Imaging-Hepatobiliary Tract

Question 1

Most prevalent surgical disease in industrial countries

Answer 1

Cholecystitis

Question 2

What do you need to do to reliably exclude cholecystitis?

Answer 2

Imaging. The differential in history and physical can range from pancreatitis to peptic ulcers to acute hepatitis.

Question 3

1st line treatment for imaging the hepatobiliary tract

Answer 3

1) Ultrasound. HIDA scan can also be used which is shown below. A radioactive tracer is injected that stimulates bile production. You can then follow bile movement to look for obstruction.

Question 4

What imaging modality can be used for stenting and getting biopsies of the hepatobiliary tract?

Answer 4

ERCP. It goes through the ampulla of Vater and up into the hepatobiliary system.

Question 5

Why would you do intraoperative cholangiography?

Answer 5

To confirm that there are no residual stones in the liver after removing the gallbladder.

Question 6

1st choice for gallbladder ultrasound?

Answer 6

Phased array or curvalinear

Question 7

What maneuvers can help you get the gallbladder into view on ultrasound?

Answer 7

Have the patient breath in. Put them in the left lateral decubitus

Question 8

What structure is indicated below?

Answer 8

Hepatic artery

Question 9

What structure is indicated below?

Answer 9

Portal vein. Notice the bright white fat around it.

Question 10

What structure is located anterior to the portal vein?

Answer 10

Bile duct

Question 11

Normal measurement of the bile duct?

Answer 11

3mm inner wall to inner wall. You can add 1mm per decade of life.

Question 12

What structures are shown below?

Answer 12

This is a transverse view of the portal triad. Note that the gallbladder is like a sideways exclamation point. The portal triad is the mickey mouse sign (face = portal vein, ears = artery and bile duct)

Question 13

What structures are shown below?

Answer 13

Hepatic veins, note that it looks like Bugs bunny and that there is no white around the vein like there is in the portal vein.

Question 14

What is the progression of the development of gallstones?

Answer 14

1) Precipitated sludge in bile 2) More shadowing and stones get bigger and brighter.

Question 15

What is causing cholecystitis in this patient?

Answer 15

Gallstones filling the entire gallbladder. Note the W-E-S sign (Wall-Echo-Schadow)

Question 16

How could you mess up and diagnose someone with a gallstone when it is really not?

Answer 16

Gallbladder polyp, differentiate by rotating the patient to see if gravity moves it, if not its a polyp. Also patients drinking contrast may have a duodenum that appears to have gallstones in it

Question 17

How do you differentiate biliary colic (send home with pain meds) from cholecystitis (surgical resection)?

Answer 17

You see gallstones on ultrasound, a thickened gallbladder wall or Murphy’s sign when pressing in the RUQ. Alk phos may also be elevated.

Question 18

Where do you measure the wall of the gallbladder?

Answer 18

Anteriorly against the wall of the liver so you don’t get a refractory effect

Question 19

What rare, but diagnostic condition is seen in the patient with cholecystitis?

Answer 19

Pericholecystic fluid

Question 20

What is this patient at risk for?

Answer 20

He has emphysematous cholecystitis (air in gallbladder wall), which indicates gas gangrene of the gallbladder and has a high mortality rate.

Question 21

What type of doppler should you use to test for exta-hepatic jaundice?

Answer 21

The power doppler, it measures slower flow rates that happen in the bile, obstruction of the bile duct will yield no flow.

Question 22

What is the antler sign?

Answer 22

Bile stasis within the liver from gallbladder obstruction

Question 23

What is responsible for some abdominal related sepsis?

Answer 23

Cholecystitis or cholangitis is responsible 25% of the time

Question 24

Where do you look with the ultrasound if you suspect ascites?

Answer 24

Morrison’s pouch.

Question 25

What other things do you need to keep your eyes open for when scanning the liver?

Answer 25

Hepatic cysts, gallbladder cancer and metastatic cancer. Note that you go on to a CT for advanced imaging with these conditions.

Question 26

When does ultrasound not provide the answer?

Answer 26

False negative: acute biliary obstruction shows no dilation of bile duct. False positive: hepatitis, heart failure show thickened gallbladder walls.

Question 27

Why wasn’t ultrasound used to diagnose the gallstone obstruction in this patient?

Answer 27

Ultrasound is good for proximal stones. This stone is distal and obstructing the pancreas.

Question 28

What is your diagnosis in this patient?

Answer 28

Note the fluid surrounding the liver and the modularity of the liver. This patient has ascites due to portal hypertension.

Question 29

What is your diagnosis in this patient?

Answer 29

Multiple hepatic metastasis

Question 30

What modality is highly sensitive for diagnosing acute cholecystitis?

Answer 30

HIDA scan.

Question 31

What is the most useful way to diagnose choledocholithiasis?

Answer 31

MRI/MRCP

Question 32

A 29 year old male presents with acute abdominal pain that does not radiate and is localized to the RUQ. Physical exam reveals + Murphey’s sign. Abdominal radiograph and ultrasound reveal no stones, wall thickening or bile duct narrowing. His CT is shown below. What is your diagnosis?

Answer 32

Duodenitis with a perforated duodenal ulcer. Note the adjacent inflammatory change.

Question 33

An elderly woman presents with dull abdominal discomfort and jaundice. Physical exam reveals a palpable mass in the URQ. Labs reveal elevated bilirubin and normal amylase, lipase and WBC. Her ultrasound is shown below. What is your diagnosis?

Answer 33

Ultrasound reveals Courvoisier’s gallbladder (distended w/sludge stones and no wall thickening). This is indicative of malignancy, she had adenocarcinoma in the distal common bile duct.