The Gallbladder and the Biliary System Flashcards
(82 cards)
1
Q
Sludge
A
Thickenedbile
2
Q
Where does Sludge frequently occur from?
A
bilestasis
3
Q
Sludge can be occasionally found in?
A
CBD
4
Q
Sludge
Sonographicfinding?
A
AprominentGBcontaininglowlevel internalechoes
Particlescanbesmall
5
Q
Sludge can also be seen in combination with?
A
cholelithiasis, cholecystitis,andother biliarydiseases
6
Q
Wall Thickness causes of GB?
A
- Cholecystitis
- Adenomyomatosis
- Cancer
- Acquiredimmunodeficiencysyndrome
- Cholangiopathy
- Sclerosingcholangitis
7
Q
Wall Thickness
Nonbiliarycauses?
A
–Diffuseliverdisease
–Pancreatitis
–Portalhypertension
–Heartfailure
8
Q
Wallthickness
Sonographicfindings?
A
–Measuredwhenthetransducerisperpendiculartotheanterior GBwall
– TransverseplaneONLY
– Shouldclearlydemarcatetheanteriorwall
– Measuredfromoutertooutermargins
9
Q
Cholecystitis?
A
AninflammationoftheGB
10
Q
Types of Cholecystitis?
A
– Acute – Chronic – Acalculous – Emphysematous – Gangrenous
11
Q
Acute cholecystitis
A
Mostcommoncauseischolelithiasisthatcreatesacysticductobstruction
• Foundfrequentlyinfemales`
12
Q
Clinicalsymptoms of Acute cholecystitis?
A
– AcuteRUQpain
– PositiveMurphy’ssign
– Fever
– Leukocytosis
13
Q
Complications of Acute cholecystitis?
A
– Empyema
– Emphysematousorgangrenouscholecystitis
– Perforation
14
Q
Acutecholecystitis
Sonographicfindings?
A
– AGBwithanirregularoutlineofathickenedwall – Asonolucentareamaybepresentwithinthe thickenedwall
–Occasionallyathickenedwallwillbeseeninanormal individual
• Relatedtothedegreeofcontraction
15
Q
Chroniccholecystitis
A
- MostcommonformofGB inflammation
* Endresultofnumerous attacksofacute cholecystitis
16
Q
Chroniccholecystitis symptoms?
A
–MayhavetransientRUQpain
– Notenderness
17
Q
Chroniccholecystitis
Sonographicfindings?
A
–Frequentlycholelithiasis
– ContractedGB –Coarsewallthickening – WESsign
18
Q
Acalculouscholecystitis?
A
•AcuteinflammationoftheGBintheabsenceofcholelithiasis
• Mostlikelycausedbydecreasedbloodflow throughthecysticartery
– Trauma,burns,postoperativepatients
• Extrinsiccompressionofthecysticductbya massorlymphadenopathy
• PositiveMurphy’ssign
19
Q
Acalculouscholecystitis
Sonographicfindings?
A
–ThickenedGBwall
•Greaterthan4–5 mm
–Echogenicsludge – DilatedGB
–Presenceofpericholecysticfluidwithinascitesand/or subserosaledema
20
Q
Emphysematouscholecystitis
A
- Rarecomplicationofacutecholecystitis
- Associatedwiththepresenceofgasforming bacteriaintheGBwallandlumenwith extensionintothebiliaryducts
- 50%ofpatientshavediabetes
- Lessthan50%havegallstones
- Gangrenewithassociatedperforationisa complication
21
Q
Emphysematouscholecystitis
Sonographicfindings?
A
–Ifthegasisintraluminallookforaprominent brightechoalongthe anteriorwallwithring downorcomettail artifactdirectlyposterior totheechogenic structure
22
Q
Gangrenouscholecystitis
A
- Complicationofacutecholecystitis • Mayleadtoperforation
- GBwallmaybethickenedandedematous withfocalareasofexudate,hemorrhage,and necrosis
- Maybeulcerationsandperforationsresultinginpericholecysticabscessesorperitonitis
- Stonesorfinegravelmayoccurin80‐95%of patients
23
Q
Gangrenouscholecystitis
Sonographicfindings?
A
–PresenceofdiffusemediumtocoarseechogenicdensitiesfillingtheGB lumenintheabsenceofbileductobstruction
– Echogenicmaterialhasthreecharacteristics
• Doesnotshadow
• Isnotgravitydependent
• Doesnotshowalayeringeffect
24
Q
ThemostcommondiseaseoftheGB?
A
Cholelithiasis
25
Cholelithiasis
May be a single large stone or hundreds of tiny stones • Tiny stones are the most dangerous • Can enter the bile ducts and obstruct the outflow of bile
26
If a patient has Cholelithiasis, what happens after eating a fatty meal?
Physiology GB contracts after eating a fatty meal
27
What are the Clinical presentation of Cholelithiasis?
```
5 F’s
• Fat
• Female
• Forty
• Fertile
• Fair Skinned (Milky complexion)
```
28
What are other factors of Cholelithiasis?
* Pregnancy
* Diabetes
* Oral contraceptive use
* Hemolytic diseases
* Diet-induced weight loss
* Total parenteral nutrition
29
Symptoms of Cholelithiasis?
* Patients are asymptomatic until a small stone lodges in the cystic or common duct
* RUQ pain with radiation to the shoulder after a high fat meal
* Epigastric pain
* Nausea & vomiting
30
Cholelithiasis
| Sonographic findings?
•Evaluated for increased wall thickness, presence of internal reflections within the lumen and posterior shadowing
• Frequently patients have a dilated GB
• Smaller stones (1‐2mm) are more difficult to distinguish
• When the GB is completely packed with stones you will only be able to image the anterior border
- Wall echo shadow sign (WES)
31
Shift patient position to demonstrate the presence of movement?
* Supine
* LLD
* Erect
* Stones should shift to the more dependent portion of the GB
32
Why does Cholelithiasis cause acoustic shadowing?
Shadow from a gallstone is attributed to acoustic impedance of the stones, refraction through them or diffraction around them
•Their size, location, and position in relation to the focus of the beam and the intensity of the beam
33
What are the exceptions for a stone to cast acoustic shadowing?
Size of the stone is important
| 3mm or less may not shadow?
34
Shadow is dependent on the relationship between what?
Stone and the sound beam
35
Choledochal cysts
• May be the result of pancreatic juices refluxing into the bile duct because of an anomalous junction of the pancreatic duct into the distal common bile duct, causing a wall abnormality, weakness, and outpouching of the ductal walls
36
Choledochal cysts?
Common or rare?
More commonly in?
Rare
| More commonly found in females than males
37
Choledochal cysts,
| Clinical symptoms?
* Abdominal mass
* Pain
* Fever
* Jaundice
38
Choledochal cysts
| Sonographic findings?
•Appear as a true cyst in the RUQ with or without apparent communication with the biliary system
39
Choledochal cysts
Sonographic findings,
Classified by anatomy?
* Localized cystic dilation of the CBD
* Diverticulum from the CBD
* Invagination of the CBD into the duodenum
* Dilation of the entire CBD and the CHD
40
Hyperplastic cholecystitis?
•Represented by a variety of degenerative and proliferative changes of the GB
41
Hyperplastic cholecystitis.
| Characterized by?
* Hyperconcentration
* Hyperexcitablity
* Hyperexcertion
42
Hyperplastic cholecystitis,
| More common in?
Females
43
Hyperplastic cholecystitis,
| How many types and what kind?
Two types
•Cholesterolosis
•Adenomyomatosis
44
Cholesterolosis
A condition in which cholesterol is deposited within the lumina propria of the GB
45
Cholesterolosis associated with?
Cholesterol stones
46
Cholesterolosis,
| Known as?
* Known as a strawberry gallbladder
| * The mucosa resembles the surface of a strawberry
47
Cholesterolosis,
| Conditions?
* Most do not show thickening of the GB wall
* A small percentage of patients with this condition will show cholesterol polyps
* Polyps
* Small well defined soft tissue projections from the GB wall
* Cholesterol polyp is the most common pseudotumor of the GB
48
Cholesterolosis
| Sonographic finding?
* Small smooth wall projections seen to arise from the GB wall
* Usually multiple
* Do not shadow
* Remain fixed to the wall with changes in patient position
* Comet‐tail artifact may be present
49
Adenoma
•Benign neoplasms of the GB with a premalignant potential lower than colonic adenomas
50
What does Adenoma usually occur as?
A solitary lesion
51
Smaller lesions in Adenoma are?
smaller lesions are pedunculated
52
Larger lesions in Adenoma may?
may contain foci of malignant transformation
53
What should be suspected if the GB wall is thickened adjacent to the adenoma?
malignancy should be suspected
54
Adenoma
| Sonographic appearances?
•Thickening of the
GB wall making an hourglass appearance
•Twinkle artifact
without real vascularity
55
Acute cholecystitis
| Symptoms?
–Hydrops,
- Sludge
- Positive Murphy’s sign
- Presence or absence of pericholecystic fluid
56
Adenomyomatosis
* Hyperplastic change in the GB wall
| * May be scattered over a large part of the mucosal surface of the GB
57
Rokitansky‐Aschoff sinuses associated with?
Adenomyomatosis
58
Rokitansky‐Aschoff Sinuses
–Small mucosal herniations into the muscular layer of the gallbladder
59
Adenomyomatosis,
| Sonographic findings?
* Appear as small elevations in the GB lumen
* Maintain their initial location during positional changes
* Are the cause for a comet tail
* No shadow is seen posterior
60
Porcelain gallbladder
A rare occurrence, Calcium incrustation of the GB wall
61
Porcelain gallbladder,
| Associated with ______ in the majority of patients?
Gallstones
62
Porcelain gallbladder, symptoms?
Asymptomatic
| •25% will develop cancer of the GB wall
63
How is Porcelain Gallbladder diagnosis made?
Diagnosis is made as an incidental finding or when a mass is found on physical examination
64
Porcelain Gallbladder,
| Sonographic findings?
•Bright echogenic echo is seen in the region of the GB
with posterior shadowing
•Differential will include WES sign
65
Gallbladder carcinoma
* Tumor infiltrates the GB and causes thickening and rigidity of the wall
* A rapidly progressive disease
* Occurs most frequently in women 60 yrs or older
66
Gallbladder carcinoma, Mortality rate and is associated with?
1. 100%
| 2. Associated with cholelithiasis in 80‐90%
67
Gallbladder carcinoma, increases the risk of?
* Increased incidence of GB cancer
| * Twice as common as cancer of the bile ducts
68
In Gallbladder carcinoma, adjacent liver is often invaded by?
by:
1. direct continuity extending through tissue spaces,
2. the ducts of Luschka,
3. the lymph channels, or any combination
69
In gallbladder carcinoma, obstruction of the cystic duct results from?
Direct extension of the tumor or extrinsic compression by involved lymph nodes
•Occurs early
70
Gallbladder carcinoma,
| Sonographic findings?
* The global shape of malignant gallbladder masses is similar to that of the GB
* Mass is heterogeneous solid or semisolid echo texture
* GB wall is markedly abnormal and thickened
* Adjacent liver tissue in the hilar area is often heterogeneous due to tumor spread
* May be dilated biliary ducts within the liver parenchyma causing the “shotgun” sign
* Almost never detected at a resectable stage
* Obstruction of the cystic duct occurs early
* Causes nonvisualization of the GB on oral cholecystogram
71
Dilated biliary ducts
1. Must be greater than 4mm
2. Biliary ducts parallel the portal system
3. Generally a duct more than 6 mm in diameter is considered borderline and more than 10 mm is considered dilated
72
Dilated biliary ducts,
| CHD has an internal diameter of?
= less than 4mm
•Duct diameter of 5 mm is borderline
•Duct diameter of 6 mm requires further investigation
73
Biliary obstruction,
| Three primary areas for obstruction?
* Intrapancreatic
* Suprapancreatic
* Porta hepatic
74
Extrahepatic biliary obstruction, the sonographer should?
localize the level and cause of the obstruction
75
Biliary obstruction, Intrapancreatic, What are the three conditions that cause the majority of biliary obstruction at the level of the distal duct and cause extrahepatic duct to be entirely dilated?
* Pancreatic carcinoma
* Choledocolithiasis
* Chronic pancreatitis with stricture formation
76
Biliary obstruction, Suprapancreatic obstruction?
Obstruction originates between the pancreas and the porta hepatis
•Head of the pancreas, the intrapancreatic duct, and the pancreatic duct are normal with ultrasound
77
Biliary obstruction, Suprapancreatic obstruction most common case is?
Most common cause is malignancy or adenopathy
78
Biliary obstruction, Porta hepatic obstruction?
* Usually due to a neoplasm
* Ultrasound will show intrahepatic ductal dilation and a normal CBD
* Hydrops of the GB may be present
79
Biliary obstruction, Other causes of obstruction?
* Cholangiocarcinoma originates within the larger bile ducts
| * Klatskin’s tumor
80
Klatskin’s tumor
* Specific type of cholangiocarcinoma
* Can occur at the bifurcation of the CHD
* Involvement of both the central left and right duct
* Most suggestive sonographic feature to indicate cholangiocarcinoma is isolated intrahepatic duct dilation
* Obstructing mass may not be visualized, a nonunion of the Rt and Lt ducts is characteristic for a Klatskin’s tumor
81
Mirizzi syndrome,
| Cause?
Cause for extrahepatic biliary obstruction due to an impacted stone in the cystic duct
82
Mirizzi syndrome,
| Sonographic findings?
•Intrahepatic ductal dilation is seen with a normal size CBD and a large stone in the neck of the GB or cystic duct
