PANCREAS + BILIARY TEST

How does the gallbladder contract when you eat?

The hormone Cholecystokinin is released into the bloodstream, making the muscular wall of the GB contract

What duct/s are not normally seen on US unless they are obstructed?

Intrahepatic ducts and cystic duct

Feeling referred RT shoulder pain may indicate which GB pathology?

Cholecystitis

Elevated serum bilirubin indicates what?

Hepatocellular damage

Elevated GGT and ALP indicates what?

Biliary Obstruction

Characteristics of the GB

Intraperitoneal organ that is pear shaped w/thin muscular outer wall & mucous membrane inner lining

Hartman’s pouch?

GB folds back on itself/abnormal diverticulum in GB neck

Junctional fold?

Fold between body and neck (infundibulum)

Phrygian cap

Folding of fundus

A GB wall thickness over how many mm is considered abnormal?

3mm

What are the normal measurements of the GB

7-10cm long and 3-4cm in diameter

What does the cystic duct connect?

Gallbladder neck with common hepatic duct to form the common bile duct

The cystic duct is 4cm long and shaped like what?

S-shaped

Valve of Heister’s

Spiral folds which control bile flow in the cystic duct and prevent kinking of the duct

The intrahepatic biliary tree branches converge aka join to form what?

Rt and Lt Hepatic duct

CHD is formed by what?

Rt and Lt Hepatic ducts

The CHD is normal in diameter up to how many mm?

4mm

T/F - The CHD diameter is measured inner wall to inner wall (only the lumen)

True

What forms the CBD?

CHD and Cystic duct

The CBD diameter is normal up to 6mm or up to how many mm per decade of age?

1mm

T/F - The CBD passes posterior to the 1st part of the duodenum

True

The CBD joins the main pancreatic duct as it enters which portion of the duodenum, via the ampulla of vater?

2nd portion

What are the circular, muscle fibers that surround the terminal CBD and main pancreatic duct?

Sphincter of Oddi

The CHD is normal up to how many mm in diameter?

4mm

HIDA Scan (Hepatobiliary iminodiacetic acid)

Nuclear medicine imaging test that evaluates the function of your liver, gallbladder, and bile ducts. By tracking the flow of a radioactive tracer, docs can diagnose inflammation, blockages, or other issues in the biliary system

Cholecystokinin (CCK) is administered, which simulates the ingestion of a fatty meal (like a taco bell luxe box)

Always do US first because you will be asked about duct size and stones

Vascular supply of GB

Arterial: RT Hepatic Artery to Cystic Artery

Venous: Cystic vein to portal vein

Agenesis means what

Congenital anomaly where there is no GB (bye bye)

Biliary Interposition

Congenital anomaly where CHD and Cystic Duct are absent

Since they’re gone, the main hepatic ducts drain directly into the GB and from Rt and LT Hepatic ducts. Then, bile goes from GB to CBD

Biliary Atresia

Congenital anomaly where the biliary tree is absent from the hilum of the liver to the duodenum (CHD and CBD)

You can tell someone is born with this when they are jaundiced beyond 14 days of age

What is Biliary Atresia associated with

Polysplenia syndrome - multiple tiny spleens

Absent IVC

Situs inversus - organs on opposite side

Cardiac anomalies

What is the triangular cord sign

Seen with biliary atresia; Echogenic, triangular structure anterior to the portal vein

A triangular cord thickness greater than 3 or 4mm is a common threshold for a positive sign

Kasai Portoenterostomy (KPE)

Surgical treatment to facilitate bile drainage (within 60 days) 38% of kids can survive with their own liver for 30 years after KPE

Liver transplant

Choledochal Cyst

Congenital bile duct anomaly consisting of cystic dilation of the extrahepatic bile ducts and has segmental cystic dilation usually of the CBD

It looks like a large cystic mass in porta hepatis and is prevalent in ASIA (33%0

Caroli’s disease

Type of choledochal cyst that is non-obstructive, saccular or beaded in appearance

Intrahepatic

What is a choledochal cyst associated with

Pancreatitis

Cholangitis

Cirrhosis

Portal hypertension

Cholangiocarcinoma

What is sludge

Thiqqened bile (calcium bilirubinate and cholesterol granules)

it is often caused by stasis, prolonged fasting OR GB disease

long-term parenteral nutrition (TPN) aka tube feeding, can induce what?

GB stasis

T/F - Sludge always has a shadow

False; It will only have shadows if it is accompanied by stone or milk of calcium bile (limy bile)

Sludge balls (tumefactive sludge)

Mobile, rounded organization of sludge always add color flow to prove it’s not a mass

What is the most common disease of the gallbladder, that includes single, large gallstones or multiple tiny stones

Cholelithiasis

T/F - Tiny stones are less dangerous than large ones

False

Patients may be asymptomatic with cholelithiasis until a stone lodges in what duct/s?

Cystic or common duct

Sonographic appearance of Cholelithiasis

Echogenic foci, Acoustic shadowing, gravity dependent

what is total contraction aka “WES Sign”

Wall echo shadow is basically when there are so many stones, the GB is shadowed

Etiology

Abnormal bile composition (most common) as a result of too much cholesterol, bile salts or bilirubin.

Can also be caused by stasis, bacterial infection, some medication like GLP1s

What are the 5 F’s of Cholelithiasis

Fat, Female, Forty, Fertile, and Fair

Besides the 5 F’s, what are other risk factors or cholelithiasis?

Pregnancy, diabetes, oral contraceptive use (bruh), hemolytic diseases, diet-induced weight loss, and total parenteral nutrition

What is the term for the inflammation of the gallbladder that can be acute or chronic, acalculous, emphysematous, or gangrenous

Cholecystitis

What is the most common cause of acute cholecystitis?

Gallstones

What are the sonographic sings of cholecystitis

Gallstones, sonographic murphy’s sign, diffuse wall thickening >3mm, GB dilation >5cm, pericholecystic fluid, sludge

Acute cholecystitis

Associated with RUQ pain, possible fever and leukocytosis

Some complications include:

• Empyema - pus filled GB

• Gangrene

• Perforation - GB so inflamed, wall explodes

• Pericholecystic abscess

Chronic cholecystitis

Defined clinically as recurring symptoms of biliary colic due to multiple previous episodes of cholecystitis

The sono findings are the same as acute

It may include a smaller, contracted GB with stones and a thick wall, usually there is no pericholecystic fluid and it may not elicit a murphy’s sign

What does calculous mean

95% of the time, it occurs from calculous

Chronic and intermittent

Stasis

Ischemia

• Fistula - abnormal communication between two things that shouldn’t be there

What does Acalculous mean?

Due to “other than stones”

Often in critically ill hospitalized patients

Stagnant bile

Change of vascular supply to GB

Tube feedings >3 months

Trauma

Infection or Sepsis

Acalculous cholecystitis

The acute inflammation of the GB in the absence of cholethiasis and is most likely caused by decreased blood flow through the cystic artery.

The patient will have a positive MURPHY’s SIGN

What are some conditions that can cause Acalculous Cholecystits?

• Conditions that produce depressed motility (eg, trauma, burns, postoperative patients, HIV) could come B4 acalculous cholecystitis

• Extrinsic compression of the cystic duct by a mass or lymphadenopathy

Torsion of the GB is a very rare condition that is found more often in who?

Older women

Torsion of the GB characteristics

Associated with a mobile GB with a long suspensory mesentery; The symptoms are like acalculous cholecystitis

The GB will look massively inflamed and distended and the cystic artery and cystic duct may become twisted

If the GB becomes twisted more than 180 degrees, with torsion of the GB, there is a risk of developing what?

Gangrene

What is the term for “an uncommon cause for extrahepatic biliary obstruction as a result of an impacted stone in the cystic duct”

Mirizzi’s syndrome

What are some signs of Mirizzi’s syndrome

• Painful jaundice

• Large, impacted stone in the GB neck or cystic duct

• A mechanical obstruction of the CHD

• CHD and intrahepatic duct dilation

• CHD dilated above the level of stone

• Normal size CBD

T/F - Occasionally, a fistula can form between GB & CHD due to erosion in Mirizzi’s syndrome?

True

On US, if you see an intrahepatic ductal dilation with a normal-size common duct and a large stone in the neck of the GB or cystic duct, what is it a sign of?

Mirizzi’s syndrome

What is Porcelain GB

Rare condition common in older females where the GB wall is calcified, producing a wall-shadow.

Usually found incidentally but is causes an increased chance of GB cancer

Empyema

Pus-filled, infected GB behind an obstructed cystic duct that is suspected when there are atypical bile echoes

If it ruptures and leaks, it will lead to PERITONITIS

The symptoms are the same as acute cholecystitis, with addition of FEVER

What is caused when an empyema ruptures and leaks?

Peritonitis

Gangrene/Emphysematous Cholecystitis

Acute cholecystitis due to GB wall ischemia and infection; 75% evolves into grangrenous cholecystitis (leads to perforation); Surgical emergency

OFTEN E.COLI

Gangrene/Emphysematous Cholecystitis occurs most commonly in who

Diabetic patients

How can Gangrene/Emphysematous Cholecystitis look?

Necrosis, focal wall thickening, intramural abscess, sludge that doesn’t move, and can even produce a comet tail or ring down artifacts

What does Emphysematous mean?

Producing gas forming organisms that make a champagne sign (bubbles travel to the top)

What is the common echo feature of gangrene

The presence of diffuse medium to coarse echogenic densities filling the GB lumen in the absence of bile duct obstruction

Characteristics:

1. Does not cause shadowing

2. Is not gravity-dependent

3. Does not show a layering effect

GB Perforation

Rare, but life-threatening complication of acute cholecystitis that consists of a localized fluid collection in the GB fossa

Sonographic findings are:

• Irregular GB wall

• Focal wall defect

• Gallstones

GB perforation usually occurs in which part of the GB?

Fundus

Adenoma

Benign neoplasm that is the localized elevation of epithelial lining (it has a wide base)

Usually small and doesn’t have shadows but it is attached to the wall

Usually singular and it is hard to distinguish from a polyp

Adenomas are usually between how many mm in size?

5-20mm

T/F - Since adenomas are benign, they are never removed no matter the size

False; GB removed if adenoma large due to cancer concern

Cholesterol Polyp

Large deposits of cholesterol attached to the inner wall of GB by a stalk or pedicle

Rounded hyperechoic and non-shadowing

Benign and NOT pre cancerous

As long as a cholesterol polyp is under how many mm, it is not worrisome?

10mm

Adenomyomatosis (Cholesterol crystals)

Hyperplastic changes involving the GB wall causing overgrowth of the mucosa; Not a precursor to cancer and is characterized by a V-shape/ comet tail artifact

Associated with

• Intra-luminal diverticula (pouch)

• Rokitansky-Aschoff sinusus (RAS)

Cholesterolosis (Strawberry GB)

Develops as a result of abnormality in metabolism of cholesterol within GB wall; Associated with cholesterols tones and looks like a cute lil strawberry; It is found incidentally and is asymptomatic

GB Carcinoma

Primary carcinoma of the GB that is RARE and is nearly always a rapidly progressive disease with a mortality rate close to 100% Twice as common as cancer of the bile ducts and occurs most frequently in women over 60 yrs of age

What is associated with 80% to 90% of patients with cholelithiasis?

GB carcinoma

What is the rare, but most frequent, form of biliary CA?

GB Adenocarcinoma

GB adenocarcinoma

Associated with cholelithiasis and progresses rapidly so symptoms are generally too late; Ofc, it is most common in females over 60 yrs old and the 5-year survival rate is less than 5%

Since it is cancer, it looks…

• Large irregular mass

• Thickened, rigid walls

• Usually found in the BODY of GB

GB adenocarcinoma is most commonly found in what part of the GB?

Body

Metastatic disease

Directly extends from stomach, pancreas, bile ducts, blood or lymphatic routes

Sonographically, it looks similar to primary cancer

T/F - Cholelithiasis is always present whenever metastatic disease is involved?

False; only usually

What are the causes of biliary obstruction?

Choledocholithiasis - stones in the duct

Mirizzi syndrome

Cholangiosarcoma

Biliary Atresia

Choledochal cyst

Cholangitis - inflammation of bile ducts

Caroli’s disease

Pancreatic adenocarcinoma

GB carcinoma

With biliary obstruction, elevated Labs are what?

ALP, GGT, and Bilirubin

In the majority of patients, biliary obstruction is due to pathology in what?

Distal CBD

Most common causes of biliary obstruction are what?

Gallstones and carcinoma of the head of the pancreas; Pt will come in with jaundice but might not have pain

What is the Shotgun Sign

Sign of biliary obstruction after the CBD and GB dilate, making parallel channels adjacent to the portal veins

CBD and GB will dilate within how many hours of obstruction

24

What is the most common location for an obstructing stone that causes the whole biliary system to distend?

Distal CBD

At which level of obstruction will only the CHD and intrahepatic ducts dilate, causing the GB to contract?

CHD

At what level of obstruction do only the intrahepatic ducts dilate, leading to the GB contracting as well?

At level of the Rt/Lt hepatic ducts

Caroli Disease/Caroli’s Syndrome

A congenital anomaly of the biliary tract characterized by multifocal segmental dilation of intrahepatic bile ducts; Usually genetic and can cause hepatic fibrosis; Associated with portal hypertension and autosomal recessive polycystic kidney disease

Cholangiocarcinoma (Bile Duct Carcinoma)

Primary sclerosing cholangitis is most common predisposing condition, and the most common finding is bile duct dilation; Patients will usually have jaundice, weight loss, and abdominal pain

Klatskin tumor

A cholangiocarcinoma located at hepatic hilum resulting in intra but not extrahepatic ductal dilation

Bile duct adenocarcinoma

Usually originates within extrahepatic bile ducts (CHD or CBD)