ARDMS Abdomen Board Review (LIVER)
Terms in this set (211)
In 1654, Glisson did what when it comes to liver structural classification?
Studied liver topography, defining "Glissons capsule" and the portal triad (Glissons pedicle).
In 1888, Rex defined what when it comes to liver structural classification?
The right and left lobes.
In 1898, Cantile initiated what when it comes to liver structural classification?
The concept of functional liver anatomy, defined "Cantile line" (main lobar fissure).
In 1951, Hjorsto described what when it comes to liver structural classification?
In 1953, Healey/Schroy divided the liver into:
5 segments (medial, lateral, posterior, anterior, and caudate).
In 1957, Goldsmith/Woodburne divided the liver into:
4 segments based on distribution of hepatic veins, each having 2 subsegments.
In 1957, Couinaud divided the liver into:
8 segments based on portal vein distribution. Also divided the liver into sectors defined by the hepatic veins.
In 1982, Bismuth divided the liver into:
Right and left hemiliver. Changed Couinauds sector names.
In 1989, Federative Committee on Anatomical Terminology (FCAT) tried to do what?
Unify terminology making it internationally accepted.
In 2000 during the World Congress of IHPBA in Brisbane, what was presented?
What is the remnant of the Ductus Venosus? What does it separate?
Left lobe from caudate lobe.
What fissure divides the left lobe into medial and lateral segments?
The left intersegmental fissure.
What fissure divides the right lobe into anterior and posterior segments?
The right intersegmental fissure.
What divides the right and left hepatic lobes by an oblique plane between the IVC and gallbladder fossa?
The main lobar fissure.
The port triad vessels include:
The main portal vein, the proper hepatic artery, and the common hepatic duct.
What is the echogenicity of normal structures in decreasing order?
HYPER to HYPO:
What is the normal liver echogenicity? What is the echogenicity compared to the renal cortex?
An inferior projection of the right lobe which is commonly seen in women:
What is the location and usefulness of the LHV?
Location: Left intersegmental fissure
Usefulness: Divides medial and lateral segments of the left lobe.
What is the location and usefulness of the MHV?
Location: Main lobar fissure
Usefulness: Separates right and left lobes.
Peritoneal reflections to the far right and left of the bare area:
Right and left triangular ligament.
Peritoneal reflections which suspend the liver from the diaphragm:
What might the ligamentum theres do in Cirrhosis?
Reanalyze to function as a venous collateral.
A remnant of the umbilical vein extending from the umbilicus to the left portal vein:
What type of waveform in the hepatic artery may indicate organ rejection?
What type of resistance does the hepatic artery show normally?
The proper hepatic artery runs _________ and is located ________.
Parallel to the main portal vein;
Anterior to the left of the main portal vein.
Hepatic vein waveforms are typically ______ which reflects ________.
Right atrial filling, contracting, and relaxation.
The portal triad is intersegmental or intrasegmental and they do what?
Intrasegmental and they course to the center of each segment.
Hepatic veins have what kind of walls?
The caudate lobe receives branches from ___________.
Both left and right portal veins.
The left lobe is supplied by _________.
The left portal vein.
The right lobe is supplied by __________.
The right portal vein.
How many segments are there of the liver?
The caudate lobe is supplied by branches of the ______ and is drained by ______ which enter directly into the _______.
Left and right portal venous and hepatic arterial systems;
small veins (emissary veins);
The caudate lobe lies on the ________ surface of the liver between the _______ and the _________ of the liver.
medial left lobe.
The left lobe is divided into:
Medial (formerly quadrate) and lateral segments.
The right lobe is divided into:
Anterior and posterior segments.
The liver is divided into what 3 lobes?
Right, left, and caudate.
Each segment of the liver has its own:
Portal vein, hepatic artery, and bile duct.
Hepatic veins are intersegmental or intrasegmental, which means?
Intersegmental which means they course between the lobes and segments (interloper and intersegmental).
The upper limits of the portal vein diameter is?
13 mm. (A larger diameter may be seen in patients with portal hypertension).
What supplied greater volume and oxygen needs to the liver?
The portal vein.
What is the direction of fetal circulation?
Umbilical vein (ligamentum teres) ----> left portal vein -----> ductus venosus (ligamentum venosum) -------> IVC
What does the ligamentum teres do during portal hypertension?
Reanalyzes to from a portosystemic venous collateral.
What is a remnant of the umbilical vein? Where does it run from?
Umbilicus to left portal vein.
The portal triad is encased by a __________ called ________ giving it __________.
Glissons capsule; Hyperechoic walls.
What is the location and the usefulness of the Gallbladder fossa?
Location: Main lobar fissure.
Usefulness: Separates right and left lobes.
What is the location and the usefulness of the ligamentum teres?
Location: Left intersegmental fissure.
Usefulness: Divides caudal aspect of the left lobe into medial and lateral segments.
What is the location and usefulness of the ligamentum venosum?
Location: Left anterior margin of caudate lobe.
Usefulness: Separates caudate lobe from medial left lobe.
How is the liver measured?
Superior-inferior dimension on mid-clavicular sagittal plane.
What is the location and usefulness of the LPV (Ascending segment)?
Location: Let intersegmental fissure.
Usefulness: Divides medial from lateral segment of the left lobe.
What is the location and usefulness of the LPV (Horizontal segment)?
Location: Anterior to caudate lobe.
Usefulness: Separates caudate lobe from medial segment of the left lobe.
What is the location and usefulness of the RPV (Posterior branch)?
Location: Intrasegmental in posterior segment of the right lobe.
Usefulness: Courses centrally in posterior segment of the right lobe.
What is the location and the usefulness of the RPV (Anterior branch)?
Location: Intrasegmental in anterior segments of the right lobe.
Usefulness: Courses centrally in the anterior segment of the right lobe.
What is the location and the usefulness of the RHV?
Location: Right intersegmental fissure.
Usefulness: Divides anterior and posterior segments of the right lobe.
What is the peritoneal reflection or fold created by the passage of the embryonic umbilical vein?
The right hepatic artery may originate (replaced) from the? A replace RHA is seen where?
Superior mesentereic artery (11%);
posterior to the main portal vein.
What are the symptoms of a pyogenic abscess?
RUQ pain, leukocytosis, fever, and leveled liver function tests.
Where does a Pyogenic (Bacterial) abscess occur?
Commonly in the right lobe.
How does a Pyogenic (Bacterial) abscess reach the liver?
Via the bile ducts, portal veins, hepatic arteries, or lymphatic channels.
What is the sonographic appearance of a Pyogenic (Bacterial) abscess?
Complex mass, echogenic mass, reverberation artifact.
What is the sonographic appearance of chronic hepatitis?
Hyper echoic parenchyma, small liver, decreased echogenicity of portal vein walls.
"Starry Night" (periportal cuffing) is another name for what and how does it appear monographically?
Hypoechoic liver parenchyma, liver enlargement, hyperechoic portal vein walls.
Route of HAV
HAV: Fecal/ oral
HBV: Blood/ body fluid
HCV: Blood/ body fluid
What lab values may be elevated with hepatitis?
ALT, AST, conjugated and unconjugated bilirubin.
What is hepatitis and what does it result from?
it results from infectious (viral, bacterial, fungal) or noninfectious organisms (medication, toxins, autoimmune).
How do granulomas present on ultrasound? What are they caused by?
Small calcifications in the liver and the spleen; histoplasmosis or tuberculosis.
What are the sonographic findings of Schistosomiasis?
Occluded intrahepatic portal veins, thickening and increased echogenicity of the portal vein walls.
What are secondary signs of portal hypertension?
Splenomegaly, ascites, esophageal variceal bleeding, portosystemic collaterals.
What is one of the most common parasitic infections in humans and what is a major cause of it?
caused by portal hypertension.
What is a "Stealth Lesion" and what might it appear as?
Focal Nodular Hyperplasia (FNH), may appear as iso-attenuating and blend in with surrounding liver parenchyma.
What is Focal Nodular Hyperplasia?
A benign solid liver mass that is believed to be a developmental hyper plastic lesion related to an area of congenital vascular malformation.
What does Focal Nodular Hyperplasia look like sonographically?
Solid mass with varying echogenicity, central fibrous scar, and stellate vascularity.
An echinococcal cyst rupture or aspiration is associated with what?
What is the sonographic appearance of an echinococcal cyst?
Simple cyst, cyst within a cyst, cyst w/multiple daughter cysts, calcified mass.
What tests are used to diagnose an echinococcal cyst?
Casino skin test (70%) sensitivity, detection of antibodies (echinococcal Arc 5), indirect hemagglutination, indirect florescent antibody test.
"Sheep Hearder" refers to:
Echinococco cyst (hydatid cyst).
What are the 4 appearances of candidiasis and which is the most common? Which is earliest manifestation and most recognizable?
Wheel within a wheel: peripheral hypoechoic inner echogenic, center hypoechoic. (Earliest manifestation)
Bulls Eye: Hypoechoic center calcifies.
Uniformly Hypoechoic Focus: Most common.
Echogenic Focus: Calcification representing scar formation late in process.
What is a mycotic (fungal) infection in the blood that results in small abscesses in the liver?
Fungal abscess (candidiasis).
What is the most common extra intestinal complication of amebic dysentery?
Name 9 sonographic findings associate with AIDS:
Pneumocystis Carinii (hepatic)
What is the most common organism causing infection in AIDS patients?
What are the sonographic findings of Pneumocystis Carinii?
Diffuse, non shadowing, hyper echoic foci.
In AIDS patients, infectious agents may cause what to be thickened?
The bile ducts (Cholangitis), and gallbladder wall (Cholecystitis).
Sclerosing and AIDS cholangitis sonogaphically appear as: This may compromise the lumen causing:
Thickened biliary ducts;
Lymphoma and Kapok's Sarcoma may be seen as:
Intrahepatic mass or possibly diffuse infiltration without visualization of sonographic abnormality.
What is fatty liver? What are the leading causes?
Accumulation of triglycerides within the hepatocytes;
Alcohol abuse and obesity.
What is the most common association with fatty liver disease?
How does a human become infected with Hydatid Disease (Echinococcal cyst)?
Ingesting tapeworm eggs passed from an infected carnivore. This occurs when individuals handle infected carnivores (dogs) or ingest food contaminated with fecal material containing tapeworm eggs.
How do most people become infected with HCV today?
Before 1992, how was hepatitis commonly spread?
Blood transfusions and organ transplants.
What is the most frequent indication for a liver transplant?
HCV associated chronic liver disease.
Hepatomegaly is indicated in ______% of the patient population with a greater than _____ cm superior-inferior dimension.
What may be mistaken for hepatomegaly when only viewing the superior-inferior dimension of the liver?
What is cirrhosis? What does it result in?
A diffuse process of fibrosis and distortion of normal liver architecture;
Blood coagulopathy, hepatic encephalopathy, and portal hypertension.
What are some causes of cirrhosis?
Alcoholic liver disease
Wilson disease (copper deposition)
Right-sided heart failure / tricuspid regurgitation
Drug induced liver disease
What is the sonographic appearance of a fatty liver?
Increased echogenicity and decreased acoustic penetration (increased attenuation), difficult to visualize posterior liver and diaphragm.
What is focal fatty infiltration and where does it commonly occur?
Focal regions of increased echogenicity within a normal liver parenchyma;
Occurs at porta hepatis.
What is focal fatty sparing and where does it commonly occur?
Focal regions of normal liver parenchyma within a fatty infiltrated liver;
Commonly occurs adjacent to the gallbladder, in the portal hepatis, caudate lobe, and liver margins.
What is glycogen storage disease? What is it associated with?
Genetically acquired disorder resulting in excess deposition of glycogen in the liver;
Associated with diffuse fatty infiltration and hepatic adenomas.
Differential diagnosis of hyperechoic masses within the liver include...
Focal fatty infiltration
How does an Amebic Abscess occur?
When a parasite from the intestines reaches the liver via the portal vein.
What are the symptoms and findings of an Amebic Abscess?
RUQ pain, diarrhea, fever, leukocytosis, elevated LFT's, elevated right dome of diaphragm by X-ray.
What is the sonographic appearance of an Amebic Abscess?
Round hypoechoic/complex mass, typically in the right lobe (dome), contiguous with liver capsule.
What is a diffuse process of Fibrosis and distortion of normal liver architecture?
What occurs initially with Cirrhosis? What occurs with continued insult?
Initially liver enlargement;
Continued, hepatic atrophy resulting in blood coagulopathy, hepatic encephalopathy and portal hypertension.
What is the number 1 cause of Cirrhosis? What are other causes?
#1=Alcoholic liver disease;
Non-Alcoholic Liver Disease
What LFT's are increased with Cirrhosis?
What are the sonographic findings of Cirrhosis?
Liver atrophy (Chronic)
Caudate lobe enlargement
Surface modularity (regenerative nods)
Fatty infiltration -increased echogenicity
Changes related to portal hypertension
Increased incidence of HCC
What is portal hypertension? What is the normal pressure?
Increased pressure in the portal venous system;
What are the four types of portal hypertension and examples of each?
Extrahepatic Presinusoidal (ex. Portal vein thrombosis)
Intrahepatic Presinusoidal (ex. Schistosomiasis)
Intrahepatic -most common (ex. Cirrhosis)
Intrahepatic Postsinusoidal (Hepatic vein thrombosis)
Sonographic findings of portal hypertension include the secondary findings of?
portal systemic venous
What are some surgical techniques to lower portal pressure?
Distal splenorenal shunt/Warren
What are portal systemic collaterals?
Venous collaterals that are created connecting the portal system to the IVC, bypassing the liver.
Name five portal systemic collaterals.
1. Gastroesophageal varices
2. Reanalyzed umbilical vein
3. Splenorenal varices
4. Intestinal varices
5. Rectal varices (Hemorrhoids)
What are some physical signs of collaterals?
Dilated veins on anterior abdominal wall
Caput Medusa- Tortuous collaterals around umbilicus
Ascites- Fluid wave
What are gastroesophageal varices?
Collaterals of the distal esophagus and gastric funds, may lead to life threatening G hemorrhage.
Describe a recanalized umbilical vein.
Re-opening of the ligamentum teres to act as a collateral from the LPV to epigastric veins to the IVC.
Describe splenorenal varices.
Tortuous collateral veins seen in the splenic and left renal hilum.
Describe intestinal varies.
The veins of retroperitoneal structures such as the colon, duodenum, and pancreas. Anastomose with systemic tributaries.
Describe rectal varices.
AKA hemorrhoids, a collateral path in which the IMV drains into the rectal veins which connect with systemic tributaries.
Why are portosystemic shunts created?
To decrease portal pressure avoiding the development or rupture of gastroesophageal varies and reducing the accumulation of ascites.
In most cases, intraoperative shunting has been replaced by:
The TIPS shunt is places between what two structures?
Typically the RHV and the RPV by using jugular access.
With a widely patent TIPS, the RPV and the LPV should demonstrate...
Criteria for TIPS malfunction: What is the exception?
Low shunt velocity (<50 cm/s)
Focal velocity increase within TIPS (>190 cm/s)
Hepatopedal flow of LPV and RPV
Hepatofugual flow of the MPV (occluded TIPS);
Exception: with a recanalized umbilical vein, flow direction in LPV may be either direction.
What is preventing you from visualizing the TIPS shunt in the first 3-5 days after placement?
The material they use is called GORE Viatorr endoprosthesis. This shunt is a wire reinforced PTFE covered conduit. PTFE or polytetrafluoroethylene is a porous material that retains air after placement.
What are indication for a liver transplant in adults?
Cirrhosis of many etiologies
Viral hepatitis is leading cause of liver cancer )most common reason for liver transplant).
What is an indication for a liver transplant in children?
Preoperative sonographic evaluation for the liver transplant includes:
PV, HA, HV, IVC patenices and pressures of venous collaterals.
Postoperative sonographic evaluation for a liver transplant includes:
PV, HA, HV, IVC patenices
Peripheral fluid collection
Postoperative, what provides the only blood supply to the biliary tree?
The hepatic artery
Thrombosis or stenosis of the HA will result in biliary complications.
What is MELD?
The Model for End-Stage Liver Disease. It is a scoring system for assessing the severity of chronic liver disease. The MELD score is derived from a formula that uses the patient;s values for bilirubin, creatinine, and the international normalized ratio for prothrombin time (INR).
Sonographic findings of portal vein thrombosis include:
Hypoechoic thrombus within the PV
Increased PV caliber
portal systemic collaterals
What are the causes for a portal vein thrombosis?
Tumoral: Hepatocellular carcinoma, metastatic liver disease, pancreatic cancer.
Non-tumoral: Pancreatitis, cirrhosis, hepatitis, inflammatory bowel disease, trauma, splenectomy, hypercoagulopathy, and portal lymphadenopathy.
What is cavernous transformation?
Numerous won-like venous collaterals that parallel the chronically thrombosed PV. Typically seen with benign causes of PV thrombosis.
What is Budd-Chiari Syndrome?
A disorder characterized by hepatic vein obstruction by thrombus or tumor.
Budd-Chiari Syndrome is typically seen in what population?
Young adult women taking birth control pills.
In Budd Chiari Syndrome, patients present with signs associated with?
What are the causes of Budd Chiari?
Membranous obstruction of IVC
Majority of causes are undetermined.
In Budd Chiari Syndrome, the caudate lobe is often spared, why? What happens?
Emissary veins drain directly into the IVC;
The caudate lobe enlarges with atrophy of the right and left lobes.
What is portal vein gas?
Uncommon condition where air is noted within the intrahepatic portal veins.
What is portal vein gas associated with?
Ischemic bowel disease.
What is the cause of portal vein gas in infants due to?
Define a liver cyst and what are the sonographic criteria?
Fluid-filled space lined by biliary epithelium. Usually refer to nonparasitic simple cysts;
Anechoic, thin walled, acoustic enhancement.
If liver cysts are seen before the 5th decade of life, what should you do?
Evaluate kidneys for autosomal dominant polycystic kidney disease.
How will a hemorrhagic cyst appear as?
A cyst with internal echoes accompanied by RUQ pain and decreasing hematocrit.
What is the most common benign tumor of the liver?
What gives a hemangioma its hyperechoic appearance?
Multiple vascular channels that create multiple sonographic interfaces.
What are the sonographic findings of a hemangioma?
Hyper echoic, but can appear hypoechoic within the back- ground of fatty liver.
Typically does not demonstrate flow within.
A hemangioma may enlarge with what?
Pregnancy or administration of estrogen.
In a cavernous hemangioma, contrast enhancement imagine demonstrates what?
Characteristic centripetal flow.
What is focal nodular hyperplasia?
Benign solid liver mass believed to be a developmental hyper plastic lesion related to an area of congenital vascular malformation.
What are the sonogprahic findings of focal nodular hyperplasia?
Solid mass with varying echogenicity
Central fibrous scar
Focal nodular hyperplasia is an incidentally detected liver mass in what kind of patient?
An asymptomatic patient
Are focal nodular hyperplasia masses more commonly seen in women or men?
Differentiating what 3 liver masses are important?
Focal nodular hyperplasia
Fibrolamellar Hepatocellular Carcinoma
A hepatic adenoma is associated with the use of what?
Patients with hepatic adenomas may present with pain due to what?
Hepatic adenomas are associated with?
Glycogen storage disease
Surgical resection is recommended for patients with a hepatic adenoma due to the risk of?
What are the sonographic findings of a hepatic adenoma?
What is a hepatic lipoma?
Extremely rare fatty tumors.
What is associated with a hepatic lipoma and angiomyolipomas?
Tuberous sclerosis, a congenital familial disease.
What are the sonographic findings of a hepatic lipoma?
Propagation speed artifact
Due to the propagation speed artifact in a hepatic lipoma, what will happen to objects posterior to the mass?
They will be placed further away. This may be seen as a broken diaphragm.
List of hyper echoic hepatic masses:
Focal fatty infiltration
What is the most commonly seen solid mass of the liver?
What is the most common source of metastatic involvement in the liver?
GI, Breast, or lung cancer.
What is the sonographic appearance of metastatic disease in the liver?
Bull's eye or target
What are common sonographic patterns of hepatic metastases origination?
Hyperechoic- GI tract
Calcified- Mutinous Adenocarcinoma
Hepatocellular carcinoma commonly invades:
Venous structures (PV, HV, IVC)
What are the sonogrpahi findings of hepatocellular carcinoma?
Variable appearance, most are hypoechoic.
What labs increase in hepatocellular carcinoma?
What is the most common malignant liver tumor in early childhood?
What is hepatoblastoma associated with?
Familial adenomatous polyposis
Portal vein invasion
What lab values are increased with a hepatoblastoma?
Serum alpha fetoprotein
What is the most common primary malignant tumor of the liver?
What is Aminotransferases (Transaminases)? What does it increase with?
One of the first lab tests to asses liver is determining the presence of liver enzymes in the blood. When liver cells are damaged they spill these enzymes into the blood stream.;
It increased with a fatty liver, drug-induced, Hep A, Hep B, hep C, autoimmune Hepatitis.
What is Asparate Aminotrasnferase (AST)? [AST=SGOT]
Serum glutamic oxaloacetic transaminase (SGOT). It is present in the liver, heart, skeletal muscle, kidneys, and brain. Elevation of AST by itself is non-specific for liver disease.
What is seen with an increase of AST and not ALT?
MI, heart failure, muscle injury, CNS disease, and other non hepatic disorders. The highest elevations occur with viral hepatitis.
What is Alanine Aminotransferase (ALT)? [ALT=SGPT]
Serum glutamic pyretic transaminase (SGPT). ALT is more specific for liver disease than AST. Elevated AST and lactic dehydrogenase (LDH) with normal ALT rules out hepatic disease.
What is Gamma Glutamyl Transpeptidase (GGT)?
It is present in hepatocytes and bile epithelium. An elevation indicated hepatocellular disease and biliary obstruction. GGT is increased in most diseases that cause acute damage to the liver or bile ducts. GGT is also typically elevated in patients with acute or chronic alcohol abuse.
Increased GGT + Increased ALP = Biliary obstruction
Increased GGT + Increased ALT = Hepatocellular disease
What is Lactic Dehydrogenase (LDH)?
Enzyme found in the cells of many body tissues. Because LDH is widely distributed throughout the body, cellular image causes an elevation of the total serum LDH. LDH levels can be used to monitor treatment of some cancers.
What is Alpha Fetoprotein (AFP)? What do elevated levels occur with?
A protein synthesized by the fetal liver and levels decrease during the first year of life.;
Elevated levels occur with:
Hepatocellular carcinoma (Hepatoma)
Germ cell tumors (testes and ovaries)
Metastatic liver cancer
What are high levels of >500g/mL very suggestive of?
What is Prothrombin Time (PT)?
Prothrombin Time screens for abnormalities in the extrinsic and common pathways of coagulation. The PT is reported a the international normalized ratio (INR), which reflects the ratio of the patient's PT to the laboratory's control value. The normal range is between 10 and 13 sec.
What is Partial Prothrombin Time (PTT)?
Screens plasma for abnormalities in factors of the intrinsic and common pathways The PTT tests for deficiencies of all clotting factors except for VII and factor XIII.
What tests are monitored prior to an invasive procedure to insure proper clotting?
PT (INR), PTT and platelets.
Alpha fetoprotein (AFP) may be increased:
Acute and chronic hepatitis
Testicular cancer (non seminoma)
CA 19-9 may be increased with:
can be elevated with colorectal and bile duct cancers
Carcinoembryonic Antigen (CEA) may be elevated with:
Elevated with other cancers
Human chorionic gonadotropin (HCG) may be elevated with:
(Seminoma and non-seminoma)
Prostate-Specific antigen (PSA) might be elevated in:
Benign prostatic hypertrophy
Prostatic acid phosphatase (PAP) may be elevated in:
Intrahepatic bile ducts converge to form the:
Right and left hepatic ducts
The right and left hepatic ducts join to form the:
Common hepatic duct (CHD)
The gallbladder is located at the ________ end of the main lobar fissure.
The gallbladder neck tapers to form the _________ which joins with the __________ to form the ___________.
Common hepatic duct (CHD);
Common bile duct (CBD)
The common bile duct and the main pancreatic duct (Duct of Wirsung) join to form the:
Ampulla of vater
It is uncommon to see the cystic duct on ultrasound. Thus, we use the term "common duct" to refer to the:
Extrahepatic ductal system
At the porta hepatis, the portal triad consists of the:
The main portal vein, common hepatic duct, and proper hepatic artery. AKA the "Mickey Mouse" sign
The gallbladder is divided into the:
Neck, body, and fundus.
__________ is a spiral fold which controls bile flow in the cystic duct.
Valve of Heister's
_________ is an abnormal sacculation (diverticulum) of the neck of the gallbladder.
A __________ is a fold between the body and fundus of the gallbladder.
A _____________ is a fold between the body and the neck (infundibulum) of the gallbladder.
The CBD passes ________ to the first part of the duodenum and pancreatic head joining the main pancreatic duct (of Wirsung) at the ampulla of Vater.
The ampulla of Vater empties through the duodenal papilla, controlled by the ____________.
Spincter of Oddi
Gallbladder wall thickness less than _______ is considered normal.
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