Biliary tract dilatation without jaundice demonstrated by ultrasound

Upper abdominal ultrasonic examination demonstrated dilated bile ducts in eight patients with no history of jaundice and a normal serum bilirubin. All were proven subsequently to have extrahepatic biliary obstruction. It is important to recognise that ultrasound may be more sensitive than serum bilirubin in the diagnosis of extrahepatic biliary obstruction.     

Biliary atresia: US diagnosis

PURPOSE: To evaluate prospectively the sensitivity of ultrasonography (US) in the diagnosis of biliary atresia (BA), with surgery as the reference standard. MATERIALS AND METHODS: After institutional ethical approval and with informed parental consent, 90 consecutive fasting infants with conjugated hyperbilirubinemia underwent detailed US studies performed by a single operator with a 7.5-MHz curvilinear transducer and a 13.5-MHz linear-array transducer. The following features were prospectively recorded: gallbladder morphology, triangular cord sign, presence of a common bile duct, liver size and echotexture, splenic appearance, and vascular anatomy. The operator was blinded to results of other investigations. Sensitivity, specificity, and positive and negative predictive values were calculated for each US variable. BA and non-BA groups were compared by means of the Fisher exact test for categorical variables and an unpaired t test for continuous variables. RESULTS: Thirty infants (13 male, 17 female) had surgically confirmed BA, and 60 (35 male, 25 female) had other documented causes of neonatal jaundice; the mean ages at US assessment were 48.5 and 52.4 days, respectively (P>.5). Eight US features showed a significant difference between BA and non-BA groups (P<.001, Fisher exact test). The features with the greatest individual sensitivity and specificity, respectively, in the diagnosis of BA were triangular cord sign (73% and 100%), abnormal gallbladder wall (91% and 95%) and shape (70% and 100%), and an absent common bile duct (93% and 92%). The hepatic artery diameter was significantly larger in infants with BA than in those without BA (mean+/-standard deviation, 2.2 mm+/-0.59 vs 1.6 mm+/-0.40, P<.001), but portal vein diameters were not significantly different. By means of all these US features, 88 of 90 infants were correctly classified as having or not having BA, for an overall accuracy of 98%. CONCLUSION: BA can be distinguished with US from other causes of conjugated hyperbilirubinemia in 98% of infants if multiple US features are carefully evaluated.     

Ureterovesical obstruction and megaloureter: diagnosis by real-time US

Forty infants and children were accurately diagnosed with real-time ultrasound (US) as having megaloureter secondary to ureterovesical junction (UVJ) obstruction by an adynamic, distal ureteral segment. Characteristic US findings were dilatation of the distal ureter, often disproportionate to the appearance of the upper collecting system; lower ureteral hyperperistalsis; and a sharply tapered, incurving, distal adynamic segment, 1-3 cm long. Real-time US, used routinely in preliminary evaluation of the urinary tract in children, can facilitate early diagnosis of UVJ obstruction and thus prevent significant loss of renal function.     

Biliary tract dilatation in chronic pancreatitis: CT and sonographic findings

The authors retrospectively evaluated 44 patients with chronic pancreatitis to determine (a) what features on computed tomographic and sonographic scans were associated with biliary tract dilatation, (b) how these findings and biliary tract dilatation changed at follow-up, and (c) the correlation between the degree of biliary tract dilatation and the laboratory and histologic findings when available. Twenty-four patients had biliary tract dilatation; of this group 88% had pancreatic calcifications and 75% had a focal mass in the pancreatic head. Sixteen of the 24 patients underwent follow-up studies; in 12 there was no change in the degree of biliary tract dilatation or appearance of the pancreas. The levels of serum alkaline phosphatase and bilirubin were elevated in most of the 24 patients; at follow-up, however, there was no consistent relationship between these values and radiologic findings. Biopsy is recommended for those patients in whom the serum alkaline phosphatase level remains persistently elevated. Four of seven such patients in this study underwent biliary-enteric bypass procedures due to pathologic evidence of cholestasis.     

Biliary fascioliasis: US and endoscopic retrograde cholangiopancreatography findings

Fascioliasis is a common parasitic disease in cattle and sheep that is caused by the fasciola hepatica worm. Humans are sporadically infected by eating cyst-laden waterplants or drinking contaminated water. We reviewed the US and endoscopic retrograde cholangiopancreatography (ERCP) findings of 3 patients with proven biliary fascioliasis. All patients had atypical symptoms, complaining of intermittent pain in the right upper quadrant (RUQ). The US findings were mural thickening and dilatation of the common bile duct, and echogenic material in both gallbladder and common bile duct. The abnormalities were present for several months, and in some cases for years. The findings were confirmed by ERCP. If a patient shows the described US features in combination with atypical RUQ symptoms biliary fascioliasis should be considered. Correspondence to: H. W. A. Ooms     

Biliary dilatation in the presence of a periampullary duodenal diverticulum

Objective:

Periampullary diverticulum (PAD) often presents as an incidental CT finding. Its significance and its effect on biliary dilation are unclear. The aim of our study was to determine if the presence of a PAD is associated with abnormal dilation of the common bile duct (CBD).

Methods:

Patients with PAD were retrospectively identified from the radiology database from November 2011 to November 2012 and those with known pancreaticobiliary pathology were excluded, except patients with cholelithiasis and prior cholecystectomy. A total of 150 patients with PAD were selected as well as a control group of 150 patients with no PAD. Data with respect to demographics, PAD size and location, ductal diameter, previous cholecystectomy and liver function tests were collected. To compare the groups, the Student''s t-test and χ² analysis were used where appropriate.

Results:

The male : female ratio was 1 : 1.2 with a median average of 71 years in the PAD group. There was no statistical difference in the CBD measurement (at the pre-ampulla and pancreatic head, and distal to confluence) between the PAD and control groups (4.8, 6.9 and 6.8 mm for the PAD group; 4.7, 6.8 and 6.4 mm for the control group; p = 0.5, 0.7 and 0.3). Also, no difference was observed in the right and left intrahepatic biliary ducts (2.7, 2.7 mm for the PAD group; 2.5, 2.6 mm for the control group; p = 0.2, 0.6). There was a significantly higher incidence of cholecystectomy history (23% vs 8.7%, p < 0.01) and cholelithiasis (22% vs 11%, p < 0.01) in the PAD group, and no difference in the liver function tests. Subgroup analysis of small vs large PAD (<20 mm, ≥20 mm) did not show a difference in the CBD and intrahepatic biliary duct measurements. When comparing cholecystectomy vs non-cholecystectomy groups, CBD measurements were significantly higher in the cholecystectomy group.

Conclusion:

Our study confirms that PAD on its own does not lead to abnormal CBD dilatation. However, increased incidence of cholelithiasis and cholecystectomy was noted in the presence of PAD.

Advances in knowledge:

PAD on its own does not cause CBD dilatation.     

Biliary dilatation and duodenal intussusception secondary to enteric duplication cyst: MDCT diagnosis

Enteric duplication cysts are rare congenital anomalies that may occur anywhere along the gastrointestinal tract, most commonly involving the small bowel. The distal ileum, jejunum, and duodenum are affected in descending order of frequency. We describe a case of biliary dilatation and duodenal intussusception caused by an enteric duplication cyst in an adult patient. To our knowledge, there are no other reported cases of this entity in an adult in the English literature. Multidetector computed tomography (MDCT) findings are emphasized, and the value of multiplanar reformation (MPR) in forming a correct preoperative differential diagnosis is discussed.     

Biliary ileus: preoperative diagnosis by US. A report of two cases

The preoperative diagnosis of biliary ileus was correctly made by US in two cases (87 and 80-year-old females) referred to US studies because of nonspecific abdominal symptoms and to rule out possible acute appendicitis, respectively. Plain-film findings were unremarkable in one patient, small-bowel obstruction was detected in the latter. In both cases sonography revealed a small amount of air within the thick-walled gallbladder; the presence of mechanical ileus, and a gallstone impacted within the ileal loop. These features, together with collapsed bowel lumen distally to the stone, enabled a reliable diagnosis of biliary ileus to be made. This was confirmed by ensuing laparotomy, when a large cholesterol stone was removed in both cases. Correspondence to: V. Simonovský     

Biliary atresia and noncardiac polysplenic syndrome: US and surgical considerations

Ten percent of children with biliary atresia have an associated complex of anomalies, including polysplenia, azygous continuation of the inferior vena cava, preduodenal portal vein, hepatic arterial anomalies, and bilaterally bilobed lungs. These abnormalities will not be detected if the preoperative workup is limited to hepatobiliary nuclear scanning. Ultrasonography is important in the preoperative evaluation of patients suspected of having biliary atresia. It is important to identify the associated abnormalities preoperatively because they have an impact on the initial portoenterostomy and may preclude subsequent orthotopic liver transplantation.     

Arnold-Chiari II malformation: intraoperative real-time US

Nineteen cases in which high-resolution, intraoperative, real-time sonography was performed during decompression of an Arnold-Chiari II malformation were reviewed. The variations of the often complicated hindbrain anatomic features, well known from autopsy series, were shown in detail with intraoperative sonography. The extent of herniation of the cerebellar vermis, the medulla, and the fourth ventricle into the cervical spinal canal, as well as fourth ventricular dilatation, arachnoid cysts, and cervical hydromyelia, were also demonstrated sonographically. Real-time imaging was useful in guiding the neurosurgeon in decompression of the hindbrain, especially the fourth ventricle, in an anatomic area often obscured visually by intense fibrovascular adhesions.     

Biliary stricture dilatation: multicenter review of clinical management in 73 patients

Eighty-nine biliary strictures in 73 patients who had undergone percutaneous balloon dilatation were reviewed to determine long-term patency rates and clinical management problems. The majority of dilatations were performed in patients with anastomotic strictures (n = 44), iatrogenic strictures (n = 28), and strictures associated with sclerosing cholangitis (n = 17). Patency rates after 36 months or more were 67%, 76%, and 42%, respectively. Complications, mostly minor, occurred in less than 7% of patients. Of patients with significant biliary obstruction, 15% had little or no intrahepatic biliary duct dilatation demonstrated by cross-sectional imaging and/or direct cholangiography. No definite conclusions could be drawn about the utility of long-term internal/external stenting.     

Acute appendicitis: high-resolution real-time US findings

High-resolution, real-time ultrasonography (US) with graded compression was used to evaluate 90 patients with clinically suspected acute appendicitis. US visualization of a noncompressible appendix was the primary criterion for a diagnosis of acute appendicitis. The overall sensitivity was 89%, the specificity was 95%, and the accuracy was 93%. When the results in women were analyzed separately (n = 49), the overall accuracy was 96%. Several important limitations of US scanning were encountered. There were three false-positive examinations in patients with a sonographically visible appendix whose symptoms spontaneously resolved. Another patient had a normal compressible appendix with a thin (2-mm), symmetric wall surrounded by ascites. There were three nondiagnostic studies (3%) due to inability to compress the cecum and right lower quadrant adequately because of exquisite tenderness (two patients) or massive ascites (one patient). When interpreted in light of the clinical examination, sonography should significantly reduce the rate of false-negative appendectomies, particularly in women.     

Duplex Doppler US of the kidney: differentiation of obstructive from nonobstructive dilatation

Distinction of the obstructed from the nonobstructed dilated renal collecting system is a difficult problem often requiring interventional procedures and pressure measurements. The authors prospectively performed duplex Doppler ultrasound (US) evaluations in 21 kidneys (obstructed, n = 14; nonobstructed, n = 7) immediately before percutaneous nephrostomy. In addition, ten of the obstructed kidneys were evaluated with follow-up Doppler US after percutaneous nephrostomy. Renal obstruction caused a change in the Doppler waveform detected by means of the resistive index (RI). Thirteen of the 14 obstructed kidneys had a RI value greater than .70, while none of the nonobstructed kidneys had a RI value exceeding .70. Relief of the obstruction resulted in a reduced RI; in nine of ten kidneys, the RI was less than or equal to .70 (similar to that of the nonobstructed kidneys). When a dilated collecting system is being imaged, additional evaluation with duplex Doppler US may help distinguish obstructed from nonobstructed dilatation, which may be of particular benefit in patients with conditions that usually predispose them to collecting system dilatation.     

Hepatic artery pseudoaneurysm: diagnosis with real-time and pulsed Doppler US

Duplex ultrasonography (US), consisting of real-time and pulsed Doppler US, was used to identify a pseudoaneurysm in a patient with recurrent bleeding and chronic pancreatitis. The authors present a case that illustrates the limitations of real-time US in evaluating sonolucent masses in pancreatitis and the need for using pulsed Doppler technique.     

Biliary matrix: matrix stones as a cause of biliary obstruction.

The biliary tree secretes a mucous substance which serves as a matrix in gallstones. A case of biliary obstruction secondary to a matrix stone is reported. The characteristics and significance of biliary matrix are discussed.     

Percutaneous Biliary Interventions: Inside and Outside the Box: Advancements in Endoscopic Biliary Interventions by Gastroenterology

Endoscopic retrograde cholangiopancreatography (ERCP) is an endoscopic technique in which a specialized side-viewing endoscope is guided into the duodenum, allowing for instruments to access the biliary and pancreatic ducts. ERCP was initially developed as a diagnostic tool as computed tomography was in its infancy during that time. ERCP has evolved since its inception in the 1960s to becoming not only a valuable diagnostic resource but now an effective therapeutic intervention in the treatment of various biliary disorders. The most common biliary interventions performed by ERCP include the management of biliary obstructions for benign and malignant indications. Additionally, endoscopic ultrasound (EUS) has been increasingly utilized in diagnosing and intervening on pancreaticobiliary lesion. This article will discuss the various methods currently available for various endoscopic biliary interventions and future interventional techniques. For the management of biliary strictures, EUS can be utilized with fine need aspiration, while ERCP can be used for the placement of various stents and diagnostic modalities. Another example is radiofrequency ablation, which can be used for the treatment of hilar strictures. Achieving bile duct access can be challenging in patients with complicated clinical scenarios; other techniques that can be used for bile duct access include EUS-guided rendezvous approach, transluminal approach, Choleodochoduodenostomy, and hepatogastrostomy, along with gaining access in complicated anatomy such as in patients with Rou-en-Y anatomy. Another useful endoscopic tool is nonsurgical drainage of the gallbladder, which can be a suitable option when patients are not optimal surgical candidates. There has also been an increase in outpatient utilization of ERCP, which was previously seen as a predominantly inpatient procedure in the past. Possible future evolutions of biliary interventions include robotic manipulation of a duodenoscope and direct infusion of chemotherapeutic or immunomodulatory agents into the pancreaticobiliary tree. These advancements will depend on parallel advancements in other imaging and laboratory as well as breakthrough technology or techniques by other disciplines including interventional radiology and minimally invasive surgery.     

The infant hip: real-time US assessment of acetabular development

Until recently, radiography was the only available means of assessing acetabular development in infants with congenital hip dysplasia. Now that real-time ultrasonography (US) is successfully employed to determine hip position in infancy, it also offers an alternative method for evaluating acetabular development. In a review of 377 US studies of infant hips, the coronal-flexion images, which show a coronal section of the acetabulum with the hip in flexion, were measured to determine the percentage of the femoral head that was covered. Radiographs were measured to determine the acetabular index (angle). Acetabuli with indices exceeding the normal range for the subject's age showed head coverage of less than 33%. The 51 sonograms in this category were all associated with clinical abnormalities, whereas the 107 with coverage greater than 58% were associated with no clinical abnormalities and with consistently normal acetabular indices. The use of US in assessing acetabular development warrants continued investigation.