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Flashcards in GB Abnormal Deck (138):
1

What is the term for calcification of the GB wall?

porcelain GB

2

What is the cause of porcelain GB?

it is unknown

3

Porcelain GB occurs in association with _____ and may represent some form of _____.

gallstone disease
chronic cholecystitis

4

What determines the sonographic appearance of porcelain GB?

the degree and pattern of calcification

5

When the entire GB wall is thickly calcified, a _____ _____ line with dense posterior _____ _____ is noted.

hyperechoic semilunar
acoustic shadowing

6

Mild calcification of the GB wall appears as a(n) _____ line with variable degrees of _____.

echogenic
posterior acoustic shadowing

7

With calcification of the GB wall, the luminal contents may be _____ (visible/not visible), interrupted clumps of _____ appear as _____ foci with posterior shadowing.

visible
calcium
echogenic

8

Why is the WES sign absent with a porcelain GB?

Because the GB wall is calcified

9

What is another term for adenomyomatosis?

Rokitansky-Aschoff Sinuses

10

Adenomyomatosis can be either focal or _____. Is it benign or malignant?

diffuse
benign

11

What happens to the GB physiologically to cause adenomyomatosis?

The diverticula in the GB wall become clogged with stones or sludge

12

What is the most common U/S appearance of adenomyomatosis?

tiny echogenic foci in the GB wall that create comet-tail artifacts

13

What is the most common appearance of adenomymatosis with doppler U/S?

echogenic foci with ringdown or twinkling artifact

14

What is another term for ringdown artifact?

twinkling artifact

15

The comet-tail artifact with ringdown or twinkling from adenomyomatosis is located where in the GB?

in the Rokitansky-Aschoff sinuses

16

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.

17

Does not move, does not shadow =

polyps

18

Why is it important to distinguish between benign and malignant polyps?

Because benign are very common and malignant require early intervention to improve outcome.

19

What are the two most frequently used criteria to identify a polyp as benign?

multiplicity
size below 10mm

20

Malignancy of polyps has been documented in 37-88% of resected polyps that were

larger than 10mm

21

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

22

Approximately half of all polyps are _____ polyps.

cholesterol

23

This kind of polyp represents the focal form of GB cholesterolosis.

cholesterol polyp

24

Cholesterolosis results in the accumulation of _____ (such as _____ and _____) in the GB wall. It is a common _____ condition of the GB.

lipids
triglycerides
cholesterol
non-neoplastic

25

T or F? Polyps DO NOT roll and DO NOT produce posterior shadowing.

True

26

The diffuse form of cholesterolosis is called

strawberry GB

27

Where does strawberry GB get its name?

golden yellow lipid deposits agains the red GB mucosa

28

Cholesterolosis is usually asymptomatic but if there are symptoms, it is usually in the form of

colicky abdominal pain

29

Although cholesterolosis and adenomyomatosis appear similar, the main difference is that cholesterolosis doesn't have

comet tail reverberation artifact (ring down or twinkling)

30

The 2 most common lesions that cause biliary obstruction are

gallstones
carcinoma of the pancreas head

31

The increase of what 2 hormones is usually associated with biliary obstruction?

serum alkaline phosphatase
bilirubin

32

The condition of irregular, tortuous, enlarged bile ducts is called

dilated intrahepatic ducts

33

Two other terms for dilated intrahepatic ducts are

parallel channel sign
shotgun sign

34

When bile ducts branch into star-shaped configurations, this is called

stellate confluence

35

Bile structues attenuate sound much _____ (more/less) than blood, which creates posterior acoustic enhancement.

less

36

Lots of posterior enhancement with bile structures =

dilated intrahepatic ducts (aka parallel channel sign or shotgun sign)

37

With the shotgun sign, these vessels are dilated, with the _____ being anterior to the _____.

CBD
MPV

38

The part of the biliary tree that dilates as a result of obstruction depends on the

level of obstruction

39

With this kind of obstruction, the entire system distends, including the GB.

distal CBD obstruction

40

With this kind of obstruction, the proximal ducts will distend and the GB will be contracted.

CHD obstruction

41

With Rt and LT hepatic duct obstruction, these ducts dilate

intrahepatic ducts

42

Congenital bile duct anomalies that consist of cystic dilation of the INTRA or EXTRA hepatic bile ducts are

choledochal cysts

43

The most widely used classification system for choledochal cysts divides them into _____ groups.

5

44

The most common type of cystic dilation with choledochal cysts is

Type 1 - dilation of the CBD

45

With Type 1 choledochal cyst classification, fusiform dilation occurs between the distal _____ and MPV.

CBD

46

This type of choledochal cyst classification is very rare and occurs with true diverticuli of the bile ducts.

Type 2

47

This choledochal cyst classification is confined to the intraduodenal portion of the CBD.

Type 3

48

Type 3 of choledochal cyst classification is also referred to as

choledochoceles

49

This type of choledochal cyst classification occurs with multiple intra and extra hepatic biliary dilations.

Type 4a

50

This type of choledochal cyst classification occurs with only extrahepatic biliary dilations.

Type 4b

51

Type 5 of the choledochal cyst classification system is also called

Caroli's Disease

52

Which types of the choledochal cyst classification system are intrahepatic and which are extrahepatic?

INTRA
Type 4a and 5

EXTRA
Type 1, 2, 3, 4a, 4b

53

Sonographically, choledochal cysts appear as a

cystic structure with may contain internal sludge, stones, or solid neoplasm

54

Surgical resection is advocated for choledochal cysts because

a proven risk of cholangiocarcinoma with all choledochal cysts

55

_____ is necessary to ensure that the dilation is not a result of distal neoplasm, especially in the case of Type _____ choledochal cysts.

ERCP
1

56

Caroli's disease =

intrahepatic

57

Multiple cyst structures that converge toward the porta hepatis, and communicating with the bile ducts, are the sonographic findings of what condition?

Caroli's Disease

58

With Caroli's Disease, _____ and _____ may accumulate in the ectatic ducts that will result in posterior acoustic shadowing.

sludge
calculi

59

This syndrome is caused by a stone in the cystic duct, which causes compression of the CHD. Clinical symptoms are jaundice, pain, and fever.

Mirizzi Syndrome

60

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 _____.

distal
CHD

61

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.

Mirizzi Syndrome

62

Blood clot in the biliary tree =

Hemobilia

63

Air within the biliary tree =

Pneumobilia

64

This results from previous biliary intervention, like biliary-enteric anastomoses or CBD stents.

pneumobilia

65

What is the sonographic appearance of pneumobilia?

Intrahepatic linear echogenic regions that often produce distal acoustic shadowing.

66

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

pneumobilia

67

Inflammation of the ducts. Antecedent biliary obstruction is an essential component of this associated in 85% of cases with CBD stones.

acute (bacterial) cholangitis

68

These are clinical presentations of _____:

Leukocytosis
Elevated alkaline phosphatase and bilirubin
Charcot's triad (fever, RUQ pain, jaundice)

acute (bacterial) cholangitis

69

What makes up Charcot's triad?

fever
RUQ pain
jaundice

70

T or F? Acute cholangitis is a medical emergency.

True

71

With colangitis, the bile is most commonly infected by _____ _____ _____, which are often retrieved in blood cultures.

gram-negative enteric bacteria

72

An inflammatory process affecting the biliary tree in the advanced stages of HIV infection.

HIV Cholangiopathy

73

Patients present with severe RUQ or epigastric pain, markedly elevated alkaline phosphatase BUT normal bilirubin levels.

HIV cholangiopathy

74

Elevated alkaline phosphatase and bilirubin =
Elevated alkaline phosphatase but not bilirubin =

cholangitis
HIV cholangiopathy

75

Bile duct wall thickening, intra and extra hepatic
Focal structures and dilations
CBD dilation
Diffuse GB wall thickening

HIV cholangiopathy

76

A chronic disease process that affects the ENTIRE biliary tree. More frequently affects men with a median age of 39 years.

Primary Sclerosing Cholangitis

77

With primary sclerosing cholangitis, about 80% of people also have _____, usually _____.

concomitant inflammatory bowel disease
ulcerative colitis

78

T or F? With primary sclerosing cholangitis most patients are asymptomatic.

True

79

Cholangiocarcinoma develosp in 7-30% of people with _____.

primary sclerosing cholangitis

80

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

81

Is liver disease required in the latter stages of primary sclerosing cholangitis?

Yes

82

Can primary sclerosing cholangitis recur after a liver transplant?

Yes

83

This is a parasitic roundworm which as been estimated to infect up to 25% of the world's population.

Ascariasis

84

Ascariasis is transferred by _____ route and is most common in _____.

fecal-oral route
children

85

An ascariasis worm is generally _____ long and up to _____ in diameter.

20-30cm
6mm

86

An ascariasis worm is active within the _____ and may enter the biliary tree retrogradely through the _____, causing biliary obstruction.

small bowel
Ampulla of Vater

87

The appearance of ascariasis depends on

the number of worms within the bile ducts

88

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).

echogenic line
stent

89

Transversely, an ascariasis worm has a target appearance because

the rounded worm surrounded by the bile duct

90

When ascariasis infestation is heavy, multiple worms may lie adjacent to each other within a distended _____ give a _____-like appearance.

duct
spaghetti

91

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.

GB carcinoma

92

About 98% of GB carcinomas are _____, with squamous cell carcinoma and _____ accounting for the rest.

adenocarcinomas
metastases

93

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

GB carcinoma

94

What are the 2 patterns of GB Carcinoma tumor spread?

1) contiguous hepatic spread (most common)
2) lymphatic spread

95

Why is contiguous hepatic invasion the most common?

Because the GB wall is thin and little connective tissue separates it from the liver parenchyma.

96

With contiguous hepatic invasion, GB tumors also extend along the _____ (vessel) into the porta hepatic, where they mimic _____ _____.

cystic duct
hilar cholangiocarcinomas

97

With contiguous hepatic invasion, tumor extension into the _____ (vessels) or encasement of the PV or _____ (vessel) may ensue.

bile ducts
hepatic artery

98

With contiguous hepatic invasion, direct invasion into adjacent loops of _____, especially the _____ or _____, is not unusual. As well as _____ to the peritoneum.

bowel
duodenum
colon
metastases

99

This type of spread may occur in the absence of invasion of the adjacent organs.

lymphatic spread

100

The first nodes affected with lymphatic spread are in the

hilar region

101

What is the only chance of cure with lymphatic spread?

surgical resection

102

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 _____ _____.

cholecystectomy
lymph nodes

103

T or F? The sonographic appearance of lymphatic spread varies.

True

104

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

105

The absence of a normal GB with no history of cholecystectomy (removal) should raise suspicion with

lymphatic spread

106

This kind of GB malignancy may appear as a polypoid mass.

GB adenocarcinomas

107

Which malignancy is the cause of more than half of metastases to the GB?

melanoma

108

This is an uncommon neoplasm that may arise from any portion of the biliary tree. The highest incidence is in northeast Thailand.

cholangiocarcinoma

109

Another term for cholangiocarcinoma is

bile duct carcinoma

110

Cholangiocarcinoma has 2 types which are

intrahepatic
extrahepatic

111

This is the least common bile duct carcinoma, but represents the 2nd most common primary malignancy in the liver.

intrahepatic cholangiocarcinoma

112

Incidence of intrahepatic cholangiocarcinoma has increased dramatically due to people with _____ and long-term _____.

cirrhosis
hepatitis

113

The most common findings with intrahepatic cholangiocarcinoma are a large hepatic mass with (3)

hypervascularity
solid
hetergeneous echotexture

114

A clue to differentiate intrahepatic cholagniocarcinoma from hepatocellular carcinoma is there is a much higher incidence of _____ with intrahepatic cholangiocarcinoma.

ductual obstruction

115

The most common appearance of intrahepatic cholangiocarcinoma is

1 or more polypoid masses confined to the bile ducts

116

The risk factors for cholangiocarcinoma are (2)

1) primary sclerosing cholangitis (most common)
2) chronic biliary stasis and inflammation

117

Cholangiocarcinoma is classified by anatomic location, such as (3)

1) intrahepatic (aka peripheral)
2) hilar (aka Klatskins)
3) distal

118

Another term for intrahepatic is

peripheral

119

Hilar cholangiocarcinoma =

Klatskins tumor

120

The overall prognosis for cholangiocarcinoma is

dismal

121

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.

122

This a cholangiocarcinoma located at the hepatic hilum (junction of the rt and lt hepatic duct)

Klatskin tumor

123

The results of a cholangiocarcinoma located at the hepatic hilum (Klatskin tumor) is

intrahepatic dilation ONLY

124

The junction of the rt and lt hepatic duct is called

hepatic hilum

125

Curative treatment for hilar cholangiocarcinoma is

surgical resection

126

Patients with an unresectable hilar cholangiocarcinoma tumor

die within 12 months

127

This kind of cholangiocarcinoma is clicinally indistinguishable from the hilar forms with progressive jaundice seen in 75-90% of patients.

distal cholangiocarcinoma

128

Metastases of the GB mimic different appearances of _____ and affects both _____ and _____ hepatic ducts.

cholangiocarcinoma
intra
extra

129

The primary sites of malignancy for metastases of the GB are (3)

breast
colon
melanoma

130

This is the most common malignant neoplasm that obstructs the biliary tree.

pancreatic adenocarcinoma

131

Pancreatic adenocarcinoma at the head of the pancreas typically causes this GB condition

Courvoisier GB

132

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.

Courvoisier GB

133

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.

non-compressibility

134

Ascariasis =

Round worms

135

Tumor invasion of bile ducts, encasement of the PV, or hepatic artery occurs with this GB carcinoma

Klatskin tumor

136

With Klatskin Tumor, what state would the GB be in and why?

Contracted
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.

137

Air in bile ducts =

Pneumobilia

138

A mass that is hypervascular, irregular, with multiple stones in the GB is most likely

GB cancer