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60 Cards in this Set

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  • Back
Where do tumors metastasizing to the gallbladder originate?
The stomach, pancreas and bile ducts
(Debra said to know this)
Will there usually be cholelithiaisis with
1) primary gallbladder carcinoma?
2) cancers metastasizing to the gallbladder from other organs?
1. Yes
2. No
What conditions will cause diffuse thickening (> 3.0 mm) of the gallbladder wall, even though there is no inflammation?
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)
What conditions will cause focal (local) thickening of the gallbladder wall, even though there is no inflammation?
1. Adenomyomatosis
2. Adenomatous polyp
3. Cholesterol polyp
4. Papillary adenomas
5. Gallbladder carcinoma
6. Metastatic wall masses
What conditions can cause pseudo wall thickening?
1. Too high gain setting
2. Beam average artifact
3. Tumefactive sludge
What is a sonographic sign of biliary dilatation?
"Too many tubes", with posterior acoustic enhancement
(See Pp 126, 130-132)
What is a typical measurement for the
1. CHD?
2. CBD?
1. 4 mm, but up to 7mm is OK
2. 8 mm
What word means "gallstones in the CBD"?
Choledocholithiasis
(See P 124)
What term means "cancer of the bile ducts"?
Cholangiocarcinoma
How frequently are stones present with Cholangiocarcinoma?
1/3 of the time
What age group is most likely to experience cholangiocarcinoma?
People in their 50's and 60's
What gender is most likely to be affected by cholangiocarcinoma?
Males
In order of likelihood, what are the most common sites of cholangiocarcinoma?
1. Distal CBD
2. Hepatic ducts
3. Cystic duct
4. Duodenal portion of CBD
(See P 122)
What structure, normally difficult to visualize sonographically, will appear dilated in case of cholangiocarcinoma in the distal bile duct?
The main pancreatic duct
What is the name given to the bile duct carcinomas arising at the hepatic duct bifurcation (more properly called an "anastamosis" than a "bifurcation"?
Klatskin tumor
(Debra said to know this)
What will be the sonographic appearance of a Klatskin tumor?
Dilatation of the intrahepatic ducts but not extrahepatic ducts
(See Pp 141, 143)
(Debra said to know this)
What is the gender prevalence of cholangitis?
Same in men and women
What will be the lab test results with cholangitis?
1. High bilirubin
2. High alkaline phosphatase
3. High AST
4. High ALT
5. High white blood cell count
What term means "the presence of gas in the biliary system"?
Pneumobilia
(See slide 155 for "classic picture" we should know; also see slide 156)
(Debra says to know this)
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?"
Biliary atresia
What are the 3 clinical symptoms of biliary atresia, and when are these observed?
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.
What two observations indicate neonatal hepatitis (as opposed to biliary atresia)?
Gallbladder length >= 1.5 cm
Liver hyperechoic or normal
What condition presents as a segmental, saccular, or beaded appearance to the intrahepatic ducts?
Caroli's Disease
What does Caroli's Disease lead to?
Bile stasis, bacterial growth, and, due to compression of parenchymal cells, impairment of liver function.
What are clinical symptoms of Caroli's Disese?
1. Crampy pain
2. Fever
3. Intermittent jaundice (I don't know why it should only be intermittent)
What is the sonographic appearance of Caroli's Disease?
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)
What is the term for "condition involving cystic dilatation of bile ducts, with anomalous insertion into the pancreatic duct?"
Choledochal cysts
(See slides 174, 175)
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?
Nothing
What is a sonographically visible, sensitive indicator of biliary obstruction?
CBD > 1.3 cm
What are 4 possible sonographically visible signs of distal bile duct obstruction?
1. Intrahepatic bile duct dilation
2. Extrahepatic bile duct dilation
3. Pancreatic duct dilation
4. Gallbladder dilation
What are 7 possible causes of distal bile duct obstruction?
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
What would distinguish an obstruction in the CHD from a distal bile duct obstruction?
If the obstruction is in the CHD, the intrahepatic bile ducts will be dilated, but the extrahepatic bile ducts will be normal sized.
What are 5 possible causes of CHD obstruction?
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)
Where do stones in ducts originate?
They may pass from the gallbladder through the cystic duct, or they may simply form in the duct itself.
Stones in the bile duct will be (hyperechoic / hypoechoic), and (will / will not) produce posterior shadowing.
hyperechoic
will
"Too many tubes" will produce posterior (enhancment / shadowing)
enhancement
What are 2 names for the visualization of dilated left and right hepatic ducts?
"Parallel channel sign" or
"Double channel sign"
What observation would cause a diagnosis of simply "jaundice" to be recast as "obstructive jaundice?
Visualization of dilated bile ducts.
What are 7 conditions that can mimic choledocholithiasis?
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
What is a specific type of adenocarcinoma concerning the biliary system?
Primary biliary carcinoma
What are often precursors of biliary carcinoma?
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.
What is another precursor to both gallbladder carcinoma and biliary carcinoma?
Ulcerative colitis (ulcer = a sore that fails to heal, colitis = inflammation of the lining of the colon)
What are the clinical signs & symptoms of cholangiocarcinoma?
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
What are some sonographically visible symptoms which may indicate biliary carcinoma?
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.
What is the name of the point at which the left and right hepatic ducts join to form the common hepatic duct?
The Klatskin
What is a reasonable differential diagnosis for a Klatskin tumor?
Lymphadenopathy, because of the small size of a Klatskin tumor
What are 5 possible causes of cholangitis?
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)
What are the clinical symptoms of cholangitis?
1. Repeated attacks of cholangitis with fever and chills
2. Epigastric or RUQ pain
3. Jaundice
What are the sonographic symptoms of cholangitis?
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.
How will sclerosing and AIDS cholangitis appear differently from just regular cholangitis?
With sclerosing and AIDS cholangitis, there will be less dilation of the ducts, but more wall thickening.
What are the differentials for cholangitis?
1. Biliary obstruction
2. Caroli's disease
Air or gas pockets (will / will not) cause (posterior enhancment / shadowing)
will
shadowing
What appear to be calcifications in the biliary system may actually be _______.
pneumobilia (gas in the biliary system)
What are 5 potential complications of biliary atresia?
1. Death without surgical intervention
2. Cirrhosis
3. Portal hypertension
4. Cholangitis
5. Malabsorption
Where does a choledochal cyst usually occur?
Where the CBD meets the pancreatic duct
What are complications of choledochal cysts?
Reflux of pancreatic juice into the CBD leads to
1. Cholangitis
2. Duct dilatation
What are the clinical symptoms of choledochal cysts?
1. Patient < 10 years old
2. Failure to thrive
3. Pain
4. Intermittent jaundice
5. Palpable mass.
6. Infection
7. Fever
What are the sonographic symptoms of choledochal cysts?
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)
What are differentials for choledochal cysts?
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).
What can produce posterior shadowing from a bile duct?
High calcium content in the bile, known as "milk of calcium" bile