Biliary Tree disease

Question 1

Choledochal cysts?

Answer 1

Congenital, focal, or diffuse cystic dilation of the biliary tree

Question 2

Choledochal cysts may be the result of?

Answer 2

pancreatic juices refluxing into the bile duct because of an anomalous junction of the pancreatic duct into the distal common bile duct, causing duct wall abnormality, weakness, and outpouching of the ductal walls

Question 3

coledochal cysts risk?

Answer 3

Rare
More common in women than in men (4:1), with an increased incidence in infants
Most often seen in East Asia populations
May be associated with gallstones, pancreatitis, or cirrhosis

Question 4

choledochal cysts s/s?

Answer 4

Abdominal mass
Pain
Fever
Jaundice

Question 5

choledochal cysts diagnosis?

Answer 5

Diagnosis may be confirmed with a nuclear medicine hepatobiliary scan

Question 6

Choledochal Cysts- type 1?

Answer 6

fusiform dilation of the common bile duct.
Most common, along with type Iva
Associated with a long common channel (>20 mm) between the distal bile duct and the pancreatic duct

Question 7

Choledochal Cysts- type 2?

Answer 7

cysts are true diverticuli of bile ducts

Question 8

cholecochal cysts type 3?

Answer 8

cysts (choledochoceles) are confind to the intraduodenal portion of the CBD

Question 9

Choledochal Cysts- type IVa?

Answer 9

cysts are intrahepatic and extrahepatic biliary dilations

Question 10

Choledochal Cysts- type IVb?

Answer 10

cysts are confined to the extrahepatic biliary tree

Question 11

choledochal cysts- type V?

Answer 11

cysts have been classified as Caroli’s disease

Question 12

Answer 12

choledochal cyst

Question 13

Caroli’s Disease?

• type
• involves
• associated with
• affects

Answer 13

Rare,congenital disease
Type  V
Involves intrahepatic biliary tree
Associated with medullary sponge kidneys
Affects men &women equally
Usually diffuse

Question 14

Caroli’s Disease complications? (6)

Answer 14

Biliary stasis
Cholangitis 
Stones and sepsis
Hepatic fibrosis
Portal hypertension
At risk for cholangiocarcinoma

Question 15

what is Caroli’s Disease?

Answer 15

Multiple cystic structures in the area of the ductal system converge toward the porta hepatis.
Masses seen as localized or diffusely scattered cysts communicate with the bile ducts.
Differential diagnosis includes polycystic liver disease.
Ducts may show a beaded appearance as they extend into the periphery of the liver.
Ectasia of the extrahepatic and common bile ducts may be present.
Sludge or calculi may reside in the dilated ducts.

Question 16

Answer 16

caroli’s disease

Question 17

Dilated Biliary Ducts?

Answer 17

Generally a duct >6 mm in diameter is considered borderline; >10 mm is dilated.

Question 18

Most common cause of biliary obstruction?

Answer 18

presence of a tumor or thrombus within the ductal system

Question 19

Obstruction of biliary ductal system is diagnosed by ultrasound when the sonographer finds?

Answer 19

the presence of ductal dilation

- This finding is called “too many tubes” or “shotgun” sign when intrahepatic ducts are dilated.

Question 20

Three primary areas for biliary obstruction?

Answer 20

Intrapancreatic
Suprapancreatic
Porta hepatic

Question 21

Intrapancreatic Obstruction- Three conditions cause the majority of biliary obstruction at the level of the distal duct and cause the extrahepatic duct to be entirely dilated?

Answer 21

Pancreatic carcinoma
Choledocholithiasis
Chronic pancreatitis with stricture formation

Question 22

Suprapancreatic Obstruction?

Answer 22

Originates between the pancreas and the porta hepatis
The head of the pancreas, the intrapancreatic duct, and pancreatic duct are normal with ultrasound.
The most common cause for this obstruction is malignancy or adenopathy at this level.

Question 23

Porta Hepatic Obstruction?

Answer 23

This area of obstruction is usually the result of a neoplasm.
In patients with obstruction at the level of the porta hepatis, ultrasound will show intrahepatic ductal dilation and a normal common duct.
Hydrops of the gallbladder may be present.

Question 24

Cholangiocarcinoma

Answer 24

Rare malignancy that originates within the larger bile ducts (usually the common duct or common hepatic duct)

Question 25

Klatskin tumor?

Answer 25

is a specific type of cholangiocarcinoma that can occur at the bifurcation of the common hepatic duct, with involvement of both the central left and right ducts

Question 26

The most suggestive sonographic feature that indicates cholangiocarcinoma is?

Answer 26

isolated intrahepatic duct dilation

Question 27

characteristic for a Klatskin tumor?

Answer 27

nonunion of the right and left duct

Question 28

Mirizzi syndrome?

Answer 28

uncommon cause for extrahepatic biliary obstruction as a result of an impacted stone in the cystic duct, which creates extrinsic mechanical compression of the common hepatic duct

Question 29

mirizzi syndrome presentation?

Answer 29

painful jaundice - Stones may penetrate into the common hepatic duct or the gut, resulting in a cholecystobiliary or cholecystenteric fistula

Question 30

Answer 30

mirizzi syndrome

Question 31

Primary choledocholithiasis?

Answer 31

Stones form within ducts related to diseases causing strictures or dilation of bile ducts resulting in stasis

Question 32

causes of Primary choledocholithiasis?

Answer 32

Sclerosing cholangitis Caroli’s disease Parasitic infections of liver Chronic hemolytic disease –sickle cell anemia Prior biliary surgery-enteric anastomosis

Question 33

Secondary choledocholithiasis?

Answer 33

Migration of stones from the gallbladder into the CBD

Question 34

Secondary choledocholithiasis symptoms?

Answer 34

Patients present to emergency with RUQ/epigastric pain

Question 35

sono signs of Secondary choledocholithiasis?

Answer 35

Dilated CBD proximal to stone Intrahepatic ducts may also be dilated Large stones shadow ,smaller stones may not shadow GB distension

Question 36

Majority of stones will be in?

Answer 36

distal CBD at the Ampulla of Vater

Question 37

CBD stones D/D?

Answer 37

Blood clot-hemobilia Papillary tumor Biliary sludge

Question 38

Intrahepatic Bile Duct Stones are seen in patients with?

Answer 38

systic fibrosis

Question 39

fistulas are usually the result of?

Answer 39

Injury Surgery Infection Inflammation

Question 40

Hemobilia cause?

Answer 40

- Main cause of hemobilia is biliary trauma secondary to percutaneous biliary procedures or liver biopsies - cholangitis - cholecystits - vascular malformations - abdominal trauma - malignancies

Question 41

hemobilia clinical findings?

Answer 41

- pain - bleeding - trauma

Question 42

Pneumobilia on u/s?

Answer 42

Air within biliary tree appears as bright echogenic linear structures following portal triads Reverberation ringdown artifact

Question 43

pneumobilia etiology?

Answer 43

Previous biliary intervention-iatrogenic | Patient presents with acute abdomen

Question 44

Pneumobilia 3 causes?

Answer 44

1-Emphysematous cholecystitis 2-Choledochoduodenal fistula: - Caused by stone in CBD- inflammation 3-Cholecystoenteric fistula: - Prolonged acute cholecystitis erodes into an adjacent bowel loop

Question 45

Gallstone ileus?

Answer 45

paralysis of nerves Stones may pass from gallbladder into the bowel by a cholecystoenteric fistula Frequently involves duodenum or transverse colon Result of prolonged inflammation of GB

Question 46

Acute Bacterial Cholangitis

Answer 46

Antecedent biliary obstruction: | Associated in 85% of cases with CBD stones

Question 47

Acute Bacterial Cholangitis causeS?

Answer 47

Stricture due to trauma or surgery Choledochal cysts Partially obstructive tumors

Question 48

Acute Bacterial Cholangitis clinical presentation?

Answer 48

Classic Charcot’s Triad- Fever RUQ pain Jaundice

Question 49

Parasitic infections-flukes--Fascioliasis

Answer 49

Larvae travel through bowel wall -peritoneal cavity-liver capsule into liver parenchyma Matures and produces eggs in the biliary tree Symptoms relate to biliary obstruction: Jaundice Fever Abscess

Question 50

Flukes- Fascioliasis sono findings?

Answer 50

``` Hepatomegaly Hilar adenopathy Lesions: Hypoechoic or mixed echogenicity Present in 90% cases Flukes may be seen within ducts & GB ```

Question 51

Recurrent Pyogenic Cholangitis

Answer 51

Chronic biliary obstruction, stasis & stone formation Leads to recurrent episodes Etiology remains unknown

Question 52

Recurrent Pyogenic Cholangitis sono findings?

Answer 52

``` Lateral left Lobe most often affected Acute complication: Sepsis Chronic complications : Biliary cirrhosis and cholangiocarcinoma ```

Question 53

Primary Sclerosing Cholangitis?

Answer 53

``` Chronic inflammatory disease of entire biliary tree Fibrosing inflammation of small and large bile ducts More frequent in men Median age 39yrs Etiology not known 80% of patients however, have inflammatory bowel disease-colitis ```

Question 54

Primary sclerosing cholangitis leads to?

Answer 54

``` Biliary strictures Cholestasis Biliary cirrhosis Portal hypertension Hepatic failure ```

Question 55

Secondary Sclerosing Cholangitis etiology?

Answer 55

``` AIDS cholangiopathy Bile duct neoplasm Biliary tract surgery Trauma Choledocholithiasis Congenital anomalies ```

Question 56

Cholangiocarcinoma

Answer 56

cancerous (malignant) growth in one of the ducts that carries bile from the liver to the small intestine

Question 57

Cholangiocarcinoma risk factors?

Answer 57

Age Recurrent biliary infections Stone disease

Question 58

Cholangiocarcinoma 3 classifications?

Answer 58

Hilar: 60%-also called Klatskin’s tumor Distal: 30%- distal CBD Intrahepatic: 10%-also called- Peripheral

Question 59

Klatskins tumor?

Answer 59

``` Hilar: most common Located in porta hepatis Causes fibrous tissue formation Difficult to ID and stage Symptoms- Jaundice, pruritis, increased LFTS, nodes ```

Question 60

second most common primary malignancy of the liver?

Answer 60

Intrahepatic cholangiocarcinoma

Question 61

Metastases to the Biliary Tree ?

Answer 61

Most common tumor sites that can spread to the biliary system are from the breast, colon, or melanoma. Metastases can affect the intrahepatic and extrahepatic ductal systems. On sonography, the appearance of metastases is similar to that of cholangiocarcinoma.