CTL Pathology: 42% Biliary System

A patient presents with RUQ pain and nausea 1 week post-cholecystectomy. What findings on the image are most suggestive of

Abscess formation in the GB fossa

RUQ pain, positive Murphy's sign and fever are common clinical symptoms of

Acute cholecystitis

All of the following terms can be used to describe the findings on the image, except A) strawberry, gallbladder B) hyperplastic cholecytosis C) cholesterolosis D) adenomyomatosis

Adenomyomatosis

An otherwise asymptomatic patient presents for an abdominal ultrasound due to elevated LFTs. The gallbladder demonstrates thickened walls within a regular internal contour. Several small echogenic foci are noted within the wall, and each exhibit a small common tail artifact. Which of the following conditions is identified in this exam.

Adenomyomatosis

Twinkle artifact is an expected findings and cases of

Adenomyomatosis

Which of the following biliary conditions is associated with the formation of Rokitansky- Aschoff sinus

Adenomyomatosis

What biliary anomaly is suspected, if jaundice process more than 14 days after birth

Biliary atresia

An infant is referred for an abdominal sonogram due to prolong jaundice after birth. A small, triangular, echogenic area is identified at the portal vein bifurcation, the new, definite extrahepatic duct is noted. The gallbladder is very small and abnormally shaped. These findings are most suggestive of.

Biliary atresia Triangular, chord, sign refers to the echogenic area above the portal vein. Bifurcation indicates the obliterated bile duct, a small or absent gallbladder in fasting patients is abnormal. These two findings in a fasting infant are the widely excepted criteria for biliary atresia.

The GB wall is asymmetrically thickened with hypervascularity and perfusion defects noted on color Doppler evaluation. Intraluminal membranes and sludge are also present. What is the most likely cause for these findings?

Gangrenous cholecystitis

Inflammation of the biliary tree common an HIV patients is called

HIV cholangitis

Which of the following gallbladder abnormalities have a very similar appearance on ultrasound evaluation and clinical history is necessary for differentiation

Hemobilia and sludge

What term describes the gallbladder that is filled with bile that is Isa coworker to the liver and it's difficult to identify an ultrasound

Hepatization

Which of the following correctly describes how to differentiate cholangitis from cholangiocarcinoma

cholangitis is a diffuse disease process while cholangiocarcinoma causes focal mass formation

An impacted stone in the gallbladder neck increases the risk of developing

cholecystitis and gangrene

Because there is a risk of cholangiocarcinoma with all cases of ____________, surgical resection is recommended

choledochal cysts

What is the most common cause of cholangitis

choledocholithiasis

The WES sign indicates a diagnosis of

cholelithiasis

The patient has a history of of adenomyomatosis of the GB. What acoustic artifact is expected to be present on the US images of the GB

comet tail The cholesterol deposits in the abnormally second GB walls, cause the comet tail artifact

If the common hepatic duct is obstructed, how will this affect other biliary structures?

contracted GB and dilated intrahepatic ducts Amount of biliary tree dilation varies with the location of the obstruction. Obstructed, right hepatic duct will cause dilated intrahepatic ducts in the right lobe (left ductal stone dilates ducts in the left lobe) Obstructed CHD will cause a dilation of the intrahepatic ducts and a contracted GB, because nobody was reaching the cystic duct to fill the GB distal CBD is the most common location for obstruction in causes dilated intrahepatic/extrahepatic ducts and GB

Acute cholecystitis can lead to prominent _____________ and its branches with color Doppler evaluation of the thickened GB wall

cystic artery Acute cholecystitis can lead to GB wall thickening and hypervascularity. The cystic artery and it's branches will be prominent with color Doppler evaluation of the thickened GB wall

Mirizzi syndrome is caused by obstruction of the _________ while Courvoisier GB is related to obstruction of the ___________

cystic duct, distal cbd

A long-standing, partial obstruction of the cystic duct will most likely lead to which of the following

mucocele of the GB

An US demonstrates a non- shadowing, non-mobile, Echogenic foci within the GB that most likely represents

polyp

Which of the following describes how to differentiate adenomyomatosis of the gallbladder from cholesterolosis of the gallbladder

the polyps in cholesterolosis do not exhibit the comet tail artifact but polyps with adenomyomatosis do demonstrate the artifact

Which of the following describes how to differentiate tumefactive sludge from gallbladder carcinoma

use color doppler over the area of interest

Which image demonstrates a GB with characteristics of adenomyomatosis. Use the mouse to position the cursor over the GB.

.

GB polyps measuring greater than _________ in diameter are highly suspicious for malignancy.

10mm

Acute cholecystitis is associated with gallbladder wall thickening __________. Cholangitis is associated with ductal wall thickening _____________

>3mm,>2mm

Cholelithiasis without cholecystitis is a common finding in patients with _____________, cholecystitis without Cholelithiasis is a coming finding in patients ______________

A consistently low, fat diet, on long-term total parenteral nutrition

Acalculous cholecystitis is a common finding in all of the following except A) sepsis B) a history of recent abdominal surgery C) a history of a prolonged low fat diet D) AIDS

A history of a prolonged low fat diet Acalculous cholecystitis- no associated stones; see. In chronically ill patients; AIDS post surgery or trauma, sepsis, chronic IV nutrition, congestive heart failure. A prolonged low fat diet would usually be associated with stone formation without cholecystitis due to diminished need for bile in the digestive system

Patient presents for a two month follow up for liver transplant. Lab tests indicate abnormal LFTs, increase bilirubin and jaundice. The US exam demonstrates a new focal dilation of the bile duct at the porta hepatis with mildly dilated intrahepatic ducts just inside the liver. The pancreas is normal. These findings are most consistent with.

Biliary stricture Biliary stricture is a common complication of liver transplant. A mass in the ampulla of Vater will cause dilation of the pancreatic duct too. Budd-Chiari syndrome refers to obstruction of the hepatic veins. Choledochocyst, are a congenital malformation of the duct.

The complications caused by a large gallstone in the duodenum obstructing. The gastric outlet are collectively referred to as.

Bouveret syndrome

Which of the following is a congenital defect that causes bile stasis, impairs liver function and is associated with medullary sponge kidney and hepatic fibrosis

Caroli disease Caroli disease is a congenital defect of the bile ducts that leads to numerous cysts in the biliary tree. The malformation causes bile stasis and impairs liver function. It is associated with medullary sponge kidney and hepatic fibrosis

Numerous liver cysts with a Central Dot sign are most suggestive of

Caroli disease Caroli disease is a congenital defect of the bile ducts that results in numerous is formation in the biliary tree. This is demonstrate a Central dot sign, which refers to echogenic darts with color flow within cystic lesions. .

A patient presents for an abdominal US to further evaluate findings identified on a CT exam. The CT report indicates numerous cystic structures throughout the liver. They communicate with the biliary tree. Which of the following could be used to describe the expected US diagnosis

Caroli disease or choledochal cysts Caroli disease leads to focal ectasia of the biliary tree, causing biliary cyst formation. The cysts related to Caroli disease are usually much larger and more difficult than choledochocyst formation. This is associated with PCLD (polycystic liver disease) do not communicate with the biliary tree.

Primary sclerosing cholangitis significantly increases the risk of developing

Cholangiocarcinoma

A 6 month old Asian female presents with jaundice and fever. While scanning the liver, you note a 1cm anechoic, round dilation of the extrahepatic CBD at the ports hepatis. Color Doppler does not demonstrate flow within the structure. Which of the following is the most likely diagnosis

Choledochal cyst Choledochal cyst are congenital defects if the biliary tree that are more commonly found in the Asian population. US usually demonstrates a focal dilation of the biliary tree near the porta hepatis. The dilation can be cystic or fusiform. If the cyst causes ductal obstruction, pain, jaundice and fever can develop

While scanning the gallbladder, you noticed several echogenic foci within the mildly thickened wall that do not demonstrate reverberation artifact. These findings are most suggestive of.

Cholesterolosis

Which of the following abnormalities is associated is production of milk of calcium bile? A) chronic cholecystitis B) hepatoma C) acute cholecystitis D) cirrhosis

Chronic cholecystitis

What are the two acoustic artifacts that are associated with biliary hamatoma formation in the liver?

Comet tail and twinkle Biliary Harmatoma: AKA von Meyenburg complexed are focal developmental lesions of the liver. Small nodules usually appear echogenic and cause a diffusely heterogeneous appearance of the liver tissue. Numerous echogenic foci with a ring down artifact (, two) or seen throughout the liver. Twinkle artifact is usually noted on color Doppler evaluation of the foci.

Diffuse or focal GB wall thickness may be seen with all of the following except

Courvoisier GB Courvoisier GB refers to an overdistended non-tender GB without wall thickening (hydrops) commonly caused by an ampulla of vater obstruction

A 64yr old patient presents with painless jaundice. The GB is over-distended with a biliary obstruction at the level of the Ampulla of Vater. Which of the following best describes this condition

Courvoisier sign Painless jaundice, distended GB and an obstruction at the Ampulla of Vater at the 3 characteristics of Courvoisier syndrome or sign. Mirizzi syndrome is even a stone in the cystic duct causes extrinsic compression of the CBD, very painful

The most common finding with choledochoal cysts is

Cystic dilation of the common bile duct Choledochal cyst occurs due to congenital weaknesss if ductal walls and most common affects the CBD. It is more common in women, usually of Asian decent. The Todani classification lists 5 types of choledochal cysts Type I: cystic fusiform dilation of the CBD, most common Type II: diverticulum of the CBD Type III: Choledochocele found in the intraduodenal portion of the duct Type IV: dilation if the intrahepatic and extrahepatic ducts Type V: dilation if the intrahepatic ducts (Caroli disease)

Which structure is indicated by #1

Dilated CBD

Obstruction of the common bile duct by a pancreatic head mass will lead to

Dilated GB and biliary tree

Based on these images where is the obstruction

Distal common bile duct An extra hepatic duct obstruction must be present because the intrahepatic an extra pair of ducks are dilated. The obstruction is in the distal CBD. Portal thrombosis would not lead to dilated intrahepatic branches. The portal branches with a trophy, and fill with thrombus once the MPV is thrombosed.

Jaundice is a complication of

Ductal obstruction and red blood cell destruction Jaundice is caused by an increase in bilirubin in the blood. A ductal obstruction will lead to increased bilirubin levels in the blood due to the inability of the liver to excrete it properly. If the liver does not process the bilirubin properly due to hepatocellular disease, jaundice will occur. Bilirubin comes from the normal destruction of old red blood cells. If the liver does not conjugate the bilirubin from the RBCs or there is an excessive amount of RBC destruction, the bilirubin will remain in the blood, also causing jaundice

Patient presents for an abdominal ultrasound with RUQ pain, nausea, fever, and leukocytosis. An abnormal enlarged GB demonstrates thickened walls at 1.2 cm. An anterior segment of the wall is echogenic and ring. Down artifacts and dirty shadowing are present posterior to this area. Which of the following conditions is identified on this exam

Emphysematous cholecystitis

Which of the following biliary abnormalities would be an acute complication caused by a bacterial infection if the gallbladder

Emphysematous cholecystitis

A 45-year-old female patient presents with nausea, vomiting, and RUQ pain, fever, and increased WBC. The GB is enlarged and filled with echogenic material that does not shadow or demonstrate fluid levels. These findings are most consistent with.

Empyema of the GB

What is the most common cause of pneumobilia?

Endoscopic retrograde cholangiopancreatography (ERCP)

Choledochocyst is

Focal dilation of the biliary tree

Tumefactive sludge can be found in

GB

Which structure is indicated by #4

GB

Chronic cholecystitis is commonly associated with

GB carcinoma

Patient presents with intermittent RUQ pain and nausea. No lab information was available at the time of the ultrasound exam. The findings on the exam are most suggestive of.

GB metastasis The color Doppler demonstrates blood flow in the intraluminal contents, which indicates tumor formation. GB metastases most commonly present for presents as an intraluminal mass without associated stones. Primary GB cancer, most commonly presents as an intraluminal mass with stone formation. Tumefactive, sludge, and empyema would not demonstrate blood flow in the sludge/pus

Which of the following is associated with prolonged fasting

GB sludge

Which of the following statements regarding gallbladder sludge is not true A) GB sludge is always associated with wall thickening B) tumefactive sledge can have a sonographic appearance similar to GB carcinoma C) sludge can appear as varied layers of echogenic material in the gallbladder lumen D) changing patient position and rescanning the gallbladder can differentiate sludge from artifact

GB sludge is always associated with wall thickening

Which of the following causes of diffuse dilation of the intrahepatic biliary tree, without dilation of the extrahepatic biliary tree

Klatskin Tumor Klatskin tumor is a type of cholangiocarcinoma that commonly forms near the junction of the right and left portal vein junction (jntrahepatic porta hepatis). Any mass within the liver or at the porta hepatis can lead to intrahepatic ductal dilation with a normal CBD. Brenner tumors form in the ovaries A mass at the valves of Heister wojld cause isolated dilation of the cystic duct of the GB. A mass at the Ampulla of Vater would cause intrahepatic and extrahepatic ductal dilation

Tumefactive sledge, with demonstrate a sonographic appearance, similar to all of the following, except A) primary GB carcinoma B) benign polyp C) membranous gangrenous cholecystitis D) secondary GB carcinoma

Membranous gangrenous cholecystitis Membranous gangrenous cholecystitis would cause a diffusely second GB wall with hyper vascularity and intraluminal membranes. There may be areas where perfusion defects are detected in the second wall they color Doppler, which indicate areas of necrosis. Abscess formation may also be demonstrated.

Which of the following is caused by infection or ischemia of the gallbladder wall?

Membranous gangrenous gallbladder

Which of the following is associated with the findings on the image displayed A) Kurkenberg tumor formation in the duodenum B) obstruction of the ampulla of Vater C) adenocarcinoma formation in the pancreatic head D) more than one of the above

More than one of the above The tumors listed would've struck the distal CBD in cause dilation of the intrahepatic in extrahepatic docs. I've had a tumors could lead to extrinsic compression of the biliary duct, causing intrahepatic dilation.

Which of the following would present with no signs of jaundice A) hepatitis B) mucocele of the GB C) a stone at the ampulla of Vater D) sphincter of Oddi dysfunction

Mucocele of the GB

A four month old presents for an abdominal ultrasound following a recent kasai procedure. Which of the following ultrasound findings would indicate the procedure was a success.

Normal liver echotexture with a normal biliary duct diameter The Kasai procedure is performed to treat biliary atresia. A segment of the doctor system is directly connected to a portion of the G.I. tract. The Larry tree dilation should reduce in the expected homogenous liver appearance should return to normal.

A 66yr old female presents for an abdominal US due to bloating and pain following a recent cholecystectomy. The bile ducts demonstrate varied level of increased echogenicity with dirty shadowing and ring down artifact posterior to several segments. These findings are most consistent with

Pneumobilia

A patient presents with RUQ pain after a recent endoscopy procedure. The findings on the image are most suggestive of

Pneumobilia The image demonstrates Pneumobilia. It is a complication of ERCP, biliary tree procedures and cholangitis. Note the Echogenic foci and ring down artifact from the air in the biliary tree

This patient has an increased risk of developing

Porcelain GB Chronic cholecystitis is demonstrated. These patients are at an increased risk of developing porcelain GB and primary GB carcinoma

Which structure is indicated by #3

Portal vein

A patient presents for an abdominal ultrasound due to nausea and vomiting. While scanning the GB, the patient asks you to take a break due to the pain caused by the transducer pressure. How should you report this to the radiologist

Positive Murphy sign

Patient presents with a low-grade fever, leukocytosis, nausea, diarrhea and LLQ pain what is the most likely explanation for the findings on this image

Primary Sclerosing cholangitis

A patient presents for an abdominal ultrasound for pain. The chart holder, recent x-ray report that stated as possible porcelain GB present. How old is abnormality appear on the ultrasound exam.

The GB wall will demonstrate varied levels of linear calculation

Cholelithiasis without cholecystitis is most likely to be seen in a patient with

a history of a prolonged low fat diet

64-year-old female presents with recent weight loss and mild jaundice. Lab values demonstrate normal, WBC levels, but increase levels of direct bilirubin, alkaline phosphatase and prothrombin time. The gallbladder demonstrates a small wall mass that is Isa correct to the liver tissue. The wall measures four. 5 mm in maximum thickness. Multiple stones are present within the lumen. Which of the following best describes the findings on the image.

Primary gallbladder carcinoma and cholelithiasis Primary GB cancer, most commonly presents as a diffusely second GB wall with cholelithiasis. Increased levels of direct bilirubin, alkaline phosphatase, and prothrombin time along with normal white blood cell count are all signs of gallbladder cancer. Normal white blood cell count indicates no information and no cholecystitis

Which of the following is not true regarding milk of calcium bile A) also called limey bile B) layering of bile/ calcium with change of patient position C) related to hyper function of the GB D) lumen filled with highly Echogenic material with shadowing

Related to hyperfunction of the GB

If pneumobilia is suspected, visualization of what acoustic artifact should be supported to diagnose

Ring down

A 56-year-old male presents with a history of abdominal pain. Lab testing demonstrates isolated leukocytosis. He had a recent colonoscopy that demonstrated left-sided ulcerative colitis. These ultrasound findings are most suggestive of.

Sclerosing cholangitis Sclerosing cholangitis causes diffuse thickening of the bile duct walls, and is commonly associated with ulcerative colitis. The patient may present with fever, leukocytosis and associated cholecystitis.

A 35 year old male patient presents for a RUQ ultrasound due to pain increased alkaline phosphatase and conjugated bilirubin. You identify dilated intrahepatic ducts in both lobes of the liver, while the CBD and GB appear within normal limits. Which of the following describes the cause for these findings

Stone in the common hepatic duct The labs indicate a biliary obstruction. The presence of dilated intrahepatic ducts in both lobes indicated the right and left ducts are blocked = obstruction at the CHD. Biliary atresia refers to the absence of an "opening" in the ductal system. It is a congenital defect that is fatal if untreated

An 85-year-old patient presents with a history of epigastric pain. Lab values are normal. The exam demonstrates normal intrahepatic ducts and a 10 mm CBD that appears patent. The pancreas appears normal. What is the most likely reason for the 10 mm CBD

The CBD normally dilates with age

A New liver mass in a patient with sclerosing cholangitis should cause suspicion for

The development of cholangiocarcinoma

Which of the following is a true statement regarding the image displayed

The gallbladder is contracted with second walls and polyp formation caused by adenomyomatosis

Which of the following statements is true regarding the image displayed

The gallbladder wall demonstrates a solid mass and the CBD is significantly dilated

Which of the following correctly describes how to differentiate a large stone (>3 cm) from the porcelain GB

The posterior wall of the GB can be evaluated in patients with porcelain gallbladder, but not impatiens with a large stone

Which of the following statements best describes the findings on the image

There is a polyp located on the inferior wall of the GB neck

A non-infectious cause of acalculous cholecystitis is _____________ and an infection cause of acalcuous cholecysitis is _______________

Total parenteral nutrition, human immunodeficiency virus

Which of the following is the most likely cause for the findings on the image

Tumor of the ampulla of vater The GB is enlarged with internal debris. There is significant intrahepatic ductal dilation. These two findings indicate an extra hepatic obstruction

A biloma is

a collection of bile in the peritoneal cavity

A Choledochocele is

a cyst of the intraduodenal portion of the duct

Which of the following are types of hyperplastic cholecystosis

adenomyomatosis and cholesterolosis Hyperplastic cholecystosis is a spectrum of degenerative and proliferative changes seen in the GB. This includes adenomyomatosis and cholesterolosis

Which of the following is a cause of parasitic cholangitis

biliary ascariasis Bacterial cholangitis is nearly always associated with ductal obstruction (stone or tumor). Bile is infected by gram negative bacteria. Parasitic chilangitis involves liver flukes or ascariasis. May see worms within the inflamed ducts as Echogenic tortuous strands in the lumen. HIV infection. Most patients with primary sclerosing chilangitis have inflammatory bowel disease or ulcerative colitis. It causes chronic inflammation and fibrosis of the biliary ducts

Primary GB carcinoma most commonly presents as

diffusely thickened GB wall with stones

Primary GB carcinoma, most commonly presents as

diffusely thickened GB wall with stones

Bacterial cholangitis is nearly always seen with

ductal obstruction by a stone or tumor

Which of the following is least likely to be associated with GB sludge

elevated cholecystokinin levels CCK causes the gallbladder to contract and expel bile. High levels of CCK would cause the GB to contract and limit the possibility of biliary stasis and sludge formation

Which type of gallbladder disease is more common in males and diabetic patients

emphysematous cholecystitis

What structure is indicated by #2

hepatic artery

Which of the following correctly describes the abnormal response seen on an ultrasound exam when a fatty meal is given to a patient with suspected biliary obstruction

if a biliary obstruction is present the bile duct diameter will increase immediately after the meal Fatty meal administration Used to assess biliary dynamics, gallbladder, contractility, obstruction Ingestion of fatty foods causes the release of cholecystokinin which causes GB contraction Positive exam- ducts increase in more than 1 mm due to increased bile levels Negative exam - ducts do not change in size or decrease size slightly

The bile duct diameter should be measured with the calipers placed from

inner wall to inner wall

If a gallstone impaction is suspected

scan the patient in multiple positions to attempt to move the stone

Which of the following can lead to a false positive diagnosis of stones in the biliary system?

shadowing from surgical clip in porta hepatis

Which of the following biliary conditions is the most common cause of acute cholecystitis

stone lodged in cystic duct