Bile ducts and gallbladder Flashcards Preview

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Flashcards in Bile ducts and gallbladder Deck (74):
1

What is the pathology behind PSC? What is the natural history? What is the median survival?

Fibrosing inflammation Chronic progression from initial cholangitis to periportal hepatitis to septal fibrosis to bridging necrosis to cirrhosis 12 years

2

What are the cholangiographic features of PSC?

Band strictures (beaded appearance) Nonuniform, segmental strictures Pruned tree appearance of intrahepatic ducts Diverticular outpouching Mural irregularity

3

What is the feared complication with PSC? When is is suspected?

Cholcangiocarcinoma Suspect when there is a dominant stricture

4

What is the mechanism for PBC? What diseases is it associated with? What is the marker? What is the pathophysiology

T-cell mediated immune response RA, Sjogrens, Hashimotos Antimitochondrial antibody Small duct destruction with inflammatory cellular infiltrate

5

What are the cholangiographic features of PBC? Early vs late

Early - may be normal Late - Cirrhosis, crowding, tortuosity and deformity of the bile ducts. Enlarged benign reactive lymph nodes in the hepatic portal

6

What are the bugs related to AIDS induced cholangiopathy?

Cryptosporidium and CMV

7

Intrahepatic ductal strictures with papillary stenosis?

AIDS cholangiopathy

8

What feature is unique to AIDS cholangiopathy?

Papillary stenosis

9

What is ascending cholangitis?

Obstruction of the biliary tree with bacterial infection of the bile.

10

What is a common liver finding in ascending cholangitis?

Hepatic abscess

11

Cystic hepatic lesion communicating with biliary tree in septic patient?

Hepatic abscess complicating ascending cholangitis

12

What is the most common bug in ascending cholangitis?

E coli

13

Bile duct stones Ductal dilation and focal strictures Acute peripheral tapering Decreased arborization of intrahepatic ducts

Oriental cholangiohepatitis

14

What is the bug in oriental cholangiohepatitis

Clonorchis, Ascariasis, nutritional deficiency

15

What is the main difference between PSC and PBC?

PBC affects small bile ducts only

16

What is the target sign in relation to choledocholithiasis?

Ring of water attenuation around a stone

17

What is the crescent sign in relation to choledocholithiasis

Only a crescent of water surrounds the calculus

18

What are the 3 types of gallstone?

1) cholesterol 75% 2) pigmented 20% - crystallization of calcium bilirubinate, can be black (blood, sickle cell) or brown (bile, infection) 3) Mixed

19

What is Admirand's triangle

Balance of cholesterol, bile acids, and lecithin (phospholipid) in the gallbladder

20

What is a pseudocalculus?

Apparent filling defect within the ampulla due to sphincter of oddi spasm

21

What is a helpful sign to differentiate pseudocalculus from real stone?

Pseudocalculus will only have a crescent along the superior aspect that disappears with time/glucagon Real stone will have a crescent along the inferior aspect as well.

22

Differentiate spasm of sphincter of oddi with Papillary stenosis?

Spasm will relax over time

23

What is a sign of fixed narrowing of the ampulla?

Upstream dilation of both the common bile and pancreatic.

24

What are the associations with ampullary carcinoma?

FAP, HNPCC

25

Inflammatory stricture of the common hepatic or common bile duct due to impacted stone in the cystic duct or neck of the gallbladder.

Mirrizzi syndrome

26

What is the most common cause of common hepatic duct narrowing?

Hilar lymphadenopathy

27

Multiple and recurrent papillary adenomas in the biliary tract. US - multiple solid filling defects attached to the wall of a dilated extrahepatic duct extremely rare

Biliary papillomatosis

28

Are papillary adenomas premalignant?

Yes

29

Multiloculated cystic lesion along the biliary tree with well defined thick capsule? Seen in middle aged white women

Biliary cystadenoma

30

Differentiate cystadenoma from echinococcal and hepatic abscess

Echinococcal - peripheral intracystic cysts and wall calcification and history of travel to endemic area Abscess - multiple well defined cystic masses with rim hyperenhancement and fevers/leukocytosis

31

What are signs of a biliary cystadenocarcinoma over cystadenoma?

Carcinoma: thick septae enhancing nodular components calcifications

32

What are the two types are biliary cystadenocarcinoma> which one has a better prognosis?

Those that contain ovarian stroma and those that do not Ovarian stroma favors better prognosis

33

What is the analogy to intraductal cholcangiocarcinoma?

IPMN pancreas

34

Which cholangiocarcinoma has the best prognosis?

Those growing in the CBD (ie extrahepatic) have easier chance for resection

35

What is a klatskin tumor?

Cholangiocarcinoma involving the upper common hepatic duct

36

What is a limiting factor for removal of a klatskin tumor?

One hepatic lobe must be tumor free

37

What is the enhancement pattern of a klatskin tumor?

Hypo/isoattenuating compared to liver during arterial and portal venous phase Enhances on delayed phase

38

Why do scirrhous cholangiocarcinomas enhance on delayed imaging?

They incite a desmoplastic reaction

39

What are the two types of cholangiocarcinoma?

Intra and extrahepatic

40

What is the most common biliary tract anomaly?

Aberrant intrahepatic duct draining into a contralateral main or common hepatic duct.

41

Are biliary leaks more common with laparoscopic or open cholecystectomy?

laparoscopic

42

Name 3 associations with choledochal cysts

Biliary tract stenosis/atresia Congenital hepatic fibrosis Medullary sponge kidney

43

What is the patholophysiology choledochal cysts

Anomalous connection between pancreatic duct and biliary system allows pancreatic secretions to weaken the wall of the duct

44

choledochal cyst types

Q image thumb

1 - fusiform

2 - pedunculated

3 - at ampulla, choledochocele

4 - intra and extrahepatic

5 - intrahepatic (carolis)

45

46

What is a type 3 choledochal cyst?

Choledochocele

47

What is carolis disease? is it AR or AD? How does it present radiographically? What are the associations?

 

What is a good differentiating feature between carolis and PSC?

Autosomal recessive disease, results in alternating regions of narrowing and saccular/fusiform dilatation within the intrahepatic ducts

Associated with renal diseases (medullary sponge kidney, polycystic kidney disease, medullary cystic disease)

PSC is rarely saccular

48

What are the risks with carolis disease?

100x risk of adenocarcinoma

stone formation

recurrent cholangitis

liver abscess

49

What biliary disease does renal tubular ectasia have an association with?

Caroli disease

50

How does gangrenous cholecystitis present on US? CT?

Intramural edema or sloughing of the mucosa into GB lumen

 

Pericholecystic fluid collection due to perforation

51

What bug is associated with emphysematous cholecystitis? What disease is associated and what percentage of patients have it?

Clostridium perfringens

 

Diabetes 30%

52

How does gas appear on US?

Dirty acoustic shadowing

 

vs. clean shadowing such as that seen with a calculus

53

What are 6 causes of acalculous cholecystitis?

Hyperalimentation

Trauma

ICU setting

Infectious colitis

Vascular disease

Immunocompromised

54

What is the cause of porcelain gallbladder?

Chronically obstructed cystic duct

Chronic cholecystitis

55

What is the risk and percentage of that risk associated with porcelain gallbladder

25% incidence of gallbladder carcinoma

56

What is the wall echo shadow sign?

Seen in a gallbladder full of stones

2 echogenic lines with an intervening sonolucent line

57

What is milk of calcium bile?

Calcium carbonate/phosphate/bilirubinate that is highly concentrated within the GB due to cystic duct obstruction

58

What is gallbladder sludge?

Concentrated, echogenic bile containing particulate material consisting of cholesterol crystals and calcium bilirubinate granules

59

What is tumefactive sludge?

Ball of sludge, can mimic mass but wont have posterior shadowing

60

What makes up a cholesterol polyp?

Single layer of epithelium covering a core of cholesterol filled cells

61

How does metastatic melanoma present in the gallbladder?

Multiple polypoid intraluminal masses

62

Echogenic foci within a thickened gallbladder wall with comet down artifact suggests what? What is the pathology behind it?

Adenomyomatosis

 

Convoluted infoldings of the normal gallbladder mucosa (rokitansky aschoff sinuses) with smooth muscle proliferation

63

What is focal adenomyomatosis?

Can cause segmental narrowing and distort lumen with a masslike appearance

64

How many gallbladder carcinomas present as polypoid lesions? What is the most common manifestation? How are the differentiated from sludge on US?

25%

Infiltrating mass arising from gallbladder fossa extending into the liver

Blood flow on doppler will be seen with cancer

65

What are the two types of gallbladder cancer

Schirrous - infiltrates liver from gallbladder

 

Polypoid - grows into GB lumen

66

What is the most common tumor to metastasize to the gallbladder?

MElanoma

67

What is a phrygian cap?

Congenital infolding of the gallbladder wall with no known clinical significance

68

Differentiate between a phrygian cap and focal adenomyomatosis?

Phrygian cap will always be in the fundus and have a THIN membrane

Adenomyomatosis will be thicker and can be located anywhere

69

What is the cutoff for a normal gallbladder wall thickness? What are some causes?

3mm

Incomplete distension

Cholecystitis, adenomyomatosis, hepatitis, cirrhosis, portal hypertension, hypoproteinemia, CHF, renal failure, pancreatitis

70

Cystic thickening of the gallbladder wall is seen with what?

Gallbladder varices

71

Gallbladder varices should prompt a search for what?

Portal vein thrombosis

72

Name 5 cystic duct variations

Low insertion onto CBD

Conjoined cystic and CBD

Absent cystic duct

Insertion into RHD

Insertion at bifurcation of CHD

73

Name 3 intrahepatic ductal variations

Right posterior duct into the LHD

Right posterior into the CHD

Right posterior into the CHD bifurcation

74