ABD: CTL Pathology 42% - Biliary System

Which liver mass demonstrates characteristics most consistent with a Klatskin tumor? Use your mouse to position the cursor over the Klatskin’s tumor and click to select the mass.

Which of the following abnormalities is associated with the production of milk of calcium bile?

a. hepatoma

b. cirrhosis

c. chronic cholecystitis

d. acute cholecystitis

c

An infant is referred for an abdominal sonogram due to prolonged jaundice after birth. A small triangular echogenic area is identified at the portal vein bifurcation, but no definite extrahepatic duct is noted. The gallbladder is very small and abnormally shaped. These findings are most suggestive of:

a. choledochal cyst

b. biliary atresia

c. biliary ascariasis

d. Caroli disease

b

Tumefactive sludge would demonstrate a sonographic appearance similar to all the following, except:

a. secondary GB carcinoma

b. primary GB carcinoma

c. benign polyp

d. membranous gangernous cholecystitis

d

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

a. biliary stricture

b. abscess formation in GB fossa

c. biloma formation in GB fossa

d. porcelain GB

b

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?

a. choledocholithiasis

b. choledochal cyst

c. Caroli disease

d. Bouveret syndrome

c

Primary sclerosing cholangitis significantly increases the risk of developing:

a. cholangiocarcinoma

b. pancreatic carcinoma

c. Klatskin tumor

d. hepatic lipoma formation

a

A 35 y/o male patient presents for a RUQ ultrasound due to pain, increase 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?

a. stone in right hepatic duct

b. stone in left hepatic duct

c. biliary atresia

d. stone in common hepatic duct

d

A 85 y/o patient presents with a history of epigastric pain. Lab values are normal. The exam demonstrates normal hepatic ducts and a 10mm CBD that appears patent. The pancreas appears normal. What is the most likely reason for the 10 mm CBD?

a. cholangitis usually only affects the CBD and can lead to a focal extrahepatic dilatation

b. the obstruction in the CBD must be due to biliary stricture which is hard to visualize sonographically

c. the patient most likely has portal HTN which can cause ductal dilatation

d. the CBD normally dilates with age

d

Diffuse or focal GB wall thickening may be seen with all the following, except:

a. acute cholecystitis

b. carcinoma of the GB

c. adenomyomatosis

d. Courvoisier GB

d

A porcelain GB causes an increase in the patient’s risk for ________.

a. sclerosing cholangitis

b. choledocholithiasis

c. primary carcinoma

d. adenomyomatosis

c

Obstruction of the CBD by a pancreatic head mass will lead to:

a. dilated GB and biliary tree

b. contracted small GB with normal biliary tree

c. contracted small GB with dilated biliary tree

d. all the above are potential findings

a

A 64 y/o 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?

a. Mirizzi syndrome

b. choledochal cyst

c. Courvoisier sign

d. Murphy sign

c

Which of the following is associated with the findings on the image displayed?

a. Krukenberg tumor formation in the duodenum

b. adenocarcinoma formation of the pancreatic head

c. obstruction of the Ampulla of Vater

d. more than one of the above

d

Primary GB carcinoma most commonly presents as:

a. enlarged GB surrounded by fluid

b. small GB with thickened walls

c. focal wall mass without stones

d. diffusely thickened GB wall with stones

d

A patient presents with intermittent RUQ pain and nausea. No lab information was available at the time of the US exam. The findings on the image are most suggestive of:

a. tumefactive sludge

b. primary GB carcinoma

c. GB metastasis

d. empyema of the GB

c

A biloma is:

a. associated with malignancy of the biliary tree

b. a possible complication of LT renal surgery

c. a collection of bile in the peritoneal cavity

d. a congenital malformation of the biliary tree

c

What is the most common cause of pneumobilia?

a. GB perforation

b. biliary duct stones

c. pancreatitis

d. ERCP

d

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

a. ask the patient to perform the Valsalva maneuver

b. use color doppler over the area of interest

c. give the patient a fatty meal and rescan

d. turn off harmonic imaging

b

A patient presents for an abdomen US 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 artifact and dirty shadowing are present posterior to this area. Which of the following conditions is identified on this exam?

a. adenomyomatosis

b. chronic cholecystitis

c. cholesterol polyps

d. emphysematous cholecystitis

d

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

a. choledocholithiasis

b. pneumobilia

c. retained surgical instruments

d. surgical clips

b

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

a. porcelain GB

b. emphysematous cholecystitis

c. adenomyomatosis

d. strawberry GB

b

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

a. mucocele of the GB

b. septated GB

c. Hartmann pouch

d. porcelain GB

a

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

a. cholelithiasis

b. choledochal cysts

c. choledocholithiasis

d. mucocele of the GB

b

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

a. portal thrombosis at the porta hepatis

b. cystic artery obstruction

c. Kaposi sarcoma, intrahepatic obstruction

d. tumor of the ampulla of Vater

d

A 64 y/o female presents with recent weight loss and mild jaundice. Lab values demonstrate normal WBC levels, but increased levels of direct bilirubin, alkaline phosphatase, and prothrombin time. The GB demonstrates a small wall mass that is isoechoic to the wall tissues. The wall measures 4.5mm in maximum thickness. Multiple stones are present within the lumen. Which of the following best describes the findings on the image?

a. adenomyomatosis

b. primary GB carcinoma and cholelithiasis

c. acute cholecystitis, polyp formation and cholelithiasis

d. acute cholecystitis and cholelithiasis

b

A bile duct diameter should be measured with the calipers placed from:

a. leading edge to leading edge

b. inner to inner wall

c. outer to outer wall

d. inner to outer wall

b

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 that communicate with the biliary tree. Which of the following could be used to describe the expected US diagnosis?

a. choledochal cysts or polycystic liver disease

b. Caroli disease or choledochal cysts

c. polycystic liver disease

d. Wilson disease

b

Which of the following would present with no signs of jaundice?

a. hepatitis

b. a stone at the Ampulla of Vater

c. mucocele of the GB

d. sphincter of Oddi dysfunction

c

What biliary abnormality is a common finding in patients with hemolytic anemia?

a. cholecystitis

b. adenomyomatosis

c. cholelithiasis

d. GB carcinoma

c

A choledochocele is:

a. a type of cyst that forms in the proximal ducts of the biliary tree

b. a collection of bile that forms around a perforated GB

c. a cyst of the extrahepatic or intraduodenal portion of the duct

d. an intrahepatic collection of bile that forms around a major branch of the biliary tree

c

Acalculous cholecystitis is a common finding in all the following except:

a. AIDS

b. a history of a prolonged low fat diet

c. sepsis

d. a history of recent abdominal surgery

b

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

a. Hartmann pouch

b. adenomyomatosis

c. Bouveret syndrome

d. membranous gangernous GB

d

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

a. the GB is contracted with thickened wall and pus formation caused by infection

b. the GB is contracted and contains multiple shadowing stones within the lumen

c. the GB is contracted with thickened walls and polyp formation caused by adenomyomatosis

d. the GB is contracted with thickened walls and polyp formation caused by adenocarcinoma

c

An otherwise asymptomatic patient presents for an abdomen US due to elevated LFTs. The GB demonstrates thickened walls with an irregular internal contour. Several small echogenic foci are noted within the wall and each exhibits a comet tail artifact. Which of the following conditions is identified on this exam?

a. cholesterol polyps

b. adenomyomatosis

c. chronic cholecystitis

d. emphysematous cholecystitis

b

Mirizzi syndrome is caused by obstruction of the ________, while Courvoisier GB is related to obstruction of the _________.

a. distal CBD, cystic duct

b. intrahepatic CBD, extrahepatic CBD

c. proximal CBD, distal CBD

d. cystic duct, distal CBD

d

Cholelithiasis without cholecystitis is a common finding in patients with ______, while cholecystitis without cholelithiasis is a common finding in patients ________.

a. a consistently low high diet, on a consistently low fat diet

b. on long term TPN, on a consistently low fat diet

c. a consistently low fat diet, on long term TPN

d. congestive heart failure, with sepsis

c

Acute cholecystitis can lead to a prominent ________ and its branches with color doppler evaluation of the thickened GB wall.

a. proper hepatic artery

b. cystic artery

c. left hepatic artery

d. common hepatic artery

b

An impacted stone in the GB neck increases the risk of developing:

a. adenomyomatosis and polyp formation

b. stones and dilatation in the intrahepatic ducts

c. cholecystitis and gangrene

d. stones and dilatation in the extrahepatic ducts

c

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

a. if biliary obstruction is present, the bile duct diameter will remain unchanged immediately after the meal

b. if biliary obstruction is present, the bile duct diameter will decrease immediately after the meal

c. if biliary obstruction is present, the bile duct diameter will increase immediately after the meal

d. the cystic duct dilates to allow for a detailed lumen evaluation for a possible stone

c

What is the most likely cause for the biliary findings on the image?

a. hepatitis

b. acute cholecystitis

c. congestive heart failure

d. pancreatitis

c

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

a. binge eating

b. pancreatic tail mass

c. alcoholism

d. elevated cholecystokini levels

c

Based on the images, where is the obstruction?

a. distal CHD

b. distal CBD

c. main portal vein thrombosis with dilated portal branches in the liver

d. cystic duct

b

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

a. chronic cholecystitis

b. secondary GB carcinoma

c. adenomyomatosis

d. cholesterolosis

d

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

a. positive Morrison sign

b. patient uncooperative, unable to efficiently perform the exam

c. positive Homan sign

d. positive Murphy sign

d

Tumefactive sludge can be found in the:

a. paracolic gutters

b. GB

c. renal pelvis

d. gastric antrum

b

If pneumobilia is suspected, visualization of what acoustic artifact would support the diagnosis?

a. posterior enhancement

b. slice thickness

c. ring down

d. range resolution

c

What structure is indicated by #2?

a. hepatic artery

b. splenic vein

c. CBD

d. MPV

a

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

a. the gallstone can be located in any part of the GB while porcelain calcification only affects the GB fundus

b. a large gallstone and porcelain GB are not easily differentiated on US

c. the posterior wall of the GB can be evaluated in patients with porcelain GB but not in patients with a large stone

d. a gallstone will demonstrate significant posterior shadowing but there is no shadowing associated with the wall calcification seen with a porcelain GB

c

A new liver mass in a patient with sclerosing cholangitis should cause suspicion of:

a. development of schistosomiasis

b. a peribiliary leak

c. portal HTN

d. the development of cholangiocarcinoma

d

Which of the following is associated with prolonged fasting?

a. splenosis

b. pyloric stenosis

c. GB sludge

d. steatosis

c

If gallstone impaction is suspected:

a. place the patient in LLD and tap the patient’s back between the scapulas with the base of your wrist to attempt to move the stone

b. place the patient in LLD and ask the patient to perform the Valsalva maneuver to attempt to move the stone

c. ask the patient to stand during the exam and perform the Valsalva maneuver to attempt to move the stone

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

d

Bacterial cholangitis is nearly always seen with:

a. ductal obstruction by a stone or tumor

b. biliary ascariasis

c. ulcerative colitis

d. HIV cholangitis

a

A 66 y/o female presents for an abdominal US due to bloating and pain following a recent cholecystectomy. The bile ducts demonstrate varied levels of increased echogenicity with dirty shadowing and ring-down artifact posterior to several segments. These findings are consistent with?

a. choledocholithiasis

b. sclerosing cholangitis

c. cholangiocarcinoma

d. pneumobilia

d

What is the most common cause of cholangitis?

a. AIDS

b. Klatskin tumor

c. choledocholithiasis

d. adenomyomatosis

c

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

a. chronic cholecystitis

b. emphysematous cholecystitis

c. cholangitis

d. GB perforation

b

Jaundice is a complication of:

a. steatosis and hemangiomas

b. steatosis and polycystic liver disease

c. ductal obstruction and WBC destruction

d. ductal obstruction and RBC destruction

d

What biliary anomaly is suspcted if jaundice persists more than 14 days after birth?

a. choledochal cyst

b. biliary atresia

c. ectopic GB

d. agenesis of the GB

b

A patient presents for a 2 month follow up for a liver transplant. Lab tests indicate abnormal LFTs, increased bilirubin, and jaundice. The US exam demonstrates a new focal dilatation 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:

a. choledochal cyst

b. biliary stricture

c. mass in the Ampulla of Vater

d. Budd Chiari syndrome

b

This patient is at increased risk of developing:

a. Marfan syndrome

b. GB metastasis

c. porcelain GB

d. nephrolithiasis

c

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

a. a history of recent abdominal surgery

b. AIDS

c. sepsis

d. a history of prolonged low fat diet

d

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

a. Marfan syndrome

b. Mirizzi syndrome

c. Bouveret syndrome

d. Courvoisier syndrome

c

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

a. Brenner tumor

b. mass at the Ampulla of Vater

c. mass at the valves of Heister

d. Klatskin tumor

d

A 4 month old presents for an abdominal US following a recent Kasai procedure. Which of the following US findings would indicate the procedure was a success?

a. echogenic graft connecting the hepatic and portal venous systems in the liver with flow velocity greater than 40 cm/s

b. echogenic mesh in the abdominal wall used to close an inguinal hernia

c. echogenic mesh in the abdominal wall used to close an umbilical hernia

d. normal liver echotexture with normal biliary duct diameter

d

A 56 y/o 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 US findings are most suggestive of:

a. sclerosing cholangitis

b. hepatic artery stenosis

c. cholangiocarcinoma

d. HIV cholangitis

a

What term describes a GB that is filled with bile that is isoechoic to the liver and is difficult to identify on US?

a. Charcot triad

b. hepatization

c. Courvoisier GB

d. Mirizzi syndrome

b

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

a. shadowing and propagation speed

b. reverberation and shadowing

c. comet tail and twinkle

d. enhancement and propagation speed

c

The most common finding with choledochal cysts is:

a. cyst formation at the Ampulla of Vater

b. cystic dilatation of multiple intrahepatic ducts

c. cyst formation on the fundus of the GB

d. cystic dilatation of the CBD

d

Chronic cholecystitis is commonly associated with:

a. polyps

b. increased RBC count

c. GB carcinoma

d. pancreatic head mass

c

Which of the following is not true regarding milk of calcium bile?

a. layering of bile/calcium with change of patient position

b. also called limy bile

c. related to hyperfunction of the GB

d. lumen filled with highly echogenic material with shadowing

c

Which of the following is an acquired abnormality of the biliary system?

a. biliary atresia

b. choledochal cyst

c. sclerosing cholangitis

d. Caroli disease

c

What structure is indicated by #1?

a. splenic vein

b. MPV

c. hepatic artery

d. CBD

d

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

a. pancreatitis

b. hepatitis

c. stone lodged in cystic duct

d. mass in duodenum

c

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

a. 5 mm

b. 10 mm

c. 15 mm

d. 20 mm

b

RUQ pain, positive Murphy sign, and fever are common clinical signs of:

a. appendicitis

b. ascites

c. adenomyomatosis

d. acute cholecystitis

d

A patient presents with a low grade fever, leukocytosis, nausea, diarrhea, and LLQ pain. What is the most likely explanation for the findings on the image?

a. mass at the Ampulla of Vater

b. Caroli disease

c. biliary stricture in the cystic duct

d. primary sclerosing cholangitis

d

A patient with choledochal cysts has an increased risk of developing:

a. polycystic liver disease

b. cholangiocarcinoma

c. biliary atresia

d. portal HTN

b

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

a. choledochal cyst

b. emphysematous cholecystitis

c. pneumobilia

d. adenomyomatosis

d

A patient presents for an abdominal US for pain. The chart holds a recent x-ray report that states there is a possible porcelain GB present. How will this abnormality appear on US?

a. the GB will be hydropic with a thickened wall and an increased risk of rupture

b. there is a single large stone present with a thickened GB wall

c. the GB wall will demonstrate varied levels of linear calcification

d. the GB will be completely packed full of small stones

c

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

a. the GB demonsrates a cholesterol polyp with the comet tail artifact

b. there is a polyp located in the lateral wall of the GB fundus

c. there is a polyp located in the inferior wall of the GB fundus

d. there is a polyp located in the inferior wall of the GB neck

d

A non-infectious cause of acalculous cholecystitis is _________ and an infectious cause of acalculous cholecystitis is _________.

a. TPN, HIV

b. congestive heart failure, TPN

c. HIV, viscous bile

d. viscous bile, Mirizzi syndrome

a

Which of the following are types of hyperplastic cholecystosis?

a. adenomyomatosis and cholesterolosis

b. cholelithiasis and choledocholithiasis

c. sludge and tumefactive sludge

d. perforation and pericholecystic fluid

a

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

a. contracted GB and dilated extrahepatic and intrahepatic ducts

b. dilated GB and dilated intrahepatic ducts

c. contracted GB and dilated intrahepatic ducts

d. dilated extrahepatic ducts

c

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

a. polyp

b. sludge ball

c. calculus

d. porcelain GB

a

Numerous liver cysts with the central dot sign are most suggestive of:

a. Von Meyeburg complexes

b. Caroli disease

c. polycystic liver disease

d. hemorrhagic cysts

b

Primary GB carcinoma most commonly presents as:

a. diffusely thickened GB wall with stones

b. enlarged GB surrounded by fluid

c. small GB with thickened walls

d. focal wall mass without stones

a

What image demonstrates a GB with characteristics of adenomyomatosis?

The GB wall is asymmetrically thickened wtih 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?

a. cholesterolosis

b. chronic cholecystitis

c. adenomyomatosis

d. gangernous cholecystitis

d

Which of the following describes how to differentiate adenomyomatosis of the GB from cholesterolosis of the GB?

a. adenomyomatosis is usually focal process and cholesterolosis is a diffuse process

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

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

d. adenomyomatosis is usually a diffuse process and cholesterolosis is a focal process

b

Which of the following statements is true regarding the image displayed?

a. the MPV is significantly dilated, most likely due ot portal HTN

b. the GB is normal in appearance but the CBD is significantly dilated

c. the GB contains a stone and the MPV is significantly dilated

d. the GB wall demonstrates a solid mass and the CBD is significantly dilated

d

The twinkle artifact is an expected finding in cases of:

a. multicystic kidney disease

b. autosomal dominant polycystic kidney disease

c. adenomyomatosis

d. renal carbuncle

d

All the following terms can be used to describe the findings on the image except?

a. cholesterolosis

b. strawberry GB

c. adenomyomatosis

d. hyperplastic holecystosis

c

Acute cholecystitis is associated with GB wall thickening _______. Cholangitis is associated with ductal wall thickening ______.

a. >2 mm, >3 mm

b. >6 mm, >3 mm

c. >3 mm, >2 mm

d. >3 mm, >5 mm

c

The WES sign indicates a diagnosis of:

a. tumefactive sludge

b. cholelithiasis

c. porcelain GB

d. GB adenocarcinoma

b

Which of the following statements regarding GB sludge is true?

a. GB sludge is always associated with wall thickening

b. sludge in the GB is typically due to a hyperfunctioning GB

c. changing patient position and rescanning the GB typically has no effect on sludge layering/appearance

d. sludge can appear as varied layers of echogenic material in the GB lumen

d

What structure is indicated by #3?

a. IVC

b. CBD

c. splenic vein

d. MPV

d

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

a. volume averaging

b. comet tail

c. side lobe

d. mirror image

b

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

a. decreased color doppler gain

b. improperly decreased TGC settings

c. shadowing from surgical clip in portal hepatis

d. rejection setting too high

c

Distal cholangiocarcinoma is most commonly found _______ and a Klatskin tumor is most commonly found __________.

a. in the extrahepatic CBD near the porta hepatis, at the junction of the RT and LT hepatic ducts

b. at the junction of the RT and LT hepatic ducts, outside the liver in the CBD

c. near the dome of the liver, in the CBD near the porta hepatis

d. in the left lobe, in the right lobe

a

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

a. pneumobilia

b. choledochal cyst

c. pseudoaneurysm of the hepatic artery

d. cholangitis

b