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157 Cards in this Set
- Front
- Back
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If you are having trouble locating a small,contracted GB or a GB filled with stones, you can use the ___ as a landmark
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interlobar fissure
Middleton 29 Fig 2-1 |
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What are the normal dimensions of the GB?
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4x10cm
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What is the normal wall thickness of the GB?
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3mm
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Does a contracted GB have increased wall thickness?
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no
Middleton 29 Fig 2-2 |
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What is the difference between a junctional fold and a phrygian cap?
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A junctional fold is when the GB folds on itself in the neck or body.
A phrygian cap is at the funds Both create a change in the outer contour of the GB Middleton 30 Fig 2-3 |
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How is a septation different from a junctional fold?
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It is thinner and separate the GB in to segments that communicate through a small pore
Middleton 30 Fig 2-4 |
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What is a variant in the location of the GB?
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Intrahepatic is most common
Middleton 31 Fig 2-5 |
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What are some duplication variants of the GB?
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complete
partial agenesis Middleton 31 Fig 2-6 |
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How many hours should one fast before a GB exam?
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8 hours
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The GB should be scanned in a variety of positions to demonstrate what?
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mobility of structures
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Why is visualizing the GB neck important?
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stones can be easily missed here
Middleton 32 Fig 2-7 |
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___% of the population has gallstones
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10%
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___% of gallstones are cholesterol and ___% are pigment stones
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75% cholesterol
25% pigment |
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At what rate do gallstones become symptomatic?
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2%/year
If you go more than 10-15 years without symptoms, you are unlikely to develop cholecystitis |
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What is biliary colic
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<6hrs symptoms
stone disimpacts from GB neck or passes through the cystic duct |
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What is the best imaging modality for detection of gallstones?
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US
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What is the sonographic appearance of ALL gallstones, regardless of composition?
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mobile, echogenic, intraluminal, cast acoustic shadows
Middleton 32 Fig 2-8 |
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Stones smaller than ___mm may not cast a shadow.
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3mm
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Optimizing ___ and ___ and ___ may help to visualize stones
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high frequency, focal zone, and body positioning
Middleton 33 Fig 2-9 |
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What is the sonographic appearance of GB polyps?
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adherent to GB wall
nonmobile do not shadow Middleton 42 Fig 2-18 |
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What are the 3 layers of the Wall-echo-shadow sign, indicating a GB full of stones?
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hyperechoic = pericholecystic fat
hypoechoic = GB wall hyperechoic = stones Middleton 34 Fig 2-10 |
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How do the shadows of bowel and gallstone differ?
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dirty shadow vs clean shadow
Middleton 32 Fig 2-8E |
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T/F
It is easy to confuse tiny stones lined up along the posterior wall with the GB wall itself if you don't look for shadowing and position the patient optimally |
true
Middleton 33 Fig 2-9 E/F |
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When the specific gravity of the bile is greater than the specific gravity of stones, the stones may ___
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float
Middleton 34 Fig 2-11 |
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What is the sonographic appearance of sludge?
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mobile and non shadowing
Middleton 35 Fig 2-12 |
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What is the composition of sludge?
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calcium bilirubinate granules and cholesterol crystals
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If there are echoes within sludge, is that a bunch of little stones?
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Stones are only present if there is shadowing
Middleton 35 Fig 2-12F |
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T/F
Sludge can have an inhomogenious appearance with echogenic membranes that should not be confused with sloughed membranes, in the right clinical context |
true
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What is tumefactive sludge?
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Sludge that does not move - a sludge ball
It does not layer Middleton 35 Fig 2-12E |
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Does lack of doppler flow help to distinguish sludge ball from tumor?
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no. hypovascular tumors may not demonstrate flow, similar to sludge ball
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What 2 things can mimic intraluminal sludge?
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pus and blood
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What is the clinical significance of sludge?
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it may precipitate pancreatitis
it may be a precursor to stones (rare) |
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The PPV and NPV of gallstones and positive Murphy's sign?
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PPV 92%
NPV 95% |
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T/F
Gallbladder wall thickening >3mm occurs in the majority of pts with acute cholecystitis |
true
unfortunately, there are many other causes of GB wall thickening |
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When determining GB enlargement, is length or width more important?
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width >4cm
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gallstones are present in approximately ___% of cholecystitis
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95%
they may not always be visualized with US |
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What are the sonographic signs of acute cholecystitis?
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gallstones
wall >3mm GB enlargement pericholecystic fluid impacted stone sonographic Murphy's sign Middleton 37 Fig 2-13 |
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What are the sonographic signs of advanced acute cholecystitis?
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pericholecystic fluid
sloughed mucousal membranes irregular striated intramural sonolucencies wall ulceration, bulge, or rupture wall abscess Middleton 38 Fig 2-14 |
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Pericholecystic fluid is seen in <___% of cases of acute cholecystitis
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20%
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Pericholecystic fluid is most commonly found where?
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near the funds
Middleton 37 Fig 2-13 E/F |
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___% of cases of acute cholecystitis are acalculous
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5%
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What is the etiology of acalculous cholecystitis?
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ischemia, infection of the GB wall, cystic duct obstruction, chemical toxicity of the GB wall
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What patients tend to get acalculous cholecystitis?
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major surgery, extensive burns, major trauma, prolonged TPN
Middleton 39 Fig 2-15 |
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Who is at risk for emphysematous cholecystitis?
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elderly men, diabetics
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What causes emphysematous cholecystitis?
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ischemia, then infection with gas-forming organisms.
it is not associated with gallstones |
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What is the sonographic appearance of emphysematous cholecystitis?
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very bright reflections from a non-dependent portion of the GB wall and dirty acoustic shadow with ring-down artifact
Middleton 39 Fig 2-16 |
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What causes GB cancer?
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chronic irritation of the GB wall from gallstones
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Do women or men more commonly get GB cancer?
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women (they get more stones)
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What is the sonographic appearance of GB cancer?
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Mass centered on the GB fossa with associated stones
Middleton 40 Fig 2-17 |
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How does size differentiate a GB polyp from a GB cancer?
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polyp is almost always <5mm
5mm-1cm should be monitored >1cm may be cancer |
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What are the 2 forms of hyperplastic cholecystoses?
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adenomyomatosis
cholerolosis |
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What is cholesterolosis?
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TG and cholesterol esters are deposited in the lamina propria of the GB
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Is cholesterolosis associated with hyperlipidemia?
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no
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Most cases of cholesterolosis are of the ___ variety and are not detectable on US
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planar
"strawberry GB" because surface of GB looks like a strawberry |
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A minority of cholesterolosis are of the ___ variety
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polypoid
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What is the sonographic appearance of polypoid cholesterolosis?
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a polyp
Middleton 42 Fig 2-18 |
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What is adenomyomatosis?
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mucosal hyperplasia and thickening of the muscular layer of the GB
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What is the sonographic appearance of adenomyomatosis?
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comet tail artifacts from the superficial wall of the GB
focal segmental thickening of the GB wall Middleton 43 Fig 2-20 |
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What is a Rokitansky-Aschoff sinus?
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mucosal herniations into the muscular layer.
With adenomyomatosis, cholesterol crystals deposit in these sinuses and cause comet tail artifacts from bright reflections from the GB wall |
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What is the sonographic appearance of a Rokitansky-Aschoff sinus?
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if cholesterol crystals are deposited, there will be bright reflections and short comet tail artifacts
Middleton 43 Fig 2-20 |
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DDX of GB wall masses?
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carcinoma
polyp adenomyomatosis tumefactive sludge metastases chronic cholecystitis |
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DDX of GB wall thickening
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biliary:
cholecystitis cancer adenomyomatosis AIDS cholangiopathy sclerosing cholangitis non-biliary: hepatitis CHF pancreatitis cirrhosis portal hypertension lymphatic obstruction hypoproteinemia Middleton 44 Fig 2-21 |
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What causes marked GB wall thickening in hepatitis?
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unknown, but may be due to adjacent inflammation of the liver or excretion of the virus in the bile and direct infection of the GB
hepatitis also frequently causes GB contraction |
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GB wall varices that occur in portal hypertension can simulate GB wall thickening. How can they be detected?
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doppler
Middleton 45 Fig 2-22 |
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What is the great risk of porcelain GB?
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GB carcinoma
prophylactic cholecystectomy is recommended |
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What causes porcelain GB?
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chronic GB inflammation (stones in 95%)
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What is the sonographic appearance of porcelain GB?
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echogenic arc with dense posterior shadowing
Middleton 45 Fig 2-23 |
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What is the Ddx of porcelain GB?
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emphysematous cholecystitis (ring down artifact)
WES (if posterior wall visible, not GB full of stones) |
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The insertion of the cystic duct marks the boundary between the ___ and the ___
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common hepatic duct
common bile duct Middleton 88 Fig 4-1 |
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The right hepatic artery runs between the ___ and ___
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common duct and portal vein
Middleton 88 Fig 4-1A |
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Mickey Mouse's right ear us usually the ___ and the left ear is usually the ___
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right = CBD
left = hepatic artery Middleton 88 Fig 4-1E |
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What are 2 normal variants for the course of the hepatic artery in relation to the PV and CBD?
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two hepatic arteries
the RHA can run anterior to the CBD Middleton 89 Fig 4-2 |
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How are the RHA and CBD different in sonographic appearance?
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HA = tortuous, similar diameter through its course, may cause extrinsic compression of PV or CBD, lights up on Doppler
CBD = relatively straight, diameter varies, no extrinsic compression, does not light up on Doppler |
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The RHA normally arises from the celiac axis, but a normal variant is to arise from the ___
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SMA
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The gastroduodenal artery runs through the anterior/posterior part of the pancreatic head.
The CBD runs through the anterior/posterior part of the pancreatic head. |
GDA = anterior
CBD = posterior Middleton 88 Gif 4-1C |
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The hepatic artery runs anterior/posterior to the PV.
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anterior
Middleton 88 Fig 4-1A |
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What are some normal variants for the cystic duct insertion?
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It can insert lower than normal
Middleton 90 Fig 4-3 |
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T/F
a tortuous GB neck can simulate the appearance of the proximal duct |
true
Middleton 90 Fig 4-4 |
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What is the typical anatomic positioning for scanning the biliary tree?
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Proximal common duct = left lateral decubitus position from a right subcostal approach during deep inspiration
Distal common duct = anterior epigastric approach |
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What techniques can one use to improve the visualization of the CBD in the head of the pancreas?
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drink water
sit pt up pressure left lateral decub position and use GB as an acoustic window |
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Obstructed bile ducts are diagnosed sonographically by ___
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ductal dilatation
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What are the sonographic findings of dilated intrahepatic ducts?
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>2mm
>40% the diameter of the adjacent PV tortuous and irregular walls (compared to PV) increased through transmission stellate configuration centrally no flow on doppler Middleton 91 Fig 4-5 |
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What is the "parallel channel sign"?
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The appearance of intrahepatic PV with bile duct or artery adjacent to it
Middleton 91 Fig 4-5A/E/F |
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In the setting of portal hypertension, in the stage when the arteries dilate to compensate for decreased portal vein flow, the arteries can be confused for bile ducts. What distinguishes artery from bile duct in this situation?
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doppler
Middleton 91 Fig 4-5E/F |
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T/F
There is no universally accepted approach to the detection of extra hepatic ductal dilatation |
true
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Is the prox, mid, or distal segment of the CBD the least restricted and therefore most likely to dilate early in the course of ductal obstruction?
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mid section
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A mid-segment CBD diameter of ___mm or greater suggests ductal obstruction
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7mm
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What 2 things other than obstruction can cause extra hepatic ductal dilatation?
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advanced age
cholecystectomy (controversial) |
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If you measure the proximal bile duct, just anterior to the RHA, a diameter of > ___mm suggests obstruction
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4mm
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What is a disadvantage of measuring the proximal instead of mid bile duct to diagnose dilatation?
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the proximal bile duct may not dilate as early as the mid duct
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Instead of diagnosing ductal obstruction based on CBD diameter, what is a better approach?
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find the obstructing lesion, because a dilated duct does not necessarily mean obstruction
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T/F
A duct that is mildly dilated at all levels is more likely to be obstructed than a duct that is mildly dilated at the mid level but tapers in the proximal and distal segment |
true
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What happens to a normal CBD after a fatty meal?
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The Sphincter of Oddi relaxes, allowing bile to flow out and the duct diameter decreases
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What happens to an obstructed CBD after a fatty meal?
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It dilates by 1mm or more, as the GB contracts against the obstruction
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___% of intraductal stones do not shadow. This is likely due to lack of a significant amount of bile surrounding the stone.
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20%
Middleton 93 Fig 4-6C |
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Most intraductal stones are found where?
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in the distal portion of the intrapancreatic duct near the ampulla of Vater
Middleton 93 Fig 4-6 |
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What is the sensitivity of sonography in detecting ductal stones?
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75%
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What are some causes of false positive results for intraductal stones?
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calcifications in the hepatic artery and pancreatic head
gas in duodenal diverticula cystic duct insertion |
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What can help to verify that a suspected stone is intraductal and not a pitfall?
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transverse view
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T/F
Intrahepatic duct stones are much less common than common bile duct stones |
true
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Where do intrahepatic bile duct stones form?
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in the hepatic bile ducts
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Most primary biliary stones are ___ stones
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pigment
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Intrahepatic ducts may be single or multiple. They are more/less likely to produce a shadow than extra hepatic stones.
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less
Middleton 94 Fig 4-8 |
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What are some common pitfalls for intraductal stones?
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pneumobilia
intrahepatic arterial calcification X-Ray can help to distinguish |
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What can distinguish biliary gas (pneumobilia) from stones?
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brighter reflection
dirtier shadow only gas has ring down artifact spontaneously mobile bubbles Middleton 95 Fig 4-9 |
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What can distinguish intra hepatic arterial calcification from stones?
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double-line sign (A/P wall calc)
the kidneys and spleen will likely also show extensive calcification Middleton 95 Fig 4-10 |
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What is a Klatskin tumor?
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Bile duct cancer occurs most commonly at the bifurcation of the common hepatic duct, and when found here, is called a Klatskin tumor.
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What is the common sonographic appearance of cholangiocarcinoma (bile duct cancer)?
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location at the bifurcation of the common hepatic duct
tumor infiltrates the duct wall and produces a focal stricture dilated ducts that abruptly terminate at the level of the tumor tumor may be difficult to visualize because same echogenicity as the liver and poorly marginated Middleton 96 Fig 4-11 |
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What findings with cholangiocarcinoma suggest nonresectability?
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hepatic metastases
invasion of the portal vein encasement of the hepatic artery Middleton 96 Fig 4-11 G-I |
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List some causes of bile duct wall thickening
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sclerosing cholangitis
common bile duct stones pancreatitis ascending cholangitis AIDS cholangiopathy cholangiocarcinoma recurrent pyogenic cholangitis biliary stents intramural venous collaterals |
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What is the sonographic appearance of bile duct wall thickening?
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hypoechoic outer wall and hyperechoic inner wall
Middleton 98 Fig 4-13 |
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Does sclerosing cholangitis affect intrahepatic, extrahepatic, or both ducts?
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both
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What population is at risk for sclerosing cholangitis?
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young men with IBD, especially UC
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To what are people with sclerosing cholangitis predisposed?
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cholangiocarcinoma
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In someone with sclerosing cholangitis, what should make you suspicious of cholangiocarcinoma?
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duct wall thickening >5mm
disproportionately dilated intrahepatic ducts |
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Are prominent nodes in the region of the porta hepatis suggestive of metastatic disease in pts with otherwise uncomplicated sclerosing cholangitis?
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No, this is common in sclerosing cholangitis
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What are the 2 most common causes of AIDS cholangiopathy?
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CMV and cryptosporidium
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What are the 2 sonographic appearances of AIDS cholangitis?
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similar to sclerosing cholangitis
isolated papillary stenosis Middleton 98 Fig 4-13 and 4-14 |
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What is thought to be the etiology of a cystic bile duct lesion commonly seen in girls and young women?
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anomalous connection of the CBD and pancreatic duct, such that pancreatic secretions can reflux into the biliary tract
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What is the most common sonographic appearance of a cystic bile duct lesion?
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fusiform dilatation of the extrahepatic mid duct
Middleton 99 Fig 4-16 |
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What is the sonographic appearance of Caroli's disease?
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multifocal saccular dilatation of the intrahepatic bile ducts with sparing of the extrahepatic ducts
Middleton 100 Fig 4-17 |
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What are 2 common complications of Caroli's disease?
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complications of biliary stasis (ductal stones and obstruction, cholangitis, liver abscesses)
hepatic fibrosis with portal hypertension |
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What is "central dot sign"?
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In Caroli's disease, the dilated bile duct can surround the hepatic artery and portal vein
Middleton 100 Fig 4-17C-E |
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What is Mirizzi's syndrome?
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common bile duct obstruction caused by a gallstone in the cystic duct or the GB neck (either mass effect or inflammation reaction in the hepatoduodenal ligament)
Middleton 100 Fig 4-18 |
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With what is Caroli's disease associated?
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cystic disease of the kidney, especially medullary sponge disease (tubular ectasia)
hepatic fibrosis |
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What artery supplies the GB?
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Cystic artery, a branch of the right hepatic artery
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The CBD (extrahepatic) joins the ___ __ ___ (pancreatic duct) in the pancreas at the ___ __ ___, the opening into the duodenum
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Duct of Wirsung
ampulla of Vater |
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The cystic duct contains the spiral valves of ___
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spiral valves of Heister
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What is the composition of bile?
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water, bile salts, cholesterol, and bilirubin
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Is bile acidic or alkaline?
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alkaline, unlike the contents of the stomach
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When bile is needed, the duodenum releases ___, which causes the GB to contract
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cholecystokinin
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Why does bile flow both in fasting and nonfasting states after cholecystectomy?
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The Sphincter of Oddi loses tone
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What is the segment between the cystic duct and the junctional fold?
|
Hartmann's Pouch
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What are some causes of pneumobilia?
|
surgical anastamosis b/t bowel and biliary tree
sphincterotomy gallstone ileus |
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Wall thickness of the GB is measured on the anterior/posterior wall
|
anterior
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What causes an elevation of unconjugated bilirubin?
|
hepatocellular disease and hemolytic anemia
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What causes an elevation in conjugated bilirubin?
|
extrahepatic obstruction
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Elevated alkaline phosphatase is an early indication of ___ ___
|
biliary obstruction
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AST, ALT, and LDH levels increase in biliary ___
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biliary obstruction
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What are the clinical features of choledochal cysts?
|
intermittent jaundice
colicky RUQ pain RUQ palpable mass |
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What causes biliary atresia?
|
viral infection after birth
|
|
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What are the clinical features of biliary atresia?
|
jaundice
cirrhosis portal hypertension |
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Biliary atresia in infants is fatal unless what procedure is performed?
|
Kasai procedure - a segment of bowel is anastomosed to an exposed area of the liver
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What are some causes of hydrops of the GB?
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traumatic event (surgery, MI)
infection (Kawasaki's dz) biliary obstruction |
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Is the distal bile duct located at the porta hepatis or the head of the pancreas?
|
pancreas
|
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If biliary obstruction is limited to the right or left duct, what happens to LFTs? bilirubin level?
|
LFT's elevate, but bilirubin does not
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Bile ducts branch more/less, have more regular/irregular boarders, and have better/worse through transmission than portal veins
|
branch more
irregular borders better through transmisson |
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Bile duct diameter increases by ___mm per decade
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1mm per decade
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Is a Klatskin's tumor easy or difficult to visualize?
|
difficult
you will see dilation of intrahepatic ducts without dilation of the CBD |
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Klatskin's tumor has a poor/good prognosis
|
poor
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What is Courvoisier's sign
|
palpable GB and painless jaundice (caused by a mass in the head of the pancreas)
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What is the sonographic appearance of an ampulla of Vater tumor?
|
dilation of the CBD and pancreatic ducts without obvious stones or masses
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|
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What are 3 things that can compose GB polyps?
|
inflammatory tissue
adenomatous cholesterol |
|
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What is the most common tumor to metastasize to the GB?
|
malignant melanoma
|
|
|
What causes sludge?
|
stasis:
fasting hyperalimentation and TPN extrahepatic biliary obstruction hepatocellular disease |
|
|
What are some metabolic factors that cause gallstones?
|
obesity
DM pregnancy pancreatitis hypercholesteroliemia hyperlipidemia hemolytic anemia |
|
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What is a risk factor for emphysematous cholecystitis?
|
male
DM |
