Hepatobiliary System PDF

 FUNCTIONS OF THE GALLBLADDER GALLBLADDER DIVISIONS CONCENTRATES BILE FUNDUS THROUGH THE BODY...

 FUNCTIONS OF THE GALLBLADDER GALLBLADDER DIVISIONS CONCENTRATES BILE FUNDUS THROUGH THE BODY NECK GALLBLADDER EPITHELIUM STORES CONCENTRATED BILE CONTRACTS TO RELEASE BILE GALLBLADDER LOCATION GALLBLADDER ANATOMICAL VARIANTS GALLBLADDER ANATOMICAL VARIANTS INTRAPERITONEAL LOCATED IN THE HARTMANN POUCH JUNCTIONAL FOLD GALLBLADDER FOSSA ON THE POSTERIOR SURFACE OF THE GALLBLADDER LATERAL TO THE INFERIOR VENA CAVA, ANTERIOR AND MEDIAL TO THE RIGHT KIDNEY GALLBLADDER ANATOMICAL VARIANTS GALLBLADDER SIZE PHRYGIAN CAP NORMAL FASTING ADULT GALLBLADDER MEASURES 8-10 SONOGRAPHIC IN LENGTH AND 3-5 CM IN DIAMATER APPEARANCE NORMAL FASTING ABNORMAL FASTING GALLBLADDER GALLBLADDER ELLIPSOID ANECHOIC STRUCTURE TRANSVERSE DIAMETER ABOVE LOCATED IN THE GALLBLADDER 5 CM FOSSA WITH POSTERIOR THICK OR EDEMATOUS WALL 3 ACOUSTIC ENHANCEMENT mm DEMONSTRATES SMOOTH HYPERECHOIC WALLS 3 mm OR IRREGULAR WALL CONTOUR LESS INTRALUMINAL FOCUS OR LOCATED IN THE INFERIOR ECHOES MEDIAL ASPECT OF THE LIVER ACOUSTIC SHADOWING POSTERIOR TO THE GALLBLADDER FOSSA  SONOGRAPHIC APPEARANCE ABNORMAL FASTING GALLBLADDER -THICK EDEMATOUS WALL EXCEEDING 3 mm IN THICKNESS -IRREGULAR WALL CONTOUR -INTRALUMINAL FOCUS OR ECHOES -ACOUSTIC SHADOWING POSTERIOR TO THE GALLBLADDER FOSSA REASONS FOR NONINLAMMATORY CAUSES OF NONVISUALIZATION OF THE GALLBLADDER WALL THICKENING ENLARGED(DISTENDED) GALLBLADDER GALLBLADDER NON FASTING PATIENT NON FASTING PATIENT ASCITES DEHYDRATED SURGICALLY ABSENT LOW FAT DIET CIRRHOSIS OBLITERATION OF THE INTRAVENOUS NUTRITION GALLBLADDER LUMEN BY CONGESTIVE HEART INTESTINAL AIR OR GALLSTONE FAILURE PATIENT BODY HABITUS HYPOALBUMINEMIA ECTOPIC LOCATION ACUTE HEPATITIS AGENESIS  IF THERE IS NO CONTRACTION, SCHEDULES ARE MADE SEARCH FOR: AT THE BEGINNING OF THE GALLSTONE OR ANY CAUSE OF PATIENT’S DAY: OBSTRUCTION A STONE OR SOME OBSTRUCTION IN THE COMMON BILE DUCT LABORATORY VALUES IF THE GALLBLADDER IS DISTENDED -DECREASES THE WITH THICKENED WALLS AND FILLED WITH FLUID, THERE MAY BE EMPYEMA AMOUNT OF IF THE GALLBLADDER IS DISTENDED INTESTINAL AIR WITH THIN WALLS AND FILLED WITH FLUID, THERE MAY BE MUCOCELE -PATIENT IS FASTING ALANINE AMINOTRANSFERASE ASPARTATE ALKALINE PHOSPHATASE NORMAL RANGE 1-45 U/L AMINOTRANSFERASE NORMAL ADULT RANGE 35-150 E N Z Y M E F O U N D I N H I G H NORMAL RANGE 1-36 U/L U/L CONCENTRATION IN THE ENZYME PRESENT IN MANY ENZYME PRODUCED PRIMARILY BY LIVER THE LIVER, BONE AND PLACENTA TYPES OF TISSUE THAT IS REMAINS ELEVATED LONGER RELEASED WHEN CELLS ARE EXCRETED THROUGH THE BILE THAN AST DUCTS DAMAGED CIRRHOSIS, HEPATITIS, OBSTRUCTIVE JAUNDICE BILIARY OBSTRUCTION CIRRHOSIS, HEPATITIS LIVER METASTASIS AND MONONUCLEOSIS BILIRUBIN BILIRUBIN A PRODUCT FROM THE BREAKDOWN OF ELEVATION OF DIRECT OR HEMOGLOBIN IN OLD RED BLOOD CELLS CONJUGATED BILIRUBIN LEAKAGE INTO TISSUES GIVES THE SKIN A -OBSTRUCTION, HEPATITIS, YELLOW APPEARANCE CIRRHOSIS AND LIVER NORMAL TOTAL BILIRUBIN 0.3-1.1 mg/Dl METASTASIS NORMAL DIRECT BILIRUBIN 0.1-0.4 mg/dL ELEVATION OF INDIRECT OR UNCONJUGATED BILIRUBIN PATHOLOGY -NON OBSTRUCTIVE CONDITIONS PNEUMOBILIA PNEUMOBILIA PNEUMOBILIA PRESENCE OF GAS IN THE SONOGRAPHIC BILIARY SYSTEM APPEARANCE: ETIOLOGY: SURGICAL -HYPERECHOIC FOCUS IN PROCEDURE, TRAUMA, THE INTRAHEPATIC BILE INFECTION DUCTS CLINICAL FINDINGS: -COMET TAIL ARTIFACT ASYMPTOMATIC, RUQ OFTEN CENTRALLY LOCATED PAI N BILIARY ASCARIASIS BILIARY ASCARIASIS BILIARY ASCARIASIS WORMS THAT COLONIZE THE INTESTINAL TRACT ETIOLOGY: INGESTION SONOGRAPHIC MAY FIND THEIR WAY INTO THE BILIARY TREE AND GALLBLADDER. LIVING WORMS MAY OBSTRUCT THE OF CONTAMINATED APPEARANCE: BILIARY TREE AND GALLBLADDER AND CAUSE CHOLANGITIS, CHOLECYSTITIS, AND PANCREATITIS, WATER OR FOOD -SPAGHETTI LIKE WITH A HIGH ASSOCIATED MORTALITY. ECHOGENIC STRUCTURE WORMS ARE SEEN BY US AS MOVING TUBULAR CLINICAL FINDINGS: WITHIN A BILE DUCT ECHOGENIC STRUCTURES WITH AN ECHOLUCENT CORE. RUQ PAIN, FEVER, -NON SHADOWING LEUKOCYTOSIS -POSTERIOR ACOUSTIC ENHANCEMENT BILIARY ASCARIASIS  GALLBLADDER POLYP GALLBLADDER POLYP GALLBLADDER POLYP APPEAR AS ECHOGENIC NONSHADOWING NODULES THAT BENIGN EPITHELIAL SONOGRAPHIC EXTEND FROM THE GALLBLADDER WALL APPEARANCE: MOST ARE CHOLESTEROL TUMOR POLYPS, WHICH ARE SMALLER THAN 1 -ECHOGENIC CM AND ARE COMMONLY MULTIPLE. CLINICAL INTRALUMINAL ADENOMATOUS POLYPS ARE RARE FINDINGS: FOCUS AND INDISTINGUISHABLE FROM ASYMPTOMATIC, DULL -IMMOBILE CHOLESTEROL POLYPS. RUQ PAIN, INTOLERANCE -NON SHADOWING TO FATTY FOODS -THICKENING OF THE GALLBLADDER WALL GALLBLADDER POLYP ADENOMYOMATOSIS HYPERPLASIA OF THE EPITHELIAL AND MUSCLE LAYERS OF THE GALLBLADDER WALL CLINICAL FINDINGS: ASYMPTOMATIC, DULL RUQ PAIN, INTOLERANCE TO FATTY FOODS ADENOMYOMATOSIS ADENOMYOMATOSIS SONOGRAPHIC APPEARANCE: -ECHOGENIC INTRALUMINAL FOCUS -DIFFUSE COMET TAIL ARTIFACT -IMMOBILE ECHOGENIC BILE ECHOGENIC BILE ECHOGENIC BILE BILE BECOMES ECHOGENIC WHEN IT IS HIGHLY CONCENTRATED AND CHOLESTEROL MIXTURE OF PARTICULATE CLINICAL FINDINGS: CRYSTALS AND CALCIUM BILIRUBINATE ASYMPTOMATIC, RUQ PAIN, GRANULES PRECIPITATE AS SLUDGE. SLUDGE SOLIDS THAT HAVE COMMONLY LAYERS IN THE GALLBLADDER PRECIPITATED FROM BILE NAUSEA, VOMITING AND MAY BECOME SONOGRAPHIC APPEARANCE: QUITE VISCOUS AND FORM SLUDGE BALLS ETIOLOGY: PROLONGED NON SHADOWING LOW OR TUMEFACTIVE SLUDGE. SLUDGE BALLS USUALLY MOVE WITHIN THE GALLBLADDER FASTING, BILIARY STASIS, AMPLITUDE ECHOES LAYERING IN BUT DO NOT CAST ACOUSTIC SHADOWS. BILIARY OBSTRUCTION, THE DEPENDENT PORTION OF THE CHOLECYSTITIS, SICKLE CELL GALLBLADDER, ECHOES MOVE ANEMIA SLOWLY WITH POSITION CHANGE, MAY FILL THE ENTIRE ORGAN ECHOGENIC BILE CHOLELITHIASIS two major types: 1. cholesterol stones and 2. pigment stones Cholesterol- formed in bile that supersaturated with cholesterol and decreased amounts of bile acids and lecithin Pigmentary- composed of calcium bilirubinate (black or brown) black stones - bilirubin, polymers, calcium phosphate and carbonate -common in patients with chronic hemolytic anemia, cirrhosis brown stones - often laminated and consist of alternating layers of calcium bilirubinate and cholesterol admixed with calcium soaps - Common in patients with biliary infections or liver flukes infestation Shadowing Hyperechoic/echogenic foc i Cholelithiases CHOLELITHIASIS CHOLELITHIASIS ULTRASOUND IS THE IMAGING ETIOLOGY: ABNORMAL BILE METHOD OF CHOICE FOR COMPOSITION, BILE STASIS, INFECTION DETECTION OF GALLSTONES WITH RISK FACTORS: FAMILY HISTORY, ITS SENSITIVITY OF GREATER THAN OBESITY, PREGNANCY, DIABETES, 90%. GALLSTONES APPEAR WITHIN FEMALE PREVALENCE 4:1 THE GALLBLADDER LUMEN AS CLINICAL FINDINGS: ASYMPTOMATIC, ECHOGENIC OBJECTS THAT CAST RUQ PAIN, EPIGASTRIC PAIN, CHEST/SHOULDER PAIN, ELEVATED ACOUSTIC SHADOWS AND MOVE LIVER FUNCTION TESTS, NAUSEA, POST WITH CHANGES IN PATIENT PRANDIAL PAIN, FATTY FOOD POSITION INTOLERANCE CHOLELITHIASIS CHOLELITHIASIS CHOLELITHIASES SONOGRAPHIC APPEARANCE -HYPERECHOIC INTRALUMINAL FOCUS -POSTERIOR ACOUSTIC SHADOWING -MOBILE -WES (Wall, Echo, Shadow) CHRONIC CHOLECYSTITIS RECURRENT INFLAMMATION CHRONIC CHOLECYSTITIS SECONDARY TO INFECTION, SONOGRAPHIC APPEARANCE: OBSTRUCTION OR METABOLIC -SMALL CONTRACTED DISORDERS GALLBLADDER CLINICAL FINDINGS: ASYMPTOMATIC, VAGUE RUQ PAIN, HEARTBURN, FATTY -THICK HYPERECHOIC WALLS FOOD INTOLERANCE, INTERMITTENT -CHOLELITHIASIS, 90% OF NAUSEA, MILD INCREASE IN ASPARTATE CASES AMINOTRANSFERASE AND ALANINE AMINOTRANSFERASE, POSSIBLE -POSTERIOR ACOUSTIC INCREASE IN ALKALINE PHOSPHATASE SHADOWING AND BILIRUBIN -SLUDGE  ACUTE ACUTE CHOLECYSTITIS CHRONIC CHOLECYSTITIS CHOLECYSTITIS SONOGRAPHIC APPEARANCE ETIOLOGY: OBSTRUCTION OF THE -THICK EDEMATOUS GB CYSTIC DUCT, INFECTION, IDIOPATHIC WALL CLINICAL FINDINGS: SEVERE -IMPACTED STONE IN THE EPIGASTRIC PAIN, RUQ PAIN, BILIARY CYSTIC DUCT COLIC, POSITIVE MURPHY SIGN, -CHOLELITHIASIS, 90% NAUSEA, VOMITING, JAUNDICE, -PERICHOLECYSTIC FLUID ELEVATED AST, BILIRUBIN, AND -POSITIVE MURPHY SIGN ALKALINE PHOSPHATASE -SLUDGE MIRRIZI SYNDROME MIRRIZI SYNDROME ETIOLOGY: IMPACTED STONE IN SONOGRAPHIC APPEARANCE: THE GALLBLADDER NECK OR IMMOBILE CALCULUS IN THE CYSTIC DUCT, OBSTRUCTION OF CYSTIC DUCT OR NECK OF THE THE CHD, JAUNDICE GALLBLADDER, DILATATION OF CLINICAL FINDINGS: RUQ PAIN, THE INTRAHEPATIC AND CHD, JAUNDICE, ELEVATED BILIRUBIN, NORMAL CBD ALKALINE PHOSPHATASE, INCREASE IN ALT AND AST, MIRRIZI SYNDROME MIRRIZI SYNDROME MIRRIZI SYNDROME PORCELAIN GALLBLADDER PORCELAIN GALLBLADDER DECREASE IN THE VASCULAR REFERS TO CALCIFICATION OF THE SUPPLY TO THE GALLBLADDER GALLBLADDER WALL COMPLICATING CHRONIC CHOLECYSTITIS. US CLINICAL FINDINGS: DEMONSTRATES A HIGHLY ASYMTOMATIC, VAGUE RUQ ECHOGENIC WALL WITH ACOUSTIC PAIN SHADOWING. SONOGRAPHIC APPEARANCE: PORCELAIN GALLBLADDER IS A GALLSTONES 95%, HYPERCHOIC PREDISPOSING CONDITION TO WALL, MARKED POSTERIOR GALLBLADDER CARCINOMA. ACOUSTIC SHADOWING  PORCELAIN GALLBLADDER Wall-echo-shadow When the gallbladder is completely filled with gallstones, a confident diagnosis becomes more difficult because the extensive mural gallbladder resembles an air- filled loop of bowel. The WES calcification around the perimeter of sign is definitive evidence of a stone-filled gallbladder the gallbladder Gallstones produce a clean dark shadow, and air in the bowel produces a dirty◻brighter shadow. GALLBLADDER HYDROPS WES SIGN ETIOLOGY: OBSTRUCTION OF CYSTIC DUCT, PROLONG BILIARY STASIS, SURGERY, HEPATITIS, GASTROENTERITIS, DIABETES CLINICAL FINDINGS: ASYMTOMATIC, RUQ PAIN, EPIGASTRIC PAIN, PALPABLE MASS S O N O G R A P H I C A P P E A R A N C E : ENLARGMENT, GB DIAMETER EXCEEDING 5 CM, THIN HYPERECHOIC WALLS  PANCREAS ELONGATED ORGAN LYING TRANSVERSE AND OBLIQUELY IN THE EPIGASTRIC AND HYPOCHONDRIAC REGIONS OF THE BODY PANCREAS RETROPERITONEAL ORGAN FUNCTIONS OF THE FUNCTIONS OF THE PANCREAS PANCREAS FUNCTIONS OF THE PANCREAS EXOCRINE EXOCRINE ENDOCRINE AMYLASE-BREAKS DOWN CHOLECYSTOKININ- STIMULATES SECRETE HORMONES DIRECTLY INTO THE SECRETION OF PANCREATIC BLOODSTREAM CARBOHYDRATES LIPASE-BREAKS ENZYMES AND CONTRACTION ALPHA CELLS SECRETE GLUCAGON DOWN FATS OF GALLBLADDER BETA CELLS SECRETE INSULIN GASTRIN- STIMULATES SECRETION OF DELTA CELLS SECRETE SOMATOSTATIN TRYPSIN- BREAKS DOWN PROTEINS GASTRIC ACIDS INTO AMINO ACIDS SECRETIN-STIMULATES SECRETION OF BICARBONATE  PANCREAS DIVISION AND PANCREAS DIVISION AND LOCATION PANCREAS DIVISION AND LOCATION LOCATION TAIL HEAD MOST SUPERIOR PORTION OF LIES IN THE DESCENDING PORTION BODY OF THE DUODENUM, LATERAL TO THE THE PANCREAS LARGEST MOST ANTERIOR ASPECT SUPERIOR MESENTERIC VEIN AND ANTERIOR AND PARALLEL WITH ANTERIOR TO THE INFERIOR VENA CAVA SPLENIC VEIN LIES ANTERIOR TO THE AORTA, SUPERIOR MESENTERIC ARTERY, SPLENIC MAIN PORTAL VEIN AND HEPATIC ANTERIOR TO THE UPPER POLE OF ARTERY LIE INFERIOR TO THE LEFT KIDNEY, POSTERIOR TO STOMACH, VEIN, LEFT RENAL VEIN AND SPINE PANCREATIC HEAD LATERAL TO THE SPINE LIES POSTERIOR TO THE ANTRUM OF CBD IS SITUATED IN THE GENERALLY EXTENDS TOWARD THE STOMACH POSTEROLATERAL AND INFERIOR THE SPLENIC HILUM PORTION OF PANCREATIC HEAD DUCTS OF PANCREAS DUCTS OF PANCREAS DUCT OF WIRSUNG DUCT OF SANTORINI JOINS THE DISTAL COMMON SECONDARY SECRETORY DUCT BILE DUCT ENTERING THE DRAINING THE UPPER ANTERIOR DESCENDING PORTION OF THE PORTION OF THE PANCREAS DUODENUM THROUGH THE ENTERS THE DUODENUM AT AMPULLA OF VATER THE MINOR PAPILLA 2 cm FREQUENTLY VISUALIZED IN PROXIMAL TO THE AMPULLA OF THE BODY OF THE PANCREAS VATER NORMAL PANCREATIC SIZE SONOGRAPHIC APPEARANCE NORMAL PANCREAS HEAD SMOOTH 2.0 – 3.0 HOMOGENOUS cm PARENCHYMA NECK ADULT PANCREAS IS EITHER 1.0 – 2.0 ISOECHOIC OR HYPERECHOIC WHEN cm COMPARED TO NORMAL LIVER BODY YOUNG CHILDREN- 1.0 – 3.0 cm HYPOECHOIC OLDER TAIL ADULTS-HYPERECHOIC 2.0 – 3.0 cm  SONOGRAPHIC APPEARANCE SONOGRAPHIC APPEARANCE NORMAL PANCREATIC SIZE ABNORMAL PANCREAS NORMAL PANCREATIC DUCT ANECHOIC NON VASCULAR TUBULAR HEAD < 3.0 CM -IRREGULAR OR STRUCTURE - < 2.5 CM HETEROGENOUS SMOOTH PARALLEL HYPERECHOIC WALLS