1
Q
The Biliary System is Intimately associated
with the…
A
liver and pancreas
2
Q
Biliary System consists of…
A
- Gallbladder
- Inter and intrahepatic
bile ducts (outside &
3 inside the liver)
3
Q
Basic funtion of the Biliary System is…
A
- Transport bile through bile ducts to
gallbladder - Stores bile until needed for digestion
- Transport bile from GB through bile ducts to
the duodenum
4
Q
Why is U/S the modality of choice for the biliary system?
A
- Cystic nature of the GB and BD allows for high contrast resolution with surrounding tissue
- There is a good acoustic window
–> Liver - Can be seen in virtually all adult patients
5
Q
U/S is used most in Biliary system for
A
- Detection of gallstones
- Assessment RUQ pain
- Assess patients with jaundice
- Patients with increased LFT’s
6
Q
“Peripheral” refers to
A
- Refers to the ductules deep in the hepatic parenchyma
7
Q
“Proximal” refers to
A
- Describes the portion that is in relative proximity to the liver/hepatocytes
8
Q
“Central” refers to
A
- Refers to the ducts near to the porta hepatis
9
Q
“Distal” refers to
A
- Describes the caudal end, closer to the bowel
10
Q
The gallbladder is what kind of organ?
A
Intraperitoneal organ
11
Q
Gallbladder fossa
what is it?
location?
related to?
A
- Indentation of the posteroinferior portion of the right lobe
- Underside of segment V and IVB
- Related to main lobar fissure
12
Q
Characteristic of the gallbladder?
A
MOBILE
- Changes in location when patient changes position
- Reason to be imaged in at least 2 patient positions!
- Demonstrates whether contents are dependent or impacted
13
Q
Biliary Ducts are subdivided into…
A
intrahepatic and extrahepatic
ducts
14
Q
INTRAHEPATIC DUCTS
A
- completely or partially enclosed by liver tissue
- R and L hepatic ducts
15
Q
EXTRAHEPATIC DUCTS
examples?
A
- Common Hepatic Duct (CHD)
- Cystic Duct (CD)
- Common Bile Duct (CBD)
16
Q
RT AND LT INTRAHEPATIC DUCTS
course with….
join together to become…
A
- Course with the R and L portal veins, and hepatic arterial
branches.
–>Note: not in fixed relation to PV’s (can be anterior, posterior or tortuous about vein) - Join together to become the CHD
17
Q
COMMON HEPATIC DUCT (CHD)
formed by…
courses…
join with…
A
- Formed by R and L intrahepatic ducts, they join near the level of the porta hepatis.
- Courses inferiorly to GB neck
- Joins with cystic duct (CD) to form common bile duct (CBD)
18
Q
CYSTIC DUCT (CD)
connects…
directs flow of… from where to where?
joins with… to become…
variable junction location with the…
located….
A
- Connects GB to CHD
- Directs flow of bile from CHD into GB
- Joins with CHD to become CBD
- Variable junction location with the CHD
- Located posterinferior surface of the liver
19
Q
COMMON BILE DUCT (CBD)
origin?
courses?
anterior to…
right lateral to…
A
- Origin -> CHD and CD junction
- Courses caudally within hepatoduodenal ligament
- Anterior to MPV (sometimes posterior)
- Right lateral to HA
20
Q
CBD is joined by the _______; together they open through a small opening (__________) to the duodenum
A
CBD is joined by the pancreatic duct; together they open through
a small opening (ampulla of vater) to the duodenum
21
Q
the CBD passes posterior to…
with through or along the….
terminates as it enters the…
A
1st part of duodenum
Either through or along the posterolateral aspect of pancreas head
Terminates as it enters the posteromedial aspect of descending duodenum
22
Q
Ampulla of Vater
what is it?
_____ and ______ can join riot to entry to form a single duct
A
- Opening in the duodenum where the CBD and pancreatic duct (PD) enter
- CBD and PD can join prior to entry to form a single duct
23
Q
Sphincter of Oddi
what is it?
aids in?
A
- A muscle sheath surrounding the CBD at the ampulla of
Vater - Aids in the regulation of bile flow into the duodenum for
digestion
24
Q
Size of normal adult gallbladder
length?
width?
A
- Variable
- 7-10cm in length
- 3-5cm in width
25
Bile content of gallbladder if fasting vs non fasting
* Fasting: bile filled, easily visualized
* Non-fasting: partially bile filled GB, small GB or a bile free GB
26
In a normal adult gallbladder:
the walls are...
- measurment?
a contracted gallbladder has _____ walls
* Walls are thin
< 3mm in uniform thickness
* Contracted GB has thicker walls
* May obscure wall or luminal
abnormalities
27
size of cystic duct
measurement?
diameter approximately?
* Varies in length
- Average 4cm
* Diameter approx. 3mm AP
28
common hepatic duct lumen diameter?
average upper limit?
* Varies in length
* Luminal diameter varies:
* Average upper limit 4mm AP
29
common bile duct size?
determined by the...
* Varies in length
* Determined by the junction of the CD and CHD
* Range 8 -11.5cm
30
Average adult intraluminar diameter?
Average adult < 6mm AP and then tapers distally
31
what percent of gallbladder surface is covered by peritoneum?
the remaining is covered by?
what type?
50-70% surface covered by peritoneum
* Remaining covered by adventitial tissue that is continuous with the liver connective tissue
* Intraperitoneal
32
Gallbladder is composed of three layers
1. Mucosa
2. Muscularis Propria
3. Serosa
33
Mucosa gallbladder wall layer
composed of?
what does it do?
* Inner most layer
* Composed of columnar epithelium that secretes mucus and absorbs water
* Concentrates bile
34
Muscularis Propria gallbladder wall layer
what is it?
* Crisscrossing muscles
35
Serosa gallbladder wall layer
composed of?
* Outer most layer
* Composed of Rokitansky-Aschoff sinuses
36
Rokitansky-Aschoff sinuses
what is it?
how big is it?
* mucosal out-pouchings that go through the muscularis propria into the subserosal
tissue.
* Microscopic
37
38
Gallbladder blood supply is supplied by...
this is a branch of what?
courses?
branches into?
Cystic Artery (CA)
* Branch of Proper Hepatic A
* (Or less common: CHA of GDA)
* Courses posterior CHD and inferiorly
* Branches into superficial and deep
39
Venous drainage into the intrahepatic branches of...
Portal vein
40
41
Gallbladder is a ______ shaped organ
Divided into 3 major sections:
Pear shaped organ
1) Fundus
2) Body
3) Neck
42
Gallbladder fundus
what portion?
what type of surface?
typically extends beyond...
* Most anterior and often inferior round portion
* Peritoneal surface
* Typically extends beyond the liver
43
Gallbladder body
what section?
lies in the...
* Middle section
* Lies in the fossa on the undersurface of the liver
44
Gallbladder neck
what portion?
narrow section that is continuous with the ...
there may be a...
* Most superior portion
* Narrow section that is continuous with the cystic duct
* There may be an infundibulum called Hartman’s pouch
- Inferior out pouching of the neck
- Common location for gallstone impaction.
45
Hartman’s pouch
what is it?
inferior...
common location for...
infundibulum
* Inferior out pouching of the neck
* Common location for gallstone impaction.
46
INTRAHEPATIC DUCTS
surrounded by a...
Surrounded by a sheath of connective tissue
47
Cystic duct
what type?
includes what valves?
* Extrahepatic
* VALVES OF HEISTER
-->Mucosal folds
-->Prevent the collapse of the CD
48
VALVES OF HEISTER
in cystic duct
- mucosal folds
- prevents the collapse of the CD
49
Common bile duct
what type?
linked with?
* Extrahepatic
* Lined with connective tissue and smooth muscle fibers, that’s why it has an echogenic appearance.
50
Bile produced by liver transported to ______ via ______
Bile produced by liver transported to GI tract via biliary tree
51
Cholecystokinin – CCK
what is it?
stimulates?
causes _______ to relax
increases...
* Hormone released into the blood stream by duodenal mucosa when food is ingested
* Stimulates GB to contract
* Causes Sphincter of Oddi to relax
* Increases hepatic production of bile
52
Sphincter of Oddi
regulates...
prevents...
when closed, forces...
* Regulates passage of bile into duodenum
* Prevents reflux of gastric fluids into biliary tree
* When closed forces GB to fill with bile
53
Gallbladder size
in short axis?
in long axis?
wall thickness? measuring where?
* <5cm in short axis, <10cm in long axis
* Wall thickness: <3 mm – AP (outer to outer)
54
echogenecity of gallbladder is...
Ellipsoid anechoic structure with posterior
enhancement
55
echogenecity of lumen
Anechoic
56
echogenecity of walls
Smooth, uniform, hyperechoic
57
Thicker and irregular shaped walls will have what measurement
(>3mm AP)
58
Bile ducts are what kind of structures (in relation to blood flow)
Avascular
59
Common hepatic duct is anterior to...
Right portal vein
60
Common bile duct is anterior and right lateral to...
Anterior and right lateral to PV
61
CBD courses...
Courses superior to inferior
62
a short axis hepatic artery can be seen either ______ or ______ to CBD
A short axis HA can be seen either
anterior or posterior to CBD
63
64
What structures are identified as GB agenesis?
Biliary atresia
GB agenesis – not
developed
65
What structures are identified as GB duplication?
- Choledochal cyst
- Hartman’s pouch
- Junctional fold
- Phrygian cap
- Septated GB
66
Biliary Atresia
how serious?
* Life threatening
* Bile ducts have no normal opening
--> Bile backs up and destroys the liver
67
Choledochal cyst
Congenital, focal (one spot) or diffuse dilation of the biliary tree
68
Junctional fold
A fold in the GB, at the junction of the neck and body
69
Phrygian cap
The fundus is folded onto the body
70
Septated GB
2 or more intercommunicating compartments with a thin
septation
71
First part of GB is ____ and migrates to the _____
First is intrahepatic (enclosed in liver) and migrates to the
liver surface
72
what percent of GB is covered in peritoneum
50 to 70% covered in peritoneum – hanging off liver
73
Remainder of GB is covered with...
this space is a common area to see...
Remainder covered with adventitial tissue
* (this space common area to see edema)
74
Intrahepatic gallbladder or partially intrahepatic
occurs if...
may do what in lesser sac?
* If GB does not migrate (may pose problem for laparoscopic surgery)
VERY RARE
* May herniate in the lesser sac
75
In torsion the GB is fully enveloped in _______
hanging from...
increased...
* Gallbladder fully enveloped in visceral peritoneum
* Hanging from mesentery
* Increased mobility, higher risk for Torsion
76
ectopic positions of GB
Suprahepatic
suprarenal
within abdominal wall
in falciform ligament
Abdominal Sonography
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