Penny: Chapter 4 - The Bile Ducts

Sonographic findings of Caroli Disease

1. segmental dilatation of the intrahepatic ducts 2. the patient may also have cystic renal disease 3. Central dot sign (echogenic dot in dilated duct within liver)

intrahepatic duct considered dilated if they are

>2 mm (inner wall to inner wall)

Pneumobilia will produce: a) Through transmission b) Ring-down artifact c) Acoustic shadowing d) Edge artifact

b) Ring-down artifact (echogenic structure that produces ring-down artifact)

Which of the following is NOT a plausible cause of common bile duct obstruction in adults? a) Choledocholithiasis b) Chronic pancreatitis c) Choledochal cyst d) Pancreatic carcinoma

c) Choledochal cyst (cystic dilation of common bile duct)

The most common level for biliary obstruction to occur is the: a) Junction of the right and left hepatic ducts b) Proximal common hepatic duct c) Distal common bile duct d) Cystic duct

c) Distal common bile duct

Clinical findings of choledocholithiasis include all of the following EXCEPT: a) Jaundice b) Elevated bilirubin c) Elevated blood urea nitrogen d) Elevated ALP

c) Elevated blood urea nitrogen (kidneys)

If a gallstone, causing obstruction, is located within the distal common hepatic duct, which of the following would become dilated? a) Main pancreatic duct b) Gallbladder only c) Intrahepatic ducts d) Distal common bile duct

c) Intrahepatic ducts

Bile flow

liver -> biliary radicles--> rt/lt hepatic duct--> common hepatic duct -> cystic duct -> gallbladder -> cystic duct -> common bile duct -> ampulla of Vater--> sphincter of Oddi --> duodenum (absorption of emulsified fats)

biliary colic

pain secondary to a blockage of the biliary tree

cholangiocarcinoma

primary bile duct cancer

AIDS cholangitis

- Associated with advance HIV and AIDS - Most often results from infection with Cryptosporidium or cytomegalovirus

Acute bacterial cholangitis

- Caused by bacterial accumulation secondary to obstruction - Bacteria can be introduced during an ERCP for choledocholithiasis - Pus may be noted within the bile ducts as low-level echoes

Sonographic findings of Ascariasis

- The worm will be noted within the biliary duct as an echogenic linear structure in the sagittal plane - Movement of the worm within the duct confirms diagnosis

Sonographic findings of biliary tree atresia

1. Absent biliary ducts 2. Triangular cord sign (avascular, echogenic, tubular structure anterior to PV) 3. Sonographic signs of cirrhosis and portal hypertension

Sonographic Findings of Pneumobilia

1. Echogenic linear structures within the ducts that produce ring-down artifacts and may have dirty shadowing

clinical findings of cholangiocarcinoma

1. Jaundice 2. Pruritus 3. Unexplained weight loss 4. Abdominal pain 5. Elevated Bilirubin 6. Elevated Alkaline Phosphatase

Clinical Findings of biliary atresia

1. Neonatal jaundice 2. Elevated AST, ALT, and bilirubin

sonographic findings of choledochal cyst

1. cystic mass in the area of the porta hepatis (separate from gallbladder) 2. biliary dilatation

when biliary tree obstruction or disease is suspected, look for an elevation in

ALP, ALT, serum bilirubin, GGT, and urobilirubin

sonographic findings of cholangiocarcinoma

Dilated intrahepatic ducts that abruptly terminate at the level of the tumor A solid mass may be noted within the liver or ducts

Oriental cholangitis

Endemic to Asia Seen in America because of immigration

Charcot triad is fever, RUQ paint, and juandice

TRUE

The most common level for an obstruction to occur is the distal common bile duct

TRUE

ampulla of Vater

The merging point of the pancreatic duct and CBD just before the sphincter of Oddi; also referred to as the hepatopancreatic ampulla

Mirizzi syndrome

a clinical condition when the patient presents with jaundice, pain, and fever secondary to a lodged stone in the cystic duct

biliary stasis

a condition in which bile is stagnant and allowed to develop into sludge or stones

biliary atresia

a congenital disease described as the narrowing or obliteration of all or a portion of the biliary tree

Caroli disease

a congenital disorder characterized by segmental dilatation of the intrahepatic ducts

biliverdin

a green pigment found in the bile

Klatskin tumor

a malignant biliary tumor located at the junction of the right and left hepatic ducts

cholangiography

a radiographic procedure in which contrast is injected into the bile ducts to assess for the presence of disease

bilirubin

a yellowish pigment found in bile that is produced by the breakdown of old red blood cells by the liver

For patients older than age 60, or those who have had a cholecystectomy, a maximum diameter of _____ may be considered normal. a) 1 cm b) 12 mm c) 14 mm d) 1.5 cm

a) 1 cm

The biliary duct WALL should never measure more than: a) 2 mm b) 9 mm c) 4 mm d) 5 mm

a) 2 mm

The Klatskin tumor is located: a) At the junction of the right and left hepatic ducts b) At the junction of the cystic and common bile duct c) At the junction of the common bile duct and common hepatic duct d) Between the pancreatic head and the duodenum

a) At the junction of the right and left hepatic ducts

The presence of an echogenic dot in the nondependent part of a dilated duct representing small fibrovascular bundles is seen with: a) Caroli disease b) Choledochal cysts c) Biliary atresia d) Mirizzi syndrome (impacted stone in cystic duct)

a) Caroli disease

Which of the following is NOT associated with the development of pneumobilia (air within biliary tree)? a) Cholangiopneumonia b) Gastric surgery c) Acute cholecystitis d) Fistula formation

a) Cholangiopneumonia

Which of the following is associated with Charcot triad? a) Cholangitis b) Cholesterolosis c) Klatskin tumor d) Choledochal cyst

a) Cholangitis

Air within the biliary tree is referred to as: a) Pneumobilia b) Cholangitis c) Choledocholithiasis d) Cholesterolosis

a) Pneumobilia

Sonographically, you visualize scattered echogenic linear structures within the liver parenchyma that produce ring-down artifact. What is the most likely diagnosis? a) Pneumobilia b) Choledocholithiasis c) Sludge balls d) Cholesterolosis

a) Pneumobilia

Which of the following would be the most distal portion of the biliary tree? a) Common bile duct b) Common hepatic duct c) Gallbladder d) Intrahepatic radicles

a) common bile duct

Which segment of the biliary tree tends to dilate first with obstruction? a) Intrahepatic b) Extrahepatic

a) extrahepatic

Which of the following is considered the most proximal portion of the biliary tree? a) Intrahepatic radicles b) Cystic duct c) Common hepatic duct d) Common bile duct

a) intrahepatic radicles

pneumobilia

air within the biliary tree

ascariasis

an infection of the small intestine that is caused by Ascaris lumbricoides, a parasitic roundworm

ulcerative colitis

an inflammatory bowel disease that leads to the development of ulcers within the bowel

A Klatskin tumor is a form of: a) Lymphocytic carcinoma b) Cholangiocarcinoma c) Pancreatic carcinoma d) Gallbladder carcinoma

b) Cholangiocarcinoma

A 32-year-old female patient presents to the sonography department with a history of fever, leukocytosis, and right upper quadrant pain. Sonographically, you visualize dilated bile ducts that have thickened walls and contain sludge. What is the most likely diagnosis? a) Choledocholithiasis b) Cholangitis c) Mirizzi syndrome (impacted stone in cystic duct) d) Biliary atresia

b) Cholangitis

A gallstone located within the biliary tree is referred to as: a) Cholecystitis b) Choledocholithiasis c) Cholangitis d) Cholangiocarcinoma

b) Choledocholithiasis

Which of the following could accidentally introduce bacteria into the biliary tree and thus cause cholangitis? a) Computed tomography b) Endoscopic retrograde cholangiopancreatography c) Magnetic resonance imaging d) Radiography

b) ERCP

A patient presents with jaundice, pain, and fever secondary to an impacted stone in the cystic duct. This is referred to as: a) Caroli syndrome (dilation of intrahepatic ducts) b) Mirizzi syndrome c) Choledochal cysts d) Biliary atresia

b) Mirizzi syndrome

The merging point of the pancreatic duct and common bile duct at the level of duodenum is referred to as the: a) Sphincter of Oddi b) Ampulla of Vater c) Common bile duct d) Cystic duct

b) ampula of Vater

The yellowish pigment found in bile that is produced by the breakdown of old red blood cells by the liver is: a) Biliverdin b) Bilirubin c) Cholesterol d) Chyme

b) bilirubin

Which of the following disorders is associated with the sonographic triangular cord sign? a) Cholangitis b) Choledocholithiasis c) Biliary atresia d) Ascariasis

c) Biliary atresia

An abdominal sonogram is ordered for an infant in the intensive care unit who is suffering from jaundice and fever. Sonographically, you visualize a cystic mass within the common bile duct that is causing a focal enlargement. This is most suggestive of: a) Cholangiocarcinoma b) Mirizzi syndrome c) Choledochal cyst d) Biliary atresia

c) Choledochal cyst

The yellowish staining of the whites of the eyes and the skin secondary to a liver disorder or biliary obstruction is referred to as: a) AIDS cholangitis b) Pruritus c) Jaundice d) Bilirubinemia

c) Jaundice

Which of the following is characterized by fibrotic thickening of the bile ducts, found most often in young males, and is associated with inflammatory bowel disease or ulcerative colitis? a) Ulcerative biliary atresia b) Oriental cholangitis c) Sclerosing cholangitis d) AIDS biliary atresia

c) Sclerosing cholangitis

The muscle that controls the emptying of bile and pancreatic juices into the duodenum is the: a) Cystic duct b) Ampulla of Vater c) Sphincter of Oddi d) Common bile duct

c) Sphincter of Oddi

Ascariasis is: a) a form of biliary tree carcinoma b) A congenital disorder characterized by segmental dilatation of the intrahepatic ducts c) Caused by a parasitic roundworm d) A type of ringworm that invades the liver

c) caused by a parasitic roundworm

Primary biliary tree cancer is referred to as: a) Gallbladder carcinoma b) Biloma c) Cholangiocarcinoma d) Lymphangioma

c) cholangiocarcinoma

Most common cause of common bile duct obstruction are

choledocholithiasis, chronic pancreatitis, acute pancreatitis, and pancreatic carcinoma

inflammatory bowel disease

chronic inflammation of all or parts of the bowel

double-duct sign

coexisting dilation of the common bile duct and pancreatic duct

If an obstructive biliary calculus is located within the distal common duct, which of the following could ultimately dilate? a) Common bile duct b) Gallbladder c) Common hepatic duct d) All of the above

d) All of the above

A 64-year-old man presents to the sonography department for a RUQ sonogram. He is complaining of abdominal pain, weight loss, and pruritus. Sonographically, you visualize an area of dilated ducts that abruptly end. What is the most likely diagnosis? a) Biliary atresia b) Choledocholithiasis c) Caroli syndrome d) Cholangiocarcinoma

d) Cholangiocarcinoma

Inflammation of the bile ducts is referred to as: a) Pneumobilia b) Choledocholithiasis c) Cholelithiasis d) Cholangitis

d) Cholangitis

Which of the following is typically found in pediatric patients (first discovered) and is described as the cystic dilation of the common bile duct? a) Biliary atresia b) Mirizzi syndrome c) Caroli disease d) Choledochal cyst

d) Choledochal cyst

Which of the following would be the most common cause of obstructive jaundice? a) Klatskin tumor b) Cholangiocarcinoma c) Biliary atresia d) Choledocholithiasis

d) Choledocholithiasis

The spiral valves of Heister are located within the: a) Common bile duct b) Pancreatic duct c) Common hepatic duct d) Cystic duct

d) Cystic duct

All of the following are clinical findings consistent with cholangiocarcinoma EXCEPT: a) Pruritus (severe itchiness of the skin) b) Weight loss c) Elevated bilirubin d) Dilation of the intrahepatic ducts (Klatskin tumor)

d) Dilation of the intrahepatic ducts (dilated intrahepatic duct abruptly terminate at mass)

All of the following are forms of cholangitis EXCEPT: a) Acute bacterial b) AIDS c) Oriental d) Parabolic

d) Parabolic

A congenital disease in which there is narrowing or obliteration of the bile ducts is referred to as: a) Caroli disease b) Mirizzi disease c) Choledochal cysts d) Biliary atresia

d) biliary atresia

Which of the following would be the least helpful laboratory value to analyze in patients with suspected biliary tract disease? a) ALT b) ALP c) GGT d) Creatinine

d) creatinine (kidneys)

endoscopic retrograde cholangiopancreatography (ERCP)

endoscopic procedure that utilizes fluoroscopy to evaluate the biliary tree and pancreas

Charcot triad

fever, right upper quadrant pain, and jaundice associated with cholangitis

Schlerosing cholangitis

increased risk for cholangiocarcinoma (primary biliary tree cancer), fibrotic thickening of bile ducts, affects young men, associated with inflammatory bowel disease or ulcerative colitis

cholangitis

inflammation of the bile ducts

acute pancreatitis

inflammation of the pancreas secondary to the leakage of pancreatic enzymes from the acinar cells into the parenchyma of the organ

pruritus

severe itchiness of the skin

Parallel tube sign (shotgun sign)

the enlargement of the common duct to the size of the adjacent portal vein within the porta hepatis

shotgun sign

the enlargement of the common duct to the size of the adjacent portal vein within the porta hepatis; also referred to as the parallel tube sign

hepatopancreatic ampulla

the level of the biliary tree where the common bile duct and the main pancreatic duct meet; may also be referred to as the ampulla of Vater

Sphincter of Oddi

the muscle that controls the emptying of bile and pancreatic juices into the duodenum; also referred to as the hepatopancreatic sphincter

hepatopancreatic sphincter

the muscle that controls the emptying of bile and pancreatic juices into the duodenum; may also be referred to as the sphincter of Oddi

Central dot sign

the presence of echogenic dots in the nondependent part of the dilated duct representing small fibrovascular bundles; seen with Caroli diseaset

chronic pancreatitis

the recurring destruction of the pancreatic tissue that results in atrophy, fibrosis, scarring, and the development of calcification within the gland