Gi -- Bile Ducts And Gallbladder

Front 1

1. What is adenomyomatosis of the GB?
2. What are the imaging features of adenomyomatosis?
3. What study can help distinguish andenomyomatosis from GB carcinoma?

Back 1

1. Hyperplastic condition of GB wall in which small mucosal diverticula protrude into the GB wall. No malignant potential.
2. There are 3 morphologic patterns of GB adenomyomatosis:
- Diffuse, involving entire GB wall.
- Segmental, usually causing annular constriction in the body
- Focal (usually in fundus). Focal form can appear as a discrete mass, or “adenomyoma”.
- MR characteristics: GB wall thickening with intramural lesions that are hyperintense on T2, hypointense on T1, and non-enhancing.
- “Pearl necklace sign”: curvilinear arrangement of bright intramural cavities on T2 weighted imaging.
3. If cannot exclude malignancy, PET/CT may be useful.

Front 2

What are the cholangiographic features of PSC?

Back 2

1. Band strictures leading to a beaded appearance.
2. Nonuniform, segmental strictures 1-2 cm long.
3. Pruned tree appearance of intrahepatic ducts
4. Diverticular outpouchings
5. Mural irregularity

Front 3

1. What is the course of PSC?
2. Does PSC affect intrahepatic or extrahepatic ducts?
3. If there is a doninant stricture seen on cholangiogram, what should you consider?

Back 3

1. Progresses from cholangitis to cirrhosis.
2. Affects both intrahepatic and extrahepatic ducts. However, the extrahepatic duct may be normal in upto 20%.
3. Dominant stricture should raise concern for a complicating cholangioCA.

Front 4

1. What are the imaging features of AIDS cholangiopathy?
2. What common opportunistic infections are seen in AIDS pts?
3. AIDS pts are at increased risk for what two primary malignancies?

Back 4

1. AIDS cholangiopathy can be indistinguishable from PSC. However, the combination of PSC changes plus papillary stenosis is highly suspicious for AIDS cholangiopathy. Thought to be related to infection from either Cryptosporidium or CMV.
2. Candida, CMV, HSV, Cryptosporidum, Mycobacterial infections.
3. NHL and Kaposi sarcoma

Front 5

1. What are the imaging features of Oriental cholangiohepatitis?
2. What is a complication of bacterial cholangitis?

Back 5

1. Chronic infection leads to stricture formation resulting in intraductal pigmented stones and dilatation of intra and extrahepatic ducts. Chronic obstruction and infection leads to lobar atrophy.
2. Bacterial cholangitis can be complicated by biliary abscesses due to bile stasis or obstruction. The abscess cavitives communicate with bile ducts. NOTE: chronic cholangitis can result in bile duct stricture.

Front 6

1. What are the imaging features of PBC?
2. What is PBC associated with?
3. What serological marker is positive with PBC?

Back 6

1. PBC affects the small bile ducts, whereas PSC usually affects the larger bile ducts. Chronic disease results in cirrhosis. There are non-specific biliary changes -- crowding and deformity of bile ducts.
2. PBC is associated with other autoimmune diseases including RA, Sjogren syndrome, Hashimoto thyroiditis.
3. Antimitochondrial antibody.

Front 7

1. What entity can mimic choledocholithiasis?
2. What key finding can distinguish spasm of the sphincter of Oddi from choledocholithiasis?

Back 7

1. Spasm of the sphincter of Oddi can mimic choledocholithiasis. It occurs in the ampullary segment of the CBD. With relaxation of the sphincter (which can be assisted with the use of glucagon), the filling defect disappears.
2. Choledocholithiasis will have contrast outlining the superior and inferior aspect of the filling defect. Sphincter of Oddi spasm will only show that a superior meniscus is present.

Front 8

1. What is the cause of papillary stenosis?

Back 8

1. Inflammation or fibrosis usually from pancreatitis, choledocholithiasis, or surgical trauma can result in papillary stenosis. It can also be seen in pts with AIDS cholangiopathy.

Front 9

1. What is the most common cause of narrowing of the common hepatic duct?

Back 9

1. Hilar LAD

Front 10

What is the DDX of diffuse GB wall thickening?

Back 10

- Collapsed gallbladder
- Acute and chronic cholecystitis
- Hepatitis
- Hypoproteinemia = liver failure and renal disease
- Cirrhosis and portal HTN
- Pancreatitis
- Heart failure

Front 11

What is the DDX of the masses and filling defects in the GB?

Back 11

Gallstones
Tumefactive sludge
Cholesterol polyp
Adenomyomatosis
GB cancer
Mets

Front 12

What is the most common primary malignancy to metastasize to the GB?

Back 12

1. Melanoma (less common pancreatic and gastric). GB polyps in pts with h/o melanoma should be viewed with suspicion. However, mets from melanoma are usually present somewhere else.

Front 13

1. What are the two morphologic tumor types affecting the GB?
2. What are the imaging findings of the scirrhous type of GB cancer?
3. What are the imaging findings of the polypoid type of GB cancer?
4. What are the routes of spread of GB cancer?

Back 13

1. Scirrhous and polypoild
2. Scirrhous form infiltrates the liver from the GB.
3. Polypoid form grows into and eventually fills the gallbladder lumen.
4. Local tumor spread to the liver and porta hepatis (leading to biliary obstruction). Lymphatic spread to regional lymph nodes. Hemotogenous dissemination to the liver and other organs.

Front 14

1. What is adenomyomatosis?
2. What are the imaging findings of adenomyomatosis?
3. What are the most common locations of adenomyomatosis?
4. What does diffuse involvement mimic?

Back 14

1. Convoluted infoldings of the gallbladder mucosa into the gallbladder wall which is thickened 2/2 smooth muscle proliferation.
2. Wall thickening can be diffuse or segmental. Cholesterol crystals can precipitate within the Rokitansky Aschoff sinuses leading to comet tail artifact.
3. MC located in the fundus of the GB where it mimics a GB mass. Occasionally, it presents as annular thickening of the GB wall fundus with thick septation that causes near complete segmentation of the GB.
4. Diffuse involvement can be confused with acute or chronic cholecystitis.

Front 15

1. What are the complications of Caroli's disease?
2. What is Caroli's disease assoicated with in the kidney?

Back 15

Caroli disease implies multiple cystic dilations of bile ducts. Communication with bile ducts is a key feature distinguishing Caroli disease from other cystic masses, making MRCP or ERCP valuable additional diagnostic tests.

1. Stone formation, recurrent cholangitis, liver abscess, and HCC (100x the risk of developing HCC).
2. Renal tubular ectasia (medullary sponge kidney).

Front 16

Hyperechoic gallbladder wall

Back 16

- Porcelain GB
- Wall echo shadow complex of GB filled with stones.
- Emphysemaous cholecystitis

Front 17

Xanthogranulomatous cholecystitis

Back 17

Xanthogranulomatous cholecystitis is a rare form of chronic cholecystitis whose imaging appearance mimics gallbladder carcinoma. Irregular gallbladder wall thickening, infiltrative margins, and cholelithiasis are commonly seen with xanthogranulomatous cholecystitis.

Front 18

gallbladder carcinoma

Back 18

A soft tissue mass in the gallbladder and gallbladder fossa with invasion into the liver and biliary ductal dilatation is a highly concerning appearance for gallbladder carcinoma.

Front 19

Choledocholithiasis

Back 19

MRCP imaging must be interpreted with caution to distinguish choledocholithiasis from artifactual causes of hypointense filling defects (gas, clot, clip artifact, arterial pulsation artifact, etc.).

Front 20

1. What are the imaging findings of gallbladder cancer?
2. What inflammatory process of the gallbladder mimics cancer?

Back 20

GB carcinoma:
- Mass w/n the GB fossa with no identifiable GB
- Asymmetric or diffuse GB wall thickening.
- Invasion of the duodenum, colon, and liver
- Periportal, pancreaticoduodenal, hepatic, and celiac LAD
- Peritoneal carcinomatosis and hematogenous mets.
2. Xanthogranulomatous cholecystitis: chronic inflammatory condition of the GB with hypodense nodules or bands within the GB wall due to lipid laden macrophages. May see invasion into the liver, abdominal wall. LAD is less common.

Front 21

Ductal dilatation

Back 21

PRIMARY SCLEROSING CHOLANGITIS
- Classically = string of beads appearance.
- periportal fibrosis appears as areas of low SI on T1WI and high SI on T2WI.
ASCENDING CHOLANGITIS:
- bacterial infection of an obstructed biliary system.
- 2/2 choledocholithiasis and strictures from prior surgery.
AIDS CHOLANGIOPATHY
- 2/2 infection with CMV or cyptosporidiosis
- multiple intrahepatic biliary strictures, disal ampullary stenosis, and cholecystitis.
NEOPLASM:
- CholangioCA: may cause long segment strictures and prestenotic ductal dilatation with wall thickening.
- Mets can also cause ductal dilatation.
HEPATIC ARTERY STENOSIS/OCCLUSION IN A POST-TRANSPLANT LIVER: