NUC biliary and pancreas quiz (10/16)

The gallbladder is a storage site for _____ which is secreted by the _____.

bile ; liver

The bile ducts are the vessels that carry the bile from the __________ of

the liver to the _____________ , and then to the intestine. The medical

term cholangio refers to the bile ducts (chol(e)-bile, angio=vessel).

lobules ; gallbladder

When we evaluate the Biliary System, we always include what?

the Gallbladder, bile ducts , pancreas, and liver

After a fatty meal, Food in the stomach and duodenum causes _________ ______ _______ to relax and gallbladder to _________, ejecting large amount of _____ into intestine where it aids digestion by emulsifying _____.

Sphincter of Oddi ; contract ; bile ; fats

Primary purpose of bile ducts and gallbladder is to transport bile

from the ______ to the __________ to regulate its flow

liver ; intestine

How much bile does the liver secrete each day?

1-2 liters

Bile drains into what and travels towards the intestine?

biliary ducts

When body is in the fasting state, the ______ ___ __________ keeps enough

tension of the _________ ____ _________ to prevent much bile getting into

duodenum

Sphincter of Oddi ; Ampulla of Vater

What lab value: Liver enzyme that is very sensitive to biliary obstruction.

Elevation indicates mechanical obstruction of the bile ducts

(like stone)

Alkaline Phosphatase (ALP)

What lab value: Elevation can indicate biliary tract obstruction

Alanine Aminotransferase (ALT)

What lab value: Elevation can indicate cholestasis

Aspartate Aminotransferase (AST)

What makes up the bile ducts?

Includes the Common Hepatic Duct, Cystic Duct and Common Bile Duct

What duct:

• Joins the main pancreatic duct at the ampulla of Vater to enter

the descending portion of the duodenum

• Located anterior to the main portal vein and lateral to the hepatic

artery

CBD

Bile backs up in the _____ and is forced into the ____________ which stores

and concentrates bile until the meal is eaten (particularly the fatty

meal)

CBD ; gallbladder

When ___________ empties and peristalsis in ___________ slows, Sphincter

of Oddi ________ and gallbladder __________, limiting flow of bile into

intestine once again.

stomach ; duodenum ; tightens ; relaxes

What causes the gb to contract & Sphincter of Oddi to relax?

Cholesystokinin

What causes liver to secrete more bile?

secretin

What hormones also stimulate the pancreas to secrete its digestive

enzymes?

secretin and cholecystokinin

what emulsify dietary lipids so they can be absorbed

much like detergent breaks down & surrounds dirt in the laundry?

Bile salts

What 4 things describe the cystic duct?

• Drains the gallbladder

• Contains spiral valves of Heister

• Joins the CHD to form the Common Bile Duct

• Not typically seen with ultrasound

The cystic duct is connected to the _____ of the gallbladder.

neck

What is located anterior to the main portal vein and lateral to the hepatic

artery?

common bile duct

What is the normal diameter of the CBD?

6mm or less

The gallbladder is an _____________ organ located in the __________ __________.

intraperitoneal ; gallbladder fossa

The gallbladder lies lateral to the______ and anterior and medial to the ________ __________.

IVC ; right kidney

What are the divisions of the GB?

• Fundus

• Most inferior and anterior portion

• Blind ending

• Body

• Mid portion between fundus and neck

• Neck

• Narrowed area that tapers to connect with the cystic duct

What is the normal wall measurement for the GB?

3mm or less

What is the normal A-P measurement for the GB?

5cm or less in the transverse plane

What is the normal length of the GB?

8-12cm

What is the Phrygian cap?*

• Fold of gallbladder fundus against body

• Common

What is the required patient prep for a GB exam?

- The patient MUST be NPO—NOTHING to eat or drink (some places will let them have sips of water) for at least 8 hours.

- Typically, the patient is instructed to have nothing to eat or drink after midnight the night before the sonogram

- if the patient is not NPO, the gallbladder will usually appear small and thick-walled due to its contracted state.

- The problem is that pathologic conditions of the gallbladder such as cholecystitis also have this appearance.

- Sonograms done on patients who are not NPO can result in a false positive diagnosis of pathology or the report stating that the condition could not be ruled out.

Why is the GB imaged in two different positions?

The purpose of these maneuvers is to

demonstrate the mobility of gallstones and to

make sure that no stones are lodged in the neck

or cystic duct

In order to make the confirmed diagnosis of ____________(as

opposed to polyp or tumor), you MUST document that their

position in the gallbladder changes when the patient changes

position

cholelithiasis (stones in GB)

The gallbladder is attached to the bile duct by the_______ _________ and

normally lies in the gallbladder fossa of the liver, but it is not

_________ ___________ to the liver, so its position is __________ dependent

cystic duct ; tightly fastened ; gravity

- When the patient rolls to the left, the gallbladder fundus moves to the left in response to gravity.

- When the patient sits upright, the fundus of the gallbladder moves inferiorly.

if the GB wall measures more than 3mm what could it indicate?

cholecystitis

For the CBD measurement it should be 6mm or less. Once the patient reaches age __, the normal measurement increases 1mm per ________.

60 ; decade

So, normal CBD size for someone in their 60's is 6-7mm, 70's=7-8mm, etc.

Post-cholecystectomy, the normal CBD size can reach _____ mm.

8-10

Often the GB folds at the junction of the neck and the body, creating a small echogenic linear structure within the GB, which often creates a shadow. This is called a __________ _________.

junctional fold

It is important to

recognize this as a normal

structure and to note that

small stones can be

disguised by its presence.

Rolling the patient onto

his or her side can often

eliminate the problem by

"unfolding" the fold.

In the long/sag view the GB appears more ______. In trans the GB appears more ___________.

stretched out ; circular

What connects the GB and the portal vein?

Main lobar fissure

Describe the Hartmann pouch

Posterior pouch between the neck and junctional fold

What are the rare congenital GB anatomic variants?

- Septations within the GB

- Rare

- Duplicated GB

- Extremely rare

- Confirmed with nuclear medicine hepatobiliary scan

- Agenisis of the GB

- Extremely rare

- Usually confirmed with exploratory laproscopy or laparotomy

The pancreas is located in the ________ _______ space and is a ____________ structure. However, there is a small portion of the __________ __________ that is in the ____________ cavity.

Anterior pararenal ; retroperitoneal ; pancreatic head ; peritoneal

The pancreas lies in a __________ ___________ plane and extends

from C-loop of __________ to hilum of _________.

horizontally oblique ; duodenum ; spleen

What are the posterior landmarks of the pancreas? Hint: 5

Aorta, IVC, SMA, Splenic Vein, and Portal Confluence

__________ __________ arises from aorta just superior to

pancreas body

Celiac Axis

__________, ____________, and ____________ __________ lie

________ and ___________ to pancreas, which can make

it difficult to image due to overlying bowel gas.

Stomach ; duodenum ; transverse colon

anterior ; lateral

What is the normal length of the pancreas?

12-18 cm

Dependent on age and body habitus

What is the pancreas divided into? Hint: 5

head, neck, body, tail, and uncinate

process

What is the primary secretory duct mainly seen in the body and what are the abnormal measurements? Pancreas

Duct of Wirsung ; greater than 2mm in body is considered and greater than 3mm is considered abnormal for head/neck

What is the secondary secretory duct for pancreas?

Duct of Santorini

What surrounds CBD and pancreatic ducts as they go into

duodenum?

Sphincter of Oddi

Arises anteriorly from aorta at superior border of

pancreas (Seagull in transverse)

celiac axis

Tortuous artery that runs along superior/anterior border

of body and tail of pancreas

splenic artery

(just ABOVE where the splenic vein is visualized)

Runs along superior border of neck/head of pancreas

Common hepatic artery

Runs along anterior/lateral portion of

pancreatic head before dividing into superior

pancreaticoduodenal branches

Gastroduodenal artery

Arises from the aorta posterior to the

pancreatic body

Superior mesenteric artery

Runs along posterior border of pancreatic

tail and body from splenic hilum to portal

confluence

splenic vein

- Runs posterior to the neck of the pancreas

and anterior to the uncinate process

- Long axis of this vessel is in the sagittal plane

Superior mesenteric vein

Splenic Vein and Superior Mesenteric Vein

join at portal confluence posterior to

pancreatic neck

This vessel proceeds posterior to pancreatic

head into porta hepatis

Portal vein

Runs anterior to portal vein and lateral

(right) of hepatic artery

Runs through groove on inferior/posterior

portion of pancreatic head

Joins pancreatic duct at Ampulla of Vater

CBD

Pancreas has both _________ and ____________

functions

endocrine ; exocrine

The primary function of pancreas is __________

exocrine

○ Involves secretion of digestive enzymes

(pancreatic juice) into duodenum via Ampulla of Vater

○ These secretions are necessary for normal digestion and absorption of food

What secrete hormones involved in endocrine function of pancreas?

Islets of Langehans

What are the 3 types of Islets of Langerhans cells and what are their basic functions?

- Beta Cells: secrete insulin

- Most numerous type

- Insulin stimulates liver to form glycogen from glucose

- Also stimulates certain cells to take up more glucose from bloodstream

- Net effect of insulin is to decrease levels of glucose in bloodstream

- Alpha Cells: secrete glucagon

- Stimulates cells to release glucose to meet energy needs of body

- Antagonistic to insulin

- Stimulates liver to break glycogen down to glucose for use

- Net effect of glucagon is to increase levels of

glucose in bloodstream

- Delta Cells: secrete somatostatin

- Inhibits production of both insulin and glucagon

- Helps to keep glucose levels in blood from making large swings

What is the congenital anomaly: annular pancreas?

Pancreas encircles the duodenum

Thought to occur during rotation of the

ventral bud to meet the dorsal bud

Ventral bud as split (bifid) formation that is

not usual

May cause duodenal stenosis

What is the congenital anomaly: Ectopic Pancreatic Tissue

Pancreatic tissue found within the wall of

the bowel

Can be found in the foregut or midgut

Functioning tissue which can develop

inflammation or tumors just like the

normal pancreas

What is the congenital anomaly: Pancreas Divisum

Occurs in about 10% of the population

* The Duct of Wirsung & the Duct of

Santorini do not fuse, and each drain

separately into the duodenum

What is a special thing a patient can do to better help visualize the pancreas?

Drink a lot of water

- If pancreas is extremely difficult to visualize,

have patient drink at least 12-16 oz. of water

○ Water will displace gas in stomach and

provide an acoustic window (like bladder

provides a window to visualize the uterus)

○ Water should ideally come from a bottle and

should be drank through a straw to minimize

air bubbles being swallowed

○ The patient should also be in upright or left

lateral decubitus position

_______, _________, _________, _________, and ______ of the

pancreas should be evaluated, comparing

it to the liver for echogenicity and texture

Size, shape, texture, contour, and lie

When the pancreas is measured in long plane that is the pancreas in the ________ section.

transverse

What landmark would you see: Long Pancreas Head

IVC

What landmark would you see: Long Pancreas Neck/UP

SMV

What landmark would you see: Long Pancreas Body

Aorta, Celiac axis, SMA

What landmark would you see: Long Pancreas Tail

just past posterior dive of splenic artery and vein

CBD

1

Cystic duct

2

Cystic artery

3

Right and left hepatic duct

4

Right and left hepatic arteries

5

Common hepatic duct

6

Proper hepatic artery

7

Right gastric artery

8

Ampulla of vater

1

fundus of gallbladder

2

Body of gallbladder

3

Hartmanns pouch

4

Neck of gallbladder

5

Heister's valve

6

right hepatic duct

7

Left hepatic duct

8

common hepatic duct

9

Cystic duct

10

Common bile duct

11

Pancreatic duct

12