Biliary Tract Patho Flashcards
(119 cards)
1
Q
Most common cause of GB wall thickening?
A
Cholecystitis
2
Q
Besides cholecystitis, other causes of GB wall thickening (5)
A
hypoalbuminemia ascites hepatitis CHF pancreatitis
3
Q
Prehepatic cause of jaundice
A
increased bilirubin production
4
Q
Hepatic causes of jaundice (5)
A
acute liver inflammation chronic liver disease infiltrative liver disease inflammation of bile ducts genetic disorders
5
Q
prehepatic jaundice occurs if there is increased bilirubin production, which may be due to (3)
A
hemolysis - breakdown of RBC
ineffective erythropoiesis - overproduction of hemoglobin
absorption of large amounts of hemoglobin - internal bleeding
6
Q
Acute liver inflammation is one cause of hepatic jaundice because it….
A
reduces the liver’s ability to conjugate
7
Q
Hepatic related jaundice occurs with infiltrative liver diseases such as (4)
A
metastatic liver disease
hemochromatosis (inc iron absorption)
Alpha 1 antitryspin deficiency
Wilson’s disease (inc Copper absorption)
8
Q
Inflammation of the bile ducts is a hepatic related cause of jaundice that may be due to (2)
A
primary biliary cholangitis
sclerosing cholangitis
9
Q
genetic disorders that can cause hepatic jaundice include (2)
A
Gilbert’s syndrome
Crigler-Najjar syndrome (dec enzyme for conjugation)
10
Q
Post hepatic cause of jaundice is due to an
A
obstruction of biliary tree, anything that blocs the bile ducts
11
Q
obstruction that blocks the ducts causes pale _____ and dark _____, which is a post hepatic cause of janudice.
A
pale stool
dark urine
12
Q
9 examples of biliary obstruction
A
choledocholithiasis Mirizzi syndrome cholangiocarcinoma cholangitis biliary atresia choledochal cyst Caroli's disease pancreatic adenocarcinoma GB carcinoma
13
Q
Long-term total parenteral nutrition (TPN) induces GB stasis, which may create (3)
A
sludge
milk of calcium bile
gallstones
14
Q
_____ appears as nonshadowing, echogenic material which layers and shifts with patient position.
A
sludge
15
Q
calcium bilirubinate granules and cholesterol crystals
A
sludge
16
Q
What sonographic finding distinguishes tumefactive sludge from gallstones?
A
no shadowing with tumefactive sludge
17
Q
causes of biliary stasis that may result in sludge (5)
A
prolonged fasting TPN - intravenous feeding hemolysis cystic duct obstruction cholecystitis
18
Q
cholelithiasis
A
gallstones
19
Q
WES or double arc sign
A
Wall-Echo-Shadow seen with a GB filled with stones
20
Q
Sonographic criteria for cholethiasis (3)
A
mobile
strongly echogenic
acoustic shadowing
21
Q
Gallstones are composed of
A
cholesterol
calcium bilirubinate
calcium carbonate
22
Q
Cholelithiasis may obstruct the cystic duct resulting in ______ _______ and possible complications such as (4)
A
acute cholecystitis
- empyema - collection of pus in the pleural space
- GB perforation
- pericholecystic abscess
- bile peritonitis - secondary to perforation/rupture of the GB, duct, GI
23
Q
Signs and symptoms of acute cholecystitis
A
RUQ pain
fever
leukocytosis
24
Q
Sonographic features of acute cholecystitis (5)
A
gallstones Murphy's sign diffuse wall thickening GB dilation sludge
25
Murphy's sign
intense point of tenderness transducer pressure directly on the GB
90% sensitive and specific
26
Obstruction at the level of the ampulla of Vater is suggested if _____ is elevated.
amylase
27
Complications of acute cholecystitis include (5)
```
empyema
gangrenous cholecystitis
perforation
pericholecystic abscess
bilioenteric fistula
```
28
Acute cholecystitis
Diffuse GB wall thickening due to cystic duct obstruction by a gallstone
29
Following initial stages of acute cholecystitis (obstruction, ischemia), _______ _______ may follow.
bacterial infection
30
Chronic cholecystitis (chronic GB disease) is characterized by recurring symptoms of ______ _____ due to multiple episodes of acute cholecystitis.
biliary colic
31
T/F - sonographically the findings for chronic cholecystitis are different from acute.
F - does not appear different
| may include thick-wall, contracted GB, sludge, obstructing cystic duct stone
32
Emphysematous cholecystitis
due to acute cholecystitis with wall ischemia and infection
| -thought to be a different pathogenesis than calculous cholecystitis
33
Emphysematous cholecystitis occurs more commonly in
diabetic men
34
Emphysematous cholecystitis has a higher rate of _______ and ________.
gangrene and perforation
35
With gangrenous cholecystitis, perforation is inevitable, resulting in ____________ and _________.
pneumoperitoneum and peritonitis
36
What five things can casue gas in the biliary system?
```
post ERCP
post sphincter of Oddi papilotomy
choledochojejunostomy
gallbladder (biliary) fistula
emphysematous cholecystitis
```
37
Choledochjejunostomy
procedure for creating an anastomosis of the CBD to the jejunum, performed to relieve symptoms of biliary obstruction and restore continuity to the biliary tract
38
empyema of the GB
acute cholecystitis in the presence of bacteria-containing bile progressing to infection where the GB fills with purulent material (atypical bile echoes)
- initiated by cystic duct obstruction
- symptoms the same as acute but with fever
39
GB perforation
- complication of acute cholecystitis
- fundus is most common part
- localized fluid collection in GB fossa
- Dx difficult, delayed treatment results in higher morbidity and mortality rates
40
Complications from GB perforation (3)
peritonitis
pericholecystic abscess
biliary fistula
41
acalculous cholecystitis
acute cholecystitis without gallstones
- caused by: bile stasis, dec. GB contraction, infection (secondary event)
- sonographic: wall thickening, Murphy sign, pericholecystic fluid
42
Acalculous cholecystitis is typically a secondary event in critically ill patients and is associated with (8)
```
parenteral (intravenous) nutrtion (>3 months)
post operative abd surgery
severe trauma
severe burns
sepsis
HIV/AIDS
blood transfusion reaction
high-does opiod anagesics
```
43
increased hypoalbuminemia casuing ascites and CHF are other casues of _____ _____ _______
GB wall thickening
44
Milk of calcium bile is aka
limey bile
45
What is limey bile?
sludge-liek material with a high concentration of calcium
46
_______ _______ is associated with chronic cholecystitis and GB obtsruction of cystic duct
Limey bile
47
sonographic appearance of milk of calcium bile
may be seen as layering of sludge that results in distal acoustic shadowing
48
What is porcelain GB
calcification of the GB wall assocaited with chronic cholecystitis
49
Hydrops of the GB
aka mucocele of the GB
- overdistended GB filled with mucoid or clear and watery content
- usually noninflammatory
- results from outlet obstrcution of the GB (commnly impacted stone in the neck of the GB or in the cystic duct)
50
What is suggested if a grossly distended, thin-walled GB, measuring >5cm x 11cm, an impacted stone in the infundibulum or neck of the GB or in the cystic duct, and clear fluid content?
possible mucocele
51
T/F - GB polyps that are greater than 10mm and demonstrate growth are most likely to be malignant
True
52
cholesterolosis
aka strawberry GB
- lipids are depositied into the wall, appearing like polyps of differnt sizes (can be as large as 1cm)
- usually clinically silent but can be the casue of colicky abdominal pain
53
T/F - GB carcinoma is not realted to porcelain GB.
False
54
Adenomyomatosis
hyperplastic changes of the GB wall, overgrowth of mucosa, thickening of wall, and formation of diverticula
55
diverticula in the GB wall accumulate stones or sludge and is aka
rokitansky-aschoff sinuses or RAS
56
Adenomyomatosis is sonographically seen as hyperechoic foci within a thickened wall that casue what kind of artifact?
comet-tail (reverberation) artifact
57
Adenomyomatosis is sonographically seen as hyperechoic foci within a thickened wall that casue what kind of artifact?
comet-tail (reverberation) artifact
58
In the majority of patients, biliary obstruction is due to pathology in the _____ _____.
distal CBD
59
Two most common lesions associated with biliary obstruction
gallstones
| carcinoma of the head of the pancreas
60
lab values associated with distal biliary obstruction
alp (alkaline phosphatase)
conjugated bilirubin/direct
gamma glutamyl transpeptidase (GGT)
61
Distal biliary obtsruction results in progressive dilatation of the ________ and _______ biliary tree.
extrahepatic to intrahepatic (distal to proximal)
62
causes of biliary obstruction
```
choledochalithiasis
mirizzi syndrome
cholangiocarcinoma
cholangitis
biliary atresia
choledochal cyst
caroli's disease
pancreatic adenocarcinoma
GB carcinoma
```
63
How can you distinguish dilated intrahepatic ducts from portal veins?
"parallel channel sign" or "shotgun sign" which refers to the dilated intrahepatic ducts adjacent to the portal vein
64
Cause of intrahepatic bile duct dilitation only (4)
cholangiocarcinoma (Klatskin tumor)
intrahepatic choledocholithiasis
recurrent pyogenic cholangitis
Caroli's disease
65
choledocholithiasis is the presence of ______ in the bile ducts and is the most common casue of ________ obstructive jaundice.
calculi
| extrahepatic obstructive jaundice
66
Symptoms associated with choledocholithiasis?
```
biliary colic (RUQ pain(
jaundice
```
67
Lab values that increase with choledocholithiasis?
ALP
conjugated bilirubin
GGT
68
Complication associted with choledocholithiasis
biliary cirrhosis
cholangitis
pancreatitis
69
Mirizzi syndrome
extrahepatic biliary obtsruction due to an impacted stone in the cystic duct casuing extrinisc mechanical compression of the CHD
70
findings associated with mirizzi syndrome
intrahepatic duct dilitation
cystic duct stone
curved segmental stenosis of CHD
cholecystocholedochal fistual
71
Symptoms associated with cholangiocarcinoma (bile duct carcinoma)
jaundice
weight loss
abdominal pain
72
Klatskin Tumor
cholangiocarcinoma located at the hepatic hilum (junction of RT/LT hepatic ducts)
-results in intrahepatic dilitation, not extrahepatic
73
______ _____ _____ is the most common predisposing condition for bile duct carcinoma and dilatation of the _____ bile ducts is the most common finding
primary sclerosing cholangitis
| intrahepatic
74
Biliary Ascariasis
casued by parasitic roundworm that blocks the ampulla of vater or the main pancreatic duct resulting in acute pancreatitis (inc. amylase and lipase)
-can also travel into the biliary tree casuing ductal dilation with increased levels of conjugated bilirubin resulting in acute cholangitis or acute cholecystitis
75
cholangitis
bacterial infection sueprimposed on a biliary tree obstruction
76
A history of choledocholithiasis or recent biliary tract manipulation associated with fever (chills, rigors), RUQ pain, jaundice - The charcot triad - is highly suggestive of ______.
cholangitis
77
Cuases of cholangitis?
```
choledocholithiasis*
ERCP
obstructive tumor (panc head)
```
78
cholangitis result in in increased:
```
ALP
conjugated bili
GGT
amylase and lipase
WBC
```
79
biliary atresia
absence of extrahepatic ducts (CHD and CBD)
| suspected when janudice (hyperbilirubinemia) persists beyond 14 days of age
80
Biliary atresia is associated with
polysplenia syndrome
absent IVC
situs inversus, situs ambiguous
cardiac abnormalites (ASD, VSD)
81
Pneumobilia
air in the biliary tract
| echogenic foci in the intrahepatic bile ducts, comet-tail reverberation artifact
82
Causes of pneumobilia
```
ERCP
sphincter of Oddi papilliotomy
choledochojejunostomy
GB fistula
emphysematous cholecystitis
```
83
choledochal cysts
congenital bile duct anomaly consisteing of cystic dilatation of the intra or extrahepatic bile ducts.
-five classes of cysts, most common involves dilatation of the CBD, aneurysmal
84
sonographic findings associated with choledochal cysts involving the CBD
2 cystic structures in the RUQ (dilated CBD and GB)
| inrahepatic bile duct dilatation
85
Choledochal cysts are ore prevalent in _____.
Asia, more than 33% of reported cases are from Japan
| -symptoms usually occur before age 10
86
Choledochal cysts are associated with (6)
```
pancreatitis
cholangitis
heaptic abscesses
cirrhosis
portal HTN
cholangiocarcinoma
```
87
A congenital anomaly of the biliary tract charcterized by multifocal segmental dilatation of the intrahepatic bile ducts.
Caroli's Disease/Syndrome
88
Caroli's Disease is associated with (3)
congenital hepatic fibrosis
portal HTN
polycystic kidney disease
89
Sonographic appearance of Caroli's Disease/Syndrome?
multiple cystic structures that converge toward the porta hepatis communicating with the bile ducts
-sludge and calculi may accumulate in these ectatic ducts reuslting in posterior acoustic shadowing
90
Most common cause of malignant neoplasm obstructing the biliary tree?
Pancreatic adenocarcinoma
91
Pancreatic adenocarcinoma at the head of the pancreas typically causes _______ _______.
Courvoisier gallbladder
92
Enlarged, non-diseased gallbladder due to a mechanical obstruction of the CBD.
Courvoisier GB
93
The _____ ______ sign refers to the dilatation of the CBD and the duct of Wursung.
Double Duct Sign
94
Common causes of the Double Duct Sign include (3)
carcinoma of the head of the pancreas (Panc adenocarcinoma)
ampullary tumors
stone at the ampulla of Vater
95
_______ ______ ______ is an inflammation and fibrosis of the intrahepatic and extrahepatic bile ducts.
Primary Sclerosing Cholangitis
96
Sonographic findings associated with Primary Sclerosing Cholangitis
thickening of the bile duct walls
| findings associated with cirrhosis
97
Labs associated with Primary Sclerosisng Cholangitis (4)
ALP
GGT
ALT/AST
Conjugated Bilirubin
98
Primary Sclerosing Cholangitis is associated with
inflammatory bowel diease (ulcerative colitis)
ERCP
Cholangiocarcinoma
- thought be autoimmune but the casue is unknown
- ERCP for diagnosis
- results in liver failure
99
________ ________ __________ is a chronic and progressive cholestasis due to destruction of the small intrahepatic bile ducts leading to end-stage liver disease.
Primary Biliary Cirrhosis
- Dx with liver biopsy
- etiology unknown, presumed to be autoimmune in nature
100
Labs associated with primary biliary cirrhosis
ALT/AST
ALP
GGT
Antimitochondrial antibodies (AMAs)*
101
Ultrasound findings associated with primary biliary cirrhosis
nonspecific
increased liver echogenicity
findings associated with cirrhosis and portal HTN
-F/U every 6m for HCC
102
stones, mobile, shadowing
cholelithiasis
| move the patient!
103
non-shadowing, mobile, layering
sludge
104
thick, poetntially non-mobile and mass like
tumefactive sludge
105
thick wall with "seperating" layers
acute cholecystitis, edema in the wall
106
contracted, thick wall
chronic cholecystitis
107
echogenic foci protruding into GB, stalk, comet-tail artifact
GB Polyp
| optimize for resolution (highest frequency, SonoCT/Harm off)
108
echogenic foci in the wall, "strawberry", cholesterol deposits
adenomymatosis vs cholesterolosis
109
broad based projections into GB with blood flow
GB carcinoma
| optimize Color because not NML vessels and won't be fast (gain up, sm box, etc)
110
dilated GB with intrinsic obstruction
hydrops
111
hydrops GB w/ acute painless jaundice, extrinsic compression
Courvoisier's GB
112
WES
Porcelain GB
113
sludge containing microcal deposits
Milk of Ca
114
dirty shadowing in the GB
Emphysematous cholecystitis
115
saccular dilatation, intra or extra
Caroli's Disease
| should communicate with duct unlike choledochal cysts
116
stone in the duct
choledochalithiasis
| -have been reports of intrahepatic stones
117
liver like mass at porta hepatis, intra-hepatic dilatation
Klatskin's Tumor
118
non-specific unless klatskin's
cholangiocarcinoma
119
inflammation of the biliary ducts
primary sclerosing cholangitis
