Biliary Imaging

Question 1

MRCP imaging techniques

Answer 1

MRCP = T2 weighted sequences to view fluid in biliary tract/surrounding structures

fast spin echo sequences

intremediate T2 (TE 80-100ms) best suited for biliary ductal syste

Question 2

advantages/disadvantages of MRCP over ERCP

Answer 2

Advantages

• MRCP has the ability to see extra-luminal findings.
• MRCP can visualize excluded (obstructed) ducts.
• MRCP is non-invasive.

Disadvantages

• MRCP does not allow for concurrent therapeutic intervention.
• MRCP does not actively distend the biliary ductal system with contrast. -MRCP has worse spatial resolution compared to ERCP.

Question 3

gadoxetic acid disodium

Answer 3

Eovist

Question 4

gadobenate dimeglumine

Answer 4

Multihance

Question 5

contrast enhanced MRCP

Answer 5

FS T1 weighted with gadolinium contrast agents with biliary excretion

short T1 relaxation resulting in T1 hyperintense biliary fluid (20-45 min delay to allow for biliary excretion)

Question 6

Todani system

Answer 6

divides choledochal cysts based on number, distribution, morphology

type I: fusiform dilation
type II: extrahepatic saccular dilation
type III: intraduodenal bile duct dilation
type IV: multiple segments dilated
type V: intrahepatic dilation/caroli disease

Question 7

choledochal cysts vs hamartomas

Answer 7

choledochal cysts communicate with biliary tree

hamartomas do not communicate with biliary tree

Question 8

biliary anatomic variants

Answer 8

low insertion of cystic duct

aberrant right posterior duct

Question 9

aberrant right posterior duct clinical significance

Answer 9

right hepatic liver donor; 2 right hepatc ducts must be anastomosed separately

Question 10

when are choledochal cysts diagnosed? increased risk?

Answer 10

childhood; increased risk for cholangiocarcinoma

Question 11

most common type of extrahepatic cyst

Answer 11

type 1 choledochal cyst

Question 12

caroli disease association

Answer 12

polycystic kidneys

Question 13

caroli syndrome

Answer 13

caroli disease + hepatic fibrosis

Question 14

central dot sign

Answer 14

CECT: small branch of portal vein and hepatic artery dilated bile ducts

Question 15

type of cholcystitis seen in ICU pts

Answer 15

acalculus colecystitis

Question 16

CT diagnosis of acute cholecystitis

Answer 16

gallbladder wall thickening >3mm
pericholecystic fluid
gallbladder hyperemia
galbladder calculi

Question 17

complications of acute cholecystitis

Answer 17

gangrenous cholecystitis, gallbladder perforation, emphysematous cholecystitis

Question 18

gangrenous cholecystitis cause? treatment?

Answer 18

increased intraluminal pressure&raquo_space; wall ischemia

wall thickening asymmetric/intraluminal membranes present

treat: emergent cholecystectomy/cholecystostomy

Question 19

acute gallbladder perforation complications

Answer 19

subacute peroration&raquo_space; pericholecystic abscess

bile peritonitis

cholecystoenteric fistula

Question 20

emphysematous cholecystitis

Answer 20

gas forming bacteria in the lumen/wall of gallbladder

typical patient: elderly diabetic

treatment: emergent cholecystectomy/cholcystostomy; conservative in high risk patients

Question 21

porcelain gallbaldder

Answer 21

peripherally calcified gallbladder wall, thought to be sequelae of chronic cholecystitis

controversial increased risk of gallbladder carcinoma; treatment with non-emergent cholecystectomy

Question 22

Charcot’s triad

Answer 22

fever, abdominal pain, jaundice

Question 23

most common cause of ascending cholangitis

Answer 23

choledocholithiasis

Question 24

imaging findings of ascending cholangitis

Answer 24

hyperenhancement/thickening of walls of bile ducts; often with CBD stone

Question 25

PSC, associations, complications

Answer 25

idiopathic inflammator destruction of bile ducts associated with UC, more common in males cirrhosis, cholangiocarcinoma, recurrent biliary imagings

Question 26

PSC imaging characteristics

Answer 26

beaded, irregular appearance of CBD and intrahepatic bile ducts

Question 27

PSC mimic

Answer 27

HIV cholangiopathy; although HIV cholangitis is more associated iwth papillary stenosis

Question 28

PBC

Answer 28

inflammation/destruction of smaller bile ducts than PSC middle aged women --> pruritis --> hepatic cirrhosis

Question 29

AIDS cholangitis

Answer 29

biliary infection with ryptosporidium and CMV; present with RUQ pain, fever, elevated LFTs papillary stenosis (different than PSC)

Question 30

recurrent pyogenic cholangitis/oriental cholangiohepatitis

Answer 30

parasie: clonorchis sinesis pigment stone formation, biliary stasis, cholangitis indigenous to SE asia recurrent jaundice/fevers increased risk of cholangiocarcinoma

Question 31

triad of recurrent pyogenic cholangitis

Answer 31

pneumobilia, lamellated bile duct filling defects, intrahepatic/extrahepatic bile duct dilation/strictures

Question 32

biliary cystadenoma

Answer 32

benign cystic neoplasm in middle aged women; does not communicate with biliary system abdominal pain, n/v, obstructive jaundice; may be large may recur after resection

Question 33

biliary cystadenoma imaging

Answer 33

large multiloculated cystic mass; septations distinguish from simple cyst no thick enhancing wall large solid component/thick calcificationshould raise concern for cystadenocarcinoma

Question 34

cholangiocarcinoma

Answer 34

malignant tumor of biliary ductal epithelium --> duct obstruction and intrahepatic ductal dilation, capsular retraction >> lobar atrophy hilar tumor at intrahepatic ducts is known as Klatskin tumor

Question 35

risk factors for cholangiocarcinoma

Answer 35

Choledochal cyst(s). Primary sclerosing cholangitis. Familial adenomatous polyposis syndrome. Clonorchis sinensis infection. Thorium dioxide (alpha-emitter contrast agent), not used since the 1950s. Thorium dioxide is also associated with angiosarcoma and HCC.

Question 36

gallbladder carcinoma

Answer 36

chronic gallblader inflammation >> carcinoma scirrhous infiltrating mass that invades through wall into liver; sometimes polypoid mass, rarelymural thickening

Question 37

gallbladder metastasis

Answer 37

melanoma