Ch. 15 The Biliary System

The length of the cystic duct is highly variable, ranging from _____ to ____ cm. An average length of _____ has been reported at surgery.

-1 to 3.5 -4 cm

The upper limits of a CHD in a geriatric patient is ____ mm.

-10 mm

Schwartz reports a CHD length of___ to____ cm

-3 to 4 cm

A fairly widely accepted upper limit for the inner diameter of the CHD is?

-4 mm.

The common bile duct (CBD) length of ___ to ____ cm has been suggested.

-8 to 11.5

When a patient has fasted correctly for the exam and a bile-filled gallbladder is visualized, it is found to have a normal length of approximately ____ to _____ cm. in the majority of patients.

-8 to 9 cm

Function of the Biliary System?

-Drain the liver of bile

True or False A fasting patient will not have a distended gallbladder.

-False

True or False Positive Murphy's sign (LUQ pain) on physical examination.

-False- RUQ

Indentation located on the posteroinferior portion of the right lobe of the liver where the gallbladder is situated?

-Gallbladder fossa

A small sacculation (out-touching may be seen in some patients in the area of the gallbladder neck. This has been called?

-Hartmann's pouch -infundibulum

From the sinusoids, blood converges into hepatic veins and finally the ______ before returning to the heart.

-IVC

The gallbladder is drained by tributaries of the hepatic venous portal system, which carry blood into the?

-IVC

The extrahepatic portal triad has become known as?

-Mickey's Sign or Mickey Mouse Sign

The thin, reflective, main lobar fissure may be demonstrated between which two structures?

-Portal vein & gallbladder

Which hepatic duct is usually longer?

-The left hepatic duct

Sonographic Appearance p. 238 True or False Much of the biliary system is readily appreciated on sonography.

-True

True or False A gallbladder may be obscured or hidden by bowel gas.

-True

True or False A patient who has fasted (not eaten) since midnight prior to an ultrasound examination may present with a bile-filled, easily visualized gallbladder. A patient who has eaten, causing the gallbladder to partially or completely empty to aid digestion, may present with a partially bile-filled, small gallbladder or, a collapsed, bile-free gallbladder, that may appear as nonexistent at first.

-True

True or False A small, tubelike (vermiform or wormlike) gallbladder may appear as a bile duct and be missed on sonography.

-True

True or False A teaspoon typically holds approximately 5 mL of fluid; therefore the gallbladder holds approximately 8 teaspoons of fluid.

-True

True or False An injectable form of CCk has been used to stimulate the gallbladder during sonographic examination for a type of function test.

-True

True or False As previously noted, an empty or contracted gallbladder may be small and can be overlooked.

-True

True or False Bile in the gallbladder is much more concentrated than hepatic bile.

-True

True or False Changing patient position or transducer position may be necessary to examine the entirety of the fundus.

-True

True or False If a shadow interrupts the wall, the shadow may indicate abnormal anatomy and deserves further study.

-True

True or False In the absence of a disease, the other portion of the biliary may prove difficult to appreciate because they are so small.

-True

True or False In the average patient, bile ducts other than the common duct are small and usually not appreciated sonographically.

-True

True or False Localized thickening of the gallbladder wall may indicate the presence of a mass or other condition that would call for further investigation.

-True

True or False The biliary system may not develop normally, which can cause different types of deviations to occur. Deviations are of special interest to the sonographer because they may challenge adequate examination. For example, what appears to be a septated gallbladder (a gallbladder with divisions or septations), may simply be a gallbladder folded onto itself. If the patient's position is changed, the gallbladder may unfold to reveal no septation.

-True

True or False The gallbladder acts as the storage receptacle for bile, and the various ducts provide a place to which the bile flows.

-True

When gallbladder fails to develop

-agenesis

Bile ducts sonographic appearance?

-avascular anechoic tubular structures -Thin, bright wall margins

The main lobar fissure helps from the "______" in which the gallbladder lies.

-bed

Store the _____ until it is needed to aid digestion.

-bile

The ampulla of Vater is where the intraduodenal CBD empties ________ to assist in the digestive process.

-bile

The sphincter of Oddi forces the gallbladder to fill with _______.

-bile

Bile is produced by the liver and carried to the gastrointestinal system by the _________ system.

-biliary

The funds of the gallbladder can be challenging to visualize because of its close proximity to __________.

-bowel Bowel often creates a shadow that partially obscures the fundus.

Inflammation of the gallbladder?

-cholecystitis

When fats and amino acids are ingested, the duodenal mucosa releases _____________, a peptide hormene.

-cholecystokinin (CCK)

The ____________ is larger in diameter and can be seen on ultrasound closely associated with the portal venous system.

-common duct

The common bile duct empties into the?

-duodenum

cholelithiasis

-formation or presence of gallstones, which are calcifications in the gallbladder or biliary duct.

Cholelithiasis

-gallstones

The portion of the CBD inferior to the duodenum is the?

-infraduodenal

The portion of the CBD within the duodenum is the?

-intraduodenal

An __________ gallbladder will be totally (or almost totally) enclosed in liver tissue.

-intrahepatic

Bile reservoir on posteroinferior surface of _____.

-liver

Blood is conveyed from the gastrointestinal tract via the portal vein to the ______.

-liver

The right and left main ducts join at approximately the level of the ____________ to form the CHD, the proximal portion of the CD.

-liver hilum

The gallbladder fossa or bed is closely related to the _________ of the liver.

-main lobar fissure

The spiral valves of Heister prevent the cystic duct from?

-overdistending or collapsing

The sonographic appearance of a longitudinal section of the normal, distend gallbladder is that of anechoic or nearly anechoic ______-shaped structure with thin, bright wall.

-pear

There are times when the gallbladder is simply difficult to see, not because of some structural variation, but because of ___________.

-physiology

Floating gallstones, _________ (protruding masses from the inner wall of the gallbladder), and other masses may be present in the fundus of the gallbladder and easily missed on casual examination.

-polyps

Choledocholithiasis

-presence of gallstones in the biliary ducts.

The gallbladder is located on which quadrant?

-right upper quadrant

The ______________, located in the duodenum, regulates the passage of bile into the duodenum and at the same time prevents reflux of gastrointestinal fluids into the biliary system.

-sphincter of Oddi

Common duct longitudinal section may be noted as _____ bright, parallel lines separated by just 1 mm or so of anechoic bile.

-two

Gallbladder is divided into (3)?

1.) Fundus 2.) Body 3.) Neck

The proper hepatic artery supplies the (2)?

1.) Gallbladder 2.) Liver

Mickey Mouse sign

1.) Right ear= CBD 2.) Left ear= proper hepatic artery 3.) Face= Main portal vein

Bile remaining constituents include (5)?

1.) cholesterol 2.) bilirubin (bile pigment) 3.) proteins 4.) electrolytes 5.) mucus

1.) The proximal portion of the CD (common duct) is referred as to? 2.) The distal portion of the CD (common duct) is referred as to?

1.) common hepatic duct 2.) common bile duct

1.) The _________________ extends inferiorly from the liver hilum to the level of the ______________, where it meets the _____________. It is anterior to the _____________ and ______________.

1.) common hepatic duct (CHD) 2.) gallbladder neck 3.) cystic duct 4.) right portal vein 5.) Proper hepatic artery

The _________ connects the gallbladder to the CHD. It directs the flow of bile it receives from the CHD, directly into the gallbladder.

1.) cystic duct

The main lobar fissure serves as a landmark for locating what?

1.) gallbladder 2.) gallbladder fossa

Cholecystokinin stimulates the ___________ to contract and the ___________ to relax and increses hepatic production of ____.

1.) gallbladder 2.) sphincter of Oddi 3.) bile

1.) The left and right intrahepatic ducts join at approximately the level of the liver ________. 2.) Also called?

1.) hilum 2.) porta hepatis or doorway

The biliary system is intimately associate with (2)?

1.) liver 2.) pancreas

The gallbladder concentrates the bile by secreting ______ and absorbing ______.

1.) mucus 2.) water

The hepatic artery, or common hepatic artery, as it is often called, divides into (2)?

1.) proper hepatic 2.) gastroduodenal arteries.

Inside the gallbladder are many minute, inward folds or ______. These folds aid in concentrating the bile through absorption of _______ and secretion of ____.

1.) rugae 2.) water 3.) mucus

The cystic duct, CBD and part of the CHD are extrahepatic biliary ducts that are lined with (1)?

1.) subepithelial connective tissue 2.)smooth muscle fibers

Bile is composed mostly of ________ and __________.

1.) water (82%) 2.) bile acids (12%)

True or False It is especially uncommon for the gallbladder, CHD, and CBD to be imaged.

False- "common"

True or False The cystic artery usually originates from the right branch of the gastroduodenal artery.

False- proper hepatic artery

True or False Due to its long mesentery, the gallbladder will change location as the patient changes position.

-True

True or False Even though this are of folds is called a valve, it is a misnomer. There does not seem to be any valve or flow control action; bile flows freely in both directions through the cystic duct.

-True

The normal gallbladder is approximately ___ to___ cm in diameter and holds approximately ____ mL of bile.

1.) 3 to 5 cm 2.) 40 mL

Portal triads are composed of (3)?

1.) Bile duct 2.) Portal vein 3.) Hepatic arteries

The hepatic portal system includes all the veins draining the gastrointestinal tract including( 3)?

1.) Spleen 2.) Pancreas 3.) gallbladder

There are three distinct layers of the gallbladder wall, they are?

1.) The inner mucosa 2.) The middle fibromuscular layer 3.) The outer serous layer

The bile duct and pancreatic duct(s) empty what into the duodenum?

1.) bile and pancreatic enzymes to assist the digestive process.

The ________ duct and _______ duct(s) may join and form one duct or remain separate and enter the ________ together.

1.) bile duct 2.) pancreatic duct(s) 3.) duodenum

The left and right intrahepatic ducts join at approximately the level of the liver hilum (also called the porta hepatis, or doorway) to form the ____________ or_______________.

1.) biliary duct 2.) common duct (CD)

Blood therefore passes through two sets of "exchange" vessels: the _________ within the organs of the gastrointestinal tract, the spleen, pancreas, and gallbladder and the _________.

1.) capillaries 2.) hepatic sinusoids

1.) The common hepatic duct joins the cystic duct to form the?

1.) common bile duct

The cystic artery may, on occasion, originate directly from the (3)?

1.) common hepatic artery 2.) gastroduodenal artery 3.) proper hepatic artery

The gallbladder may be descriptively divided into three major section, they are (3)?

1.) funds 2.) body 3.) neck

The biliary system consist of? Name function as well.

1.) gallbladder- acting as a reservoir for bile. 2.) bile ducts- ducts that drain the liver of bile.

Bile from the liver reach the gallbladder through which ducts (3)?

1.) hepatic ducts 2.) The proximal portion of the common duct (the common hepatic duct) 3.) cystic duct

A gallbladder found to be just at the inferior border of the right lobe of the liver with the patient supine may then be found to have shifted closer to the __________ when the patient is placed on the ______ side with the ______ side raised. This patient repositioning is known as the?

1.) midline 2.) left 3.) right -left lateral decubitus (LLD) or left lateral oblique (LLO) positions.

The proper hepatic artery passes __________ (anterior/posterior) to the CHD and _____________ (anterior/posterior) to the cystic duct. At this point, it travels inferiorly and divides into __________ and ________ branches.

1.) posterior 2.) anterior 3.) superficial 4.) deep

When referring specifically to the CBD, anatomists use terms that relate its location to the duodenum, they are (4)?

1.) supraduodenal 2.) retroduodenal 3.) infraduodenal 4.) intraduodenal

1.) Some imagers believe that by simply bending the right arm 90 degrees at the elbow and then placing that hand over the midline, the location of the gallbladder may be estimated- with the gallbladder being in the are of the______. 2.) (True or False) This method is not particularly accurate but it does give a rough idea of the location of the gallbladder.

1.) wrist 2.) True

What is the function of the sphincter of Oddi?

-The sphincter of Oddi aids in regulating bile flow into the duodenum.

True or False Certain conditions, such as cholecystitis (inflammation od the gallbladder), may cause the walls to appear edematous and perhaps even greatly thickened.

-True

The diameter or the right and left hepatic ducts has been reported at between _____ to _____ cm.

-0.1 to 0.2 cm

2.5 cm equals _____ in.

-1 inch.

It is a good rule of thumb to consider it normal for extrahepatic duct to dilate approximately _____ mm per decade of life.

-1 mm

One study has reported the diameter range from approximately _____ to ____ mm in the normal patient, depending on age, previous surgery, and gallblader function disease.

-1 to 7 mm

The diameter of the common bile duct (CBD) has been reported to be ___ to ____ mm in the normal patient.

-1 to 7 mm

The diameter of the common bile duct (CBD) has been reported to be up to _____ mm in a patient after cholecystectomy (surgical removal of the gallbladder).

-10 mm

Some reports have cited gallbladder length as much as _____ cm as measured from the neck to the fundus.

-12 cm

CBD lengths of up to ___ cm have been reported.

-17 cm

Oikarinen gives a CHD lenght of ____ to _____ cm and a _____ to _____ for the right and left hepatic ducts.

-2 to 6.5 cm -0.5 to 2.5 cm

The diameter of the cystic duct is approximately ____ mm.

-3 mm

The walls of the gallbladder are generally only a few millimeters thick, up to approximately _____ mm.

-3 mm This wall thickness is important to note.

True or False The CBD is posterior and slightly right lateral to the main portal vein and right lateral to the proper and common hepatic arteries.

-False- The CBD is anterior and slightly right lateral to the main portal vein and right lateral to the proper and common hepatic arteries.

Which is the term used to describe venous blood that passes through two capillary exchange systems before reaching the heart?

-Portal circulatory route

The lumen of the cystic duct contains a series of mucosa folds, the ____________.

-Spiral valves of Heister

True or False From its origin at the level of the CHD and cystic duct, the CBD runs inferiorly along the right border of the lesser omentum, along the hepatoduodenal ligament; passes posterior to the first portion of the duodenum; passes posterior through or lies on the back of the posterolateral portion of the pancreas head; and enters the posteromedial aspect of the descending portion of the duodenum and terminates.

-True

True or False Pressure differences in the biliary system, along with the stimulated contraction of the gallbladder, seems to govern the flow of bile.

-True

True or False The basic function of the biliary system is to drain the liver of bile and then store the bile until it is needed to aid digestion.

-True

True or False The common bile duct (CBD) is a continuation of the CHD but described separately based on its location and association with adjacent anatomy that is different from the anatomy associated with the CHD.

-True

True or False The gallbladder is not totally surrounded by hepatic tissue; however, it is possible for this to occur.

-True

True or False The gallbladder is perfused by the hepatic artery branch of the celiac artery, which is a branch of the abdominal aorta.

-True

True or False The length and inside diameter of the CHD are variable.

-True

True or False The overall length of the normal gallbladder is highly variable, depending on the amount of bile within and any existing normal variant.

-True

True or False The shape of the normal gallbladder has been likened to that of a pear.

-True

True or False The wall thickness is slightly less when the gallbladder is full or distended (the walls are stretched) as compared with an empty gallbladder when the walls are slightly thicker.

-True

True or False With experience, the sonographer discovers that the gallbladder has a wide variety of shapes, sizes, and locations.

-True

The infraduodenal portion of the CBD is the portion previously mentioned that may be located within a groove on the posterolateral portion of the head of the pancreas or pass directly through the head. At this point, the CBD either joins the pancreatic duct(s) to form a single duct or remains separate and enters the ________________.

-ampulla of Vater

The common bile duct (CBD) is the ___________(proximal/distal) (superior/inferior) portion of the common duct (CD).

-distal or inferior

The cystic duct, CBD and part of the CHD are?

-extrahepatic biliary ducts (not enclosed by liver tissue).

The ______________ is located on the posteroinferior portion of the right lobe of the liver where the gallbladder is situated.

-gallbladder fossa

Porta comes from the Latin word porta, which means?

-gateway.

The gallbladder is perfused by the ____________.

-hepatic artery

The intrahepatic ducts unite to form the right and left main __________.

-hepatic ducts.

Venous drainage of the gallbladder is by way of the________.

-hepatic portal system

The portal vein subdivides until the blood reaches the ________.

-hepatic sinusoids

The ampulla of Vater may also be called?

-hepatopancreatic ampulla -an opening into the duodenum

Surrounded by a sheath of connective tissue, intrahepatic bile ducts and hepatic arteries accompany portal vein in _______ that radiate throughout the lobes and segments of the liver.

-portal triads

The __________ is the gateway through which blood returning from the gastrointestinal tract and accessory organs passes before returning to the heart.

-portal vein

The portion of the CBD posterior to the duodenum is the?

-retroduodenal

Soto and Castrillon report that the CHD should be measured at the level of the_____________ where it crosses between the CHD and the portal vein.

-right hepatic artery

A muscle sheath- known as the ________ or ________ - surrounds the CBD at the ampulla of Vater.

-sphincter of Oddi or Oddi's muscle

The part of the CBD superior to the duodenum is the?

-supraduodenal