Pathological Conditions of the Biliary System

what are 6 other causes for obstructive jaundiced and biliary duct dilation

1. pancreatic head carcinoma

2. cholangiocarcinoma

3. sclerosing cholangitis

4. hepatoma

5. GB cancer

6. biliary atresia

what are 5 symptoms of obstructive jaundiced and biliary duct dilitation

1. yellow skin and sclera

2. weight loss

3. elevated bilirubin and alk phos

4. RUQ pain

5. pruritis

cancer in the bile ducts is called ____

cholangiocarcinoma

sclerosing cholangitis

inflammation of bile ducts that causes a narrowing

pruritis

skin itchiness from jaundice

what are 3 levels where obstruction can occur in the biliary system

1. CBD

2. Ampulla of Vater

3. GB alone

obstruction at the level of the ampulla of vater will cause dilatation of both ____ and ____ duct

biliary and pancreatic

ampulla of vater obstructions most commonly are due to _____

pancreatic head carcinoma or acute pancreatitis

what are some causes for intrinsic biliary obstruction

1. stones

2. biliary atresia/choledochal cyst

3. carcinoma of ampula of vater

4. cholangiocarcinoma

5. pancreatitis which causes duct stricture

6. post liver TX bile duct stenosis

what are some causes for extrinsic biliary obstruction

1. carcinoma of head of the pancreas

2. pancreatitis

3. lymphadenopathy at porta hepatis

4. masses at porta hepatis

5. intrahepatic tumors

what are 2 diffuse hepatic conditions that cause biliary obstruction

1. sclerosing cholangitis

2. caroli’s disease

a normal CHD has internal diameter of ___, ____ is borderline, and ____ requires further investigation

<4, 5, 6mm

can a pt have a normal size hepatic duct and still have a distal obstruction

yes

a normal CBD has internal diameter slightly greater than the hepatic duct, ____ is borderline, and ____ is dilated

>6, >10 mm

bile ducts can _____ after cholecystectomy

enlarge

Obstruction of biliary ductal system is diagnosed by ultrasound when the sonographer finds the presence of _____

ductal dilation

what finding is seen when intrahepatic ducts are dilated

“too many tubes“ or “shotgun“ sign

what effect can fibrosed or infiltrative disease of the liver have on biliary obstruction

can prevent intrahepatic dilation (due too lack of complaince of the hepatic parenchyma)

biliary obstruction may present as ____

jaundice

when is painful jaundice seen

with acute obstruction or infection that may invade biliary tree

what are the 3 primary areas for biliary obstruction

1. porta hepatic

2. suprapancreatic

3. intrapancreatic (most distal)

porta hepatic biliary obstruction is usually the result of a ______

neoplasm

what does the intrahepatic ducts and the CBD look like with porta hepatic biliary obstruction

dilated intrahepatic ducts, normal CBD

_____ of the gallbladder may be present with porta heptatic biliary obstruction

hydrops

suprapancreatic biliary obstruction originated between the ________

pancreas and the porta hepatis

what do the intrapancreatic duct, pancreatic duct, and the head of the pancreas look like with the presence of suprapancreatic biliary obstruction

normal

the most common cause for suprapancreatic biliary obstruction is _____

malignancy or adenopathy

what is being shown in this image

suprapancreatic biliary obstruction (bile duct is dilated due to mass)

what 3 conditions cause the majority of biliary obstruction at the level of the distal duct and cause the extrahepatic duct to entirely dilate

1. pancreatic carcinoma/cancer of ampulla of vater

2. choledocholithiasis

3. chronic pancreatitis with stricture formation

uncommon cause for extrahepatic biliary obstruction as a result of an impacted stone in the cystic duct, which creates extrinsic mechanical compression of the common hepatic duct

mirizzi syndrome

what is the anatomy behind mirizzi syndrome

cystic duct inserts unusually low into CHD so they run parallel to each other

what is the sonographic appearance for mirizzi syndrome

immoble calculus in cystic duct or neck and dilation of intrahepatic duct

what is this image showing

mirizzi syndrome

what is this image showing

intrahepatic ductil dilatation (shot gun sign)

what is this image showing

intrahepatic ductil dilatation

what is this image showing

dilated intrahepatic ducts secondary to mass in porta hepatis (irregular walled, dilated bile ducts)

_____ is stones in the bile duct

choledocholithiasis

what is one of the most common causes of biliary obstruction

choledocholithiasis

___% of pts with GB stones will have choledocholithiasis

15%

choledochalithiasis is associated with _____

calculous cholecystitis (GB inflammation due to gallstones in cystic duct)

the cystic duct is most common area for choledocholithiasis but can commonly be found in the distal portion of the _____ near the pancreatic head

CBD

what is this image showing

choledocholithiasis (in CBD)

what is this image showing

choledocholithiasis

what is cholangitis

inflammation of the bile ducts (caused by baterial infection, acquirred or congenital)

cholangitis put pt at risk for ______

cholangiocarcinoma

what is charcots triad

1. fever

2. jaundice

3. RUQ pain

what are the clinical symptoms for cholangitis

biliary colic, charots triad, elevated serum leukocytosis,bilirubin,and alkaline phosphate, leukocytosis

the cholangitis sonography is ____ bile ducts and ____ formation

thickening, pus

what is this showing

cholangitis (note bile duct walls are thickened)

what is this showing

cholangitis (note bile duct walls are thickened)

A chronic hepatobiliary disease in which the walls of the bile ducts become inflamed which causes narrowing

primary sclerosing cholangitis

what causes primary sclerosing cholangitis

often idiopathic (may be associated with inflammatory bowel disease)

what are the clinical symptoms for primary sclerosing cholangitis

jaundice, pruritis, fatigue, gallstones can be present

what is the sonography for primary sclerosing cholangitis

1. thick bile ducts

2. hyperechoic bile ducts throughout liver, ductal strictures or dilations

what is this image showing

primary sclerosing cholangitis

what is this image showing

primary sclerosing cholangitis

______ is a disease caused by the parasitic roundworm ascaris lumbricoides

ascariasis

ascariasis is contracted via ______

fecal-oral route (fecal matter)

ascariasis worms are usually _____cm long

20-30cm

ascariasis grows in the _____ before entering biliary tree through ampulla of vater

small bowel

ascariasis causes _____

acute biliary obstruction

what are the clinical symptoms for ascariasis

asymptomatic or biliary colic

what is this image showing

ascariasis

what are these images showing

ascariasis (dilated duct showes movement)

intrahepatic calculi occurs in patients with ________

recurrent pyogenic cholangitits (aka oriental cholangiohepatitis/intrahepatic pigment stone disease)

intrahepatic calculi is very common in what continent

asia

what are choledochal cysts

congenital, focal or diffuse cystic dilation of the biliary tree

_____ may result from pancreatic juices refluzing into the bile duct

choledochal cysts

what are the symptoms for choledochal cysts

1. abdominal mass

2. pain

3. fever

4. jaundice

what are the classifications for choledochal cysts

Type I, Type II, Type III, Type IVa, Type IVb, Type V (caroli’s disease)

type I choledochal cysts are ____ dilation of the common bile duct

fusiform

type II choledochal cysts are true ____ of the bile ducts

diverticuli

type III choledochal cysts (_________) are confined to the intraduodenal portion of the CBD

choledochoceles

type IVa choledochal cysts are condinded to the ____ biliary tree

extrahepatic

type V choledochal cysts are classified as _____ disease

caroli’s

what is caroli’s disease

congenital disease where bile ducts dilate and can become infected and seperate from the bile duct to form choledochal cysts

caroli’s disease has been associated with _____

cystic kidney disease

caroli’s disease is usually found in _____

childhood or early adulthood

what is the sonography for caroli’s disease

multiple biliary cysts continuous with the biliary tree, stones and echoes may appear in tree

what is shown in this image

caroli’s disease (cystic structures continuous with biliary tree)

what is shown in this image

caroli’s disease (cystic structures continuous with biliary tree)

what is shown in this image

choledochal cysts, diverticuli projections off biliary tree

what is shown in this image

choledochal cyst

what is clonorchiasis

parasitic worm from raw freshwater fish

what happens to the bile ducts with clonorchiasis

dilatation of bile ducts with wall thickening and echogenic focus within

intrahepatic biliary tumores are RARE and primarily limited to ______ and _____

cystadenoma and cystadenocarcinoma

what is the sonographic appearance of intrahepatic biliary neoplasms

cystic mass with multiple septa and papillary excrescences

what are the differential diagnoses for intrahepatic biliary neoplasms

hemorrhaic cyst or infection, echinococcal cyst, abscess, or cystic metastasis

cholangiocarcinoma is also known as _______

biliary adenocarcinoma

cholangiocarcinoma can mimic ___

HCC (hepatocellular carcinoma)

cholangiocarcinoma arises from the ______

wall of the bile duct

cholangiocarcinoma can occur anywhere in the biliary system, however it is most commonly found _______

at the union of the common hepatic duct (inbetween the rt and lt hepatic ducts)

what is the cholangiocarcinoma called when found at the union of the common hepatic duct

klatskin tumor

what are the clinical symptoms for cholangiocarcinoma

RUQ pain, malaise, anorexia, jaundice, biliary colic

what is the sonography for cholangiocarcinoma

large hepatic mass (hypo to hyperechoic), masses within the ducts may be outlined, duct wall thickening, focal duct stricture or duct termination

what is the sonography of klatskin tumors

very difficult to detect, mass at the hilum

what is shown in this image

intrahepatic cholangiocarcinoma (dilated ducts with abrupt termination)

what is shown in this image

intrahepatic cholangiocarcinoma (dilated ducts with ill defined mass

what is shown in this image

klatskin tumor (mass with dilated ducts that terminate)

what is shown in this image

klatskin tumor (mass with dilated ducts that terminate)