Chapter 11: the gallbladder and the biliary system (workbook)

The normal wall thickness of the gallbladder is less than ____ mm.

3

To ensure maximum dilation of the gallbladder, the patient should be given nothing to eat for at least _____ hours before the ultrasound exam.

8 - 12

The gallbladder serves a reservoir for _____ that is drained from the hepatic ducts in the liver.

Bile

The ______ from the small intestine stimulate the liver to make more bile. This activates intestinal and pancreatic enzymes.

Bile salts

The gallbladder commonly resides in a _____ on the medial aspect of the liver.

Fossa

On a transverse scan, the common duct, hepatic artery, and portal vein have been referred to as the ____________ sign.

Mickey Mouse

An uncommon cause for extrahepatic biliary obstruction is a result of an impacted stone in the cystic duct creating extrinsic mechanical compression of the common hepatic duct is _____ syndrome.

Mirizzi

Gallbladder variant in which part of the fundus is bent back on itself.

Phrygian cap.

The most common cause of billiary ductal system obstruction is the presence of a(n) _____ or _____ within the ductal system.

Tumor; thrombus

The main pancreatic duct joins the common bile duct, and together they open through a small ampulla (the ampulla of ______) into the duodenal wall.

Vater

The differential for a porcelein gallbladder would include a packed bag or _____ sign.

WES

The ____ sign is described as a contracted bright gallbladder with posterior shadowing caused by a packed bag of stones.

Wall echo shadow (WES)

Yellow pigment in bile formed by the breakdown of red blood cells.

bilirubin.

Inflammation of the bile duct.

cholangitis.

Removal of the gallbladder.

cholecystectomy.

Inflammation of the gallbladder, may be acute or chronic.

cholecystitis.

Hormone secreted into the blood by the mucosa of the upper small intestine; stimulates contraction of the gallbladder and pancreatic secretion of enzymes.

cholecystokinin.

Cystic growth on the common duct that may cause obstruction.

choledochal cyst.

Stones in the bile duct.

choledocholithiasis.

Gallstones in the gallbladder.

cholelithiasis.

Variant of adenomyomatosis; cholesterol polyps.

cholesterolosis.

Extends from the point where the common hepatic duct meets the cystic duct; drains into the duodenum after it joins with the main pancreatic duct.

common bile duct.

Refers to common bile and hepatic ducts when cystic duct is not seen.

common duct.

Bile duct system that drains the liver into the common bile duct.

common hepatic duct.

Connects the gallbladder to the common hepatic duct.

cystic duct.

Excessive bilirubin accumulation causes yellow pigmentation of the skin; first seen in the whites of eyes.

jaundice.

Small septum within the gallbladder, usually arising form the posterior wall.

junctional fold.

Travels horizontally through the pancreas to join the common bile duct at the ampulla of Vater.

pancreatic duct.

Small, well-defined soft tissue projection from the gallbladder wall.

polyp.

Calcification of the gallbladder wall.

porcelain gallbladder.

Central area of the liver where the portal vein, common duct, and hepatic artery enter.

porta hepatis.

Describe the factors that produce a shadow in the gallbladder

Acoustic impedance of gallstones; refraction through them; diffraction around them; their size; location, and position in relation to the beam focus, and the intensity of the beam

Clinically the patient with acute cholecystitis presents with these symptoms.

Acute RUQ pain (positive Murphy), Fever, and Leukocytosis.

A hyperplastic change in the gallbladder wall is ______.

Adenomyomatosis

_______ within the duodenum may also give rise to a dirty shadow in the RUQ.

Air or gas

The common duct is seen just _____ to the portal vein before it dips posteriorly to enter the head of the pancreas.

Anterior

The hepatic artery lies _____ and to the _____ of the portal vein.

Anterior; left

Sonographically, the common duct lies _____ and to the _____ of the portal vein in the region of the porta hepatis and gastrohepatic ligament.

Anterior; right

The majority of stones in the common bile duct have migrated from the gallbladder. Common duct stones are usually associated with ______.

Calculous cholecystitis

On ultrasound, multiple cystic structures that converge toward the porta hepatis are seen in ______disease.

Caroli's

______ may be the result of pancreatic juices refluxing into the bile duct because of an anomalous junction of the pancreatic duct into the distal common bile duct, causing duct wall abnormality, weakness, and outpouching of the ductal walls.

Chloledochal Cysts

______ causes increasing pressure in the biliary tree with pus accumulation.

Cholangitis

List the six biliary causes of gallbladder wall thickening

Cholecystitis, Adenomyomatosis, Cancer, Acquired Immunodeficiency Syndrome, Cholangiopathy, and Sclerosino Cholangitis.

Bile is the principal medium for excretion of bilirubin and ______.

Cholesterol

The common hepatic duct is joined by the cystic duct to form the ______ duct.

Common bile

The sign that indicates an extrahepatic mass compressing the CBD, which can produce an enlarged gallbladder, is called ______.

Courvoiser's sign

The arterial supply of the gallbladder is from the _____ artery, which is a branch of the right hepatic artery.

Cystic

A small ______ fold has been reported to occur along the posterior wall of the gallbladder at the junction of the body and infundibulum.

Echogenic

A fairly rare complication of acute cholecystitis associated with the presence of gas-forming bacteria in the gallbladder wall and lumen with extension into the biliary ducts is called ______.

Emphysematous cholecystitis

Because of _____ tissue within the main lobar fissure of the liver (which lies between the gallbladder and the right portal vein), this bright linear reflector is a reliable indicator of the location of the gallbladder.

Fat/fibrous

Clinically the patient falls under the five "F's": ______, ______, ______, ______, and ______.

Female, Fat, Forty, Fertile, Fair

What is the most notable sonographic finding with carcinoma of the gallbladder?

Gallbladder wall is markedly abnormal and thickened

Small part of the gallbladder that lies near the cystic duct where stones may collect.

Hartmann's pouch.

Tiny valves found within the cystic duct.

Heister's valve.

When the right subcostal approach used, the common hepatic duct is seen as a tubular structure anterior to the portal vein. The right branch of the _____ artey can be seen between the duct and the portal vein as a small circular structure.

Hepatic

The patient is initially examined with ultrasound in full _____. The patient should also be rolled into a steep _____ or upright position (to ensure there are no stones in the gallbladder) in an attempt to separate small stones from the gallbladder wall or cystic duct.

Inspiration; Decubitis

The job of the sonographer is to localize the level and cause of the obstruction. List the three primary areas where obstruction occurs.

Intrapancreatic obstruction, Suprapancreatic obstruction, and Porta hepatic obstruction.

Cancer at the bifurcation of the hepatic ducts; may cause asymmetrical obstruction of the biliary tree.

Klatskin's tumor.

Positive sign implies exquisite tenderness over the area of the gallbladder upon palpation.

Murphy's sign.

To obtain a cross section of the portal triad, the transducer must be directed in a slightly, _____ path from the left shoulder to the right hip.

Oblique

On sagittal scans, the right branch of the hepatic artery usually passes ____ to the common duct.

Posterior

The most classic symptom of gallbladder disease is ______ pain, usually occurring after ingestion of greasy foods.

RUQ

A gallbladder attach may cause pain in the _____ shoulder.

Right

The gallbladder may be identified as a(n) _____ oblong structure located anterior to the right kidney, lateral to the head of the pancreas and duodenum.

Sonolucent

List the 2 primary functions of the extrahepatic biliary tract.

The transportation of bile from the liver to the intestine and regulation of its flow

Explain why the patients position should be shifted during ultrasound examination.

To demonstrate movement of stones.

Small plypoid projections from the gallbladder wall.

adenomyomatosis.

Small opening in the duodenum in which the pancreatic and common bile duct enter to release secretions.

ampulla of Vater.

Storage pouch for bile.

gallbladder.

Massive enlargement of the gallbladder.

hydrops.

Low-level echoes found along the posterior margin of the gallbladder; move with change in position.

sludge.

The end parts of the common bile duct and main pancreatic duct and the ampulla are surrounded by circular muscle fibers known as the ______.

sphincter of Oddi

Small muscle that guards the ampulla of Vater.

sphincter of Oddi.

Sonographic pattern found when the gallbladder is packed with stones.

wall echo shadow (WES) sign