Flashcards in GB Abnormal Deck (138):
What is the term for calcification of the GB wall?
What is the cause of porcelain GB?
it is unknown
Porcelain GB occurs in association with _____ and may represent some form of _____.
What determines the sonographic appearance of porcelain GB?
the degree and pattern of calcification
When the entire GB wall is thickly calcified, a _____ _____ line with dense posterior _____ _____ is noted.
Mild calcification of the GB wall appears as a(n) _____ line with variable degrees of _____.
posterior acoustic shadowing
With calcification of the GB wall, the luminal contents may be _____ (visible/not visible), interrupted clumps of _____ appear as _____ foci with posterior shadowing.
Why is the WES sign absent with a porcelain GB?
Because the GB wall is calcified
What is another term for adenomyomatosis?
Adenomyomatosis can be either focal or _____. Is it benign or malignant?
What happens to the GB physiologically to cause adenomyomatosis?
The diverticula in the GB wall become clogged with stones or sludge
What is the most common U/S appearance of adenomyomatosis?
tiny echogenic foci in the GB wall that create comet-tail artifacts
What is the most common appearance of adenomymatosis with doppler U/S?
echogenic foci with ringdown or twinkling artifact
What is another term for ringdown artifact?
The comet-tail artifact with ringdown or twinkling from adenomyomatosis is located where in the GB?
in the Rokitansky-Aschoff sinuses
If you don't see twinkling artifact within the comet-tail artifact in the GB, what should be done?
Further study to rule out neoplasm.
Does not move, does not shadow =
Why is it important to distinguish between benign and malignant polyps?
Because benign are very common and malignant require early intervention to improve outcome.
What are the two most frequently used criteria to identify a polyp as benign?
size below 10mm
Malignancy of polyps has been documented in 37-88% of resected polyps that were
larger than 10mm
Other malignancy risk factors for a person with polyps are (6)
1) older than 60
2) single lesion
3) gallstone disease
4) rapid change in size
5) sessile morphology
6) doppler velocity of more than 20cm/sec and resistive index of less than 0.65
Approximately half of all polyps are _____ polyps.
This kind of polyp represents the focal form of GB cholesterolosis.
Cholesterolosis results in the accumulation of _____ (such as _____ and _____) in the GB wall. It is a common _____ condition of the GB.
T or F? Polyps DO NOT roll and DO NOT produce posterior shadowing.
The diffuse form of cholesterolosis is called
Where does strawberry GB get its name?
golden yellow lipid deposits agains the red GB mucosa
Cholesterolosis is usually asymptomatic but if there are symptoms, it is usually in the form of
colicky abdominal pain
Although cholesterolosis and adenomyomatosis appear similar, the main difference is that cholesterolosis doesn't have
comet tail reverberation artifact (ring down or twinkling)
The 2 most common lesions that cause biliary obstruction are
carcinoma of the pancreas head
The increase of what 2 hormones is usually associated with biliary obstruction?
serum alkaline phosphatase
The condition of irregular, tortuous, enlarged bile ducts is called
dilated intrahepatic ducts
Two other terms for dilated intrahepatic ducts are
parallel channel sign
When bile ducts branch into star-shaped configurations, this is called
Bile structues attenuate sound much _____ (more/less) than blood, which creates posterior acoustic enhancement.
Lots of posterior enhancement with bile structures =
dilated intrahepatic ducts (aka parallel channel sign or shotgun sign)
With the shotgun sign, these vessels are dilated, with the _____ being anterior to the _____.
The part of the biliary tree that dilates as a result of obstruction depends on the
level of obstruction
With this kind of obstruction, the entire system distends, including the GB.
distal CBD obstruction
With this kind of obstruction, the proximal ducts will distend and the GB will be contracted.
With Rt and LT hepatic duct obstruction, these ducts dilate
Congenital bile duct anomalies that consist of cystic dilation of the INTRA or EXTRA hepatic bile ducts are
The most widely used classification system for choledochal cysts divides them into _____ groups.
The most common type of cystic dilation with choledochal cysts is
Type 1 - dilation of the CBD
With Type 1 choledochal cyst classification, fusiform dilation occurs between the distal _____ and MPV.
This type of choledochal cyst classification is very rare and occurs with true diverticuli of the bile ducts.
This choledochal cyst classification is confined to the intraduodenal portion of the CBD.
Type 3 of choledochal cyst classification is also referred to as
This type of choledochal cyst classification occurs with multiple intra and extra hepatic biliary dilations.
This type of choledochal cyst classification occurs with only extrahepatic biliary dilations.
Type 5 of the choledochal cyst classification system is also called
Which types of the choledochal cyst classification system are intrahepatic and which are extrahepatic?
Type 4a and 5
Type 1, 2, 3, 4a, 4b
Sonographically, choledochal cysts appear as a
cystic structure with may contain internal sludge, stones, or solid neoplasm
Surgical resection is advocated for choledochal cysts because
a proven risk of cholangiocarcinoma with all choledochal cysts
_____ is necessary to ensure that the dilation is not a result of distal neoplasm, especially in the case of Type _____ choledochal cysts.
Caroli's disease =
Multiple cyst structures that converge toward the porta hepatis, and communicating with the bile ducts, are the sonographic findings of what condition?
With Caroli's Disease, _____ and _____ may accumulate in the ectatic ducts that will result in posterior acoustic shadowing.
This syndrome is caused by a stone in the cystic duct, which causes compression of the CHD. Clinical symptoms are jaundice, pain, and fever.
With Mirizzi Syndrome, the stone is often impacted in the _____ cystic duct and the accompanying inflammation and edema result in the obstruction of the adjacent _____.
You should consider this condition when biliary obstruction, with dilation of the biliary ducts, is seen at the level of the CHD; in conjunction with a picture of acute or chronic cholecystitis.
Blood clot in the biliary tree =
Air within the biliary tree =
This results from previous biliary intervention, like biliary-enteric anastomoses or CBD stents.
What is the sonographic appearance of pneumobilia?
Intrahepatic linear echogenic regions that often produce distal acoustic shadowing.
Posterior dirty shadowing and reverberation artifacts are seen, with movement of the air bubbles, best seen after changing the patient's position, is diagnostic of this
Inflammation of the ducts. Antecedent biliary obstruction is an essential component of this associated in 85% of cases with CBD stones.
acute (bacterial) cholangitis
These are clinical presentations of _____:
Elevated alkaline phosphatase and bilirubin
Charcot's triad (fever, RUQ pain, jaundice)
acute (bacterial) cholangitis
What makes up Charcot's triad?
T or F? Acute cholangitis is a medical emergency.
With colangitis, the bile is most commonly infected by _____ _____ _____, which are often retrieved in blood cultures.
gram-negative enteric bacteria
An inflammatory process affecting the biliary tree in the advanced stages of HIV infection.
Patients present with severe RUQ or epigastric pain, markedly elevated alkaline phosphatase BUT normal bilirubin levels.
Elevated alkaline phosphatase and bilirubin =
Elevated alkaline phosphatase but not bilirubin =
Bile duct wall thickening, intra and extra hepatic
Focal structures and dilations
Diffuse GB wall thickening
A chronic disease process that affects the ENTIRE biliary tree. More frequently affects men with a median age of 39 years.
Primary Sclerosing Cholangitis
With primary sclerosing cholangitis, about 80% of people also have _____, usually _____.
concomitant inflammatory bowel disease
T or F? With primary sclerosing cholangitis most patients are asymptomatic.
Cholangiocarcinoma develosp in 7-30% of people with _____.
primary sclerosing cholangitis
Irregular, circumferential bile duct wall thickening of varying degrees, encroaching on and narrowing the lumen. Focal strictures and dilations of the bile ducts ensue.
primary sclerosing cholangitis
Is liver disease required in the latter stages of primary sclerosing cholangitis?
Can primary sclerosing cholangitis recur after a liver transplant?
This is a parasitic roundworm which as been estimated to infect up to 25% of the world's population.
Ascariasis is transferred by _____ route and is most common in _____.
An ascariasis worm is generally _____ long and up to _____ in diameter.
An ascariasis worm is active within the _____ and may enter the biliary tree retrogradely through the _____, causing biliary obstruction.
Ampulla of Vater
The appearance of ascariasis depends on
the number of worms within the bile ducts
With ascariasis a single worm appears as a tube or as a parallel _____ _____ within the bile ducts and can be similar in appearance of a biliary _____ (so it is important to know patient history).
Transversely, an ascariasis worm has a target appearance because
the rounded worm surrounded by the bile duct
When ascariasis infestation is heavy, multiple worms may lie adjacent to each other within a distended _____ give a _____-like appearance.
This is an uncommon condition of the GB. It is most common in the elderly. It has a 3:1 female to male predominance. It is associated with gallstones, chronic gallstones disease, and resultant dysplasia.
About 98% of GB carcinomas are _____, with squamous cell carcinoma and _____ accounting for the rest.
The patterns of this condition are:
1) Mass arising in the GB fossa, obliterating the GB and invading the adjacent liver (most common)
2) Focal or diffuse, markedly abnormal and irregular wall thickening
3) Intraluminal polypoid mass
What are the 2 patterns of GB Carcinoma tumor spread?
1) contiguous hepatic spread (most common)
2) lymphatic spread
Why is contiguous hepatic invasion the most common?
Because the GB wall is thin and little connective tissue separates it from the liver parenchyma.
With contiguous hepatic invasion, GB tumors also extend along the _____ (vessel) into the porta hepatic, where they mimic _____ _____.
With contiguous hepatic invasion, tumor extension into the _____ (vessels) or encasement of the PV or _____ (vessel) may ensue.
With contiguous hepatic invasion, direct invasion into adjacent loops of _____, especially the _____ or _____, is not unusual. As well as _____ to the peritoneum.
This type of spread may occur in the absence of invasion of the adjacent organs.
The first nodes affected with lymphatic spread are in the
What is the only chance of cure with lymphatic spread?
With lymphatic spread, if the tumor is not confined to the mucosa, an extended _____ involving resection of 3-5mm rim of adjacent liver tissue is removed and dissection is required of the bile and cystic ducts and regional _____ _____.
T or F? The sonographic appearance of lymphatic spread varies.
Why is it hard to see the masses that replace the GB fossa sometimes with lymphatic spread?
Because they are small and blend into the liver
The absence of a normal GB with no history of cholecystectomy (removal) should raise suspicion with
This kind of GB malignancy may appear as a polypoid mass.
Which malignancy is the cause of more than half of metastases to the GB?
This is an uncommon neoplasm that may arise from any portion of the biliary tree. The highest incidence is in northeast Thailand.
Another term for cholangiocarcinoma is
bile duct carcinoma
Cholangiocarcinoma has 2 types which are
This is the least common bile duct carcinoma, but represents the 2nd most common primary malignancy in the liver.
Incidence of intrahepatic cholangiocarcinoma has increased dramatically due to people with _____ and long-term _____.
The most common findings with intrahepatic cholangiocarcinoma are a large hepatic mass with (3)
A clue to differentiate intrahepatic cholagniocarcinoma from hepatocellular carcinoma is there is a much higher incidence of _____ with intrahepatic cholangiocarcinoma.
The most common appearance of intrahepatic cholangiocarcinoma is
1 or more polypoid masses confined to the bile ducts
The risk factors for cholangiocarcinoma are (2)
1) primary sclerosing cholangitis (most common)
2) chronic biliary stasis and inflammation
Cholangiocarcinoma is classified by anatomic location, such as (3)
1) intrahepatic (aka peripheral)
2) hilar (aka Klatskins)
Another term for intrahepatic is
Hilar cholangiocarcinoma =
The overall prognosis for cholangiocarcinoma is
Why does U/S play an important role in both detection and staging of Klatskins?
because it is often the first modality used in assessment of these tumors and is performed prior to any biliary manipulation or stent placement.
This a cholangiocarcinoma located at the hepatic hilum (junction of the rt and lt hepatic duct)
The results of a cholangiocarcinoma located at the hepatic hilum (Klatskin tumor) is
intrahepatic dilation ONLY
The junction of the rt and lt hepatic duct is called
Curative treatment for hilar cholangiocarcinoma is
Patients with an unresectable hilar cholangiocarcinoma tumor
die within 12 months
This kind of cholangiocarcinoma is clicinally indistinguishable from the hilar forms with progressive jaundice seen in 75-90% of patients.
Metastases of the GB mimic different appearances of _____ and affects both _____ and _____ hepatic ducts.
The primary sites of malignancy for metastases of the GB are (3)
This is the most common malignant neoplasm that obstructs the biliary tree.
Pancreatic adenocarcinoma at the head of the pancreas typically causes this GB condition
This is an enlarged, often palpable GB in a patient with carcinoma of the pancreas head. It is associated with jaundice due to obstruction of the CBDs.
The diagnosis of a hydropic GB is solely made on the _____ of the GB. Do not rely on measurements. Some GB happen to be small and others large.
Tumor invasion of bile ducts, encasement of the PV, or hepatic artery occurs with this GB carcinoma
With Klatskin Tumor, what state would the GB be in and why?
Because with Klatskin tumor (a cholangiocarcinoma) the hepatic hilum is clogged by mass so bile can't get out of liver and into GB or CBD.
Air in bile ducts =