Biliary System Flashcards

Question

Complications of Cholecystitis what is this?

Answer 1

* **Gangrenous cholecystitis** * rupture of GB * mortality 20% * Gangrene causes nerve death so that 65% of pts have a negative murphy sign. * Emphysematous cholecysitis * rare * 40% occur in diabetics * Empyema https://radiopaedia.org/cases/gangrenous-cholecystitis-3

Answer 2

* xanthogranulomatous cholecystitis * women begtween 60-70 * RUQ pain * vomiting leukocytosis * Postive Murphies * Gallstones * marked thickening of GB wall * Inflammatory changes in contiguous hepatic parenchyma * difficult to differentiation from adenocarcinoma * Complications * perforation * abscess formation * fistulous tracts to the duodenum or skin * extension of the inflammatory process to the liver, colon or surrounding soft tissues

Answer 3

* posterior shaddow. * very small stones may not shadow, reposition the patient to heap up calculi * Mobility of stones * gravity dependant movememnt * stones impacted in the neck or stones adherent to the wall will not move * Wall-echo-shaddow (WES triad, double arc sign) is seen if the GB is contracted (type II) and completely filled with stones * WES can also be seen with * porcelain GB * emphysematous cholecystitis * highly reflective echo originating from the anterior surface of the calculus

Answer 4

cholangiocarcinoma associations * Image = klatskin tumour * ASSCIATIONS * UC * Chlonorchis exposure in Asian population * Caroli Disease * Benzene and toluene exposure

Answer 5

* Based on the level of traumatic injury in relation to the confluence of the LHD and the RHD * type 1: Injury \>2cm distal to the confluence * type 2: injury \< 2cm distal to confluence * Type 3: Injury immediately distal to confluence but with intact confluence * Type 4: A destroyed confluence

Answer 6

* Gallstone obstruction 95% * Acalculous cholecystitis 5% * USS features * Luminal distension \> 4cm * Wall thickening \> 5mm edema, congestion * thickening is usually worse on the hepatic side * Gall stones * Cystic duct stones may be difficult to detect if they are not surrounded by bile * +ve murphy sign * pericholecystivc fluid

Answer 7

* Ducts within Papillar = ampulla * the CBD drains into the duodenum through the ampula * Y type * CBD and pancreatic duct combine before insertion into ampulla * 75% * V type * CBD and PD insert jointly into ampulla * 25% * U type * CBD and PD insert separately into ampulla * 5% * long common channel: * CBD and PD merge \> 1.5cm proximal to ampulla * increased risk of biliary tract ca.

Answer 8

* single * multiple 10% * 5-20mm * 60% a/w cholelithiasis * found in 0.5% of cholecystectomy patients (F \> M) * more common in * peutz-jeghers * familial adenomatous polyposis * Polys \>1cm require a careful search for features a/w malignancy * thickening or nodularity of the GB wall * evidence of hepatic invasion * indistinct margin between liver and GB * bilary duct dilatation * peripancreatic or hepatoduodenal ligament adenopathy * GB adenomas are usually smoothly marginated. * Intraluminal polyploid masse should raise concern for malignancy * homogeneously hyper echoic * Can be difficult to distinguish from non calcified gall stones. Pathology A wide variety of entities appear as polyps and histology is variable: * **benign polyps: 95% of all polyps** * cholesterol polyps: \>50% of all polyps 3,7,14 * adenoma: ~30%, possibly premalignant 4 * inflammatory polyps: ~10% 14 * other rare entities (see benign tumours and tumour-like lesions of the gallbladder) * **malignant polyps: 5% of all polyps** * adenocarcinoma: ~90% of malignant polyps * other rare entities including * metastases to gallbladder * squamous cell carcinoma * angiosarcoma * Case Discussion The management and follow-up of gallbladder polyps is controversial and practice varies between centres. However, due to the increased risk of malignancy, polyps measuring 10mm or greater should be considered for cholecystectomy 1. This patient underwent cholecystectomy and a gallbladder adenoma with low-grade dysplasia was confirmed by histopathology.

Answer 9

* Intraluminal soft tissue density * polypoid * fungating * asymmetrically thickened GB wall * Usually no bilary dilatation * Cholelithiasis * Direct invasion of liver * direct extension 50% * distant liver mets 5% * Gastrohepatic and hepatoduodenal ligaments * ligamentous extension 75% * direct invasion into duodenum 50% * LN mets 70% * LN's * Foramen of winslow node * superior and posterior pancreaticoduodenal nodes * hepatic and celiac nodes * peritoneal spread * carcinomatosis 50% * intestinal obstruction

Answer 10

* 10-20% of pop have gallstones * 30% are calcified * 30-50% are asymptomatic

Answer 11

Mirizzi syndrome is a rare complication of gallstone disease in which a gallstone becomes impacted in the cystic duct or neck of the gallbladder causing compression of the common bile duct (CBD) or common hepatic duct, resulting in proximal obstruction. The patient may present initially with colicky epigastric pain or manifest with hyperbilirubinaemia (jaundice). The obstructive jaundice can be caused by direct extrinsic compression of CHD/CBD by the stone or from fibrosis of the same caused by chronic inflammation. A cholecystocholedochal fistula can occur as a further complication to this condition if left untreated.

Answer 12

* Dilated intrahepatic ducts with normal extra hepatic ducts * hilar lesions * central obstruction * lesions are usually infiltrative so that a mass is not usually apparent * encasement of PVs causes irregular enhancement by CT * Peripheral lesions * may present as a focal mass or be diffusely infiltrative * retain contrast material on delayed scans * occasionally invade veins * ERCP patterns * short annular constricting lesion 70% * long stricture 10% * intraluminal polyploid mass 5%

Answer 13

* if there is no cholelithiasis, the catheter is usually left for 3 weeks. * at this point, the catheter is clamped to make sure that there is adequate internal drainage. * if the patient tolerates clamping the catheter can be removed, * if there is cholecystitis, the catheter is left in place until the patient is stable and can undergo a surgical cholecystectomy * Unlike pts with acalulous cholecystitis, pts with cholelithiasis have an irritant in the GB and thus a reason for inflammation to recur.

Answer 14

**Bilomas** refer to extrabiliary collections of bile. They can be either intra- or extrahepatic. Terminology There is a slight discrepancy in the reported literature in the use of the term "biloma". Many authors have used it exclusively to refer to intrahepatic bile collections or other bilious collections which are discretely organised rather than free biliary leak into the peritoneum (choleperitoneum: a rarely used term). Clinical presentation Although usually asymptomatic, they may present with symptomatic bile peritonitis 7. Pathology They can result from a number of causes: spontaneous trauma postinstrumentation transcatheter arterial chemoembolisation (TACE) percutaneous ethanol injection microwave ablation percutaneous biliary drainage post surgical, e.g. injury to duct of Luschka following cholecystectomy 6 Seventy percent of bilomas are localised to the right upper quadrant, whereas the remaining 30% develop in the left upper quadrant. A biloma may wall off or may continue to demonstrate active bile leakage.

Answer 15

AKA bile duct hamartoma/adenoma Von Meyenburg complex * Can simulate metastases or microabscesses * therefore histo dx is needed. * Multiple bile duct hamartomas may simulate mets or hepatic abscesses * small well-defined hypoattenuating or isoattenuating mass * little if any hancement * MRI: * usually hypo on T1 and * iso or hyper on T2 * No enhancement post Gd * USS * hypoechoic lesions contained central echogenic focus with ring down artifact as a result of cholesterol crystals

Answer 16

Primary sclerosing cholangitis RFs: UC

Answer 17

* Iatrogenic cholangitis after intraarterial chemotherapy * ischaemic cholangiopathy * floxuridine has been used * strictures of CHD, frequently involving the biliary bifurcation * sparing of the distal CBD (disease Hallmark)

Answer 18

* Choledocholithiasis * stone in the CBD * Typically a/w high grade obstection and jaundice * 75% diagnostic accuracy

Answer 19

1. non invasive 2. cheaper 3. no radiation 4. no anesthesia 5. less operator dependant 6. allows better visualisation of the ducts proximal to obstruction 7. allows for observation of extraductal disease

Answer 20

1. Scan liver with USS and choose appropriate entry site 2. Go through the liver to minimize the occurrence of a bile leak 3. Anesthetise skin 4. Place 22-gauge need into GB under US guidance 5. Place catheter in GB in Tandem. 6. Visualize catheter tip by the US before deploying catheter 7. Aspirate bile for culture. 8. Connect the catheter to the collecting bag

Answer 21

Bouveret syndrome is a gastric outlet obstruction produced by a gallstone impacted in the distal stomach or proximal duodenum. It was described by Leon Bouveret in 1896 (,1) and occurs most commonly in elderly women with a mean age of 68.6 years (,2).

Answer 22

**cholangiocarcinoma** Risk factors: PSC UC Liver parasites choledochal cysts

Answer 23

* Pseudofilling defects * pseudodilatations * nonvisualisation of the ducts * Filling defects are usually due to stones (dependant) * air (non-dependant\_ * tumours hemorrhage (dependant) or * sludge (dependant) * Infrequent causes of filing defects include * susceptibility artifact from adjacent clips, * metallic bile duct stents, * folds, or * flow voids (central

Answer 24

* Normal * low union * parallel course * anterior spiral course * posterior spiral course

Answer 25

Peribiliary Cysts * Peribiliary cysts occur in the setting of chronic liver disease where it is a rare, benign, and often asymptomatic disorder. They consist of cystic formations around the intrahepatic biliary ducts, primarily in a hilar distribution. Unlike choledochal cysts (for example in Caroli disease), peribiliary cysts do not communicate with the biliary tree. * Related to the peribiliary glands. **_Differential diagnosis_** Imaging differential considerations include: * **von Meyenburg complexes:** although in this setting biliary hamartomas are more diffuse throughout the liver rather than hilar in distribution and would be more space out * **Caroli disease:** a congenital disorder involving multifocal intrahepatic choledochal cysts of the segmental intrahepatic bile ducts

Answer 26

* Unexplained fever * suspected cholecytitis * rationale for catheter placement is to decompress an inflamed GB. * GB must be distended

Answer 27

* Choledochal cysts * cystic dilatation of the CBD * type I fusiform * Type II saccular/diverticulum * lined with duodenal mucosa * Tupically occur in children and young adults * most common in Japan/asia * 20 fold increased risk of bile duct malignancy they are usually excised. * Clinical triad * jaundice * abdopain (infection of bile) * Palapble mass.

Answer 28

* Indication: Biliary obstruction * steps after transhepatic cholangiogram: 1. after cannulation of the bile duct, advance a nitinol guidewire (or the guide wire that comes with the one-stick access set) through the needle into the biliary system. 2. Obtain as much purchase as possible. 3. Remove needle 4. Pass plastic catheter over guidewire. 5. exchange guide wire for a 0.038 metal wire or Terumo, pass guidewire indo duodenum 6. Dilate skin tract up to 12 Fr 7. Place drainge catheter over guide wire (Cope, Ring catheters) 8. Perform catheter injection with contrast material to adjust placement of side holes.

Answer 29

Cholesterolosis Strawberry GB * Triglucerides and cholesterol are deponsitied in macrophages of the GB wall. * The cholesterol nodues stud the wall and give the GB the appearance of a strawberry * lipd deposits are echogenic and \<1mm * no shadowing * inflammation is not a prominent feature * a/w multiple 0.5-1mm polyps * https://www.ultrasoundcases.info/unusual-cases-3748/

Answer 30

* Sludge is echogenic bile * layering of particulate material within bile * calcium bilirubinate * cholesteral crystals * no posterior shaddowing * Causes * fasting (bc of decreased cholecystokinin CCK) * 10 days 30% of pts have sludge * 6 weeks 100% of pts * Hyper alimentation (decreased CCK) * Infection * obstruction * Stasis of GB Cholecystokinin (CCK or CCK-PZ; from Greek chole, "bile"; cysto, "sac"; kinin, "move"; hence, move the bile-sac (gallbladder)) is a peptide hormone of the gastrointestinal system responsible for stimulating the digestion of fat and protein. Cholecystokinin, officially called pancreozymin, is synthesized and secreted by enteroendocrine cells in the duodenum, the first segment of the small intestine. Its presence causes the release of digestive enzymes and bile from the pancreas and gallbladder, respectively, and also acts as a hunger suppressant.[5][6]

Answer 31

* Contrast agent injection is performed thought the endoscope after cannulation of papilla of CBD * Complications * pancreatitis 5% * duodenal perforation * GI bleed

Answer 32

* Sphincter of Oddi spasm * Treated with papillotomy * Causes * cholecystectomy * stones * trauma * AIDS cholangiopathy

Answer 33

* Demonstration of biliary anatomy. * the first step before biliary drainage or stent placement. * PROCEDURE * RIGHT HEPATIC LOBE * Antibiotic coverage is routine * use a lateral midaxillary approach, advance one-stick system into the liver * attach extension tubing and syringe filled with contrast * slowly inject contrast while retracting the needly under fluoroscopy * repeat until opacification of bile ducts * LEFT HEPATIC LOBE * Antibiotic coverage is routine * use a midline approach, advance one stick system into a biliary radical under US guidance. * attach extension tubing and syringe filled with contrast * slowly inject contrast during fluoroscopy to confirm the biliary placement of the needle * Ensure the syringe is air-free in order to not obscure the view for future attempts.

Answer 34

The concentration of intravesicular calcium salts in longstanding cystic duct obstruction. Radiographically, GB contents appear dense

Answer 35

* Multiple cystic structures converging toward porta hepatis * beaded appearance of intrahepatic bile ducts * most of the cysts arranged in a branching pattern * central dot sign * very specific sign of Caroli disease in which portal radicals are partially or completely surrounded by abnormally dilated and ectatic bile ducts on both sonography and CT * Sludge, calculi in dilated ducts

Answer 36

* Biliary stones

Answer 37

1. Cholangio ca 10% 2. Biliary cirrhosis 3. Portal hypertension

Answer 38

1. cholesterol stones are caused by preciptiation of supersaturated bile (western pop) 2. pigment stones are the precipitate of calcium bilirubinate (asian pop) 3. Mixed stones are the most common.

Answer 39

* Medullary sponge kidney 80% * Infantile polycystic kidney disease

Answer 40

* benign group of disease * accumulation of cholesterol and fats in the GB * Two forms * adenomyomatosis * cholesterolosis * no neoplastic potential * uncertain clinical significance * Commonly seen in cholecystectomy specimen * less commonly identified by US or cholecystogram Gallbladder cholecystoses are conditions characterised by the accumulation of cholesterol (and other fats) in the gallbladder. There are two main forms: adenomyomatosis: mucosal hyperplasia with growth toward the muscular layer - thickened muscular layer. Cholesterol accumulation is intraluminal (within the Rokitansky-Aschoff sinuses), therefore, lined by mucosal epithelium 2,3 cholesterolosis: mucosal hyperplasia with the accumulation of cholesterol esters and triglycerides in the macrophages of the lamina propria - appearance is known as “strawberry gallbladder" 2,3

Answer 41

* decreased spatial res, making MRCP less sensitive to abnormalites of the peripheral intrahepatic ducts (eg Sclerosing cholangitis) and pancreatic ductal side branches (chronic pancreatitis) * imaging in the physiologic, nondistened state which decreased the sensitive to detect subtle ductal anomalies * Cant perform therapeutic endoscopic or percut intervention for obstructing bile duct lesions. * therefore in pts with high clinical suspicion of CBD obstruction, ERCP should be the initial imaging modality to provide timely intervention * eg sphincterotomy * dilation * stent placement * stone removal

Answer 42

* Obesity * hemolytic anemia (pigment stones) * Abnormal enterohepatic circulation of bile salts (CD, SB resection) * Diabetes * Cirrhosis * Hyperparathyroidism

Answer 43

* Phrygian cap * junctional fold * fold between infundibulum and body. May be hyperechoic and cause posterior shaddowing * Agenesis of the GB Rare * more common causes of nonvisualised GB * previous cholecystectomy * non fasting * chronic cholecystitis

Answer 44

* Chronic cholecystitis with erosion of a gall stone into the GIT 90% * Penetration of a posterior duodenal ulcer into the CHD 5% * Tumour * Trauma

Answer 45

* 20% * GB wall thickening * cholelithiasis * Sludge * Biliary dilatation * Lymphadenopathy * Asctits * GB wall thickening is relatively common and may be marked. Cause unknown. Only symptomatic patients should be treated for acalculous cholecystitis which may be due to Cryptosporidium +/- CMV

Answer 46

* normal in 60% * Right posterior ducts drain directly into LHD 20% * RIght posterior duct right anterior duct and LHD form the CHD 10%

Answer 47

* Percutaneous cholecystostomy is often performed for acalculous cholecystitis in ICU patients with unexplained sepsis. * In these patients USS findings are not helpful in making the dx of acute cholecystitis and a trial of cholecystostomy is often warranted * clinical response is typically seen in 60% of pts

Answer 48

* Trauma * Burns * Prolonged fasting * hyperalimentation * diabetes * AIDS * COlitis * hepatic arterial chemo * post partum * vascular insufficiency overview Acalculous cholecystitis is defined as cholecystitis that occurs without a gallstone. This typically occurs in critically ill patients due to a combination of factors (e.g. bile stasis and hypoperfusion). Acalculous cholecystitis often goes unrecognized initially, because of intubation and sedation. This can lead to a high rate of progression to gallbladder necrosis (50%) and perforation (10%). The term “necrotizing cholecystitis” has been proposed for this disease, to emphasize its potentially malignant course. pathogenesis Pathogenesis may be summarized roughly as follows. In some ways, this may be conceptualized as a paralytic ileus of the gallbladder. (1) Lack of enteral nutrition and hypoperfusion create a hypotonic, dilated gallbladder. Distension of the gallbladder increases wall tension, further impairing perfusion of the gallbladder wall. Biliary stasis causes concentration of biliary detergents, which may damage the gallbladder wall. (2) Further complications ensue: Necrosis and perforation of the gallbladder may occur. Superinfection with enteric bacteria may occur (empyema of the gallbladder). Note that many cases of acalculous cholecystitis occur without bacterial infection. https://emcrit.org/ibcc/acalculous-cholecystitis/

Answer 49

* GB wall thickening * fibrosis * chronic inflammation * Rokitansky-Aschoff sinuses (intramural epithelial crypts) * Gallstones * Failure of GB to contract in response to CCK * Porcelain GB: * wall calcifications * increased risk of GB carcinoma * Thickened gallbladder wall. Streaky echogenic lines from the anterior GB wall in keeping with comet-tail artifact. No gallstones. Case Discussion The comet-tail artifact is a type of ultrasound reverberation artifact caused by cholesterol crystals being trapped within Rokitansky-Aschoff sinuses in gallbladder adenomyomatosis.

Answer 50

* Biliary stent placement * Indication: * malignant biliary stricture * inability to place an endoscopic stent * Steps post catheterization and decompression 1. Inject existing catheter to determine exact site of stricture 2. choose appropriate stent lengths * 42mm, 64mm, 94mm 3. place ultra-stiff guide wire 4. remove indwelling catheter 5. place 8 Fr peel away sheath 6. Deploy expandable stent (eg wall stent, 10mm diameter) 7. Inject to confirm the location 8. leave safety catheter in. 9. Remove guidewire.

Answer 51

* * acute cholangitis * Infection of obstructed bile ducts * Ecoli \> klebsiella \> pseudomonas * Causes * choledocholithiasis * stricture * Sclerosing cholangitis * Infected drainage Catheter * Ampullary Carcinoma * Imaging features * Dialtation of intrahepatic ducts * dialted CBD * pigment stones and sludge in intrahepatic bile ducts * pathognomonic * Segmental hepatic atrophy * Liver abscess, pancreatitis Figure 2 BAC in a patient with CBD stones. Coronal image from contrast material–enhanced multidetector computed tomography (CT) shows pus (arrowhead) layering within one of several dilated intrahepatic ducts (arrows). Intra-ductal sludge could have the same appearance. The patient underwent biliary drainage; abundant pus was aspirated. https://pubs.rsna.org/doi/10.1148/rg.297095051

Biliary System Flashcards

(76 cards)