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KEVIN BURANT IV > Chapter 26 - Liver, Biliary Tree and Gallbladder (CHERI NOTES) > Flashcards

Chapter 26 - Liver, Biliary Tree and Gallbladder (CHERI NOTES) Flashcards

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1
Q

__ is the current method of choice for most hepatic imaging.
(p.692)

A

DYNAMIC BOLUS CONTRAST-ENHANCED MDCT

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2
Q

___ is used as a screening method for patients with abdominal symptoms and suspected diffuse or focal liver disease. (p.692)

A

ULTRASOUND

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3
Q

___ are used to assess hepatic vessels and tumor vascularity.
(p.692)

A

COLOR FLOW and SPECTRAL DOPPLER

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4
Q

____ is used in the characterization of cavernous hemangiomas
and focal nodular hyperplasia. (p.692)

A

RADIONUCLIDE IMAGING

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5
Q

MDCT of the liver is performed using a ___ or ___ protocol

of multiple scans of the entire liver. (p.692)

A

THREE-PHASE or FOUR-PHASE

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6
Q

Maximum enhancement of the liver is attained during the ___ phase to demonstrate hypovascular lesions as low-attenuating masses on a background of brightly-enhanced parenchyma. (p.692)

A

PORTAL VENOUS phase

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7
Q

2/3 of the hepatic blood supply comes from the ____. (p.692)

A

PORTAL VEIN

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8
Q

maximum enhancement of the liver parenchyma occurs at
____ to ___ seconds following hepatic arterial enhancement.
(p.692)

A

60 to 120 seconds

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9
Q

Delayed images are obtained several minutes after contrast
injection to document late-contrast fill-in of _____ and
delayed enhancement of ____. (p.692)

A

HEMANGIOMA and CHOLANGIOCARCINOMA

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10
Q

Gadolinium-based contrast agent which is akin to

iodine-based contrast agents used in CT. (p.692)

A

Gadopentetate dimeglumine (Magnevist)

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11
Q

Liver-specific contrast agents such as ____ have conventional properties of the extracellular agents as well as being taken up by hepatocytes; which improves the detection and
characterization of small lesions. (p.692)

A

Gadoxetate disodium (Eovist)

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12
Q

_____ emerged as a method of hepatic lesion detection and
characterization in patients who cannot receive IV contrast.
(p.692)

A

DIFFUSION-WEIGHTED MR

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13
Q

____ is used for quantitation of liver fatty infiltration and other diffuse hepatic diseases. (p. 692)

A

MR spectroscopy

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14
Q

____ is used as a rapid screening modality to detect diseases
of the liver; biliary tree and gallbladder. (p.692)

A

ULTRASOUND

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15
Q

Radionuclide imaging of liver offers functional information

in characterizing lesions such as ____. (p.692)

A

FOCAL NODULAR HYPERPLASIA

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16
Q

_______ is very useful for definitive diagnosis of

cavernous hemangioma. (p.692)

A

RADIONUCLIDE BLOOD POOL IMAGING

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17
Q

Transient enhancement difference are seen during either
____ phase imaging or ____ phase imaging on MDCT and
dynamic MR. (p.694)

A

ARTERIAL phase imaging or

PORTAL VENOUS phase imaging

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18
Q

meaning of the acronyms THADs or THIDs (p.694)

A

TRANSIENT HEPATIC ATTENUATION DIFFERENCES or
TRANSIENT HEPATIC INTENSITY DIFFERENCES

-this results in focal areas of increased or decreased enhancement during the various phases of the parenchymal enhancement.

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19
Q

Portal venous flow may be altered by these three causes.

p.694

A
  1. PORTAL BLOCKADE BY TUMOR OR THROMBUS
  2. EXTRINSIC COMPRESSION CAUSED BY RIBS OR DIAPHRAGMATIC SLIPS; OR TUMORS OF THE LIVER CAPSULE
  3. THIRD INFLOW from systemic veins in the pericholecystic; parabiliary; and epigastric-paraumbilical venous systems.
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20
Q

Systemic venous blood drains into ___ altering normal intrahepatic blood flow. (p.694)

A

HEPATIC SINUSOIDS

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21
Q

On CT, the attenuation of normal liver parenchyma is ____ than the attenuation of normal spleen parenchyma on unenhanced images. (p.694)

A

EQUAL TO OR GREATER THAN

-following bolus IV contrast administration; the normal parenchymal enhancement is less than that of the spleen during arterial phase; and equal to or greater than that of the spleen during the portal venous phase.

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22
Q

On MR T1WI; the normal liver is slightly higher signal intensity than the ____; and most focal lesions appear as lower-intensity defects.

A

SPLEEN

  • with T2WI; the normal liver is less than or equal to the spleen in signal strength; and most lesions appear as high-intensity foci.
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23
Q

2 evidences of HEPATOMEGALY. (p.694)

A
  1. Rounding of the inferior border of the liver

2. Extension of the right lobe of the liver inferior to the lower pole of the right kidney.

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24
Q

A liver length greater than ___ cm; measured in the midclavicular line; is considered enlarged. (p. 694)

A

greater than 15.5 cm

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25
______ is normal variant of hepatic shape found most often in women. It refers to an elongated inferior tip of the right lobe of the liver. (p.694)
REIDEL LOBE - When a Reidel lobe is present; the left lobe of the liver is respondingly smaller in size.
26
TRUE OR FALSE. | The left lobe of the liver may; as a normal variant; be elongated and surround a portion of the spleen.(p.694)
TRUE
27
___ is the most common abnormality demonstrated by hepatic imaging. (p.694)
FATTY LIVER (HEPATIC STEATOSIS) - 15% prevalent in the general population - in 50% of patients with hyperlipidemia - up to 75% of patients with severe obesity
28
2 most common causes of FATTY LIVER. (p. 694)
1. ALCOHOLIC LIVER DISEASE 2. NON-ALCOHOLIC FATTY LIVER DISEASE related to metabolic syndrome of insulin resistance; obesity; diabetes; hyperlipidemia and hypertension.
29
Give 6 other causes of fatty liver aside from alcoholic liver disease and non-alcoholic fatty liver disease. (p.694)
1. VIRAL HEPATITIS 2. DRUGS (esp.steroids and chemotherapy agents) 3. NUTRITIONAL ABNORMALITIES 4. RADIATION INJURY 5. CYSTIC FIBROSIS - all conditions injure hepatocytes by altering hepatocellular lipid metabolism; with defects in free fatty acid metabolism resulting in accumulation of triglycerides within hepatocytes. 6. STORAGE DISORDERS
30
Fatty liver is initially reversible but may progress to____ with further progression to cirrhosis. (p.694)
STEATOHEPATITIS | CELL INJURY; INFLAMMATION AND FIBROSIS
31
____ includes a continuum of liver disease that extends from simple fatty liver through non-alcoholic steatohepatitis (NASH) to cirrhosis. (p.694)
NON-ALCOHOLIC FATTY LIVER DISEASE (NASH) | - is diagnosed solely by liver biopsy showing inflammation and fibrosis in addition to hepatic steatosis.
32
On US, the normal liver parenchyma is equal to; or slightly more echogenic; than the ___ and ____ parenchyma. (p.695)
RENAL CORTEX and SPLENIC PARENCHYMA
33
Three reliable US findings of fatty liver (p.695)
1. LIVER ECHOGENICITY distinctly greater than that of the renal cortex 2. LOSS OF VISUALIZATION of normal echogenic portal triads in the periphery of the liver. 3. POOR SOUND penetration with loss of definition of the diaphragm.
34
On CT; fat infiltration lowers the attenuation of the hepatic parenchyma; and makes the liver appear ____ dense than the spleen. (p.695)
LESS - the liver normally has a slightly higher attenuation than the spleen or blood vessels. - differences in density between liver and spleen are most reliably judged on non-contrast images - on postcontrast images; the normal spleen enhances maximally 1 to 2 minutes before maximal liver enhancement and is thus transiently brighter than the normal liver.
35
Fatty liver enhances __ than normal liver. (p.695)
LESS
36
On unenhanced CT; fatty liver is diagnosed when the liver attenuation is __ H less than the spleen attenuation; or when the liver attenuation is less than ___ H. (p.695)
10 H; 40 H - when fatty liver is severe; blood vessels may appear brighter than the dark liver on unenhanced CT
37
Comparison of CT and US findings may yield the diagnostic ________ sign; with fatty liver being dark on CT and bright on US. (p.695)
FLIP-FLOP sign
38
___ is the MR method most sensitive to the diagnosis of fatty liver. (p.695)
GRADIENT ECHO IMAGING WITH FAT AND WATER MOLECULES IN-PHASE AND OUT-OF-PHASE - same technique used to characterize benign adrenal adenomas
39
On IN-PHASE images; the signal from water and fat molecules are _____. (p.695)
ADDITIVE
40
ON OUT-PHASE images; the signals from water and fat _____. | p.695
CANCEL OUT EACH OTHER
41
A loss of signal intensity between in-phase and out-of-phase | images is indicative of ____. (p.695)
FATTY LIVER
42
This opposed-phase chemical shift GRE technique is more sensitive in the detection of _____ intracellular fat characteristic of fatty liver. (p.695)
MICROSCOPIC intracellular fat
43
Fat-saturation MR techniques, have greater sensitivity for __fat. (p.695)
MACROSCOPIC fat
44
Iron deposition in the liver will also cause a ___ on out-of-phase MR imaging and is a potential pitfall in MR diagnosis of fatty liver in patients with cirrhosis. (p.695)
LOSS OF SIGNAL
45
Characteristic features of fatty deposition include these TWO findings. (p.695)
1. LACK OF MASS EFFECT (no bulging of the liver contour or displacement of intrahepatic blood vessels) 2. ANGULATED GEOMETRIC BOUNDARIES between involved and uninvolved parenchyma.
46
Fatty changes can develop within __ weeks of hepatocyte insult and may resolve within __ days of removing the insult. (p.695)
3 weeks: 6 days - patterns of fatty infiltration are strongly related to hepatic blood flow.
47
____ fatty liver involving the entire liver is the most common pattern. (p.695)
DIFFUSE fatty liver
48
____ fatty liver involves a geographic or fan-shaped portion of the liver with the same imaging features as diffuse fat deposition.
FOCAL fatty liver - focal fat may simulate a liver tumor; - however the area of involvement has a density characteristic of fat.
49
Focal fat (in fatty liver); is most adjacent to the ___; ____ and ____. (p.695)
FALCIFORM LIGAMENT; GALLBLADDER FOSSA; AND PORTA HEPATIS - these are the areas prone to altered hepatic blood flow with systemic flow; and focal fat deposition may be related to higher concentrations of insulin in these areas.
50
______ in a diffusely fatty infiltrated liver may be the most confusing pattern becaused spared areas of normal parenchyma may convincingly simulate a liver tumor. (p.695)
FOCAL SPARING
51
Fat-spared areas are most commonly found in segment ___. | p.696
segment IV
52
The fat-spared area is hypoechoic relative to the rest of the liver on US and is of higher density than the rest of the liver on CT. What is this RADIOLOGIC SIGN? (p.696)
FLIP-FLOP sign
53
___ fatty liver is an uncommon pattern of fat deposition throughout the liver in multiple atypical locations. (p.696)
MULTIFOCAL FATTY LIVER
54
____ fatty liver is seen as HALOS OF FAT surrounding the portal veins; hepatic veins or both. (p.696)
PERIVASCULAR fatty liver - unknown cause
55
____ fatty liver is seen only in patients with renal failure on peritoneal dialysis and only when INSULIN is added to the dialysate. (p.696)
SUBCAPSULAR fatty liver - high concentrations of INSULIN in the subcapsular liver leads to fat deposition
56
``` _____ hepatitis most commonly causes no abnormalities on hepatic imaging (p.696) ```
ACUTE hepatitis - in some patients; diffuse edema lowers the parenchymal echogenicity and causes the portal venules to appear unusually bright on US.
57
In ____ hepatitis; areas of necrosis show ill-defined areas of low density on CT. (p.696)
ACUTE FULMINANT hepatitis
58
_____ hepatitis is characterized pathologically by portal and perilobular inflammation and fibrosis. (p.696)
CHRONIC hepatitis - causes include chronic viral infection; and hepatitis B and C. - perilymphatic lymph nodes are commonly visualized. - US may show a subtle coarse increase in hepatic echogenicity.
59
The primary role of imaging patients with chronic hepatitis is to detect ____. (p.696)
HEPATOCELLULAR CARCINOMA
60
____ is characterized pathologically by diffuse parenchymal destruction fibrosis with alteration of hepatic architecture; and innumerable regenerative nodules that replace normal liver parenchyma. (p.696)
CIRRHOSIS
61
Give 4 causes of cirrhosis. (p. 696)
1. HEPATIC TOXINS (alcohol; drugs; and aflatoxin from a grain fungus) 2. INFECTION (viral hepatitis; esp.types B and C) 3. BILIARY OBSTRUCTION 4. HEREDITARY (Wilson Disease)
62
In the U.S.: 75% of cirrhotic patients are ___. In Asia and Africa: most cases of cirrhosis are due to ___. (p.____)
CHRONIC ALCOHOLICS; | CHRONIC ACTIVE HEPATITIS
63
7 imaging findings of CIRRHOSIS? (p.696)
1. HEPATOMEGALY (early) 2. ATROPHY OR HYPERTROPHY of hepatic segments 3. COARSENING OF HEPATIC PARENCHYMAL TEXTURE. 4. NODULARITY OF THE PARENCHYMA; often most noticeable on the liver surface 5. HYPERTROPHY OF THE CAUDATE LOBE with shrinkage of the right lobe 6. REGENERATING NODULES 7. ENLARGEMENT OF THE HILAR PERIPORTAL SPACE (>10 mm) reflecting parenchymal atrophy.
64
Extrahepatic signs of CIRRHOSIS include the presence of _______ as evidence of portal hypertension; splenomegaly; and ascites. (p.696-697)
PORTOSYSTEMIC COLLATERALS
65
TRUE OR FALSE. The pathological changes of cirrhosis are irreversible; but disease progression can be limited or stopped by eliminating the causative agent. (stop drinking alcohol). (p.____)
TRUE
66
______ is an effective treatment for portal hypertension and long-term control of esophageal variceal bleeding. (p.697)
TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS)
67
DIAGNOSIS? US finding of heterogeneous parenchymal with coarsening of the echotexture and decreased visualization of the small portal triad structures. (p.697)
CIRRHOSIS - CT finding may be normal in the early stages or may reveal parenchymal inhomogeneity with patchy areas of increased and decreased attenuation. - MR shows heterogeneous parenchymal signal on T1WI and T2WI. High-signal fibrosis on T2WI is the predominant cause of the heterogeneous appearance.
68
_____ are conditions that cause diffuse hepatic nodularity or portal hypertension including pseudocirrhosis of treated breast CA metastases; miliary metastases; sarcoidosis; schistosomiasis; Budd-Chiari syndrome; nodular regenerative hyperplasia and idiopathic portal hypertension. (p.697)
MIMICS OF CIRRHOSIS
69
HCC may arise ____ or as a _______ process from a regenerative nodule to low-grade dysplastic nodule to high-grade dysplastic nodule to small HCC to large HCC. (p.697)
DE NOVO or STEPWISE
70
_____ are the most common nodule and are a regular pathologic feature of cirrhosis due to attempted repair of hepatocyte injury. (p.697)
REGENERATIVE NODULES - composed primarily of hepatocytes that are surrounded by coarse fibrous septations.
71
Small regenerative nodules size? (p.___)
< 3 mm
72
Larger regenerative nodules (> __ mm) produce the macronodular pattern of cirrhosis. (p.697)
>3 mm
73
Very large regenerative nodules (up to __ cm) can mimic | mass. (p.697)
up to 5 cm
74
Regenerative nodules are supplied by the _____ and thus show no enhancement on arterial phase postcontrast imaging. (p.____)
PORTAL VEIN
75
Regenerative nodules, because they consist of proliferating hepatocytes, are typically _____ on US; CT and MR imaging. (p.697)
INDISTINCT - uncommonly; regenerative nodules are hyperintense to liver on T2WI; reflecting the accumulation of fat; protein or copper.
76
Regenerative nodules that accumulate iron (siderotic nodules) are ___ signal intensity on T1WI and T2WI. (p.697)
LOW
77
Infarction of regenerative nodules results in __ signal on T2WI. (p.697)
HIGH
78
Regenerative nodules show ___ enhancement on arterial phase postcontrast CT and MR imaging. (p.697)
NO
79
____ nodules show foci of low-grade or high-grade dysplasia. | p.697
DYSPLASTIC
80
____ -grade dysplastic nodules show minimal atypia; | have no mitosis; and are not premalignant. (p.697)
LOW-grade dysplastic nodules
81
____ -grade dysplastic nodules shows moderate atypia; have occasional mitosis; may secrete alpha fetoprotein (AFP), but are not frankly malignant. (p.697)
HIGH-grade dysplastic nodules - they are however considered premalignant
82
TRUE OR FALSE. Dysplastic nodules are almost never hyperintense on T2WI, differentiating them from HCC. (p.697)
TRUE
83
Siderotic dysplastic nodules with iron accumulation are ___ signal on T1WI and T2WI. (p.698)
LOW
84
___ nodule is a radiologic term used to describe nodules that are high iron content and appear as low-signal nodules on both T1WI and T2WI. (p.698)
SIDEROTIC nodule
85
TRUE OR FALSE. Dysplastic nodules may disappear on imaging follow-up. (p.698)
TRUE
86
____ HCC; defined as less than 2 cm diameter; overlap the | appearance of high-grade dysplastic nodules. (p.698)
SMALL HCC - on T1WI: hypointense nodule with internal foci isointense to liver parenchyma - on T2WI: the nodules are of low intensity with foci of high-signal intensity.
87
TRUE OR FALSE. | High signal intensity on T2WI differentiates small HCC from dysplastic nodules. (p.699)
TRUE
88
___ content within the nodules raises the risk of HCC. (p.699)
FAT
89
Small HCCs shows the hallmark finding of ____ enhancement | on ____ phase dynamic MR. (p.699)
INTENSE; ARTERIAL
90
TRUE OR FALSE. The American Association for the Study of Liver Diseases (AALSD) no longer requires biopsy to diagnose HCC. (p.___)
TRUE
91
Small nodules that are ________ on arterial phase postcontrast CT or MR and show _____ of contrast on portal venous phase are considered to be HCC. (p.699)
HYPERVASCULAR: WASHOUT
92
HCC developing within a dysplastic nodule may produce a characteristic _____ appearance seen as a high-signal focus within a low-intensity nodule. (p.699)
NODULE WITHIN A NODULE - high signal focus enhances avidly on arterial phase.
93
On US; ____ HCCs appear as a well-circumscribed hypoechoic mass in the cirrhotic liver. (p.699)
SMALL HCC - on T1WI: hypointense nodule with internal foci isointense to liver parenchyma - on T2WI: the nodules are of low intensity with foci of high-signal intensity.
94
3 MIMICS OF HCC? (p.699)
1. NON-SPECIFIC ARTERIALLY ENHANCING LESIONS 2. PSEUDOLESIONS 3. THADs - lesions are features of cirrhosis related to arterio-portal shunts and fibrotic obstruction of the portal vein. - these non-specific lesions are usually isointense on delayed imaging; unlike in HCC which commonly becomes hypointense to the surrounding liver on delayed imaging.
95
_____ describes mass-like areas of fibrosis found in livers with advanced cirrhosis. (p.699)
CONFLUENT FIBROSIS - extensive fibrosis produces a wedge - shaped mass radiating from the porta hepatis associated with parenchymal atrophy and flattening or retraction of the liver capsule.
96
Key feature of Confluent Liver Fibrosis. (p.699)
VOLUME LOSS OF THE AFFECTED PORTION OF THE LIVER. *the central portion of the right hepatic lobe is most often involved.
97
``` CT Imaging appearance of Confluent Liver Fibrosis in A. Noncontrast-CT B. Arterial phase contrast CT C. Portal venous phase contrast CT (p.699) ```
A. NECT: LOW ATTENUATION B. Arterial phase CECT: MOST LESIONS (60%) SHOW LITTLE TO NO ENHANCEMENT; WHEREAS THE REMAINDER ISOENHANCE WITH LIVER PARENCHYMA C. Portal venous phase CECT: MOST LESIONS ARE HYPODENSE OR ISODENSE TO LIVER PARENCHYMA; whereas 17% showed hyperenhancement
98
``` MR Imaging appearance of Confluent Liver Fibrosis in A. On T1WI B. On T2WI C. Postcontrast MR (p.____) ```
A. T1WI: Hypointense B. T2WI: ACUTE fibrosis - has high fluid content and appears bright on T2WI CHRONIC fibrosis - is low in fluid content and appears bright on T2WI C. Post-Contrast MR: Negligible enhancement on arterial phase and late enhancement on delayed venous phase.
99
_____ is a pathological increase in portal venous pressure that results in the formation of portosystemic collateral vessels that divert blood flow away from the liver into the systemic circulation. (p.699)
PORTAL HYPERTENSION
100
3 causes of PORTAL HYPERTENSION (p.699)
1. PROGRESSIVE VASCULAR FIBROSIS ASSOCIATED WITH CHRONIC LIVER DISEASE 2. PORTAL VEIN THROMBOSIS OR COMPRESSION 3. PARASITIC INFECTIONS (SCHISTOSOMIASIS)
101
9 imaging signs of PORTAL HYPERTENSION (p.699)
1. Visualization of portosystemic collaterals (coronary; gastroesophageal; splenorenal; paraumbilical; hemorrhoidal; and retroperitoneal) 2. Increased portal vein diameter (>13mm) 3. Increased superior mesenteric and splenic vein diameters (>10mm) 4. Portal vein thrombosis 5. Calcifications in the portal and mesenteric veins 6. Edema in the mesentery; omentum and retroperitoneum 7. Splenomegaly due to vascular congestion 8. Ascites 9. Reversal of flow in any portion of the portal venous system (hepatofugal flow)
102
_______ may occur as a complication of cirrhosis; or may be caused by portal vein invasion or compression by tumor; hypercoagulable states; or inflammation (pancreatitis). (p.699)
PORTAL VEIN THROMBOSIS
103
On CT and US; the _____ is seen as a hypodense plug within the portal vein. (p.699)
THROMBUS
104
TRUE OF FALSE. | Malignant thrombus in the portal vein is contiguous with and extends from the primary tumor. (p.699-700)
TRUE
105
TRUE OF FALSE. Cavernous transformation of the portal vein develops when small collateral veins adjacent to the portal vein expand and replace the obliterated portal vein. (p.700)
TRUE - These collateral veins appear as a tangle of small vessels surrounding the thrombosed portal vein
106
_____ refers to a group of disorders characterized by obstruction to hepatic venous outflow involving one or more hepatic veins. (p.700).
BUDD-CHIARI SYNDROME
107
TRUE OR FALSE. Hepatic venous obstruction causes increased pressure in the hepatic sinusoids; resulting in liver congestion; portal hypertension and decreased hepatic perfusion. (p.700)
TRUE
108
Three causes of Budd-Chiari syndrome (p.700)
1. COAGULATION DISORDERS 2. MEMBRANOUS WEBS OBSTRUCTING THE HEPATIC VEINS OR IVC (most common in Asian countries) 3. MALIGNANT TUMOR INVASION OF THE HEPATIC VEINS - CAUDATE lobe is spared because of its venous drainage to the IVC.
109
COMMA SIGN is seen in what syndrome? (Comma-shaped intrahepatic collateral vessels may be seen on CT or MR. (p.700)
BUDD-CHIARI SYNDROME
110
In BUDD-CHIARI SYNDROME; blood flow to the right and left hepatic lobes is severely impaired resulting in a characteristic _______ pattern on contrast-enhanced CT. (p.700)
FLIP-FLOP pattern
111
_______ is a common complication of congestive heart failure and constrictive pericarditis. (p.700)
PASSIVE HEPATIC CONGESTION - Hepatic venous drainage is impaired and the liver becomes becomes engorged and swollen.
112
4 Imaging findings in PASSIVE HEPATIC CONGESTION (p.700)
1. DISTENTION OF THE HEPATIC VEINS AND IVC 2. REFLUX OF IV CONTRAST INTO THE HEPATIC VEINS AND IVC 3. INCREASED PULSATILITY OF THE PORTAL VEIN 4. INHOMOGENEOUS CONTRAST ENHANCEMENT OF THE LIVER.
113
4 Secondary findings in PASSIVE HEPATIC CONGESTION | p.700
1. Hepatomegaly 2. Cardiomegaly 3. Pleural effusions 4. Ascites
114
_____ may be primarily resulting from a hereditary disorder that increases dietary iron absorption or secondary due to excessive iron intake usually from multiple blood transfusions or chronic disease including cirrhosis; myelodysplastic syndrome and certain anemias. (p.700)
HEMOCHROMATOSIS - the susceptibility effect of iron; best appreciated on T2* images; causes loss of signal in tissues with excessive iron accumulation.
115
The ____ pattern of iron deposition is seen with increased iron absorption of primary hemochromatosis and with secondary hemochromatosis caused by chronic anemias. (p.700)
PARENCHYMAL
116
The ____ pattern of iron deposition is seen in secondary hemochromatosis; with iron overload caused by blood transfusions. (p. 700)
RETICULOENDOTHELIAL - excess iron accumulation occurs in reticuloendothelial cells in the liver; spleen; and bone marrow - MR shows diffuse decreased signal in all three areas.
117
The ___ pattern of iron deposition is rare but dramatic; | occuring only in patients with intravascular hemolysis caused by mechanical heart valves. (p.700)
RENAL - excess iron deposition occurs in the proximal convoluted tubules of the renal cortex; causing a loss of cortical signal. On T1WI and T2WI; and thus reverse in the normal corticomedullary differentiation pattern.
118
Gas in the _____ may be an ominous imaging sign associated with bowel ischemia in adults and necrotizing enterocolitis in infants. (p.701)
gas in the PORTAL VENOUS SYSTEM - CT reveals air in branching tubular structures extending to the liver capsule. - Air is commonly evident within the mesenteric and central portal veins - conventional radiographs show streaks of low density in the periphery of the liver.
119
GAS IN THE PORTAL VENOUS SYSTEM versus AIR IN BILIARY TREE? (p.701)
In distinction; AIR IN THE BILIARY TREE is more central; | not extending to within 2 cm from the liver capsule.
120
In normal liver; the most common hypervascular lesions are ____ (GIVE 4). (p.701)
1. HEMANGIOMA; 2. FOCAL NODULAR HYPERPLASIA; 3. HEPATIC ADENOMA 4. HYPERVASCULAR METASTASES
121
In cirrhosis; the most common hypervascular lesions are __ and ___. (p.701)
HCC and DYSPLASTIC NODULES
122
____ are the most common MALIGNANT masses in the liver. | p.701
METASTASES - 20 times more common than primary liver malignancies
123
Hepatic metastases most commonly originate from the __; __ and __. GIVE 3. (p.701)
GI TRACT; BREAST and LUNG | MNEMONIC: Liver Mets BLoG
124
The most characteristic feature of Liver Metastases is ______ enhancement; creating a ______ on post-contrast CT and MR images. (p. 701)
BAND-LIKE PERIPHERAL enhancement; | TARGET LESION
125
TRUE OR FALSE. Metastatic disease must be considered in the | differential diagnosis of virtually all hepatic masses. (p.701)
TRUE - multiplicity of lesions favors metastatic disease
126
On CT; hypovascular metastases are most apparent on _____ phase images when the background liver is maximally enhanced and the metastatic lesions are of low attenuation. (p.701)
PORTAL VENOUS phase
127
The most common HYPOVASCULAR LIVER METASTASES are___ (GIVE 5). (p.702)
1. COLORECTAL 2. LUNG 3. PROSTATE 4. GASTRIC 5. UROEPITHELIAL CARCINOMAS Mnemonic: Check PLUG
128
TRUE OR FALSE. HYPERvascular metastases overlap the appearance of HCC. (p.702)
TRUE - MR and CT show arterial phase enhancement with rapid washout on portal venous and delayed images.
129
HYPERVASCULAR METASTASES are associated with ____ | GIVE 6). (p.702
``` 1. PRIMARY NEUROENDOCRINE TUMORS (pancreatic islet tumors; carcinoid tumor;and pheochromocytoma). 2. RENAL CELL CARCINOMA 3. THYROID CARCINOMA 4. MELANOMA 5. SOME SARCOMAS 6. CHORIOCARCINOMA ```
130
_____ is second only to metastases as the common cause of a liver mass. (p.702)
CAVERNOUS HEMANGIOMA
131
What is the most common benign liver neoplasm?; | found in 7% to 20% of the population and more commonly in women.(p.702)
CAVERNOUS HEMANGIOMA - this tumor consists of large; thin-walled; blood-filled vascular spaces separated by fibrous septa. - blood flow through the maze of vascular spaces is extremely slow; resulting in characteristic imaging findings. - thrombosis within the vascular channels may result in central fibrosis and calcification
132
Larger lesions; GIANT HEMANGIOMAS (> ____ cm); occasionally causes symptoms. (p.702)
> 5 cm
133
TRUE OR FALSE. The size of most cavernous hemangiomas is stable over time. (p.702)
TRUE - enlargement of cavernous hemangiomas is a cause for reassessment.
134
US feature of a cavernous hemangioma. (p. 702)
Well-defined; uniformly hyperechoic mass in 80% of patients - no Doppler signal is obtained from most cavernous hemangiomas because the flow is too slow.
135
CT feature of a cavernous hemangioma. (P. 702)
Well-defined; hypodense mass on unenhanced scans - because the lesion consists mostly of blood;attenuation of the hemangioma is similar to that of blood vessels within the liver.
136
What is the characteristic pattern of enhancement with bolus IV contrast in cavernous hemangiomas? (p.702)
DISCONTINUOUS NODULAR ENHANCEMENT FROM THE PERIPHERY OF THE LESION THAT GRADUALLY BECOMES ISODENSE OR HYPERDENSE COMPARED TO THE LIVER PARENCHYMA. - the degree of contrast enhancement parallels that of hepatic blood vessels during all postcontrast phases.
137
The contrast enhancement in cavernous hemangiomas persists | for __ to __ minutes following injection because of slow flow within the lesion. (p. 702)
20 to 30 minutes
138
Areas of fibrosis remain ____ in all image sequences. (p. 702)
DARK
139
MR contrast enhancement pattern of cavernous hemangiomas. | p.702
Well-marginated mass with discontinuous peripheral nodular enhancement; leading to progressive fill-in of the lesion on delayed imaging (>5 minutes). - brightness of enhancement parallels the blood pool
140
Central areas of fibrosis,usually seen in ___ hemangiomas (>5 cm); do not enhance. (p.702)
GIANT
141
_____ hemangiomas (< 1.5 cm) fill in more rapidly; and the peripheral nodular enhancement may not be evident depending upon the timing of the images. (p.703)
SMALL CAPILLARY hemangiomas
142
FLASH hemangiomas ____ contrast on delayed images; whereas other small early phase-enhancing lesions; such as HCC and hypervascular metastases; show early and progressive _____. (p.703)
RETAIN; CONTRAST-WASHOUT
143
Radionuclide scanning using _____ as a blood pool agent is extremely accurate in the diagnosis of cavernous hemangioma. (p. 703)
TECHNETIUM-LABELED RED BLOOD CELLS
144
____ is the most common primary malignancy of the liver. | p.703
HEPATOCELLULAR CARCINOMA - 5th most common tumor in the world and the 3rd most common cause of cancer-related death (following lung and gastric cancer).
145
Give 3 risk factors of HEPATOCELLULAR CARCINOMA. (p.703)
1. CIRRHOSIS 2. CHRONIC HEPATITIS 3. VARIETY OF CARCINOGENS (sex hormones; aflatoxin; and thorotrast) Mnemonic: 3 C’s of HCC
146
In asia; most HCCs are found in patients with _____. (p.703)
CHRONIC ACTIVE VIRAL HEPATITIS
147
___ is the most sensitive imaging modality for the detection of HCC at 81% (p.703)
MR
148
Elevation in serum ______ is found in 90% of patients and is strongly suggestive of hepatoma in patients with cirrhosis. (p.703)
ALPHA FETOPROTEIN
149
Three major growth patterns of hepatomas that affect their imaging appearance. (p.703-704)
1. SOLITARY MASSIVE 2. MULTINODULAR 3. DIFFUSE INFILTRATIVE
150
_____ HCC growth pattern which appears as a single large mass with or without satellite nodules. (p.704)
SOLITARY MASSIVE HCC
151
____ HCC growth pattern which appears as multiple discrete nodules involving a large area of the liver. (p.704)
MULTINODULAR HCC
152
_____ HCC growth pattern which manifests as innumerable tiny indistinct nodules throughout the liver distorting the parenchyma but not causing a discrete mass. (p.704)
DIFFUSE HCC
153
High intensity on T1WI reflects the accumulation of __; ___ or ____ within the tumor (HCC). (p.704)
FAT; GLYCOGEN; or COPPER - fat shows signal loss on opposed-phase or fat saturation images.
154
Moderate high signal on T2WI is quite specific for HCC as dysplastic nodules are not high signal unless ____. (p.704)
INFARCTED
155
Arterial phase enhancement in HCC reflects ____ with supply from the ____ artery. (p.704) - This is considered an essential characteristic for diagnosis.
NEOANGIOGENESIS; HEPATIC artery - enhancement is HOMOGENOUS in small lesions and HETEROGENOUS in large lesions.
156
The classic and most common appearance of HCC on MR is | ___ signal on T1WI; __ signal on T2WI; with ____ enhancement and venous _____. (p.704)
LOW; HIGH; ARTERIAL ENHANCEMENT;VENOUS WASHOUT - delayed images commonly show late enhancement of an outer rim or capsule; a feature highly sensitive and specific.
157
6 imaging characteristics of large HCCs (p.704)
1. MOSAIC PATTERN (80 to 90% with HCC) of confluent small nodules separated by thin septations and necrotic areas; best seen on T2WI 2. DISTINCT TUMOR CAPSULE 3. EXTRACAPSULAR EXTENSION (40% to 80%) of tumor with satellite lesions or tumor projection through the capsule 4. VASCULAR INVASION (25%) of tumor into portal veins or; less commonly hepatic veins 5. EXTRAHEPATIC DISSEMINATION to abdominal lymph nodes; bones; lungs; and adrenals 6. PATTERN OF CONTRAST ENHANCEMENT - heterogeneous enhancement during arterial phase with rapid washout of contrast during portal venous and equilibrium phase.
158
Washout to become hypointense on delayed postcontrast images is a feature of ____; not seen with regenerative or dysplastic nodules. (p.705)
HCC
159
_______ is a common finding related to portal vein compression or occlusion by the tumor with compensatory increase in hepatic arterial supply. (p.____)
PERITUMORAL ARTERIAL PHASE ENHANCEMENT - peritumoral enhancement is commonly wedge-shaped and confined to the segment of the liver with compromised portal venous supply. (p.705)
160
Approximately 24% of liver tumors are surrounded by a fibrous capsule or pseudocapsule. This encapsulated HCC; a variant of the solitary massive form; is found more frequently seen in ____ populations and has a ___ prognosis.(p.____)
ASIAN; BETTER
161
___ metamorphosis is a common histologic finding in HCC and hepatic adenomas.(p.705)
FATTY metamorphosis
162
_____ shunting is seen as early or prolonged enhancement of the portal vein; or as a wedge-shaped area of parenchymal enhancement adjacent to the tumor.(p.705)
ARTERIOPORTAL shunting
163
Abundant copper binding protein in cancer cells may lead to _____ within the tumor. (p.705)
EXCESSIVE COPPER ACCUMULATION - high copper concentration causes the tumor to appear hyperdense on noncontrast CT and hyperintense (due to T1 shortening effect) on T1WI on MR.
164
____ HCC (approximately 13% of cases) appears as a heterogeneous permeative extensive tumor difficult to differentiate from the distorted parenchyma or cirrhosis.
DIFFUSE HCC - Vascular invasion and portal vein thrombosis is a prominent clue to the diagnosis. - hypointensity on delayed images is highly indicative of diffuse tumor.
165
______ is as benign solid mass consisting of abnormally arranged hepatocytes, bile ducts and Kupffer cells. (p.705) - second to hemangioma as the most common benign liver tumor
FOCAL NODULAR HYPERPLASIA (FNH) - most tumors are diagnosed in women of childbearing age.
166
Liver lesion that is mostly solitary; less than 5 cm in diameter; and are hypervascular with a CENTRAL FIBROUS SCAR containing thick-walled blood vessels. - Lesions are lobulated and well-circumscribed but lack a capsule. (p.705)
FOCAL NODULAR HYPERPLASIA (FNH) - benign lesions that do not require treatment but must be differentiated from hepatic adenoma and fibrolamellar carcinoma. - found most commonly in women - twice as common as hepatic adenoma and is not related to oral contraceptive use
167
Because of the presence of ___ cells, most (50% to 70%) FNH will show normal or increased radionuclide activity on technetium sulfur colloid liver-spleen scans. (p. 705)
KUPFFER CELLS
168
DIAGNOSIS? US finding of slight bulge in the liver contour or subtle alteration of parenchymal echogenicity may be the only clues to the presence of a lesion. Color Doppler may show its central vascularity. (p.705)
FOCAL NODULAR HYPERPLASIA(FNH)
169
DIAGNOSIS? CT FINDING of a subtle; slightly hypoattenuating lesion on unenhanced images. Post-contrast shows characteristic intense homogeneous enhancement in arterial phase sometimes with visualization of the large feeding vessels. Contrast washes out early on portal venous phase. The lesion is isointense and commonly near invisible on delayed-phase equilibrium images. (p.705)
FOCAL NODULAR HYPERPLASIA (FNH)
170
MR key diagnosis to recognize Focal Nodular Hyperplasia? | p.705
FNH is near isointense to liver parenchyma on all precontrast MR sequences - central scar is hypointense on T1WI and isointense to slightly hyperintense on T2WI
171
______ are rare; benign liver tumor that carry a risk of life threatening hemorrhage and potential for malignant degeneration.(p.705)
HEPATIC ADENOMAS - surgical removal of the tumor is advocated
172
Liver tumor found most commonly in women on long-term oral contraceptives. (p.705)
HEPATIC ADENOMAS - additional risk factors include androgen steroid intake and glycogen storage disease - tumor size is commonly 8 to 15 cm but may be up to 30 cm size.
173
Hepatic adenomas appear as ____ on technetium sulfur colloid | radionuclide scans; allowing differentiation from FNH. (p. 706)
COLD DEFECTS
174
________ is considered a separate clinical entity characterized by the presence of multiple adenomas (>10) in an otherwise normal liver in patients (usually young women) without risk factors for hepatic adenomas. (p.706)
LIVER ADENOMATOSIS
175
DIAGNOSIS? (LIVER TUMOR) US finding shows a well-circumscribed tumor that is usually heterogeneous depending on content of fat; necrosis; hemorrhage; or rarely calcification. High fat content or intratumoral hemorrhage makes the lesions appear hyperechoic.
LIVER ADENOMATOSIS
176
DIAGNOSIS? (LIVER TUMOR) CT finding shows well-circumscribed tumors that are often low in attenuation because of internal fat; necrosis; or old hemorrhage. Calcifications in areas of old hemorrhage or necrosis are present in 15%. Post-contrast scans show intense homogeneous enhancement during arterial phase that becomes isodense with liver on portal venous and delayed-phase scans. (p.706)
LIVER ADENOMATOSIS
177
With hepatocyte-specific contrast administration; adenomas | appear _____ to liver parenchyma on delayed images obtained 1 to 3 hours.(p.706)
HYPOINTENSE
178
_______ is a hepatocellular malignancy with clinical and pathologic features that are distinct from HCC. - typically present as a large liver mass in an adolescent or young adult (mean age, 23 years) with none of the risk factors for HCC; and without elevation of alpha fetoprotein levels. (p.706)
FIBROLAMELLAR CARCINOMA - cords of tumors are surrounded by prominent fibrous bands that emanate from a central fibrotic scar.
179
Liver tumor with a characteristic appearance of a large; lobulated hepatic mass with central scar and calcifications. (p.706)
FIBROLAMELLAR CARCINOMA - the central scar with radiating septa mimics the appearance of FNH
180
TRUE OR FALSE. LYMPHOMA involving the liver is usually diffusely infiltrative and undetectable by imaging methods. (P.707)
TRUE
181
HEMATOMAS show the evolution and breakdown of blood products. Subacute hematomas are bright on T1WI (effect of _____ ). (p.707)
METHEMOGLOBIN
182
Chronic hematomas are dark on T2WI (effect of _____). (p.707)
HEMOSIDERIN
183
Postcontrast images of hematomas shows no evidence of | ___ enhancement. (p. 707)
RIM
184
_____ is an autosomal dominant disorder of fibrovascular dysplasia; resulting in multiple telangiectasias and arteriovenous malformations.(p._____)
HEREDITARY HEMORRHAGIC TELANGIECTASIA | OSLER-WEBER-RENDU SYNDROME
185
______ are thin-walled dilated vascular channels that appear on the skin and mucous membranes as well as throughout the body on multiple organs. (p. 707)
TELANGIECTASIAS - patient present with epistaxis and intestinal bleeding
186
Nodular transformation of the liver parenchyma without fibrosis is called ______. (p. 707)
PSEUDOCIRRHOSIS
187
_____ appear as hypervascular rounded masses resembling an | asterisk; usually a few millimeters in size. (p.____)
TELANGIECTASIAS
188
_____ is a rare disorder associated with chronic wasting from cancer or tuberculosis; or associated with the use of oral contraceptives or anabolic steroids. (p. 707)
PELIOSIS HEPATIS - cystic dilatation of the hepatic sinusoids and multiple small (1 to 3 mm) blood-filled spaces characterize the lesions. - postcontrast images show no significant arterial phase enhancement with progressive delayed enhancement on portal venous and delayed-phase images.
189
_____ is a common hepatic mass; found in 5% of the population. (p.707)
BENIGN HEPATIC CYST - cysts range in size from microscopic to 20 cm
190
TRUE OR FALSE. | Hepatic cysts do not communicate with the biliary tree. (p.____)
TRUE
191
TRUE OF FALSE. | Tiny cysts are responsible for many of the HYPOATTENUATING LESIONS TOO SMALL TO CHARACTERIZE seen on MDCT. (p.707)
TRUE
192
_____ confirms the fluid nature of benign hepatic cysts.(p. 708)
POSTERIOR ACOUSTIC ENHANCEMENT
193
TRUE OR FALSE | Benign hepatic cysts do not enhance following contrast administration.(p.____)
TRUE
194
______ is in the spectrum of autosomal dominant polycystic disease and ocassionally occurs in the absence of polycystic kidneys. (p.708)
POLYCYSTIC LIVER DISEASE - The number and size of cysts increase over time and may eventually result in massive hepatomegaly and affect hepatic function. - Cysts are prone to hemorrhage and infection
195
____ are small benign neoplasms consisting of dilated cystic branching bile ducts embedded within fibrous tissue. (p.708)
BILE DUCT HAMARTOMAS (von Meyenburg Complexes) - appear as multiple tiny (<1cm) cystic lesions throughout the liver; best recognized on MR. - low signal on T1WI and high signal on T2WI - show peripheral enhancement on postcontrast
196
___ is a rare cystic neoplasm of the biliary epithelium. (p.708)
BILIARY CYSTADENOMA/CYSTADENOCARCINOMA
197
____ are premalignant and on a continuum of disease with | adenocarcinomas. (p.708)
CYSTADENOMAS - tumors typically contain mucin and appear as large (up to 35 cm) multiloculated cystic mass - fine septations are seen in cystadenomas - presence of thick; coarse calcifications suggest malignancy - differentiation from malignant lesions by imaging may not be possible.
198
US features of BILIARY CYSTADENOMA/CYSTADENOCARCINOMA? (p.708)
LARGE MULTICYSTIC MASS; SEPTATIONS AND MURAL NODULES AND PAPILLARY PROJECTIONS IF PRESENT. - CT shows enhancement of the wall and any solid components - Calcifications are well shown by CT and favor cystadenocarcinoma - MR depicts the mass as multiseptated cystic with low signal on T1WI and high signal on T2WI
199
PYOGENIC LIVER ABSCESS is usually caused by _____ (GIVE 4) | p.709
Escherichia coli; Staphylococcus aureus; Streptococcus or Anaerobic bacteria - destruction of liver results in a solitary cavity or a tight group of individual loculated abscesses - lesion may be echogenic and appear solid on US - a peripheral rim enhances with contrast - gas is present within the lesion in 20% of cases.
200
Diagnosis of PYOGENIC LIVER ABSCESSES is confirmed by | ________. (p.709)
PERCUTANEOUS ASPIRATION - catheter or surgical drainage is indicated in pyogenic liver abscesses
201
_______ is usually solitary with thick nodular walls.(p.709)
AMEBIC ABSCESS - The lesion may be indistinguishable from pyogenic abscess; however; the patient is often more acutely ill and resides in or has travelled to endemic areas (India; Africa; the Far East; and Central and South America).
202
Amebic abscesses commonly occur in the ___ lobe of the liver causing elevation of the right hemidiaphragm and may rupture through the diaphragm into the pleural space. (p.709)
RIGHT lobe of the liver
203
In the United States (AMEBIC LIVER ABSCESS); the diagnosis is typically confirmed by ______ and the patient is treated with metronidazole. (p.709)
SEROLOGY
204
In the endemic areas (AMEBIC LIVER ABSCESS); the diagnosis is confirmed by aspiration of _____ material. (p.709)
ANCHOVY PASTE
205
the diagnosis of AMEBIC ABSCESS is typically confirmed by ______ and the patient is treated by ______. (p.709)
ASPIRATION OF ANCHOVY PASTE MATERIAL; | REPEATED ASPIRATION or CATHETER DRAINAGE
206
______ cyst is due to infestation with Echinococcus granulosus or E. multilocularis tapeworm. (p. 709)
HYDATID CYST - parasite is endemic in central and northern Europe; the Mediterranean; northern Asia; China; Japan; Turkey; and parts of North America - single or multiple cystic masses usually have well-defined walls that commonly calcify (50%) - daughter cysts may be visualized within the parent cyst (75%).
207
The ___ is the most common organ affected (95%) by hydatid cysts. (p.709)
LIVER
208
TRUE OR FALSE. Diagnostic aspiration of HYDATID CYSTS | carries a risk of anaphylactic reaction. (p.709)
TRUE - treatment is mebendazole or surgical excision
209
______tumor must always be considered for atypical cystic liver masses. (p. 709)
CYSTIC/NECROTIC tumor - METASTASES may be necrotic or predominantly cystic - HCC is ocassionally cystic - Undifferentiated embryonal sarcomas are seen in older children; adolescents;and young adults.
210
TRUE OR FALSE. TINY HYPOATTENUATING LESIONS on MDCT are detected with increased frequency related to thinner collimation; improved resolution; and rapid multiphase postcontrast scanning (p.709)
TRUE ``` - lesions smaller than 1 cm are difficult to characterize and often too small to biopsy. - differential diagnoses include cysts; hemangiomas and metastases ```
211
DIAGNOSIS? (LIVER TUMOR) - MR finding is variable fat content and internal hemorrhage; both of which produce bright foci on T1WI. - On T2WI; most are hyperintense to liver and are commonly heterogeneous because of hemorrhage or necrosis. - Postcontrast arterial phase images show heterogeneous enhancement; not as avid as FNH - Delayed contrast washout is typical. (p.706)
LIVER ADENOMATOSIS
212
_____ preferred screening method for biliary obstruction because of its low cost, high accuracy in detecting biliary dilatation and convenience. (p.710)
ULTRASOUND
213
______ has a reported sensitivity of 88% | in detection of stones in the CBD. (p.710)
UNENHANCED HELICAL CT - MR can also demonstrate biliary dilation and appears more effective than CT or US in demonstrating associated tumors.
214
_____ provides excellent visualization of the biliary tree by taking advantage of the high water content of bile and its relative stasis compared to the flowing blood. (p.710)
MR cholangiopancreatography (MRCP) - performed using heavily T2-weighted sequences with acquisition times slower than moving blood; producing high signal in the biliary tree and signal voids in the nearby blood vessels. - extreme T2-weighting demonstrates bright bile ducts with bright surrounding soft tissues
215
``` TRUE OR FALSE. However; any static fluid will also be bright on MRCP images; so ascites; hepatic and renal cysts; and fluid in the bowel may obscure the biliary tree. (p.710) ```
TRUE
216
_____ MRCP uses slice thickness of 40 to 60 mm with fat saturation to improve visualization of the biliary tree. (p.710)
THICK SLAB MRCP
217
____ and ___ images produce impressive displays of the entire biliary tree. (p.710)
HIGH-RESOLUTION 3D ACQUISITIONS and MAXIMUM INTENSITY PROJECTION (MIP) images
218
____ is now used primarily to guide therapy such as stent placement for biliary strictures; stone extraction or sphincterotomy. (p.710)
ENDOSCOPIC RETROGADE CHOLANGIOGRAPHY (ERCP)
219
Direct contrast injection of the biliary tree during ERCP produces ____ resolution images than MRCP; but duct visualization is limited to the ducts that can be filled retrograde. (p.710)
HIGHER RESOLUTION - ducts proximal to a high-grade obstruction are not visualized.
220
____ is mainly used to guide therapy when the biliary tree cannot be accessed endoscopically such as when patients have had a choledojejunostomy. (p.710)
PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY (PTC)
221
``` Operative cholangiography is used to visualize non palpable bile duct stones at surgery and _______ is used to visualize common duct stones following surgery. (p.710) ```
T-TUBE CHOLANGIOGRAPHY
222
``` Radionuclide imaging; utilizing ____; is useful for showing the patency of biliary-enteric anastomoses and for demonstrating bile leaks and fistulae. (p.710) ```
TECHNETIUM-99m-IMINODIACETIC | ACID
223
______is performed using agents such as iopanoic acid formerly used for oral cholecystography. (p.710)
CT CHOLANGIOGRAPHY
224
____ causes swelling of hepatocytes; which blocks biliary capillaries and causes and intrahepatic cholestasis without surgical obstruction. (p.711)
HEPATITIS
225
4 imaging signs of biliary dilation | p.711
``` 1. Multiple branching tubular; round or oval structures that course toward the porta hepatis 2. diameter of IHBDs larger than 40% of the diameter of the adjacent portal vein 3. Dilation of the common duct greater than 6 mm 4. gallbladder diameter greater than 5cm; when obstruction is distal to the cystic duct. ```
226
____ sign refers to dilatation of both the CBD and the pancreatic duct in the head of the pancreas. (p.711)
DOUBLE DUCT sign - dilation of both the ducts is usually caused by a tumor at the ampulla
227
TRUE OR FALSE. Benign disease is responsible for approximately 75% of cases of obstructive jaundice in the adult; whereas malignant disease causes the remainder. (p.711)
TRUE
228
GRADUAL TAPERING of a dilated common bile | duct suggests ___-. (p.711)
BENIGN STRICTURE - gallstones may be identified in the bile duct surrounded by a crescent of bile.
229
ABRUPT TERMINATION of a dilated common bile duct is characteristic of a ____ process. (p.711)
MALIGNANT
230
____ is responsible for approximately 20% of cases of obstructive jaundice in the adult. (p.711)
CHOLEDOCHOLITHIASIS - 1% to 3% of patients with choledocholithiasis will have no stones in the gallbladder. - the sensitivity of US for stones in the bile ducts ranges from 20% to 80% - stone detection by US is much improved when the CBD is dilated and the pancreatic head is well-visualized.
231
CT sensitivity for choledocholithiasis is __% to __ %; with stones appearing as intraluminal masses of varying attenuation. (p.711)
70 % to 80 %
232
____ and ____ have the highest sensitivity for stone detection (95% to 99%) - choledocholithiasis. (p.711)
CONTRAST STUDIES and MRCP - they demonstrate stones as dark-filling defects within the bright bile.
233
MRCP may miss stones smaller than ___ mm because they are lost within high-signal fluid. (p.711)
smaller than 3 mm
234
Three imaging signs of stones within the bile ducts include ___ (p.712)
1. Stone layer dependently within; allowing a crescent of bile to outline the anterior portion of the stone (the CRESCENT SIGN) 2. Stones are usually geometric or angulated in shape and lamellated in appearance 3. Periductal edema and thickening and enhancement of the wall of the bile duct occur with impacted stones or infection. - Wall thickening and enhancement is also seen with tumors
235
______ is the cause of 40% to 45% of obstructive jaundice in the adult. (p.712)
BENIGN STRICTURE
236
7 CAUSES OF BENIGN STRICTURE | p.712
1. TRAUMA 2. SURGERY 3. PRIOR BILIARY INTERVENTIONAL PROCEDURES 4. RECURRENT CHOLANGITIS 5. PREVIOUS PASSAGE OF STONES THROUGH THE BILE DUCTS 6. RADIATION THERAPY 7. PERFORATED DUODENAL ULCERS
237
The wall of the involved CBD enhanced minimally with _____ strictures. (p.712)
BENIGN strictures
238
Hyperenhancement of the CBD during portal venous phase is evidence of _____ stricture. (p.712)
MALIGNANT stricture
239
___ is responsible for approx. 8% of cases of biliary obstruction. (p.712)
PANCREATITIS -Inflammation; fibrosis; and inflammatory masses narrow the bile ducts
240
___ is associated with a history of ulcerative colitis (50% to 70% of cases). - an idiopathic; fibrosing; chronic inflammatory disease characterized by insidious onset of jaundice; with progressive disease affecting both IHBD and EHBD. (p.712)
PRIMARY SCLEROSING CHOLANGITIS | PSC
241
3 imaging findings found in PSC. PRIMARY SCLEROSING CHOLANGITIS. (p.712)
1. IHBD dilatation 2. IHBD strictures 3. EHBD wall thickening and stenosis
242
Key diagnostic finding of PSC. | p.712
Alternating dilation and stenosis produces a characteristic BEADED pattern of intrahepatic ducts. - small saccular outpouching (duct diverticula) ; demonstrated on cholangiography; are also considered to be pathognomonic - complications include biliary cirrhosis (50%) and cholangiocarcinoma
243
___ is characterized by thickening of the walls of the bile ducts and the gallbladder due to inflammation and edema. (p.712)
HIV-ASSOCICATED CHOLANGITIS - infection by opportunistic organisms; most commonly Cytomegalovirus and Cryptosporidium; as well as reaction to the HIV itself
244
____ occurs in the settng of biliary obstruction and is life-threatening with mortality as high as 65%. (p.713)
ACUTE BACTERIAL CHOLANGITIS
245
Components of CHARCOT TRIAD (p.713)
1. FEVER 2. PAIN 3. JAUNDICE Mnemonic: FPJ - infection is usually polymicrobial with gram-negative rods predominating
246
Imaging finding of ACUTE | BACTERIAL CHOLANGITIS. (p.713)
BILIARY DILATATION; USUALLY CAUSED BY A STONE IN THE DUCT; ASSOCIATED WITH PERIBILIARY CONTRAST ENHANCEMENT AND EDEMA
247
____ has in the past been called ORIENTAL CHOLANGIOHEPATITIS because it is an endemic disease in Southeast Asia. (p.713)
RECURRENT PYOGENIC CHOLANGITIS ``` - characterized by recurrent attacks of jaundice; abdominal pain; fever and chills - Intrahepatic and EHBDs are dilated and filled with soft pigmented stones and pus ```
248
``` TRUE OR FALSE. RECURRENT PYOGENIC CHOLANGITIS is associated with parasitic infestation and nutritional deficiency. (p.713) ```
TRUE ``` - findings include intraductal stones; severe extrahepatic biliary dilation; focal strictures; pneumobilia and straightening and rigidity of the intrahepatic ducts ```
249
5 complications of RECURRENT PYOGENIC CHOLANGITIS (p.713)
1. LIVER ABSCESS 2. BILOMA 3. PANCREATITIS 4. CHOLANGIOCARCINOMA 5. ATROPHY
250
____ is an uncommon congenital anomaly of the biliary tract characterized by saccular ectasia of the IHBD without biliary obstruction. (p.713)
CAROLI DISEASE (Type V) - only one hepatic lobe or segment; or the entire liver; may be affected - EHBD are spared in 50% of cases Todani Classification: - Type I: most common, EHBD - Type II: True DIVERTICULUM from EHBD - Type III: within the DUODENAL WALL - Type IV: next most common, both IHBD and EHBD - Type V: Caroli disease, multiple dilatations/cysts of IHBD only
251
``` 5 imaging findings of CAROLI DISEASE (p.713) ```
1. SACCULAR DILATATION OF IHBD 2. ENHANCING FIBROVASCULAR BUNDLES 3. SEGMENTAL DISTRIBUTION OF THE BILE DUCT ABNORMALITY WITH NORMAL APPEARANCE UNAFFECTED LIVER SEGMENTS 4. CHOLANGIOGRAPHY shows a characteristic pattern of focal biliary narrowing and saccular dilatation 5. DILATATION of the CBD (10 to 30 mm) in half the cases
252
Imaging sign found in CAROLI DISEASE; wherein enhancing fibrovascular bundles are seen centrally within many of the dilated ducts producing this sign.(p.713)
CENTRAL DOT SIGN
253
___ are uncommon congenital anomalies of the biliary tree characterized by cystic dilation of the bile ducts. (p.713)
CHOLEDOCHAL CYSTS
254
Most common choledochal cyst type (Todani Classification)? (p.713)
TYPE I - 80% to 90% - confined to the EHBD - appear as fusiform saccular dilatations of the CHD; CBD; or segments of each.
255
Choledochal Cyst type seen as a diverticula of the CBD attached by a narrow stalk. (p.713)
TYPE II
256
``` Choledochal cyst type termed CHOLEDOCHOCELES and are focal dilatations of the intraduodenal portion of the CBD closely resembling ureteroceles. ```
TYPE III
257
Choledochal cyst type defined as multiple focal dilatations of the IHBD and EHBD usually with a focal large cystic dilatation of the CBD.(p.714)
TYPE IV (next most common)
258
``` Choledochal cyst type referred to CAROLI DISEASE; which is more appropriately classified as a disease separate from choledochal cyst. (p.714) ```
TYPE V
259
______ and ___ carcinomas are the cause of 20% to 25% of cases of biliary obstruction in the adult. (p.714)
PANCREATIC and AMPULLARY | carcinomas
260
``` ____ may present as intraductal filling defects. - Colorectal cancers are the most common primary tumors associated with intraluminal biliary metastases. (p.714) ```
METASTASES
261
Findings that favor metastases over cholangiocarcinoma are the __ and __. (p.714).
``` 1. presence of a contiguous parenchymal mass 2. expansion of the duct at the site of the intraluminal mass in a patient with known colorectal cancer ```
262
__ is the second most common malignant primary hepatic tumor. (p.714)
CHOLANGIOCARCINOMA ``` - tumors arise from the epithelium of the bile ducts and are usually adenocarcinomas (90%) - growth patterns include mass-forming; periductal infiltrating; and intraductal polypoid -poor prognosis ```
263
``` _____ cholangioCA (10%) presents as an intrahepatic hypodense mass sometimes (25%) causing peripheral biliary dilatation.(p.714) ```
PERIPHERAL CholangioCA ``` - MDCT demonstrates a homogeneous low-attenuation mass with delayed; mild; thin; incomplete; rim-like enhancement. - additional findings may include capsular retraction and satellite nodules ```
264
____ cholangioCA (____ tumor) (25%) occurs near the junction of the right and left bile ducts. (p.714)
HILAR cholangioCA (Klatskin tumor) ``` - tumor is usually small; poorly differentiated; aggressive; and causes obstruction of both ductal systems - surgical resection is the only hope for cure. ```
265
``` ____ cholangioCA (65%) causes stenosis or obstruction of the CBD in most cases (95%) and presents as an intraductal polypoid mass in 5%.(p.714) ```
EXTRAHEPATIC cholangioCA ``` - shows thickening of the wall of the involved bile duct with hyperenhancement during arterial phase - abrupt stricture with thickening duct wall may be the only findings. ```
266
5 predisposing conditions of EXTRAHEPATIC CHOLANGIOCARCINOMA (p.715)
1. CHOLEDOCHAL CYST 2. ULCERATIVE COLITIS 3. CAROLI DISEASE 4. CLONORCHIS SINENSIS INFECTION 5. PSC
267
``` ___ tumor of the bile ducts may produce a large amount of mucin that markedly dilates the billiary tree and impairs the flow of bile. (p.715) ```
INTRADUCTAL PAPILLARY MUCINOUS TUMOR - tumors are intraductal; polypoid;and characterized by innumerable frondlike papillary projections
268
``` ____ (___) is most commonly encountered in the patient with a surgically created biliary- enteric anastomosis; or who has had a sphincterotomy to facilitate stone passage. (p.715) ```
GAS IN THE BILIARY TRACT | PNEUMOBILIA
269
___ fistula is most commonly due to the erosion of a gallstone through the gallbladder and into the duodenum (p.715)
CHOLECYSTODUODENAL FISTULA ``` - most common in women because of the higher incidence of gallstones - when the gallstone is large; it may cause small bowel obstruction ```
270
___ fistula is caused by a penetrating peptic ulcer eroding ino the CBD. (p.715)
CHOLEDOCHODUODENAL | FISTULA
271
____ is the imaging method of choice for the gallbladder. (p.715)
ULTRASOUND
272
____ has sensitivity and specificity comparable to US for the diagnosis of acute cholecystitis. (p.715)
CHOLESCINTIGRAPHY utilizing | technetium-99m-iminodiaceticacid
273
``` Approx. 85% of gallstone are predominantly _____; whereas 15% are pred. ____ (pigment stones) related to hemolytic anemia. (p. 715) ```
CHOLESTEROL; BILIRUBIN ``` - approx. 10% of stones are sufficiently radioopaque to be detected by conventional radiographs as laminated or faceted calcifications. ```
274
``` Fissure within gallstones may contain nitrogen gas that appears on radiographs as branching linear lucencies resembling a _____. (p.715) ```
CROW'S FOOT
275
5 conditions where | gallstones are common. (p.715)
1. Women (female:male = 4:1) 2. Patients with hemolytic anemia 3. Diseases of the Ileum 4. Cirrhosis 5. Diabetes Mellitus
276
__ detects 95% of all gallstones; whereas __ detects only 80 to 85%. (p.715)
ULTRASOUND; CT - gallstones vary in CT attenuation from fat density to calcium density
277
``` TRUE OR FALSE. Up to 20% of gallstones are ISODENSE with bile and not detected by CT; whereas some gallstones are missed because of their small size or volume averaging with the adjacent bowel. (p.715-716) ```
TRUE
278
``` Contrast studies; MRCP and T2 -weighted MR demonstrate ____ as "filling defects"; rounded or faceted dark objects within the high-density bile. (p.716) ```
GALLSTONES
279
Give 5 Differential considerations for lesions in the GB that may be mistaken for gallstones (p.716)
``` 1. Sludge balls or tumefactive biliary sludge 2. Cholesterol polyps 3. Adenomatous polyps 4. Gallbladder CA 5. Adenomyomatosis ```
280
``` ____ result from biliary stasis. Bile thickens and forms layers of bile and mobile masses that move with changes in patient position. (p.716) ```
SLUDGE BALLS or TUMEFACTIVE BILIARY SLUDGE - the presence of sludge indicates indicates lack of bile turnover; which may occur because of obstruction; or simply lack of oral food intake.
281
``` ____ polyps are common (4% to 7% of the population) benign; polypoid masses that result from accumulation of triglycerides and cholesterol in macrophages in the GB wall. (p.716) ```
CHOLESTEROL polyps (p.716) - polyps 5mm and smaller are routinely dismissed as benign cholesterol polyps
282
TRUE OR FALSE. Adenomatous polyps are potentially premalignant. (p.716)
TRUE
283
__ carcinoma may present as a polypoid GB mass (p.716)
GALLBLADDER CARCINOMA ``` - GB polyps larger than 10 mm should be considered for surgical removal because of the risk of cancer - gallstones are usually present ```
284
___ may be focal and present as a polypoid mass fixed to the GB wall. (p.716)
ADENOMYOMATOSIS
285
Refers to acute inflammation of the GB caused by gallstones obstructing the cystic duct in 90% of cases. (p. 716)
ACUTE CHOLECYSTITIS
286
Confident US diagnosis of acute cholecystitis requires the presence of these 3 findings. (p.716)
1. CHOLELITHIASIS 2. EDEMA OF THE GB WALL seen as a band of echolucency in the wall 3. POSITIVE SONOGRAPHIC MURPHY SIGN
287
Scintigraphic diagnosis of acute cholecystitis is based on ___ and ____. (p.716)
1. Obstruction of the cystic duct 2. Non-vizualization of the GB ``` - The normal GB demonstrates progressive accumulation of radionuclide activity over 30 minutes to 1 hour ff injection of technetium-99m -iminodiacetic acid. - delayed visualization of the GB may be seen in patients with biliary stasis due to fasting or hyperalimentation. ```
288
``` Diagnosis? CT demonstrates gallstones; distended GB; thickened GB wall; subserosal edema; high-density bile; intraluminal sloughed membranes; inflammatory stranding in pericholecystic fat; pericholecystic fluid; blurring of the interface between GB and liver; and prominent arterial phase enhancement of the liver adjacent to the gallbladder. (p.716) ```
ACUTE CHOLECYSTITIS - MR Findings are similar: 1. gallstones; often impacted in the neck 2. wall thickening (> 3mm) with edema 3. distended GB 4. pericholecystic fluid
289
___ cholecystitis causes special problems in diagnosis because the cystic duct is often not obstructed. (p.717)
ACALCULOUS Cholecystitis - inflammation may be due to GB wall ischemia or direct bacterial infection
290
5 conditions wherein patient is at risk for acalculous cholecystitis (p.717)
``` 1. Biliary stasis due to lack of oral intake 2. Posttrauma 3. Post-burn 4. Postsurgery 5. Total parenteral nutrition ```
291
Diagnosis? US demonstrates a distended tender GB with thickened wall but without stones. (p.717)
ACALCULOUS CHOLECYSTITIS - many patients are too ill to elicit a reliable sonographic Murphy sign
292
``` ____ is the term used to describe the presence of thick particulate matter in highly concentrated bile. (p.717) ```
SLUDGE ``` - calcium bilirubinate and cholesterol crystals precipitate in the bile when biliary stasis is prolonged because of a lack of oral intake or biliary obstruction ```
293
Causes of dense bile; give 4. | p.717
1. Sludge 2. Pus 3. Blood 4. Milk of Calcium
294
Give 5 complications of ACUTE Cholecystitis (p.717)
1. Gallbladder Empyema 2. Gangrenous Cholecystitis 3. Perforation of the GB 4. Emphysematous cholecystitis 5. Mirizzi syndrome
295
``` _____ desbribes the GB distended with pus in a patient; often diabetic; with rapid progression of symptoms suggesting an abdominal abscess. (p.717) ```
GALLBLADDER EMPYEMA
296
____ indicates the presence of | necrosis of the GB wall. (p.717)
GANGRENOUS CHOLECYSTITIS ``` - the patient is at risk for GB perforation. - findings include mucosal irregularity and asymmetric thickening of the GB wall with multiple lucent layers; indicating mucosal ulceration and reactive edema. ```
297
``` TRUE OR FALSE. Perforation of the GB is a life-threatening condition seen in 5% to 10% of cases. (p.717) ```
TRUE ``` - a focal pericholecystic fluid collection suggests pericholecystic abscess - gas is often present within the GB lumen if the perforation extends into the bowel. ```
298
``` _______ results from infection of the gallbladder with gas-forming organisms; usually E.coli or Clostridium perfringens -approx. 40% are diabetic (p.717) ```
EMPHYSEMATOUS CHOLECYSTITIS ``` - gallstones may or may not be present. -gas is demonstrated within the wall or within the lumen of the gallbladder by conventional radiography or CT. - on US; intramural gas has an arc-like configuration difficult to differentiate from calcification and porcelain gallbladder. ```
299
``` _____ refers to the condition of biliary obstruction resulting from a gallstone in the cystic duct eroding into the adjacent common duct and causing an inflammatory mass that obstructs the common duct. (p.717) ```
MIRIZZI SYNDROME ``` - visualization of a stone at the junction of the cystic duct and the common hepatic duct in a patient with biliary obstruction and gallbadder inflammation suggests the diagnosis. ```
300
``` _____ includes a spectrum of pathology that shares the presence of gallstones and chronic gallbladder inflammation. (p.717) ```
CHRONIC CHOLECYSTITIS ``` - patients with chronic cholecystitis complain of recurrent attacks of RUQ abdominal pain and biliary colic ```
301
5 imaging findings of Chronic Cholecystitis (p.717)
1. Gallstones 2. Thickening of the GB wall 3. contraction of the GB lumen 4. Delayed visualization of the GB on cholescintigraphy 5. Poor contractility
302
Give 3 variants of Chronic Cholecystitis (p.717)
1. Porcelain Gallbladder 2. Milk of Calcium bile 3. Xanthogranulomatous Cholecystitis
303
____ describes the presence of dystrophic calcification in the wall of an obstructed and chronically inflammed GB. (p.717)
PORCELAIN GALLBLADDER ``` - the condition is associated with gallstones in 90% of cases. - carries a 10% to 20% risk of GB carcinoma - Cholecystectomy is usually indicated. ```
304
______ (____) is associated with an obstructed cystic duct; chronic cholecystitis; and gallstones
MILK OF CALCIUM (LIMY BILE) - the bile is extremely echogenic on US and gallstones may be visualized within it.
305
``` _______ is an uncommon variant of chronic cholecystitis characterized by nodular depostis of lipid-laden macrophages in the gallbladder wall and proliferative fibrosis. (p.717) ```
XANTHOGRANULOMATOUS | CHOLECYSTITIS
306
``` Diagnosis? Imaging findings include marked GB wall thickening of about 2 cm; fat density nodules in the wall; narrowing of the lumen. (p.717) ```
XANTHOGRANULOMATOUS CHOLECYSTITIS ``` - Cholelithiasis is frequently present - the condition is difficult to differentiate from GB carcinoma - preservation of linear enhancement of the mucosa on post-contrast MR favors xanthogranulomatous cholecystitis over carcinoma ```
307
``` Thickening of the GB wall is present when the wall thickness measured on the hepatic aspect of the GB exceeds __ mm in patients who have fasted at least 8 hours. (p.718) ```
exceeds 3 mm
308
7 conditions associated with GB wall thickening. (p.718)
``` 1. Acute and Chronic Cholecystitis 2. Hepatitis 3. Portal venous HTN and Congestive Heart Failure 4. AIDS 5. Hypoalbuminemia 6. Gallbladder CA 7. Adenomyomatosis ```
309
``` Hepatitis causes ____; which results in reduced GB volume and thickening of the GB wall in approx.half of the patients (p.718) ```
REDUCTION IN BILE FLOW
310
Portal venous HTN and CHF may cause GB wall thickening by ___. (p.718)
PASSIVE VENOUS CONGESTION
311
GB carcinoma usually presents as a focal mass but may cause only ___ GB wall thickening. (p.718)
FOCAL GB wall thickening
312
``` ____ is the most frequent benign condition of the GB and is characterized by hyperplasia of the mucosa and smooth muscle ```
ADENOMYOMATOSIS ``` - it may be localized; usually in the fundus; segmental or diffuse involving the entire GB - coexisting gallstones are commonly present ```
313
Outpouchings of GB mucosa into or through the muscularis form characteristic ____. (p.718)
ROKITANSKY-ASCHOFF SINUSES
314
TRUE OR FALSE. Adenomyomatosis has no malignant potential. (p.718)
TRUE
315
``` DIAGNOSIS? US shows "comet-tail" reverberation artifacts emanating from inspissated bile within these sinuses in the thickened GB wall. ```
ADENOMYOMATOSIS
316
``` DIAGNOSIS? MRCP shows a "pearl necklace" appearance of the GB wall caused by bright fluid within the sinuses. (p.718) ```
ADENOMYOMATOSIS
317
DIAGNOSIS? CT shows GB wall thickening with tiny cystic spaces. (p.718)
ADENOMYOMATOSIS
318
``` TRUE OR FALSE. The presence of gallstones in 70% to 80% of cases masks the findings of cancer; esp. with US examination. (p.718) ```
TRUE - GB Carcinoma is a tumor of elderly women (>60 years; female:male=4;1)
319
TRUE OR FALSE. Calcification of the GB wall (porcelain GB) is a risk factor for GB carcinoma. (p.718)
TRUE
320
7 imaging findings of | GB carcinoma. (p.718)
1. Intraluminal soft tissue mass 2. Focal or diffuse GB wall thickening 3. Soft tissue mass replacing the GB 4. Gallstones 5. Extension of the tumor into the liver; bile ducts and adjacent bowel 6. dilated bile ducts 7. metastases to periportal and peripancreatic lymph nodes of the liver - most tumors are unresectable at discovery
321
__ is the preferred screening method for; biliary obstruction because of its low cost; high accuracy in detecting biliary dilatation; and convenience. (p.710)
ULTRASOUND - limited by incosistent visualization of the distal common bile duct (CBD) and low sensitivity for determining the cause of obstruction.
322
______ has a reported sensitivity of 88% | detection of stones in the CBD. (p.710)
UNENHANCED HELICAL CT - MR can also demonstrate biliary dilation and appears more effective than CT or US in demonstrating associated tumors.
323
_____ provides excellent visualization of the biliary tree by taking advantage of the high water content of bile and its relative stasis compared to the flowing blood. (p.710)
MR cholangiopancreatography (MRCP) - performed using heavily T2-weighted sequences with acquisitiion times slower than moving blood; producing high signal in the biliary tree and signal voids in the nearby blood vessels. - extreme T2-weighting demonstrates bright bile ducts with bright surrounding soft tissues
324
``` TRUE OR FALSE. However; any static fluid will also be bright on MRCP images; so ascites; hepatic and renal cysts; and fluid in the bowel may obscure the biliary tree. (p.710) ```
TRUE
325
_____ MRCP uses slice thickness of 40 to 60 mm with fat saturation to improve visualization of the biliary tree. (p.710)
THICK SLAB MRCP
326
____ and ___ images produce impressive displays of the entire biliary tree. (p.710)
HIGH-RESOLUTION 3D ACQUISITIONS and MAXIMUM INTENSITY PROJECTION (MIP) images
327
____ is now used primarily to guide therapy such as stent placement for biliary strictures; stone extraction or sphincterotomy. (p.710)
ENDOSCOPIC RETROGADE CHOLANGIOGRAPHY (ERCP)
328
``` Direct contrast injection of the biliary tree during ERCP produces ____ resolution images than MRCP; but duct visualization is limited to the ducts that can be filled retrograde. (p.710) ```
HIGHER RESOLUTION - ducts proximal to a high-grade obstruction are not visualized.
329
____ is mainly used to guide therapy when the biliary tree cannot be accessed endoscopically such as when patients have had a choledojejunostomy. (p.710)
PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY (PTC)
330
``` Operative cholangiography is used to visualize non palpable bile duct stones at surgery and _______ is used to visualize common duct stones following surgery. (p.710) ```
T-TUBE CHOLANGIOGRAPHY
331
``` Radionuclide imaging; utilizing ____; is useful for showing the patency of biliary-enteric anastomoses and for demonstrating bile leaks and fistulae. (p.710) ```
TECHNETIUM-99m-IMINODIACETIC | ACID
332
______is performed using agents such as iopanoic acid formerly used for oral cholecystography. (p.710)
CT CHOLANGIOGRAPHY
333
____ causes swelling of hepatocytes; which blocks biliary capillaries and causes intrahepatic cholestasis without surgical obstruction. (p.711)
HEPATITIS
334
4 signs of imaging signs of biliary dilation | p.711
``` 1. Multiple branching tubular; round or oval structures that course toward the porta hepatis 2. diameter of IHBDs larger than 40% of the diameter of the adjacent portal vein 3. Dilation of the common duct greater than 6 mm 4. gallbladder diameter greater than 5cm; when obstruction is distal to the cystic duct. ```
335
____ sign refers to dilatation of both the CBD and the pancreatic duct in the head of the pancreas. (p.711)
DOUBLE DUCT sign - dilation of both the ducts is usually caused by a tumor at the ampulla
336
TRUE OR FALSE. Benign disease is responsible for approximately 75% of cases of obstructive jaundice in the adult; whereas malignant disease causes the remainder. (p.711)
TRUE
337
GRADUAL TAPERING of a dilated common bile | duct suggests ___. (p.711)
BENIGN STRICTURE - gallstones may be identified in the bile duct surrounded by a crescent of bile.
338
ABRUPT TERMINATION of a dilated common bile duct is characteristic of a ____ process. (p.711)
MALIGNANT
339
____ is responsible for approximately 20% of cases of obstructive jaundice in the adult. (p.711)
CHOLEDOCHOLITHIASIS - 1% to 3% of patients with choledocholithiasis will have no stones in the gallbladder. - the sensitivity of US for stones in the bile ducts ranges from 20% to 80% - stone detection by US is much improved when the CBD is dilated and the pancreatic head is well-visualized.
340
CT sensitivity for choledocholithiasis is __% to __ %; with stones appearing as intraluminal masses of varying attenuation. (p.711)
70 % to 80 %
341
____ and __ have the highest sensitivity for stone detection (95% to 99%) - choledocholithiasis. (p.711)
CONTRAST STUDIES and MRCP - they demonstrate stones as dark-filling defects within the bright bile.
342
MRCP may miss stones smaller than ___ mm because they are lost within high-signal fluid. (p.711)
smaller than 3 mm
343
Three imaging signs of stones within the bile ducts include ___ (p.712)
1. Stone layer dependently within; allowing a crescent of bile to outline the anterior portion of the stone (the CRESCENT SIGN) 2. Stones are usually geometric or angulated in shape and lamellated in appearance 3. Periductal edema and thickening and enhancement of the wall of the bile duct occur with impacted stones or infection. - Wall thickening and enhancement is also seen with tumors
344
______ is the cause of 40% to 45% of obstructive jaundice in the adult. (p.712)
BENIGN STRICTURE
345
7 CAUSES OF BENIGN STRICTURE | p.712
1. TRAUMA 2. SURGERY 3. PRIOR BILIARY INTERVENTIONAL PROCEDURES 4. RECURRENT CHOLANGITIS 5. PREVIOUS PASSAGE OF STONES THROUGH THE BILE DUCTS 6. RADIATION THERAPY 7. PERFORATED DUODENAL ULCERS
346
The wall of the involved CBD enhanced minimally with _____ strictures. (p.712)
BENIGN strictures
347
Hyperenhancement of the CBD during portal venous phase is evidence of _____ stricture. (p.712)
MALIGNANT stricture
348
___ is responsible for approx. 8% of cases of biliary obstruction. (p.712)
PANCREATITIS -Inflammation; fibrosis; and inflammatory masses narrow the bile ducts
349
___ is associated with a history of ulcerative colitis (50% to 70% of cases). - an idiopathic; fibrosing; chronic inflammatory disease characterized by insidious onset of jaundice; with progressive disease affecting both IHBD and EHBD. (p.712)
PRIMARY SCLEROSING CHOLANGITIS | PSC
350
3 imaging findings found in PSC. PRIMARY SCLEROSING CHOLANGITIS. (p.712)
1. IHBD dilatation 2. IHBD strictures 3. EHBD wall thickening and stenosis
351
Key diagnostic finding of PSC. | p.712
Alternating dilation and stenosis produces a characteristic beaded pattern of intrahepatic ducts. - small saccular outpouching (duct diverticula) ; demonstrated on cholangiography; are also considered to be pathognomonic - complications include biliary cirrhosis (50%) and cholangiocarcinoma
352
___ is characterized by thickening of the walls of the bile ducts and the gallbladder due to inflammation and edema. (p.712)
HIV-ASSOCICATED CHOLANGITIS - infection by oppurtunistic organisms; most commonly cytomegalovirus and Cryptosporidium; as well as reaction to the HIV itself
353
____ occurs in the settng of biliary obstruction and is life-threatening with mortality as high as 65%. (p.713)
ACUTE BACTERIAL CHOLANGITIS
354
Components of CHARCOT TRIAD
1. FEVER 2. PAIN 3. JAUNDICE - infection is usually polymicrobial with gram-negative rods predominanting
355
Imaging finding of ACUTE | BACTERIAL CHOLANGITIS. (p.713)
BILIARY DILATATION; USUALLY CAUSED BY A STONE IN THE DUCT; ASSOCIATED WITH PERIBILIARY CONTRAST ENHANCEMENT AND EDEMA
356
____ has in the past been called ORIENTAL CHOLANGIOHEPATITIS because it is an endemic disease in Southeast Asia. (p.713)
RECURRENT PYOGENIC CHOLANGITIS ``` - characterized by recurrent attacks of jaundice; abdominal pain; fever and chills - Intrahepatic and EHBDs are dilated and filled with soft pigmented stones and pus ```
357
``` TRUE OR FALSE. RECURRENT PYOGENIC CHOLANGITIS is associated with parasitic infestation and nutritional deficiency. (p.713) ```
TRUE ``` - findings include intraductal stones; severe extrahepatic biliary dilation; focal strictures; pneumobilia and straightening and rigidity of the intrahepatic ducts ```
358
5 complications of RECURRENT PYOGENIC CHOLANGITIS (p.713)
1. LIVER ABSCESS 2. BILOMA 3. PANCREATITIS 4. CHOLANGIOCARCINOMA 5. ATROPHY
359
____ is an uncommon anomaly congenital anomaly of the biliary tract characterized by saccular ectasia of the IHBD without biliary obstruction. (p.713)
CAROLI DISEASE - only one hepatic lobe or segment; or the entire liver; may be affected - EHBD are spared in 50% of cases
360
``` 5 imaging findings of CAROLI DISEASE (p.713) ```
1. SACCULAR DILATATION OF IHBD 2. ENHANCING FIBROVASCULAR BUNDLES 3. SEGMENTAL DISTRIBUTION OF THE BILE DUCT ABNORMALITY WITH NORMAL APPEARANCE UNAFFECTED LIVER SEGMENTS 4. CHOLANGIOGRAPHY shows a characteristic pattern of focal biliary narrowing and saccular dilatation 5. DILATATION of the CBD (10 to 30 mm) in half the cases
361
Imaging sign found in CAROLI DISEASE; wherein enhancing fibrovascular bundles are seen centrally within many of the dilated ducts producing this sign.(p.713)
CENTRAL DOT SIGN
362
___ are uncommon congenital anomalies of the biliary tree characterized by cystic dilation of the bile ducts. (p.713)
CHOLEDOCHAL CYSTS
363
Most common choledochal cyst type (Todani Classification)? (p.713)
TYPE I - 80% to 90% - confined to the EHBD - appear as fusiform saccular dilatationsof the CHD; CBD; or segments of each.
364
Choledochal Cyst type seen as a diverticula of the CBD attached by a narrow stalk. (p.713)
TYPE II
365
``` Choledochal cyst type termed CHOLEDOCHOCELES and are focal dilatations of the intraduodenal portion of the CBD closely resembling ureteroceles. ```
TYPE III
366
Choledochal cyst type defined as multiple focal dilatations of the IHBD and EHBD usually with a focal large cystic dilatation of the CBD.(p.714)
TYPE IV
367
``` Choledochal cyst type referred to CAROLI DISEASE; which is more appropriately classified as a disease separate from choledochal cyst. (p.714) ```
TYPE V
368
______ and ___ carcinomas are the cause of 20% to 25% of cases of biliary obstruction in the adult. (p.714)
PANCREATIC and AMPULLARY | carcinomas
369
``` ____ may present as intraductal filling defects. - Colorectal cancers are the most common primary tumors associated with intraluminal biliary metastases. (p.714) ```
METASTASES
370
Findings that favor metastases over cholangiocarcinoma are the __ and __. (p.714).
``` 1. presence of a contiguous parenchymal mass 2. expansion of the duct at the site of the intraluminal mass in a patient with known colorectal cancer ```
371
__ is the second most common malignant primary hepatic tumor. (p.714)
CHOLANGIOCARCINOMA ``` - tumors arise from the epithelium of the bile ducts and are usually adenocarcinomas (90%) - growth patterns include mass-forming; periductal infiltrating; and intraductal polypoid -poor prognosis ```
372
``` _____ cholangioCA (10%) presents as an intrahepatic hypodense mass sometimes (25%) causing peripheral biliary dilatation.(p.714) ```
PERIPHERAL CholangioCA ``` - MDCT demonstrates a homogeneous low-attenuation mass with delayed; mild; thin; incomplete; rim-like enhancement. - additional findings may include capsular retraction and satellite nodules ```
373
____ cholangioCA (____ tumor) (25%) occurs near the junction of the right and left bile ducts. (p.714)
HILAR cholangioCA (Klatskin tumor) ``` - tumor is usually small; poorly differentiated; aggressive; and causes obstruction of both ductal systems - surgical resection is the only hope for cure. ```
374
``` ____ cholangioCA (65%) causes stenosis or obstruction of the CBD in most cases (95%) and presents as an intraductal polypoid mass in 5%.(p.714) ```
EXTRAHEPATIC cholangioCA ``` - shows thickening of the wall of the involved bile duct with hyperenhancement during arterial phase - abrupt stricture with thickening duct wall may be the only findings. ```
375
5 predisposing conditions of EXTRAHEPATIC CHOLANGIOCARCINOMA (p.715)
1. CHOLEDOCHAL CYST 2. ULCERATIVE COLITIS 3. CAROLI DISEASE 4. CLONORCHIS SINENSIS INFECTION 5. PSC
376
``` ___ tumor of the bile ducts may produce a large amount of mucin that markedly dilates the billiary tree and impairs the flow of bile. (p.715) ```
INTRADUCTAL PAPILLARY MUCINOUS TUMOR - tumors are intraductal; polypoid;and characterized by innumerable frondlike papillary projections
377
``` ____ (___) is most commonly encountered in the patient with a surgically created biliary- enteric anastomosis; or who has had a sphincterotomy to facilitate stone passage. (p.715) ```
GAS IN THE BILIARY TRACT | PNEUMOBILIA
378
___ fistula is most commonly due to the erosion of a gallstone through the gallbladder and into the duodenum (p.715)
CHOLECYSTODUODENAL FISTULA ``` - most common in women because of the higher incidence of gallstones - when the gallstone is large; it may cause small bowel obstruction ```
379
___ fistula is caused by a penetrating peptic ulcer eroding ino the CBD. (p.715)
CHOLEDOCHODUODENAL | FISTULA
380
____ is the imaging method of choice for the gallbladder. (p.715)
ULTRASOUND
381
____ has sensitivity and specificity comparable to US for the diagnosis of acute cholecystitis. (p.715)
CHOLESCINTIGRAPHY utilizing | technetium-99m-iminodiaceticacid
382
``` Approx. 85% of gallstone are predominantly _____; whereas 15% are pred. ____ (pigment stones) related to hemolytic anemia. (p. 715) ```
CHOLESTEROL; BILIRUBIN ``` - approx. 10% of stones are sufficiently radioopaque to be detected by conventional radiographs as laminated or faceted calcifications. ```
383
``` Fissure within gallstones may contain nitrogen gas that appears on radiographs as branching linear lucencies resembling a _____. (p.715) ```
CROW'S FOOT
384
5 conditions where | gallstones are common. (p.715)
1. Women (female:male = 4:1) 2. Patients with hemolytic anemia 3. Diseases of the Ileum 4. Cirrhosis 5. Diabetes Mellitus
385
__ detects 95% of all gallstones; whereas __ detects only 80 to 85%. (p.715)
ULTRASOUND; CT - gallstones vary in CT attenuation from fat density to calcium density
386
``` TRUE OR FALSE. Up to 20% of gallstones are ISODENSE with bile and not detected by CT; whereas some gallstones are missed because of their small size or volume averaging with the adjacent bowel. (p.715-716) ```
TRUE
387
``` Contrast studies; MRCP and T2 -weighted MR demonstrate ____ as "filling defects"; rounded or faceted dark objects within the high-density bile. (p.716) ```
GALLSTONES
388
Give 5 Differential considerations for lesions in the GB that may be mistaken for gallstones (p.716)
``` 1. Sludge balls or tumefactive biliary sludge 2. Cholesterol polyps 3. Adenomatous polyps 4. Gallbladder CA 5. Adenomyomatosis ```
389
``` ____ result from biliary stasis. Bile thickens and forms layers of bile and mobile masses that move with changes in patient position. (p.716) ```
SLUDGE BALLS or TUMEFACTIVE BILIARY SLUDGE - the presence of sludge indicates indicates lack of bile turnover; which may occur because of obstruction; or simply lack of oral food intake.
390
``` ____ polyps are common (4% to 7% of the population) benign; polypoid masses that result from accumulation of triglycerides and cholesterol in macrophages in the GB wall. (p.716) ```
CHOLESTEROL polyps (p.716) - polyps 5mm and smaller are routinely dismissed as benign cholesterol polyps
391
TRUE OR FALSE. Adenomatous polyps are potentially premalignant. (p.716)
TRUE
392
__ carcinoma may present as a polypoid GB mass (p.716)
GALLBLADDER CARCINOMA ``` - GB polyps larger than 10 mm should be considered for surgical removal because of the risk of cancer - gallstones are usually present ```
393
___ may be focal and present as a polypoid mass fixed to the GB wall. (p.716)
ADENOMYOMATOSIS
394
Refers to acute inflammation of the GB caused by gallstones obstructing the cystic duct in 90% of cases. (p. 716)
ACUTE CHOLECYSTITIS
395
Confident US diagnosis of acute cholecystitis requires the presence of these 3 findings. (p.716)
1. CHOLELITHIASIS 2. EDEMA OF THE GB WALL seen as a band of echolucency in the wall 3. POSITIVE SONOGRAPHIC MURPHY SIGN
396
Scintigraphic diagnosis of acute cholecystitis is based on ___ and ____. (p.716)
1. Obstruction of the cystic duct 2. Non-vizualization of the GB ``` - The normal GB demonstrates progressive accumulation of radionuclide activity over 30 minutes to 1 hour ff injection of technetium-99m -iminodiacetic acid. - delayed visualization of the GB may be seen in patients with biliary stasis due to fasting or hyperalimentation. ```
397
``` Diagnosis? CT demonstrates gallstones; distended GB; thickened GB wall; subserosal edema; high-density bile; intraluminal sloughed membranes; inflammatory stranding in pericholecystic fat; pericholecystic fluid; blurring of the interface between GB and liver; and prominent arterial phase enhancement of the liver adjacent to the gallbladder. (p.716) ```
ACUTE CHOLECYSTITIS - MR Findings are similar: 1. gallstones; often impacted in the neck 2. wall thickening (> 3mm) with edema 3. distended GB 4. pericholecystic fluid
398
___ cholecystitis causes special problems in diagnosis because the cystic duct is often not obstructed. (p.717)
ACALCULOUS Cholecystitis - inflammation may be due to GB wall ischemia or direct bacterial infection
399
5 conditions wherein patient is at risk for acalculous cholecystitis (p.717)
``` 1. Biliary stasis due to lack of oral intake 2. Posttrauma 3. Post-burn 4. Postsurgery 5. Total parenteral nutrition ```
400
Diagnosis? US demonstrates a distended tender GB with thickened wall but without stones. (p.717)
ACALCULOUS CHOLECYSTITIS - many patients are too ill to elicit to elicit a reliable sonographic Murphy sign
401
``` ____ is the term used to describe the presence of thick particulate matter in highly concentrated bile. (p.717) ```
SLUDGE ``` - calcium bilirubinate and cholesterol crystals precipitate in the bile when biliary stasis is prolonged because of a lack of oral intake or biliary obstruction ```
402
Causes of dense bile; give 4. | p.717
1. Sludge 2. Pus 3. Blood 4. Milk of Calcium
403
Give 5 complications of ACUTE Cholecystitis (p.717)
1. Gallbladder Empyema 2. Gangrenous Cholecystitis 3. Perforation of the GB 4. Emphysematous cholecystitis 5. Mirizzi syndrome
404
``` _____ desbribes the GB distended with pus in a patient; often diabetic; with rapid progression of symptoms suggesting an abdominal abscess. (p.717) ```
GALLBLADDER EMPYEMA
405
____ indicates the presence of | necrosis of the GB wall. (p.717)
GANGRENOUS CHOLECYSTITIS ``` - the patient is at risk for GB perforation. - findings include mucosal irregularity and asymmetric thickening of the GB wall with multiple lucent layers; indicating mucosal ulceration and reactive edema. ```
406
``` TRUE OR FALSE. Perforation of the GB is a life-threatening condition seen in 5% to 10% of cases. (p.717) ```
TRUE ``` - a focal pericholecystic fluid collection suggests pericholecystic abscess - gas is often present within the GB lumen if the perforation extends into the bowel. ```
407
``` _______ results from infection of the gallbladder with gas-forming organisms; usually E.coli or Clostridium perfringens -approx. 40% are diabetic (p.717) ```
EMPHYSEMATOUS CHOLECYSTITIS ``` - gallstones may or may not be present. -gas is demonstrated within the wall or within the lumen of the gallbladder by conventional radiography or CT. - on US; intramural gas has an arc-like configuration difficult to differentiate from calcification and porcelain gallbladder. ```
408
``` _____ refers to the condition of biliary obstruction resulting from a gallstone in the cystic duct eroding into the adjacent common duct and causing an inflammatory mass that obstructs the common duct. (p.717) ```
MIRIZZI SYNDROME ``` - visualization of a stone at the junction of the cystic duct and the common hepatic duct in a patient with biliary obstruction and gallbadder inflammation suggests the diagnosis. ```
409
``` _____ includes a spectrum of pathology that shares the presence of gallstones and chronic gallbladder inflammation. (p.717) ```
CHRONIC CHOLECYSTITIS ``` - patients with chronic cholecystitis complain of recurrent attacks of RUQ abdominal pain and biliary colic ```
410
5 imaging findings of Chronic Cholecystitis (p.717)
1. Gallstones 2. Thickening of the GB wall 3. contraction of the GB lumen 4. Delayed visualization of the GB on cholescintigraphy 5. Poor contractility
411
Give 3 variants of Chronic Cholecystitis (p.717)
1. Porcelain Gallbladder 2. Milk of Calcium bile 3. Xanthogranulomatous Cholecystitis
412
____ describes the presence of dystrophic calcification in the wall of an obstructed and chronically inflammed GB. (p.717)
PORCELAIN GALLBLADDER ``` - the condition is associated with gallstones in 90% of cases. - carries a 10% to 20% risk of GB carcinoma - Cholecystectomy is usually indicated. ```
413
______ (____) is associated with an obstructed cystic duct; chronic cholecystitis; and gallstones
MILK OF CALCIUM (LIMY BILE) - the bile is extremely echogenic on US and gallstones may be visualized within it.
414
``` _______ is an uncommon variant of chronic cholecystitis characterized by nodular depostis of lipid-laded macrophages in the gallbladder wall and proliferative fibrosis. (p.717) ```
XANTHOGRANULOMATOUS | CHOLECYSTITIS
415
``` Diagnosis? Imaging findings include marked GB wall thickening of about 2 cm; fat density nodules in the wall; narrowing of the lumen. (p.717) ```
XANTHOGRANULOMATOUS CHOLECYSTITIS ``` - Cholelithiasis is frequently present - the condition is difficult to differentiate from GB carcinoma - preservation of linear enhancement of the mucosa on post-contrast MR favors xanthogranulomatous cholecystitis over carcinoma ```
416
``` Thickening of the GB wall is present when the wall thickness measured on the hepatic aspect of the GB exceeds __ mm in patients who have fasted at least 8 hours. (p.718) ```
exceeds 3 mm
417
7 conditions associated with GB wall thickening. (p.718)
``` 1. Acute and Chronic Cholecystitis 2. Hepatitis 3. Portal venous HTN and Congestive Heart Failure 4. AIDS 5. Hypoalbuminemia 6. Gallbladder CA 7. Adenomyomatosis ```
418
``` Hepatitis causes ____; which results in reduced GB volume and thickening of the GB wall in approx.half of the patients (p.718) ```
REDUCTION IN BILE FLOW
419
Portal venous HTN and CHF may cause GB wall thickening by ___. (p.718)
PASSIVE VENOUS CONGESTION
420
GB carcinoma usually presents as a focal mass but may cause only ___ GB wall thickening. (p.718)
FOCAL GB wall thickening
421
``` ____ is the most frequent benign condition of the GB and is characterized by hyperplasia of the mucosa and smooth muscle ```
ADENOMYOMATOSIS ``` - it may be localized; usually in the fundus; segmental or diffuse involving the entire GB - coexisting gallstones are commonly present ```
422
Outpouchings of GB mucosa into or through the muscularis form characteristic ____. (p.718)
ROKITANSKY-ASCHOFF SINUSES
423
TRUE OR FALSE. Adenomyomatosis has no malignant potential. (p.718)
TRUE
424
``` DIAGNOSIS? US shows "comet-tail" reverberation artifacts emanating from inspissated bile within these sinuses in the thickened GB wall. ```
ADENOMYOMATOSIS
425
``` DIAGNOSIS? MRCP shows a "pearl necklace" appearance of the GB wall caused by bright fluid within the sinuses. (p.718) ```
ADENOMYOMATOSIS
426
DIAGNOSIS? CT shows GB wall thickening with tiny cystic spaces. (p.718)
ADENOMYOMATOSIS
427
``` TRUE OR FALSE. The presence of gallstones in 70% to 80% of cases masks the findings of cancer; esp. with US examination. (p.718) ```
TRUE - GB Carcinoma is a tumor of elderly women (>60 years; female:male=4;1)
428
TRUE OR FALSE. Calcification of the GB wall (porcelain GB) is a risk factor for GB carcinoma. (p.718)
TRUE
429
7 imaging findings of | GB carcinoma. (p.718)
1. Intraluminal soft tissue mass 2. Focal or diffuse GB wall thickening 3. Soft tissue mass replacing the GB 4. Gallstones 5. Extension of the tumor into the liver; bile ducts and adjacent bowel 6. dilated bile ducts 7. metastases to periportal and peripancreatic lymph nodes of the liver - most tumors are unresectable at discovery

KEVIN BURANT IV (20 decks)

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