Abdm Ultra: 100802: Gallbladder Pathology 2

Front 1

Where do tumors metastasizing to the gallbladder originate?

Back 1

The stomach, pancreas and bile ducts
(Debra said to know this)

Front 2

Will there usually be cholelithiaisis with
1) primary gallbladder carcinoma?
2) cancers metastasizing to the gallbladder from other organs?

Back 2

1. Yes
2. No

Front 3

What conditions will cause diffuse thickening (> 3.0 mm) of the gallbladder wall, even though there is no inflammation?

Back 3

1. Normal contracted gb
2. Hypoalbuminemia (low albumin) (lab test)
3. Hypoprotenemia (low protein) (lab test)
4. Ascites
5. Acute hepatitis
6. Congestive heart failure
7. Renal disease
8. AIDS
9. Pancreatitis
10. Cirrhosis
11. Portal vein area lymphatic node obstruction
12. Sepsis (the presence in tissues of harmful bacteria and their toxins, typically through infection of a wound) (hard to see what this is doing on a list of non-inflamatory causes)
(See Pp 113-117)

Front 4

What conditions will cause focal (local) thickening of the gallbladder wall, even though there is no inflammation?

Back 4

1. Adenomyomatosis
2. Adenomatous polyp
3. Cholesterol polyp
4. Papillary adenomas
5. Gallbladder carcinoma
6. Metastatic wall masses

Front 5

What conditions can cause pseudo wall thickening?

Back 5

1. Too high gain setting
2. Beam average artifact
3. Tumefactive sludge

Front 6

What is a sonographic sign of biliary dilatation?

Back 6

"Too many tubes", with posterior acoustic enhancement
(See Pp 126, 130-132)

Front 7

What is a typical measurement for the
1. CHD?
2. CBD?

Back 7

1. 4 mm, but up to 7mm is OK
2. 8 mm

Front 8

What word means "gallstones in the CBD"?

Back 8

Choledocholithiasis
(See P 124)

Front 9

What term means "cancer of the bile ducts"?

Back 9

Cholangiocarcinoma

Front 10

How frequently are stones present with Cholangiocarcinoma?

Back 10

1/3 of the time

Front 11

What age group is most likely to experience cholangiocarcinoma?

Back 11

People in their 50's and 60's

Front 12

What gender is most likely to be affected by cholangiocarcinoma?

Back 12

Males

Front 13

In order of likelihood, what are the most common sites of cholangiocarcinoma?

Back 13

1. Distal CBD
2. Hepatic ducts
3. Cystic duct
4. Duodenal portion of CBD
(See P 122)

Front 14

What structure, normally difficult to visualize sonographically, will appear dilated in case of cholangiocarcinoma in the distal bile duct?

Back 14

The main pancreatic duct

Front 15

What is the name given to the bile duct carcinomas arising at the hepatic duct bifurcation (more properly called an "anastamosis" than a "bifurcation"?

Back 15

Klatskin tumor
(Debra said to know this)

Front 16

What will be the sonographic appearance of a Klatskin tumor?

Back 16

Dilatation of the intrahepatic ducts but not extrahepatic ducts
(See Pp 141, 143)
(Debra said to know this)

Front 17

What is the gender prevalence of cholangitis?

Back 17

Same in men and women

Front 18

What will be the lab test results with cholangitis?

Back 18

1. High bilirubin
2. High alkaline phosphatase
3. High AST
4. High ALT
5. High white blood cell count

Front 19

What term means "the presence of gas in the biliary system"?

Back 19

Pneumobilia
(See slide 155 for "classic picture" we should know; also see slide 156)
(Debra says to know this)

Front 20

What term means "a rare condition in newborn infants in which the common bile duct between the liver and the small intestine is blocked or absent, and the gallbladder is also absent?"

Back 20

Biliary atresia

Front 21

What are the 3 clinical symptoms of biliary atresia, and when are these observed?

Back 21

1. Jaundice
2. Hepatomegaly
3. Acholic (clay-colored) stools

They are observed during the neonatal period, even though the biliary atresia occurred during the 4th - 8th weeks of embryonic life.

Front 22

What two observations indicate neonatal hepatitis (as opposed to biliary atresia)?

Back 22

Gallbladder length >= 1.5 cm
Liver hyperechoic or normal

Front 23

What condition presents as a segmental, saccular, or beaded appearance to the intrahepatic ducts?

Back 23

Caroli's Disease

Front 24

What does Caroli's Disease lead to?

Back 24

Bile stasis, bacterial growth, and, due to compression of parenchymal cells, impairment of liver function.

Front 25

What are clinical symptoms of Caroli's Disese?

Back 25

1. Crampy pain
2. Fever
3. Intermittent jaundice (I don't know why it should only be intermittent)

Front 26

What is the sonographic appearance of Caroli's Disease?

Back 26

1. Multiple cystic structures in the liver that communicate with the biliary tree (resembles bunches of grapes)
2. Choleolithasis or just echogenic material in the duct
3. Cholangitis
(See Pp 168, 169)

Front 27

What is the term for "condition involving cystic dilatation of bile ducts, with anomalous insertion into the pancreatic duct?"

Back 27

Choledochal cysts
(See slides 174, 175)

Front 28

Other than the fact that cholelithiasis is usually associated with primary gb carcinoma but not metastasized gb carcinomas, what else in the sonographic appearance of the mass can tip us off as to whether it is primary or metastasized?

Back 28

Nothing

Front 29

What is a sonographically visible, sensitive indicator of biliary obstruction?

Back 29

CBD > 1.3 cm

Front 30

What are 4 possible sonographically visible signs of distal bile duct obstruction?

Back 30

1. Intrahepatic bile duct dilation
2. Extrahepatic bile duct dilation
3. Pancreatic duct dilation
4. Gallbladder dilation

Front 31

What are 7 possible causes of distal bile duct obstruction?

Back 31

1. Stone in CBD
2. Choledochal cyst (cyst in bile duct)
3. Pancreatic pseudocyst
4. Pancreatitis
5. Pancreatic mass
6. Tumor in Ampulla of Vater
7. Primary biliary carcinoma

Front 32

What would distinguish an obstruction in the CHD from a distal bile duct obstruction?

Back 32

If the obstruction is in the CHD, the intrahepatic bile ducts will be dilated, but the extrahepatic bile ducts will be normal sized.

Front 33

What are 5 possible causes of CHD obstruction?

Back 33

1. Stone in the CHD (Choledocholithiasis) (this is most common cause)
2. Obstruction in right or left hepatic duct
3. Adenopathy (enlarged lymph nodes)
4. Metastatic disease (a disease which has spread from one area to a non-adjacent area)
5. Cholangitis (inflammation of the bile duct, usually due to bacterial infection)

Front 34

Where do stones in ducts originate?

Back 34

They may pass from the gallbladder through the cystic duct, or they may simply form in the duct itself.

Front 35

Stones in the bile duct will be (hyperechoic / hypoechoic), and (will / will not) produce posterior shadowing.

Back 35

hyperechoic
will

Front 36

"Too many tubes" will produce posterior (enhancment / shadowing)

Back 36

enhancement

Front 37

What are 2 names for the visualization of dilated left and right hepatic ducts?

Back 37

"Parallel channel sign" or
"Double channel sign"

Front 38

What observation would cause a diagnosis of simply "jaundice" to be recast as "obstructive jaundice?

Back 38

Visualization of dilated bile ducts.

Front 39

What are 7 conditions that can mimic choledocholithiasis?

Back 39

1. Air or residue in adjacent bowel that mimic stones.
2. Right hepatic artery crossing the common hepatic duct and indenting it.
3. Postoperative Cholecystectomy clips
4. Impression on the CBD by the cystic duct
5. Air in the biliary tree
6. Mucous plug
7. Calcification in the head of the pancreas

Front 40

What is a specific type of adenocarcinoma concerning the biliary system?

Back 40

Primary biliary carcinoma

Front 41

What are often precursors of biliary carcinoma?

Back 41

Inflammation and choleolithiasis, as is the case for gallbladder carcinoma - but these are less established for biliary carcinoma, occurring only about 1/3 of the time.

Front 42

What is another precursor to both gallbladder carcinoma and biliary carcinoma?

Back 42

Ulcerative colitis (ulcer = a sore that fails to heal, colitis = inflammation of the lining of the colon)

Front 43

What are the clinical signs & symptoms of cholangiocarcinoma?

Back 43

1. RUQ pain of acute onset or abdominal pain
2. Biliary colic
3. Jaundice
4. Weight loss, anorexia
5. Nonspecific digestive disturbances
6. Fatigue
7. Palpable gallbladder or mass

Front 44

What are some sonographically visible symptoms which may indicate biliary carcinoma?

Back 44

1. Marked biliary obstruction in the presence of a normal pancreas
2. Focal biliary tract stricture or abrupt termination
3. Delineation or a mass involving the bile duct
4. Irregularly defined, coarse acoustic shadowing arising from the obstructive mass.
5. Contained intraluminal soft-tissue echoes.
6. Echogenic bands across the lumen.
7. Hepatomegaly and ascites.

Front 45

What is the name of the point at which the left and right hepatic ducts join to form the common hepatic duct?

Back 45

The Klatskin

Front 46

What is a reasonable differential diagnosis for a Klatskin tumor?

Back 46

Lymphadenopathy, because of the small size of a Klatskin tumor

Front 47

What are 5 possible causes of cholangitis?

Back 47

1. Congenital or acquired stricture
2. Coliform (bowel) bacterial infection of bile
3. Parasitic infestation is commonly found
4. Ulcerative colitis especially with sclerosing cholangitis, AIDS cholangitis.
5. Infection is associated with biliary duct stone or post endoscopic retrograde cholangiopancreatography (ERCP)

Front 48

What are the clinical symptoms of cholangitis?

Back 48

1. Repeated attacks of cholangitis with fever and chills
2. Epigastric or RUQ pain
3. Jaundice

Front 49

What are the sonographic symptoms of cholangitis?

Back 49

1. Massively dilated ducts are frequently demonstrated as large as 3.0 cm - 4.0 cm.
2. Striking dilatation of the extrahepatic ducts is seen with the ducts packed with pigmented stones.
3. Gallbladder is large and palpable in 30% of cases.
4. Air may be visualized in the biliary system.
5. Sclerosing and AIDS cholangitis may show marked diffuse or irregular thickening of the bile duct walls with minimal or mild intraductal dilatation.
6. Bacterial cholangitis may show hyperechoic gas pockets which cast shadows.

Front 50

How will sclerosing and AIDS cholangitis appear differently from just regular cholangitis?

Back 50

With sclerosing and AIDS cholangitis, there will be less dilation of the ducts, but more wall thickening.

Front 51

What are the differentials for cholangitis?

Back 51

1. Biliary obstruction
2. Caroli's disease

Front 52

Air or gas pockets (will / will not) cause (posterior enhancment / shadowing)

Back 52

will
shadowing

Front 53

What appear to be calcifications in the biliary system may actually be _______.

Back 53

pneumobilia (gas in the biliary system)

Front 54

What are 5 potential complications of biliary atresia?

Back 54

1. Death without surgical intervention
2. Cirrhosis
3. Portal hypertension
4. Cholangitis
5. Malabsorption

Front 55

Where does a choledochal cyst usually occur?

Back 55

Where the CBD meets the pancreatic duct

Front 56

What are complications of choledochal cysts?

Back 56

Reflux of pancreatic juice into the CBD leads to
1. Cholangitis
2. Duct dilatation

Front 57

What are the clinical symptoms of choledochal cysts?

Back 57

1. Patient < 10 years old
2. Failure to thrive
3. Pain
4. Intermittent jaundice
5. Palpable mass.
6. Infection
7. Fever

Front 58

What are the sonographic symptoms of choledochal cysts?

Back 58

1. Large, cystic mass in the porta hepatis
2. Dilated CHD or CBD
3. Dilated intrahepatic bile ducts.
4. No color flow in dilated structures.
5. Calculi (mineral deposits or stones)

Front 59

What are differentials for choledochal cysts?

Back 59

1. Hepatic cyst
2. Pancreatic pseudo cyst (if located near pancreatic head)
3. Enteric duplication (duplication cysts in the GI tract. We didn't study this)
4. Hepatic artery aneurysm (but there would be blood flow in this)
5. Spontaneous perforation of extrahepatic ducts (Debra said this would be "fishy" to use as a differential).

Front 60

What can produce posterior shadowing from a bile duct?

Back 60

High calcium content in the bile, known as "milk of calcium" bile