Biliary System

Question 1

What are the sonographic signs to look for with acute cholecystitis?

Answer 1

Gallstones
Thickening of GB wall (>3mm)
Edematous wall--differentiation of layers
Distention of GB lumen (>4cm)
Impacted stone in cystic duct/ GB neck
Pericholecystic fluid collection
Hyperemic wall
\++ MS
Intrahepatic duct/ CBD dilation

Question 2

What are the sonographic findings for gangrenous cholecystitis?

Answer 2

Nonlayering bands of echogenic tissue within the lumen–sloughed membranes and blood
Irregular walls
Small collections within wall–abscesses or hemorrhage
– MS (nerves are necrosed)

Question 3

What are the sonographic signs of GB perforation?

Answer 3

Focal wall defect and deflation of GB
Pericholecystic fluid collection
Perforation extends into adjacent liver parenchyma forming abscess
Cystic liver lesion around GB fossa suggests a pericholecystic abscess

Question 4

What can arise from prolonged acute cholecystitis?

Answer 4

Gangrenous GB
Perforation
Rupture
Emphysematous cholecystitis
Empyema (pus)
Gallstone ileus
Cholecystoenteric fistula

Question 5

What does emphysematous cholecystitis appear as?

Answer 5

Frequently acalculus
Gas forming bacteria after ischemic event appears as gas in lumen and wall
Echogenic line w/ posterior dirty shadow or ring down artifact
Pneumobilia

Question 6

What are the sonographic signs for chronic cholecystitis?

Answer 6

Gallstones
Wall thickening
Fibrosis

Question 7

What differentiates acute from chronic cholecystitis?

Answer 7

Absence of:

• distension
• ++ MS
• hyperemia of wall

Question 8

Acalculous cholecystitis:

Answer 8

Common in critically ill
Those who’ve had a major surgery, trauma, sepsis, TPN, diabetes, atherosclerotic disease, HIV
Hard to assess

Question 9

Porcelain GB:

Answer 9

Wall is calcified
Dense posterior shadowing
Stones
Female dominance

Question 10

What are the sonographic signs of adenomyomatosis?

Answer 10

Invaginations of luminal epithelium
Cystic spaces/echogenic foci with comet tail artifact 
Thickening of GB wall
Focal (seen in fundus) or diffuse
Hourglass appearance

Question 11

Gallbladder carcinoma:

Answer 11

98% are adenocarcinoma
Associated with gallstones
Focal or diffuse polypoid mass arises from liver
Invades liver

Question 12

What is the sonographic appearance of GB CA?

Answer 12

Absence of normal appearing GB with no history of cholecystectomy
Immobile stone engrossed in tumor
Arterial and venous flow
Irregular wall thickening
Intraluminal mass >1cm

Question 13

What are complications of Caroli’s disease?

Answer 13

Biliary stasis
Cholangitis
Stones/sepsis
Hepatic fibrosis
Portal hypertension

Question 14

What can occur from Caroli’s disease?

Answer 14

Cholangiocarcinoma

Question 15

What can cause primary choledocholithiasis?

Answer 15

Caroli's disease
Sclerosing cholangitis
Parasites of liver
Hemolytic disease
Previous biliary surgery

Question 16

What are the sonographic signs for choledocholithiasis?

Answer 16

Dilated CBD proximal to stone
Dilated intrahepatic ducts
Shadow or no shadowing
GB distension

Question 17

The majority of CBD stones occur where?

Answer 17

Distal to ampulla of Vater

Question 18

What’s a differential diagnosis of CBD stones?

Answer 18

Blood clot- hemobilia
Papillary tumor
Biliary sludge
(none of these shadow)

Question 19

What are the signs of Mirizzi syndrome?

Answer 19

Painful jaundice
Fever
CHD obstruction

Question 20

What is Mirizzi syndrome?

Answer 20

CHD obstruction caused by extrinsic compression from an impacted stone in the cystic duct or infundibulum of the GB
Results in a fistula between cystic and CHD

Question 21

What can cause hemobilia? (blood in bile)

Answer 21

Cholangitis
Cholecystitis
Vascular malformations
Trauma
Malignancies

Question 22

What causes pneumobilia?

Answer 22

Emphysematous cholecystitis
Choledochoduodenal fistula (caused by stone in CBD)
Cholecystoenteric fistula (prolonged acute cholecystitis erodes into bowel)

Question 23

What’s a good landmark for the GB?

Answer 23

Main lobar fissure

Trv PV

Question 24

What is the normal CBD measurement?

Answer 24

<7mm (but why do I feel like we’ve also heard <6mm)

Question 25

What are the normal variants of the GB? (5)

Answer 25

Duplication
Septate
Phrygian cap
Hartmann's pouch
Junctional fold

Question 26

The GB lives in the inferior anterior portion of the liver. True or false

Answer 26

False– inferior posterior

Question 27

What helps bile run in the cystic duct?

Answer 27

Valves of Heister

Question 28

What is Charcot’s triad?

Answer 28

Fever
RUQ pain
Jaundice

Question 29

What sonographic signs are seen with acute cholangitis?

Answer 29

Dilation of intrahepatic biliary tree
Choledocholithiasis
CBD wall thickening
Hepatic abscess 
Dilated CBD >6mm
Pneumobilia 
GB wall may be thickened

Question 30

What is the sonographic appearance of flukes?

Answer 30

Diffuse dilation of peripheral intrahepatic ducts
Perioportal echoes-edema
Floating echogenic foci in GB

Question 31

What can be a complication of recurrent pyogenic cholangitis?

Answer 31

Acute- sepsis

Chronic- biliary cirrhosis and cholangiocarcinoma

Question 32

What are the sonographic signs of primary sclerosing cholangitis?

Answer 32

Fibrosis inflammation of small/large bile ducts

Question 33

What is associated with primary sclerosing cholangitis?

Answer 33

IBD

Question 34

What does primary sclerosing cholangititis lead to?

Answer 34

Biliary strictures
Cholestasis
Biliary cirrhosis
Portal hypertension
Hepatic failure

Question 35

What is a cholangiocarcinoma in the hilum of the liver called?

Answer 35

Klatskin’s tumor (60% of the time)

Also located distal CBD and intrahepatic (peripheral)

Question 36

What are the clinical signs of Klatskin’s tumor?

Answer 36

Jaundice, pruritis, increased LFT’s and nodes

Question 37

What are the most common primary sites for metastases to the biliary tree?

Answer 37

Breast
Colon
Melanoma

Question 38

What’s the second most common primary malignancy of the liver?

Answer 38

Intrahepatic cholangiocarcinoma