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Biliary/Lymph/Spleen Exam
GB Lymph and Spleen Review with Ultrasound Images
120
Anatomy
Undergraduate 2
11/17/2015

Additional Anatomy Flashcards

 


 

Cards

Term
[image]
Definition

Septated Gallbladder:

Multiple septations and honeycomb appearance

Term
[image]
Definition

junctional fold:

a fold in the GB located between the body and neck

Term
[image]
Definition

Hartman's pouch:

a bulbous region of the neck of the GB where stones can get lodged

Term
GB agenesis
Definition
This type of congenital anomaly is asymptomatic or has GB disease symptoms
Term
Hypoplasia
Definition
Incomplete development of the gallbladder/biliary tract; Associated with cystic fibrosis
Term
double gallbladder
Definition
Rare; Two separate lumens and two separate cystic ducts uniting into CBD
OR two cystic ducts opening separately into the biliary tract
Term
floating gallbladder (wandering)
Definition
Attached to its surrounding structures by the cystic duct & mesentery
At risk for torsion/necrosis
Term
ectopic GB (Intrahepatic GB) (Intraperitoneal)
Definition
GB lies w/in the liver parenchyma; may cause gallstones because of bile stasis

US: cystic structure seen in liver
Must contract after fatty meal to determine if it is indeed GB
Term
[image]
Definition

Phrygian Cap

a fold in the GB located at the fundal aspect

Term

 

Cholelithiasis

Definition
Incidence: 10-20% of adults get stones Increases with age 4 F’s = female, fair, 40 and fat (some sources say fertile) Size/Number: Fine gravel to 3-4cm Largest stone on record: 13 lb 4oz 1 to hundreds Most stones are denser than the bile Less dense stones will float
Term
Gallstones are composed of one or more of the following components:
Definition
Cholesterol
Calcium bilirubinate
Calcium carbonate
Term
Stone composition incidence
Definition
Mixed stones (90%)
80% of mixed stones are predominately cholesterol stones

Pure stones (10%)
Cholesterol stones
Calcium bilirubinate
Calcium carbonate (rare)
Term
Cause of gallstones
Definition
- Abnormal bile composition (most common)
- Bile Stasis: the sluggish movement of bile in the ducts
- Conditions assoc. w/biliary stasis:
GB dysfunction (poor contraction)
Sphincter dysfunction (spasm)
Hormonal changes (pregnancy)
-Infection (may form debris in the bile ducts)
Term
Risk Factors for Developing Gallstones
Definition
Obesity, Diabetes, Pregnancy, Pancreatitis, Alcoholic cirrhosis
Term
symptoms of gallstones
Definition
- most patients are asx
- most asx patients will develop cholecystitis
- Tenderness on exam
Term
Mirizzi Syndrome
Definition
An impacted gallstone in the cystic duct, or GB neck that can cause obstruction of the CHD by compression or inflammation around the stone

Clinical Signs: RUQ pain, Jaundice
Term
Mirizzi Syndrome US
Definition
-TWO parallel tubular structures which represent the bile duct above the level of the cystic duct and portal vein; Doppler is used to differentiate between the vascular and biliary structures
-Dilatation of the CHD & intrahepatic ducts above the level of the gallstone impacted in the cystic duct w/normal CBD below the stone
Term
gallstone US appearance
Definition
-curved surface of stone is hyperechoic
-acoustic shadow posterior
-large stones easily shadow, where small stones may not shadow
Term
Most stones are _______ ___________.
As you roll the pt, the stones will move easily.
Definition
gravity dependent
Term
What is an issue with tiny gallstones?
Definition
Numerous tiny stones may layer evenly along the posterior GB wall; may mimic GB wall; tiny stones can easily be missed
Term
floating stone
Definition
seen due to an increase in the viscosity of the bile from prolonged fasting or from air in the stone
Term
GB Sludge
Definition
Echogenic concentrated bile within the GB associated with bile stasis
Symptoms:
-RUQ pain
-Asymptomatic
Sludge may be a sign of biliary tract disease:
gallstones
cholecystitis
GB obstruction
extrahepatic biliary obstruction
Term
GB Sludge US Appearance
Definition
TYPICAL Findings:
-low level echoes
-no shadowing
-may be present w/stones
-gravity dependent
Term
What are some atypical US sludge findings?
Definition
Tumefactive Sludge:
tumor-like, does not layer or move

Sludge Balls: Round balls of sludge, mobile, non shadowing

Hepatization: Sludge completely fills the GB so that the GB and its contents become isoechoic to the liver
Term
Cholecystitis
Definition
inflammation of the GB
Term
What are the two types of acute cholecystitis?
Definition
Acute Calculous Cholecystitis
-stone is causing acute inflammation of GB; more common in females than males
Acute Acalculous Cholecystitis
- inflammation isn’t caused by a stone
Term
[image]
Definition

gallbladder WES sign

Also Called: Double Arc Sign -Purpose: Identify stones when no bile is present WES Sign Pattern: Best seen on TRANS image W: Gallbladder Wall E: Echogenic Stone S: Acoustic Shadow

Term
What are some symptoms of Acute Calculous Cholecystitis?
Definition
Nausea (90%), Vomiting, Fever, Acute onset of RUQ pain & tenderness, radiates to shoulder (irritates diaphragm), + Murphy’s sign (pain in RUQ w/deep palpation during inspiration- pressing on tender GB), postprandial pain (fatty food) 90%, Bowel gas (flatulence, abdominal distention), Jaundice (CBD obstruction)
Term
What is the ultrasound appearance of Acute Calculous Cholecystitis?
Definition
- + Murphy’s sign
- stones in CD or GB neck
- GB diameter greater or equal to 5cm in a fasting patient
-thickened GB wall with edema, hypoechoic & striated (Halo sign),greater than or equal to 3mm in a fasting patient
Term
Acute Acalculous Cholecystitis
Definition
Etiology:
Occurs in 10% of acute cholecystitis patients
Caused by stasis or vascular changes in GB
Stasis/obstruction + infection
Poor circulation/clotting w/in wall of GB

More commonly found in children and immunocompromised patients
Term
Risk factors of Acute Acalculous Cholecystitis
Definition
Recent surgery
Starvation
Prolonged fasting
CHF
Diabetes
Lymphadenopathy
Term
[image]
Definition

Accute Acalculous Cholecystitis

Same as ACC without stone in neck

May See GB Hydrops: AP Diameter of GB greater than 4 cm

Term
HIDA Scan
Definition

(Hepatobiliary iminodiacetic Acid Scan) Nuclear Medicine Dept.

-Tracks flow of bile from liver to small intestine

-Evaluates GB

-Can measure the rate at which bile is released from the GB

-Helps to diagnose: Bile duct obstruction, Bile leakage, Congenital abnormalities of bile duct, Cholecystitis, Gallstones

Term
Chronic Cholecystitis
Definition

-Repeated/Intermittent obstruction of the cystic duct by gallstones/Repeated acute attacks

-These attacks cause inflammatory changes, wall thickening and fibrosis

-Occurs predominantly in patients who are female, fair, fat & forty (4 F’s)

Term
Most common form of symptomatic GB disease
Definition
Chronic Cholecystitis
Term
Symptoms of Chronic Cholecystitis
Definition
Symptoms: Same as acute cholecystitis patients but less severe Multiple episodes of RUQ, Epi pain Nausea/Vomiting Intolerance to fatty/fried foods Flatulence + Murphy’s sign Jaundice (if CBD is obstructed)
Term
[image]
Definition

Chronic Cholecystitis

- + Murphy’s sign

- stones

- + WES sign

- may contain debris/sludge

- GB may be contracted, normal or enlarged

- Pericholecystic fluid is less common

- GB wall thick measuring greater than 3mm in a fasting pt, hypoechoic w/cystic changes, fibrotic (uniformly echogenic), wall calcifications

Term

What is the difference between Cholelithiasis and Cholecystitis on Ultrasound? Can a patient have both conditions at the same time?

 

Definition
The major difference between Cholelithiasis and Cholecystitis is that Cholecystitis presents with a positive Murphy sign. On ultrasound, the cholecystitis generally presents with a stone in the gallbladder neck or cystic duct.Cholelithiasis could present anywhere in the lumen. A patient can have both conditions at the same time.
Term

What are the 4 F’s when talking about people who are at risk for GB disease?

Definition

female

forty

fertile

fat

Term
A GB wall will measure ___ in a patient with Cholecystitis.
Definition
≥3mm
Term
accessory spleen
Definition
also called supernumerary spleen or speniculi; solitary or multiple round islands of splenic tissue typically located at the hilum (may occur anywhere in the abdomen)
Term
[image]
Definition

accessory spleen US:

small rounded masses (<5cm) located near the splenic hilum

Term
ectopic spleen
Definition
aka wandering spleen; abnormally positioned spleen caused by failure of fusion of the dorsal mesentery with the posterior peritoneum, may undergo torsion causing acute abdominal pain, use color Doppler for evidence of torsion
Term
Asplenia/Polysplenia Syndrome
Definition
Congenital abnormality resulting in an abnormal arrangement of organ:
*situs solitus: normal design
*situs inversus: mirror image, organs reversed
*situs ambiguous: between the extremes
Term
Asplenia / polysplenia syndromes are forms of situs __________.
Definition
ambiguous
Term
Asplenia
Definition
Bilateral right-sidedness
-absence of normal spleen function
-absent spleen
-two right lungs
-midline location of liver
-reversed position of aorta & IVC
-horseshoe kidney
Term
Polysplenia
Definition
Bilateral left-sideness:
-multiple small accessory spleens
-two left lungs
-left sideness azygos continuation of an interupted IVC (hepatic portion absent-hepatic veins drain directly into RA
-Biliary atresia
-absent GB
-cardiovascular abnormalities
-multiple spleens
Term
Normal Spleen Measurements
Definition
Length = < 12 cm
Width = <8 cm
Thickness = < 4 cm
Term
Causes of Splenomegaly
Definition
~mild/moderate: Portal hypertension, Infection, Aids, Trauma
~moderate: Hemolytic disorders, mono, leukemia, lymphoma, mets
~massive/severe: Myelofibrosis (bone marrow disease)
Term
What is the body's response to infection?
Definition
Granuloma - the body is unable to kill the infecting agent, fibrotic tissue develops around the organism, fibrotic tissue eventually becomes calcified
Term
What are the most common causes of a granulomatous response to infection?
Definition
Histoplasmosis Tuberculosis / Sarcoidosis
Term
How does a granulomatous response appear on US?
Definition
numerous tiny echogenic foci, with or w/out shadowing
Term
How would the spleen react to other infections?
Definition
Mono: splenomegaly
Schistosomiasis: splenomegaly, focal hypoechoic masses
Candidiasis: focal hypoechoic masses, wheel w/in a wheel, bull’s eye or target sign
Hydatid Disease: cysts w/in spleen (possibly calcified walls),cluster of calcifications
Splenic Abscess: complex mass
Term
What are some possible splenic cysts?
Definition
Epidermoid Cyst, Infectious Cyst, Post-Trauma Cyst, Pancreatic Pseudocyst, Hydatid cyst (worm, need splenectomy)
Term
What is the most common benign neoplasm of the spleen?
Definition
Hemangioma
Term
Lymphangiomas
Definition
lymph filled cystic masses; rare; hypoechoic masses w/septations and/or internal debris; no color flow to mass
Term
Metastatic Tumors of the Spleen
Definition
most spread from malignant melanomas, lymphoma, leukemia

Hodgkins & non Hodgkins lymphoma usually begins in the lymph nodes & spread to the spleen

occurs in late stages of disease
Term
What is it called when there is a loss of blood supply to a portion of the spleen?
Definition
splenic infarction - hypoechoic, wedge-shaped mass in the periphery of the spleen
Term
Intraparenchymal Hematoma
Definition
-injury is confined to the spleen
-hemorrhage occurs w/in the splenic parenchyma
-capsule remains intact
Term
Splenic Trauma
Definition
-timing is important to consider after trauma
-immediately after trauma, hematoma is liquid & easy to identify
-24-48 hrs after trauma- blood clots & can be same echogenicity of the spleen
-then it liquifies again & is easier to see
Term
Intraparenchymal Hematoma US Appearance
Definition
-splenomegaly
-normal, inhomogeneous, hypoechoic areas w/in parenchyma
-capsule not seen
-unrepaired intraparenchymal hemorrhage will resolve into a cyst
-the walls of the cyst may become calcified
Term
Subcapsular Hematoma of Spleen
Definition
-injury is confined to the spleen
-hemorrhage occurs beneath the capsule along the periphery of the spleen
-capsule remains intact

Ultrasound appearance:
-crescent-shaped mass
-anechoic to echogenic (depending on age of hematoma)
-capsule not seen
Term
Perisplenic Hematoma
Definition
-injury to spleen & splenic capsule
-splenic hemorrhage escapes through the capsule into the peritoneal cavity
-blood and clots outside the capsule
-perisplenic and subcapsular hemorrhage can occur simultaneously
-free blood and clot may occur anywhere w/in the peritoneal cavity (subdiaphragmatic, colic gutters, cul de sac)
Term
condition in which portions of or the entire GB wall has calcified
Definition
Porcelain Gallbladder - rare,more common in females & older patients, have stones 95% of the time, assoc. with potential development of GB carcinoma

US: May look like stone filled GB but lacks WES sign
Term
the clinical detection of an Enlarged/Palpable GB that is caused by a Pancreatic Head Mass (patients present with painless jaundice)
Definition
Courvoisier Gallbladder
Term
Gallbladder Hydrops (Cholecystomegaly)
Definition
a GB distention w/out wall thickening
GB Should not exceed 4 cm in width (transverse diameter)
GB should not exceed 12 cm in length (some texts say 10cm)
Term
[image]
Definition

GB Hydrops

US Appearance:

-marked distended GB (trans or AP diameter greater than 4cm)

- thin walls

-evaluate for Mirizzi’s syndrome

Term
Hemorrhagic Cholecystitis
Definition
Inflammation/infection can disrupt the blood supply to a portion of or to the entire GB wall Reduced blood supply (ischemia) may lead to a total loss of blood to the area (infarction) If blood supply is lost, vessels may rupture Hemorrhage may form in the GB wall and/or in the lumen
Term
[image]
Definition

Gangrenous cholecystitis:

A condition where inflammatory changes in the GB have resulted in an infarction, necrosis, & putrification (decaying) of GB tissue

 

+ Murphy’s sign is usually absent because the nerves to the GB wall have been destroyed

Term
[image]
Definition

Adenomyomatosis:

Diverticula within the wall of the Gallbladder (Formation of gland like tissue and exaggerated out pouching of the mucosa)


asx, common in women

 

Termed Rokitansky-Ascholff Sinuses (RAS)

Term
Emphysematous Cholecystitis
Definition
Acute Infection of the GB wall Due to vascular compromise, bacteria produces gas within the wall of the GB Stones are usually absent Progressive, possibly fatal Symptoms: fever, increased WBC, tenderness
Term
GB Fistula
Definition
Large gallstone may be lodged in one portion of the GB Over time, the stone erodes into the GB wall (called decubitus ulcer) Erosion may penetrate through the wall & adjacent intestine creating a hole between the GB & the intestine (hole is called GB fistula) GB collapses Stone may pass through the fistula into the intestine (may be w/out incidence)
Term
Other than cholecystitis, what might cause a thickened GB wall?
Definition
Contracted normal GB Hepatitis/Cirrhosis CHF Renal Disease AIDS Pancreatitis GB tumors Sepsis
Term
[image]
Definition

Cholesterosis:

Accumulation of triglycerides/cholesterol crystals in GB wall due to disturbance in cholesterol metabolism

W>M; May or may not effect GB function

 

Forms:

Diffuse: Called “Strawberry GB”

Localized: Cholesterol Deposits form polyps

-Projecting in GB lumen

-2-10 mm in Size

*Cholesterol Polyp is most common polyp

 

Term
Polyps
Definition
Papillary Adenomas:
Overgrowth of the epithelial lining
Symptoms: Asx
Size: measure <1 cm
US:Only polypoid adenomas are seen
- Usually single/fundal area
-isoechoic to GB wall
-no shadowing
-not gravity dependent
Term
What is the most common benign GB tumor?
Definition
Adenoma
Term
Most common GB cancer
Definition
ADENOCARCINOMA
represents 98% of neoplasms
Term
[image]
Definition

Adenocarcinoma:

Rock-hard mass in RUQ

Focal or diffuse wall thickening, irregular wall thickening

Mass extending into lumen

Mass filling or replacing GB lumen (60%)

Mass poorly defined & isoechoic to liver

Tumor usually has flow (doppler)

Gallstones (80-90%)

Large stone (trapped stone)

Wall calcification (porcelain GB)

Look for mets:

Liver (direct invasion is common)

Term
Adenocarcinoma
Definition
Occurs in older patients Symptoms: Early stages: Asymptomatic Late stages: Similar to Chronic cholecystitis with a recent change in symptoms; Palpable, hard RUQ mass w/liver invasion & jaundice Prognosis: Best cure: found early (incidentally) at surgery 5 year survival rate: 5%
Term
Adenocarcinoma Risk Factors
Definition
-Obesity -Cigarette smoking -gallstones -cholecystitis -porcelain GB -Polyp > 2 cm
Term
Mets to GB
Definition
Def: the spread of cancer to the GB (originates somewhere else in the body)

Not very common
Melanoma is the most common

U/S:
Focal thickening of GB wall
Stones unlikely
Multiple, polypoid lesions along GB wall
Term
Biliary Atresia
Definition
Def: absence or closure of the biliary ducts
Etiology: unknown-affects neonates
Possibly caused by Infection, Immune Disorder
Rare, M>F

Variations of Biliary Atresia:
Total absence of biliary tree
Absent intrahepatic ducts
Absent extrahepatic ducts (most common)
Small or absent GB

Symptoms/Clinical Findings:
-persistent jaundice in a newborn
-elevated Direct & Indirect Bilirubin
-Polysplenia Syndrome (20%)

US Appearance:
Small or absent GB
Fibrotic remnant of CHD (Triangular Cord Syndrome)
Intrahepatic biliary dilatation

Complications: CIRRHOSIS
PORTAL HYPERTENSION
MALABSORPTION
DEATH WITHOUT INTERVENTION

Treatment:Treatment:
Intestine-ductal anastomosis
Liver transplant
Term
Choledochal Cyst
Definition
Definition: cyst within the biliary system
Incidence:
Common in East Asian populations
Rare
Mostly female
Usually detected in children <10 yrs old

Clinical Findings: Failure to thrive-RUQ pain-Jaundice-Fever/Chill

US: -Cystic structure communicating with the bile Ducts
-Large cystic mass in the porta hepatitis which is separate from the GB
Term
CAROLI’S DISEASE
Definition
Type V Choledochal Cyst
-Non-obstructive saccular dilatation of the intrahepatic bile ducts
Incidence: Typically found in childhood through 20’s

Symptoms: Fever, Crampy pain, Intermittent Jaundice

Ultrasound Findings: Multiple cystic structures within the liver that communicate with the biliary tree
- Stones/sludge may be seen
-Doppler the structures to demonstrate no flow
Term
[image]
Definition

Intra-hepatic Biliary Dilatation

Intra-Hepatic Ducts:

Bile ducts from the peripheral parenchyma near the capsule through the right hepatic duct and left hepatic ducts

Risk Factors:

Extrinsic obstruction, Gallstones in the ducts, Mets

US:

 “Shot Gun Sign”

“Parallel Channel Sign”

Dilated Bile duct adjacent to a Portal Vein

 

 

Term
Lymph Node Visualization
Definition
Abdominal Lymph Nodes –
Normal: not seen
Abnormal: Frequently seen
Neck Lymph Nodes – normal and abnormal will be seen
Term
Lymph Node Measurements
Definition
Size Criteria <= 1.5 cm in length
Short/long ratio <.5 (flat)
Term
Abnormal Lymph Node US Findings

Clinical Symptoms
Definition
Thickened cortex exceeds fatty hilum
Asymmetric cortical thickening
No fatty hilum

Autoimmune response, “blood poisoning”, reddening & warm skin, fever, pain, swelling
Red lines = course of lymphatic vessels in affected area
Painful enlarged lymph nodes
Term
cyst that contains lymph from diseased lymphatic channels
Definition
Lymphocele

Causes: trauma or surgery
Term
enlarged lymph nodes (>1.5 cm)
Definition
Lymphadenopathy

Causes : inflammation, cancer
Term
inflammation of lymph nodes (or lymphatic channels)
Definition
Lymphangitis

Causes: infection (most common = Group A strep)
Term
Lymphatic Cancer
Definition
Clinical symptoms:
May be asymptomatic
Palpable mass, chronic back pain, weight loss, anorexia, fatigue, anemia, fever, leukopenia

Primary: Lymphoma- most common form of “blood cancer”
-Hodgkin's
-NonHodgkins (most Common)


Secondary:Metastatic disease spread to the lymphatic system
Lymph nodes are the most common site for mets

US Appearance:
Size criteria: Length >1.5cm
Long/Trans Ratio <2cm
Short axis to long axis (S/L ratio >.5cm)
round in shape
normal nodes = echogenic hilum, hilar vascularity
malignant = echogenic hilum absent, peripheral or mixed vascularity
Term
Intra-operative Cholangiogram:
Definition
During surgery to remove the GB, a catheter is placed in the cystic duct , contrast is injected into the CBD and images are taken to look for CBD stones
Performed only if ERCP is not done pre-operatively
Term
Open Cholecystectomy
Definition
Major abdominal incision
GB is exposed & removed
Cystic duct is stapled
CBD is explored manually or by intraoperative cholangiogram
T-tube may be inserted if CBD stones are present
Hospital stay is 4-5 days
Recovery is several weeks
Term
Laparoscopic Cholecystectomy
Definition
GB removed through a small incision at the umbilicus
Fibro-optic lens is used to guide the procedure
Laser beams may be used for the cutting
Day surgery (short recovery)
Term
Percutaneous Transhepatic Cholangiogram (PTC)
Definition
Inject contrast percutaneously in dilated ducts
Images hepatic & common bile ducts & looks for cause
Needle is inserted through the liver (transhepatic) and into the bile ducts
Contrast media is inserted & the ducts are outlined
Stone extraction
Biopsy
Stent placement (drainage)
Term
MRI and CT
Definition
Magnetic Resonance Imaging (MRI):
MRI able to visualize CBD and PD
Better than CT

Computerized Axial Tomography (CAT scan):
CT better at visualizing the distal CBD than U/S
US better at seeing stones in GB
Term
Magnetic Resonance Cholangiopancreatography(MRCP)
Definition
Imaging technique that uses MRI to visualize the biliary and pancreatic ducts in a non-invasive manner
Less invasive compared to ERCP
Unlike ERCP, MRCP does not require contrast to be administered into the ducts (reduces risks of contrast reactions)
Fluid in the ducts serve as a contrast substance
MRCP does not allow for stone extraction, stent insertion, biopsy
Lower resolution than direct cholangiography and can miss small stones, ampullary lesions, primary sclerosing cholangitis, and strictures of the ducts
Accurate for measurements of the bile ducts and pancreatic duct
Term
Endoscopic Retrograde Cholangiopancreatography (ERCP)
Definition
Combines upper GI endoscopy and x-rays to treat problems of bile and pancreatic ducts
Invasive, requires sedation
Image ducts & look for cause
Tumors, stones, inflammation, scarring, pseudocysts
Biopsy
Stent placement (drainage)
Term
Oral Cholecystogram
Definition
A radiologic procedure to diagnose gallstones
Replaced by US
Lipomul (iodine) given the night before to empty the GB
4 tablets of Bilopague given the night before exam
Bilopague contrast will fill the GB & outline the stones (stones usually invisible on xray):
Vis: normal function
Non-vis: slow functioning or non-functioning (obstruction, inflammation)
Term
Most common cause of Intrahepatic dilatation
Definition
Extra-hepatic Biliary Obstruction
Term
Extra-hepatic Biliary Obstruction
Definition
Involves the Common hepatic Duct, cystic duct, and common bile duct

Causes: Stones, Tumors, Inflammation, Compression of Duct
Term
Choledocholithiasis
Definition
Def:
Most common cause of E-H biliary obstruction
Single or Multiple

Clinical Signs:
- intense, persistent pain (biliary colic)
-jaundice
- N/V
- Intermittent symptoms
Term
[image]
Definition

 

Choledocholithiasis Ultrasound:

+Murphy’s sign

Round, hyperechoic w/shadowing

Neither hyperechoic or shadowing

Lies within the confines of the CBD wall

Obstruction of the CBD proximal to the stone

Air in CBD may mimic stones

 

Term
Tumors That Cause Extra-Hepatic Biliary Dilitation
Definition
Cholangiocarcinomas
Ampullary Tumor
Pancreatic Tumor
Other
Term
Cholangiocarcinoma: Intrahepatic Location
Definition
Def: rare primary malignant tumor of the bile ducts
Symptoms:
Absent Murphy’s sign
+ Courvoisier’s Sign (enlarged GB, non-tender, jaundice, no Gallstones, found on physical examination = possible malignancy)

Labs:
Increased Alk Phos
Mild increase SGOT, SGPT
Increased bilirubin + jaundice
Term
Cholangiocarcinoma: Hilar Klatskin Location
Definition
Klatskin Tumor aka Hilar Cholangiocarcinoma
Mass in the porta hepatis
Negative Courvoisier’s sign

US Appearance:
biliary obstruction
narrowing of PVs
compensatory increased flow in HAs
Term
[image]
Definition

Acute Bacterial Cholangitis:

Caused by biliary obstruction

(usually CBD stone)

 US:

Bile duct wall thickening I-H/E-H

Dilatation of bile ducts I-H/E-H

Bile duct stones & sludge

GB wall thickening

Pneumobilia (gas in the biliary system)

Liver abscesses

Term
Cholangiocarcinoma: Distal Location
Definition
US Appearance (Distal):
polypoid mass in CBD
bile duct wall thickening
prox dilatation of bile ducts
dilated GB (+) Courvoisier’s Sign
Term
Ampullary Tumor
Definition
-rare malignant tumor
Symptoms: Same as Cholangiocarcinoma
Absent murphy’s sign
+ Courvoisier’s Sign

Ultrasound Appearance:
-Mass difficult to visualize
-Dilated E-H Ducts
-Look for liver mets
Term
Pancreatic Tumor
Definition
*Malignant tumor usually in the pancreatic head
Symptoms: Same as cholangiocarcinoma
US Appearance:
Positive Courvoisier’s sign
Hypoechoic mass w/in panc head
Dilated E-H ducts
Dilated I-H ducts
Dilated GB
Liver mets
Adenopathy
Ascites
Term
most common tumor obstructing the CBD
Definition
Pancreatic Tumor
Term
Cholangitis
Definition
Description:
Inflammation of the Bile Ducts Walls
It can lead to liver inflammation, infection, abscess
Forms of Cholangitis:
Acute Bacterial Cholangitis
AIDS Cholangitis
Recurrent Pyogenic Cholangitis
Sclerosing Cholangitis
Term
U/S Criteria for Biliary Tract Disease
Definition
Murphys Sign: Tender GB on deep palpation of RUQ or probe pressure
(+) Sign of Cholecystitis

Courvoisiers Sign: Large palpable non tender GB in a jaundiced pt.
(+) Sign of neoplastic obstruction of CBD

IntraHepatic Dilatation: Tiny tortuous anechoic tubes
-No flow with Doppler
Assoc. with I-H or E-H obstruction

CHD/CBD dilatation: Measure A-P diameter, inside to inside
-Measure CHD, CBD at its largest, CBD distally

Abnormal Preop Critera: > 5 mm or > 5 mm + 1 mm for each decade over 50
Term
Hepato-Biliary Scan (HIDA
Definition
Hepatobiliary iminodiacetic acid scan
Performed in Nuclear Medicine dept.
Imaging procedure that helps track the production and flow of bile from your liver to the small intestine
Creates pictures of your liver, bile ducts and small intestine
Injects Technecium 99mm Disophin
Radioactive material goes directly to the liver & biliary tract
It fills the GB & empties into the duodenum

Hepato-Biliary Scan (HIDA):
Bile ducts:
Normal- contrast in intestine
Obstruction- no contrast in intestine
GB:
Normal- visualized GB
Cholecystitis (A/C)- non-visualized GB
Term
Inoperable Obstructing Tumor:
Bypass Surgery (Choledochojejunostomy)
Definition
Anastomosis of CBD to jejunum to relieve symptoms of biliary obstruction
Stomach is attached to the jejunum & detached from the duodenum (gastrojejunostomy)
Inoperable tumor (pancreatic tumor) would remain intact
Term
Operable Obstructing Tumor: Whipple’s Procedure
Definition
Operable Obstructing Tumor: Whipple’s Procedure:
Remove tumor, pancreatic head, duodenum, gastric antum
Attach CBD, panc, stomach to jejunum
Post-op Whipple Sonogram:
Anatomy has been significantly altered
Air in biliary system
Air in the stent
Term
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Definition

AIDS Cholangitis:

Bile duct inflammation is caused by virus or bacteria because the patient is immunally suppressed

US Appearance:

Bile duct wall thickening I-H/E-H

Mild dilatation of bile ducts

Thick walled GB

Liver may be affected

Term
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Definition

Recurrent Pyogenic Cholangitis

Cause unknown

Prolonged infection, resulting in soft mud-like pigment (bilirubin) stones

These stones occur in I-H ducts

I-H ducts may also contain debris and pus

Localized inflammation, necrosis, or abscess may occur in the liver

Assoc. w/ Cholangiocarcinoma

 

Symptoms:

Recurrent attacks of cholangitis; Pain; Fever; jaundice

 

 US Appearance:

Proximal dilatation of I-H ducts

May affect only a liver segment

Stones/sludge in I-H ducts

Stones may be in a row

Stones may or may not shadow (size) 

Term
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Definition

Sclerosing Cholangitis:

Chronic inflammation of the bile ducts causing fibrosis & scarring

It may do irreversible damage to the liver/bile ducts, leading to cirrhosis & liver failure

Symptoms:

Usually asx.; Fever; Upper abdominal pain; Jaundice; Ulcerative colitis (80%)

 

US Appearance:

Mild intrahepatic dilatation

Thickened ductal walls

Stones in IH ducts

Air in bile ducts (infection)

Cirrhosis/Portal Hypertension

Evidence of cholangiocarcinoma

GB involved in only 10-15% of cases

 

 

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