholithiasis
primary sclerosing cholangitis
AIDS cholangiopathy
strictures after invasive procedures
22
Q
irregular isoechoic mass within the liver; contiguous with the biliary tree; usually dilated intrahepatic and extrahepatic ducts
A
cholangiocarcinoma
23
Q
Hilar cholangiocarcinoma
A
Klatskin Tumor
24
Q
most common type of cholangiocarcinoma
A
Klatskin tumor
25
Where is a Klatskin tumor found?
in the hilum of the liver adjacent to the right and left hepatic duct confluence
26
Clinical symptoms of Klatskin tumor
jaundice
pruritus
weight loss
pain
27
lab testing associated with cholangiocarcinoma
increased bilirubin, alkaline phosphatase
AFP
28
Klatskin tumor causes ____ , ____
intrahepatic ductal dilatation
normal extrahepatic ducts
29
The ___ is usually normal caliber because the Klatskin tumor is proximal to it
CBD
30
dilated right and left intrahepatic ducts; normal extrahepatic ducts; solid mass adjacent to dilated ducts; hydropic gallbladder
Klatskin tumor
31
#1 primary cancer to metastasize to gb
melanoma
32
primary cancers that can metastasize to gb
melanoma
pancreas
ducts
stomach
liver
kidneys
lungs
33
____ usually presents with stones
primary biliary cancer
34
sonographic appearance of metastasis in gb
solid mass without shadowing
focal gallbladder wall thickening
lack of gravity dependence of mass
presence of vascular flow in mass
no stones
35
most common congenital biliary defect
phrygian cap
36
2nd most common congenital biliary defect
junctional fold
37
Choledochal cysts most commonly affect the:
CBD
38
Choledochal cysts are more common in:
Asian women
39
most common cause of acute cholecystitis
a stone in the gb neck or cystic duct
40
two most common causes of biliary tree dilatatiaon
stones
pancreatic head mass
41
Choledocholithiasis usually occurs in the:
distal CBD
42
most common cause of increased GB wall thickness
Acute cholecystitis
43
Emphysematous cholecystitis is more in ___ and ____
men
diabetics
44
most commonly seen in patients with inflammatory bowel disease or ulcerative colitis
primary sclerosing cholangitis
45
most commonly caused by percutaneous biliary procedures and liver biopsy
hemobilia
46
Primary gb cancer usually occurs with:
gallstones
47
most commonly presents as a diffusely thickened GB wall with stones
primary gb cancer
48
____ gb cancer usually occurs without gallstones
metastatic
49
Cholangiocarcinoma most commonly affects the:
extrahepatic ducts
50
Klatskin tumors most commonly affect the:
intrahepatic ducts
51
How is a benign polyp differentiated from a stone in the GB lumen?
a. echogenicity
b. size
c. shape
d. mobility
d
52
A polyp greater than ____ is suggestive of malignancy.
a. 3mm
b. 5mm
c. 8mm
d. 10mm
d
53
Which of the following is caused by malfunction of cholesterol metabolism causing cholesterol to be deposited in the lamina propia of the gallbladder wall?
a. cholesterolosis
b. adenomyomatosis
c. cholecystitis
d. cholangitis
a
54
How is cholesterolosis differentiated from adenomyomatosis?
a. wall thickness
b. comet tail artifact
c. presence or absence of Rokitanksy-Aschoff sinuses
d. all the above
d
55
If adenomyomatosis is segmental, what portion of the gallbladder is typically affected?
a. neck
b. body
c. fundus
d. cystic duct
c
56
Pneumobilia is a common complication of:
a. recent ERCP
b. chronic cholecystitis
c. adenomyomatosis
d. biloma
a
57
What acoustic artifact is demonstrated from the ductal system with pneumobilia?
a. ring down
b. mirror image
c. propagation speed
d. refraction
a
58
Which of the following are complication of invasive biliary procedures?
a. hemobilia
b. pneumobilia
c. biloma
d. all the above
d
59
Most cases of gb cancer have associated:
a. gallstones
b. weight gain
c. retroperitoneal lymphadenopathy
d. all the above
a
60
When gb carcinoma is suspected, what additional information should be obtained from the exam?
a. ductal diameters
b. portal hilar lymph node characteristics
c. liver tissue homogeneity
d. all the above
d
61
Which of the following describes the sonographic appearance of gb cancer extending into the liver?
a. areas of cystic degeneration in the porta hepatis
b. loss of differentiation of the gb wall and liver interface
c. macrocalcification of the gb wall
d. areas of cystic degeneration in the liver tissue
b
62
Cholangiocarcinoma that causes obstructive jaundice can also cause what clinical finding:
a. systemic HTN
b. diabetes
c. palpable gallbladder
d. congestive heart failure
c
63
Cholangiocarcinoma at the junction of the right and left hepatic ducts is called:
a. intrahepatic cholangiocarcinoma
b. extrahepatic cholangiocarcinoma
c. Klatskin tumor
d. Murphy tumor
c
64
Elevation of which of the following lab values indicates cholangiocarcinoma instead of cholangitis?
a. alkaline phosphatase
b. bilirubin
c. white blood cell count
d. alpha feto-protein
d
65
Intrahepatic duct dilatation with normal extrahepatic ducts is most suggestive of:
a. intrahepatic cholangiocarcinoma
b. extrahepatic cholangiocarcinoma
c. hilar cholangiocarcinoma
d. adenomyomatosis
c
66
How is metastasis to the gb differentiated from primary gb cancer?
a. presence or absence of cholelithiasis
b. presence or absence of internal vascularity of mass formation
c. presence or absence of wall thickening
d. presence of absence of wall hypervascularity
a
67
Which of the following abnormalities is associated with production of milk of calcium bile?
a. hepatoma
b. cirrhosis
c. chronic cholecystitis
d. acute cholecystitis
c
68
What term describes a gallbladder that is filled with bile that is isoechoic to the liver and is difficult to identify on ultrasound?
a. charcot triad
b. courvoisier gb
c. hepatization
d. mirizzi syndrome
c
69
A patient presents with a low grade fever, leukocytosis, nausea, diarrhea, and LLQ pain. What is the most likely explanation?
a. primary sclerosing cholangitis
b. biliary stricture in the cystic duct
c. mass at the ampulla of vater
d. caroli disease
a
70
The gallbladder wall is asymmetrically thickened with hypervascularity and perfusion defects noted on color Doppler evaluation. Intraluminal membranes and sludge are also present. What is the most likely cause for these findings?
a. adenomyomatosis
b. gangrenous cholecystitis
c. chronic cholecystitis
d. cholesterolosis
b
71
If gallstone impaction is suspected:
a. place the patient in the LLD position and ask the patient to perform the valsalva maneuver to attempt to move the stone
b. place the patient in the LLD position and tap the patient's back between the scapulas with the base of your wrist to attempt to move the stone
c. ask the patient to stand during the exam and perform the valsalva maneuver to attempt to move the stone
d. scan the patient in multiple positions to attempt to move the stone
d
72
Primary sclerosing cholangitis significantly increases the risk of developing:
a. Klatksin tumor
b. cholangiocarcinoma
c. pancreatic carcinoma
d. hepatic lipoma formation
b
73
An US demonstrates a non shadowing, non-mobile, echogenic foci within the gb that most likely represents:
a. polyp
b. sludge ball
c. calculus
d. porcelain gb
a
74
A new liver mass in a patient with sclerosing cholangitis should cause suspicion of:
a. the development of cholangiocarcinoma
b. portal HTN
c. the development of schistosomiasis
d. a peribiliary leak
a
75
Diffuse or gb wall thickening may be seen with all of the following, except:
a. carcinoma of the gb
b. acute cholecystitis
c. adenomyomatosis
d. courvoisier gb
d
76
Which of the following is a cause of parasitic cholangitis?
a. gram negative bacteria
b. ulcerative colitis
c. HIV infection
d. biliary ascariasis
d
77
Gallbladder polyps measuring greater than ___ in diameter are highly suspicious for malignancy.
a. 5mm
b. 10mm
c. 15mm
d. 20 mm
b
78
A 6 month old Asian female presents with jaundice and fever. While scanning the liver, you note a 1 cm anechoic, round dilatation of the extrahepatic CBD at the porta hepatis. Color Doppler does not demonstrate flow within the structure. Which of the following is the most likely diagnosis?
a. choledochal cyst
b. pneumobilia
c. pseudoaneurysm of the hepatic artery
d. cholangitis
a
79
A 64 year old female presents with recent weight loss and mild jaundice. Lab values demonstrate normal WBC levels, but increased levels of direct bilirubin, alkaline phosphatase, and prothrombin time. The gallbladder demonstrates a small wall mass that is isoechoic to the wall tissues. The wall measures 4.5mm in maximum thickness. Multiple stones are present within the lumen.
a. primary gb carcinoma and cholelithiasis
b. acute cholecystitis and cholelithiasis
c. acute cholecystitis, polyp formation and cholelithiasis
d. adenomyomatosis
a
80
Jaundice is a complication of:
a. ductal obstruction and red blood cell destruction
b. steatosis and hemangiomas
c. ductal obstruction and white blood cell destruction
d. steatosis and polycystic liver disease
a
81
An otherwise asymptomatic patient presents for an abdomen ultrasound due to elevated LFTs. The gallbladder demonstrates thickened walls with an irregular internal contour. Several small echogenic foci are noted within the wall and each exhibits a comet tail artifact. Which of the following conditions is identified on this exam?
a. chronic cholecystitis
b. emphysematous cholecystitis
c. cholesterol polyps
d. adenomyomatosis
d
82
An inflammation of the biliary tree common in HIV patients is called:
a primary sclerosing cholangitis
b. HIV cholangitis
c. pneumobilia
d. bacterial cholangitis
b
83
If the common hepatic duct is obstructed, how will this affect the other biliary structures?
a. contracted GB and dilated intrahepatic ducts
b. dilated GB and dilated intrahepatic ducts
c. contracted GB and dilated extrahepatic and intrahepatic ducts
d. dilated extrahepatic ducts
a
84
The bile duct diameter should be measured with the calipers placed from:
a. inner wall to inner wall
b. outer wall to outer wall
c. inner wall to outer wall
d. leading edge to leading edge
a
85
RUQ pain, positive Murphy sign, and fever are common clinical signs of:
a. acute cholecystitis
b. appendicitis
c. ascites
d. adenomyomatosis
a
86
A patient presents for an abdomen ultrasound with RUQ pain, nausea, fever, and leukocytosis. An abnormal enlarged gallbladder demonstrates thickened walls at 1.2 cm. An anterior segment of the wall is echogenic and ring down artifact and dirty shadowing are present posterior to this area. Which of the following conditions is identified on this exam?
a. adenomyomatosis
b. cholesterol polyps
c. chronic cholecystitis
d. emphysematous cholecystitis
d
87
Which of the following would present with no signs of jaundice?
a. a stone at the ampulla of vater
b. sphincter of Oddi dysfunction
c. hepatitis
d. mucocele of the GB
d
88
Which type of gallbladder disease is more common in males and diabetic patients?
a. gb perforation
b. emphysematous cholecystitis
c. cholangitis
d. chronic cholecystitis
b
89
What is the most common cause of cholangitis?
a. choledocholithiasis
b. Klatskin tumor
c. adenomyomatosis
d. AIDS
a
90
The twinkle artifact is an expected finding in cases of:
a. multicystic kidney disease
b. autosomal dominant polycystic kidney disease
c. adenomyomatosis
d. renal carbuncle
c
91
Cholelithiasis without cholecystitis is most likely to be seen in a patient with:
a. sepsis
b. AIDS
c. a history of a prolonged low fat diet
d. a history of recent abdominal surgery
c
92
Which of the following correctly describes the abnormal response seen on an ultrasound exam when a fatty meal is given to a patient with suspected biliary obstruction?
a. if a biliary obstruction is present, the bile duct diameter will decrease immediately after the meal
b. if a biliary obstruction is present, the bile duct diameter will remain unchanged immediately after the meal
c. the cystic duct dilates to allow for a detailed lumen evaluation for a possible stone
d. if a biliary obstruction is present, the bile duct diameter will increase immediately after the meal
d
93
What biliary anomaly is suspected if jaundice persists more than 14 days after birth?
a. biliary atresia
b. choledochal cyst
c. ectopic gb
d. agenesis of the GB
a
94
A non-infectious cause of acalculous cholecystitis is ____ and an infectious cause of acalculous cholecystitis is _____
a. total parenteral nutrition, HIV
b. CHF, total parenteral nutrition
c. HIV, viscous bile
d. viscous bile, Mirizzi syndrome
a
95
Which of the following is caused by infection or ischemia of the gallbladder wall?
a. Hartmann pouch
b. adenomyomatosis
c. Bouveret syndrome
d. membranous gangrenous gallbladder
d
96
Primary GB carcinoma most commonly presents as:
a. focal wall mass without stones
b. enlarged gb surrounded by fluid
c. diffusely thickened gb with stones
d. small gb with thickened walls
c
97
A 35 year old male patient presents for a RUQ ultrasound due to pain, increased alkaline phosphatase, and conjugated bilirubin. You identify dilated intrahepatic ducts in both lobes of the liver, while the CBD and gallbladder wall appear within normal limits. Which of the following describes the cause for these findings?
a. biliary atresia
b. stone in the right hepatic duct
c. stone in the common hepatic duct
d. stone in the left hepatic duct
c
98
Which of the following biliary abnormalities would be an acute complication caused by a bacterial infection of the gallbladder?
a. adenomyomatosis
b. porcelain GB
c. emphysematous cholecystitis
d. strawberry GB
c
99
An 85 year old patient presents with a history of epigastric pain. Lab values are normal. The exam demonstrates normal intrahepatic ducts and a 10mm CBD that appears patent. The pancreas appears normal. What is the most likely reason for the 10 mm CBD?
a. the CBD normal dilates with age.
b. the obstruction in the CBD must be due to biliary stricture which is hard to visualize sonographically.
c. cholangitis usually only affects the CBD and can lead to a focal extrahepatic dilatation
d. the patient most likely has portal HTN which can cause ductal dilatation
a
100
Which of the following correctly describes how to differentiate a large gallstone (<3cm) from a porcelain gallbladder?
a. the gallstone can be located in any part of the gallbladder while porcelain calcification only affects the gallbladder fundus
b. a gallstone will demonstrate significant posterior shadowing but there is no shadowing associated with the wall calcification seen with a porcelain gallbladder
c. a large gallstone and porcelain gallbladder are not easily differentiated sonographically
d. the posterior wall of the gallbladder can be evaluated in patients with porcelain gallbladder but not in patients with a large stone
d
