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142 Cards in this Set
- Front
- Back
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What is the medical term for gallstones?
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Cholelithiasis
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What are the 3 reasons a person might get gallstones (with the most common reason first)?
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1. Abnormal bile composition
2. Stasis (the bile staying in the gallbladder) 3 .Infection |
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What are the two major categories of gallstones?
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1 Cholesterol stones
2. Pigment stones |
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What are the categories of pigment stones, and how does this affect diagnosis and treatment?
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Pigment stones can be subdivided into "brown" or "black". However, medically, they are treated identically.
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What is the principal component of cholesterol stones?
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Crystalline cholesterol monohydrate
(Debra said to know this) |
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What is the principal component of pigment stones?
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Noncrystalline calcium bilirubinate (which includes calcium carbonate)
(Debra said to know this) |
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Although gallstones are usually of mixed composition, what color do each of the following components tend to be:
1. Cholesterol? 2. Calcium bilirubinate? 3. Calcium carbonate? |
1. White
2 Brown 3. Black |
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What are the 3 stages of gallstone formation?
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1. Saturation of bile
2. Nucleation (initiation of stone formation) 3. Growth to detectable size |
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What diameter are gallstones?
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From 5 mm to 2 cm.
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What % of the adult population will develop gallstones?
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8-10%
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What is the gender predominance of gallstones, and by what ratio?
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Women, 4:1
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In what areas of the world are most gallstones
1. Cholesterol gallstones? 2. Pigment gallstones? |
1. Western nations
2. Asia and Latin American |
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What are 8 predisposing factors for formation of stones?
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1-Obesity
2-diabetes 3- pregnancy 4-estrogen replacement 5-pancreatitis 6- biliary infection 7- alcoholic cirrhosis, 8-anemias characterized by abnormal hemolysis and increased production of bilirubin pigment. |
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Are gallstones ever asymptomatic?
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Yes, 80% are.
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What are 3 common symptoms of gallstones?
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1. RUQ pain (particularly a few hours after eating a fatty meal)
2. Nausea and vomiting 3. Fever (if associated with infection) |
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What is the most serious consequence of gallstones?
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Obstruction of the cystic duct or CBD
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What word means "inflammation of the gallbladder"?
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cholecystitis
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What word means "inflammation of one or more bile ducts"?
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cholangitis
(See Pp 147, 151-154) |
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What is the consequence of obstruction of the cystic duct or CBD?
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Hydrops = edema (a collection of watery fluid) in the gallbladder, resulting in enlargement of the gallbladder, and predisposing the patient to bacterial infection that can lead to cholecystitis or cholangitis
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What are the three necessary sonographic elements necessary to diagnose gallstones?
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1. An echogenic foci in the gallbladder
2. An acoustic posterior shadow seen in at least 2 body planes 3. Either a change in position (to the dependent portion of the gallbladder) following a change in patient position, or, for "floating stones", no such change in conjunction with the detection of sludge (fine particles of bile) (See Pp 14, 16, 17, 182, 183, 186) |
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Does sludge always develop into gallstones?
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No, in fact, it does so only a small percentage of the time.
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Cholecystitis manifests itself by a _____ wall.
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Thickened
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Is ultrasound better at diagnosing stones in the gallbladder neck or cystic duct?
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Gallbladder neck
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What are two unique characteristics pertaining to the sonographic appearance of stones in the gallbladder neck?
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1. They will sometimes produce curved, highly reflective intra-luminal shadows.
2. They may not change position with a a change in patient position |
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What are 3 frequently occurring non-biliary structures which can mimic a cystic duct stone?
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1. Echogenic fat in porta hepatis
2. Gas in duodenum 3. Refractive shadow from valves of Heister |
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What is 1 less frequently occurring structure which can mimic a cystic duct stone?
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Calcification in masses in the porta hepatis
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Bowel produces (clean / dirty) shadowing.
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dirty
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What condition pertaining to a stone in the cystic duct do we need to remember the name of?
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Mirizzi Syndrome
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What are the 4 characteristics of Mirizzi Syndrome?
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1. Impacted stone in cystic duct or gallbladder neck
2. Obstruction of CHD due to compression or inflammation 3. Resultant jaundice, cholangitis, or biliary fistulas (abnormal passageways), or cholangitis cirrhosis 4. Dilation of CHD above stone; normal CHD below stone (See Pp 19, 20, 25, 64, 65) (Debra said to know this) |
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What effect can Mirizzi Syndrome have on the biliary tree?
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Too many tubes
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What is "non-visualization" of the gallbladder?
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A shrunken or "contracted" gallbladder
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How common is a contracted gallbladder?
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It occurs in 15-25% of patients with stones
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What is the technical specification for a contracted gallbladder?
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Measures < 2.0 cm in diameter in a fasting patient
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What liver landmark can be used to help find the gallbladder neck?
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The MLF
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How will stones appear in case of a contracted gallbladder?
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They'll still look like stones, but they'll lie in the gallbladder fossa region.
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What other feature can increase confidence in diagnosing stones with a contracted gallbladder?
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Seeing a small rim of fluid (bile) above the stone
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What acronym / visual pattern is used to characterize a contracted gallbladder with stones?
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WES sign = wall, echo, shadow, also called the "double arc", where the first arc is the wall of the non-visualized gallbladder, and the second arc is the echo produced by the stones
(See Pp 33-35)) |
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What does sludge consist of?
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Mostly, calcium bilirubinate mucus, and lesser amounts of cholesterol crystals
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What is the most common predisposing factor for sludge?
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Bile stasis in the gallbladder
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Sludge often develops when a patient has been _____.
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fasting
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Sludge is a possible precursor to
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cholecystitis
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Is sludge homogeneous, or does it form layers?
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It forms layers
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Sludge can resemble ______ ____, except on the posterior wall of the gallbladder
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reverberation echoes
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Will sludge shift with patient position?
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Yes, but slowly
(Debra said to know this) |
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What 3 conditions can mimic sludge?
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1. Pseudo-sludge (on older equipment only)
2. Clotted blood in the gallbladder 3. Bleeding in the biliary tree |
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Sludge produces (high / low) amplitude echoes
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low
(Debra said to know this) |
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Sonographically, will sludge appear as a fluid?
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Yes, it will appear as a fluid, adjacent to the bile
(See Pp 39, 40) (Debra said to know this) |
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If sludge totally fills the gallbladder with low- medium level echoes, the gallbladder may be _______ with the liver.
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isoechoic
(See P 43) (Debra said to know this) |
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_______ sludge does not layer evenly and can resemble a polypoid mass, pseudotumor, or tufts of cotton.
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Tumefactive
(See P 44) (Debra said to know this) |
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Do sludge balls produce shadowing?
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No
(Debra said to know this) |
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Does tumefactive sludge produce shadowing?
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No
(Debra said to know this) |
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How do sludge balls differ in appearance from tumefactive sludge?
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Sludge balls are more rounded, and do not seem to be projecting off a base
(See P 45) (Debra said to know this) |
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What usually causes acute cholecystitis?
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An obstruction in the cystic duct
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How does an obstruction in the cystic duct lead to acute cholecystitis?
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It may interfere with the blood supply to the gallbladder, thus predisposing it to an acute infection.
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What 3 microorganisms can initiate the infection leading to acute cholecystitis?
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1. staphylococci
2. streptococcus 3. gram- negative rods |
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Other than microorganisms, what else can lead to acute cholecystitis?
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Pancreatic reflux
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What are the two most common symptoms of acute cholecystitis?
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1. Acute RUQ pain referred to the shoulder
2. Tender right subcostal region |
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What are 6 other other clinical symptoms of acute cholecystitis?
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1. Precipitation by a fatty meal
2. Palpable RUQ pain 3. Fever, nausea, vomiting (75% of patients) 4. Jaundice (25% of patients) 5. Positive Murphy's sign (including pain just from scanning) 6. Improvement within 3 days, resolution within a week |
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What 4 laboratory findings are consistent with acute cholecystitis?
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1. Elevated serum bilirubin
2. Elevated serum transaminase 3. Alkaline phosphatase 4. Increased WBC count (= leukocytosis) |
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What are the 9 sonographically visible symptoms of acute cholecystitis?
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1. 90-95% of patients will have cholelithiasis, especially in the cystic duct
2. Diffuse (all the way around) gallbladder wall thickening > 3-4 mm 3. Halo sign suggesting edema in gb wall 4. Round or oval gallbladder (instead of elongated or pear shaped) 5. A-P transverse gallbladder diameter > 5.0 mm 6. Sludge 7. Pericholecystic fluid 8. Enlarged cystic artery visible |
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What is the term for "fluid outside the gallbladder wall"?
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Pericholecystic fluid
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What term is used to describe fluid inside the gallbladder wall?
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Edema
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What word means "pus in the gallbladder walls", having a complex sonographic appearance?
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Empyema
(See P 62) |
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What word means "gas-forming bacteria in the gallbladder wall"?
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Emphysematous cholecystitis
(images on slides 56, 57, & 63) |
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What should we expect to see with Emphysematous cholecystitis?
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High intensity echoes and comet-tail artifacts (rare)
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What term means "lack of blood supply to the gallbladder"?
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Gangrenous cholecystitis
(See Pp 60, 61, 184) |
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What term means "blood poisoning"?
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Septicemia
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What are 8 possible complications of acute cholecystitis?
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1) Empyema
2) Emphysematous cholecystitis 3) Gangrenous cholecystitis 4) Perforation of the gallbladder 5) Pericholecystic abscess (images on slides 58, 59) 6) Ascending cholangitis 7) Liver abscess 8) Septicemia |
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A ringdown artifact is consistent with what gallbladder condition?
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Emphysematous cholecystitis
(slide 63) |
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What is chronic cholecystitis?
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Recurrent inflammatory changes in the gallbladder, usually due to infection or obstruction
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What are the usual precursors to a diagnosis of chronic cholecystitis?
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Gallstones and recurrent infections
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What age group is chronic cholecystitis most common in?
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The elderly
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What tissue condition is characteristic of chronic cholecystitis?
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Fibrosis of the gallbladder wall
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What is the sonographic appearance of a fibrotic gallbladder wall?
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It will be thickened and echogenic
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What are the 3 clinical symptoms of chronic cholecystitis?
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1. Intermittent RUQ and epigastric pain
2. History of intolerance to fatty and fried foods 3. Intermittent nausea and vomiting |
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What 2 laboratory tests results indicate chronic cholecystitis?
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1. Elevated Ggtp (what's that?)
2. Elevated alkaline phosphatase |
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What 5 sonographically visible symptoms indicate chronic cholecystitis?
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1. Contracted gallbladder
2 Stones with shadowing 3. Thick, echogenic gallbladder wall 4. Sludge 5. Minimal gallbladder contraction following fatty meal or cholecystokinin injection |
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What 2 complications can occur if cholecystitis is untreated?
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1. Mirizzi Syndrome
2. A fistula can appear between the gallbladder and the duodenum. This is known as "Bouveret’s syndrome". |
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What is the usual treatment for acute cholecystitis?
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Surgery to remove the gallbladder.
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What happens if surgery is not performed after an acute cholecystitis condition has been resolved?
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About 50% of the patients will have repeat occurrences within 5 years
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What is another word for "edema"?
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Hydrops
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What is hydrops of the gallbladder?
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Enlargement of the gallbladder due to blockage of the cystic duct or gallbladder neck
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What is the name for the condition in which the gallbladder becomes enlarged due to obstruction because of a mass near the distal CBD (near the pancreatic head)?
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Courvoisier’s gallbladder
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Since, with hydrops, no new bile is able to enter the gallbladder, what causes the gallbladder to become enlarged?
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Mucous secretions or pus build up and are unable to exit from the gallbladder lumen
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With both hydrops and Courvoisier's gallbladder, what happens to the gallbladder wall?
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It gets extended and stretched thin (or "tense")
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What 3 conditions can be precursors to hydrops of the gallbladder?
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1. Scarlet fever
2. Surgery 3. Prolonged biliary stasis |
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What are the clinical symptoms of hydrops of the gallbladder?
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1. May be asymptomatic
2. Palpable RUQ mass 3. Epigastric pain 4. Nausea, vomiting |
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What are the 3 sonographically visible characteristics of hydrops?
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1. Stone in cystic duct or gallbladder neck
2. Dilated gallbladder (transverse wall diameter > 5 cm) 3. Thin gallbladder walls |
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What is the name for the condition of calcification of the gallbladder wall?
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Porcelain gallbladder
(Debra said to know this) |
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What is porcelain gallbladder a manifestation of?
Is this common or rare? |
Chronic cholecystitis
Rare (Debra said to know this) |
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What are the early symptoms of porcelain gallbladder?
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It is frequently asymptomatic
(Debra said to know this) |
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What is porcelain gallbladder often a precursor of?
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Gallbladder carcinoma
(Debra said to know this) |
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What % of patients with porcelain gallbladder have stones?
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95%
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What is the gender prevalence of porcelain gallbladder?
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Females, 5:1
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What is distinctive in the sonographic appearance of porcelain gallbladder?
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1. Highly echogenic wall (may be linear or semi-lunar) from calcification
2. Very strong, dark shadowing 3. May simulate a stone-filled gallbladder devoid of bile (our images don't seem to demonstrate this, though) 4. Resembles an egg with a calcium shell (See Pp 81-83) |
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Can a calcium gallbladder expand and contract?
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The further along it is, the less it can expand and contract.
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What term means "a new and abnormal growth of tissue in some part of the body, esp. as a characteristic of cancer"?
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Neoplasm
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What term means "A benign tumor formed from glandular structures in epithelial tissue"?
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Adenoma
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What is the most common benign neoplasm of the gallbladder?
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An adenoma
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What are the symptoms of an adenoma?
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There are none.
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What is the typical diameter of an adenoma?
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< 1 cm
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What term means "a small rounded protuberance on a part or organ of the body?"
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Papillary
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How does an adenoma appear in the gallbladder?
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They seem to be rooted in the gallbladder wall, and protrude into the lumen on a stalk.
(See Pp 87, 88) |
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What are the shadowing characteristics of adenomas?
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They do not shadow.
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Do adenomas shift to the dependent portion of the gallbladder with patient movement?
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No, they do not move.
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In what area of the gallbladder will an adenoma usually be found?
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The fundus
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What term means an "outpouching"?
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Diverticululm (pl. diverticula)
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What disease has to do with "outpockets" in a structure?
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Diverticulosis
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What is the term for the condition of diverticulosis of the gallbladder?
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Adenomyomatosis
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What is the name given to cavities which may form between diverticula?
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Rokitansky-Aschoff sinuses
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With adenomyomatosis, what might be present in the Rokitansky-Aschoff sinuses?
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Small cholesterol stones / crystals
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In what region(s) of the gallbladder might the diverticula appear?
What location is most common? |
They may be diffuse (thoughout the gallbladder wall) or segmental (limited to the proximal, middle, or distal portion).
Most commonly, they are limited to the gallbladder fundus. |
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What shape might the gallbladder take with adenomyomatosis, and what is this called?
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hourglass shape
annular |
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What is the sonographic appearance of adenomyomatosis?
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1. Diffuse or segmental thickening of gallbladder wall
2. Intraluminar diverticula visible 3. Reverberative,comet-tail like ringdown artifacts from the stones / crystals 4. Possible hourglass shape to gallbladder (See Pp 93, 94) |
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How can the ringdown artifact present with adenomyomatosis be distinguished from the ringdown artifact present with emphysematous cholecystitis?
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Compared to the ringdown associated with emphysematous cholecystitis (slide 63), the ringdown associated with adenomyomatosis (slide 94) has:
1. A more localized (smaller) source area 2. A more pronounced dovetailing or comet-tail aspect to the ringdown |
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What is the name for the condition of having abnormal cholesterol deposits in the gallbladder wall?
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Cholesterolosis
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What can cholesterolosis be associated with?
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cholelithiasis
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What are the two types of cholesterolosis?
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1. Cholesterol polyps
2. Cholesterosis |
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What is a colloquial term for cholesterosis?
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Strawberry gallbladder
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What is the sonographic appearance of cholesterolosis?
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Single or multiple hyperechoic masses which project into the lumen of the gallbladder
(See Pp 97-99) |
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Will there be shadowing from the echoes with cholesterolosis?
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There may appear to be shadowing, but in actuality, it is only an edge refraction artifact
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Other than the small hyperechoic masses, what else is distinctive about the gallbladder with cholesterolosis?
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Nothing - it appears normal.
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How can we easily distinguish sonographically between an adenoma and cholesterolosis?
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We can't
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What distinguishes a cholesterol polyp or an adenoma from a gallstone?
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1. Polyps and adenomas are fixed in their location
2. Polyps and adenomas do not cast shadows (though there may be edge shadowing artifact) |
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Are cholesterol polyps benign or malignant?
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Benign
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How can we easily distinguish sonographically between adenomyomatosis and cholesterolosis?
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1. With adenomyomatosis, there will be thickening of the gallbladder wall. With cholesterolosis, there is no wall thickening.
2. With adenomyomatosis, there is a comet-tail ringdown artifact. With cholesterolosis, there is no shadowing, other than possible edge refraction artifact. |
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What is the term for "a cancer arising in the epithelial tissue of the skin or of the lining of the internal organs?"
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carcinoma
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What is the term for "a cancer of epithelia originating in glandular tissue?"
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Adenocarcinoma
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What is a specific type of adenocarcinoma concerning the gallbladder?
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Primary Gallbladder Carcinoma
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Is gallbladder carcinoma common?
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No, we're unlikely to see it more than once per year
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What is the most common biliary malignancy?
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Primary Gallbladder Carcinoma
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Out of all the GI malignancies, how common is gallbladder carcinoma?
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5th most common
(Debra said to know this) |
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What age group is most likely to experience gallbladder carcinomas?
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People in their 50's and 60's
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What racial group is most likely to be affected by gallbladder carcinoma?
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Caucasians
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What gender is most likely to be affected by gallbladder carcinoma?
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Females, 4:1
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What is often a precursor to gallbladder cancer?
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Cholelithiasis and inflammation
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What % of patients with gallbladder carcinoma will have extensions of the cancer into the liver and other structures?
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80%
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In an asymptomatic patient, do physicians consider cholelithiasis alone a problem which needs treatment?
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No
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When does cholelithiasis require treatment?
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If and when it progresses to cholecystitis
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The signs and symptoms of gallbladder carcinoma are similar to those of what condition?
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Chronic cholecystitis
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What are the symptoms of gallbladder carcinoma?
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1- May be asymptomatic for many years
2- Loss of appetite, anorexia 3- Nausea and vomiting 4- Intolerance to fatty foods 5- Belching 6- Jaundice in later stage with infiltration of the major biliary ducts and extension into the liver bed. 7-RUQ mass and pain (50% of cases) |
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What is the sonographic appearance of gallbladder carcinoma?
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Since masses vary in size, shape, and location, there are a wide variety of appearances, but in general we will see a larger mass (not just a little polyp) with irregular borders.
To be more specific, we might see the following: 1. Localized thickening of the gallbladder wall 2. Masses with irregular borders 3. Loss of the usually smooth outline of the gallbladder with replacement by an undulated configuration 4. A solid mass (with diffuse weak or strong echoes) filling the gallbladder (most common type) 5. Mass infiltrating into the gallbladder wall with markedly thickened gallbladder wall 6. Fungating mass on the wall producing an intraluminal mass with an irregular contour (See Pp 105-108) |
