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Year : 2006  |  Volume : 16  |  Issue : 4  |  Page : 477-481
Ultrasonography in obstructive jaundice - a pictorial essay


Department of Radiology, Gujarat Cancer and Research Institute, Asarwa, Ahmedabad - 380016, India

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Date of Submission10-Mar-2006
Date of Acceptance10-Jul-2006
 

Keywords: Obstructive Jaundice, Ultrasonography

How to cite this article:
Gohil Y M, Patel S B, Goswami K G, Shah S, Soni H. Ultrasonography in obstructive jaundice - a pictorial essay. Indian J Radiol Imaging 2006;16:477-81

How to cite this URL:
Gohil Y M, Patel S B, Goswami K G, Shah S, Soni H. Ultrasonography in obstructive jaundice - a pictorial essay. Indian J Radiol Imaging [serial online] 2006 [cited 2020 Sep 24];16:477-81. Available from: http://www.ijri.org/text.asp?2006/16/4/477/32250

   Introduction Top


Jaundice is a symptoms complex, characterized by yellow coloration of tissues and body fluids due to an increase in bile pigments. Jaundice is classified in hemolytic, hepatic and obstructive. Ultrasonography in obstructive jaundice is useful to differentiate non obstructive from obstructive jaundice by demonstration of dilatation of intrahepatic and extrahepatic biliary ducts, to demonstrate level and cause of obstructive jaundice, to assess resectability of tumour by giving information about local invasion, liver metastasis, distant lymphadenopathy, vascular invasion and peritoneal metastasis.


   Pathology Top


(A) Benign lesions:

1. Choledocholithiasis

Stone in CBD is may be primary resulted from bile stasis and infection or secondary from gallbladder. On sonography If CBD is dilated then calculus is seen as an echogenic nodule with acoustic shadowing. But if CBD is minimal dilated or of normal caliber, acoustic shadowing is usually not seen. Possible source of confusion with calculus are gas or particulate material in the adjacent duodenum or gas in biliary tract, pancreatic calcification, post-cholecystectomy surgical clips.

2. Mirrizi's syndrome

Mirrizi's syndrome is uncommon cause for extra hepatic biliary obstruction due to an impacted stone in the cystic duct creating extrinsic mechanical compression of the common hepatic duct. Not uncommonly, the stone penetrates into the common hepatic duct or the gut, resulting in a cholecystobiliary or cholecystenteric fistula. Sonographic findings include intrahepatic bile duct dilation, a normal size CBD, and a large stone in the neck of the gallbladder or cystic duct.

3. Post operative biliary strictures

Majority of the strictures are the result of injury to the bile duct at the time of biliary tract surgery. ERCP and PTC are investigation of choice. On sonography smooth tapering stenosis with proximal dilation of CBD, abrupt cut off of CBD, the presence Of echogenic nodule without acoustic shadowing are findings.

4. Post- inflammatory strictures

Inflammatory strictures caused by cholangitis, chronic pancreatitis, gallstones and penetrating or perforating duodenal ulcer. The most frequent findings are smooth, concentric, often tapered narrowing of the CBD. Strictures may be single or multiple and may involve any portion of the biliary tree.

5. Primary sclerosing cholangitis and AIDS cholangitis

Primary sclerosing cholangitis is chronic progressive disorder of unknown etiology that occurs commonly in young men. In about 50 % cases it is associated with ulcerative colitis. In AIDS, causes of abnormalities are infection with HIV virus and opportunistic organisms have been implicated. Sonography shows patchy smooth or irregular wall thickening of the intrahepatic bile ducts. Dilatation of biliary radicles is usually mild.

6. Recurrent pyogenic cholangitis

Recurrent pyogenic cholangitis is endemic in Southeast Asia. Recurrent nature of the disease leads to progressive biliary strictures with marked ductal dilatation and stone formation. The disease often progresses to cirrhosis. Sonographic shows combination of marked extrahepatic bile duct dilatation and intrahepatic bile duct dilatation limited to segmental branches with acute peripheral tapering ("pruned-tree" appearance), with associated biliary calculi and debris.

7. Parasitic diseases

Ascaris lumbricoides-It normally inhabits the small intestine and have propensity to migrate through the ampulla of Vater to lodge in the gallbladder and biliary tract. On USG, the worms can be recognized as tubular non-shadowing, echogenic structures in the dilated biliary tract. When they alive, the movement of the worms can be seen, and it is usually possible to seen a sonolucent inner tube within the echogenic tubular structure, which represents the alimentary canal of the worm. In transverse section, a "bull's eye" image may be seen caused by the worm inside a dilated bile duct. Ultrasound may also reveal hepatic abscesses complicating biliary ascariasis.

Biliary Hydatid- Hydatid disease can affect any organ of the body and liver is involved most commonly. Rupture is an important complication of Hydatid cyst of liver. In a patient with rupture into the biliary system, daughter cysts and membranes pass into the common bile duct producing surgical jaundice. Sonography shows Findings of Hydatid cyst in liver (cyst with daughter cyst), with connection of Hydatid cyst with CBD and linear echogenic material due to laminated Hydatid membranes, rounded small cysts due to Hydatid daughter cysts and debris due to a mixture of Hydatid membranes and daughter cysts in CBD.

8. Choledochal cysts

Choledochal cysts are uncommon congenital cysts of the bile ducts. The cysts usually manifest in childhood, and the triad of jaundice, pain and palpable sub costal mass is diagnostic. Sonographic findings reflect specific types of choledochal cysts. Todani et al classified choledochal cysts into five types.

Type I Fusiform cystic dilatation of extrahepatic CBD.

Type II Eccentric fluid filled cyst may be seen which may appear separate from the CBD, as its neck may be narrow.

Type III Choledochal cyst or choloedochocele represents localized cystic dilatation of the distal intramural duodenal portion of the CBD and is difficult to diagnose on US.

Type IV A Multiple cyst involving intrahepatic and extrahepatic bile ducts.

Type IV B There are multiple cysts involving the extrahepatic bile duct only.

Type V Also called Caroli's diseases includes single or multiple intrahepatic bile duct cysts.

Complications are choledocholithiasis, changes due to pancreatitis and /or biliary cirrhosis, portal vein thrombosis, hepatic abscess, and malignant neoplasm within the cyst wall and gallbladder.

(B) Malignant lesion causing obstructive jaundice

1.Carcinoma of gallbladder

Carcinoma of the gallbladder is the most common biliary tract malignancy. The patient usually an elderly female. Majority of tumours are inoperable at the time of diagnosis. Lymphnodes and liver invasion and local spread to duodenum, stomach, and colon is common. Three major patterns have been described on sonography. In type I, the gallbladder is surrounded or replaced by hypoechoic or heterogenous mass. In type II, there is focal or diffuse, irregular and asymmetrical wall thickening. In type 3, which is less common, a polypoid, and fungating intraluminal mass, is seen. Gall stones seen in majority of patients. Biliary obstruction in the form of dilated intrahepatic biliary radicles and CBD may seen because of direct extension via hepato-duodenal ligament or compression by lymphadenopathy. On ultrasonography differential diagnosis includes complicated cholecystitis and xanthogranulomatous cholecystitis.

2.Cholangiocarcinoma

It is uncommon tumour. It is commoner in males with peak incidence in sixth or seventh decade. High incidence is associated with sclerosing cholangitis, Caroli's disease, choledochal cysts, and ulcerative colitis. The prognosis of distally placed tumour is better than proximally placed tumours. Local and distant metastases are uncommon. Cholangiocarcinoma can be classified according to location as,[1] Intrahepatic tumour [2] Hilar lesions (the most common location) referred to as Klatskin tumour and [3] Distal ductal tumour. Cholangiocarcinoma may occur in between these general locations.

Intrahepatic Cholangiocarcinoma - They are usually large at presentation due to early asymptomatic course. Sonographic findings are nonspecific and may be seen as hypo or iso echoic masses, which may be homogenous or heterogenous. Focal intrahepatic biliary ductal dilatation and atrophy of the segment of the liver drained by these duct with retraction of overlying liver capsule may also be seen.

Hilar Cholangiocarcinoma - The most common location is either at the confluence of right and left hepatic ducts, or the proximal common hepatic duct, and has been termed Klatskin tumour. Hilar Cholangiocarcinoma are graded according to Bismuth classification. Type 1 lesion involves common hepatic duct only; type 2 lesion involves right and left hepatic ducts at confluence. First order branches are involved of either (type 3) or both (type 4) of the hepatic ducts. Ultrasound demonstrates dilatation of intrahepatic biliary radicles without any evidence of extrahepatic dilatation. Tumours may be small and difficult to visualize on sonography. Occasionally moderately echogenic tumour may be seen at confluence. Some time no mass seen at confluence except non-union of right and left hepatic biliary radicles.

Distal duct Cholangiocarcinoma - The least common location for Cholangiocarcinoma is the distal duct. Ultrasound demonstrates biliary dilatation proximal to an abrupt obstruction. Site of lesion will determine the gallbladder distention. There may be seen intraluminal polypoid lesion within bile duct. The bile duct at the level of obstruction in Cholangiocarcinoma is narrowed if the process is primarily desmoplastic and widened if there is an obstructing intraluminal mass.

3. Carcinoma of head of pancreas

Carcinoma of head of pancreas is usually presented with obstructive jaundice.

Most common ultrasonographic finding in pancreatic carcinoma is a poorly defined, homogenous or inhomogeneous hypoechoic mass in the pancreas or pancreatic fossa. When an isoechoic mass is identified, attention should be given to the size of the pancreas and nodularity of its contour. Other findings include dilation of the pancreatic duct and CBD proximal to obstruction.

4. Carcinoma of duodenum

Carcinoma of duodenum may involve CBD with direct extension or by nodal mass. Patient presents with gastric outlet problems more commonly than icterus. On sonography there may be circumferential diffuse or focal hypoechoic thickening noted with adjacent nodes.

5. Ampullary tumour

On ultrasound it is seen as polypoid mass at region of ampulla or abrupt dilatation of common duct or double duct sign. In double duct sign Common bile duct and pancreatic duct dilated without any obvious mass.[15]

 
   References Top

1.The Gallbladder and Bile duct Laing FC Diagnostic Ultrasound-Rumack CM, 1998 vol-1 175-223  Back to cited text no. 1    
2.High resolution real time ultrasound in the evaluation of the normal and obstructed biliary tract. Cooperberg PL et al Radiology, 129: 477-480  Back to cited text no. 2    
3.The accuracy of sonography in the differential diagnosis of obstructive jaundice: A comparison with cholangiography.Koenigsberg M, Weiner SN, Walzer A et al Radiology 1979, 133: 157-165.  Back to cited text no. 3    
4.Biliary dilatation: Defining the level and cause by Real time US.Laing FC, Jeffrey RB Jr, Wing VW Radiology 1986, 160: 39-42  Back to cited text no. 4    
5.Ultrasonography of carcinoma of the Gallbladder: an analysis of 80 cases.Kumar A, Agrarwal S, Berry M, et al J Clin Ultrasound 18: 1990; 715-720  Back to cited text no. 5    
6.Cholangiocarcinoma at hepatic hilus: sonographic findings Hann LE, Greatrex KV et al. AJR; 1997:168:985-989  Back to cited text no. 6    
7.Bile duct obstruction: Radiological evaluation of level, cause and tumour resectibility Robert N, Gibson et al. Radiology 1986; 160:43-47  Back to cited text no. 7    
8.Ultrasound diagnosis of rupture Hydatid cyst of liver with biliary obstruction Camunez F et al. Gastrointest Radiol 1986; 11: 330-333  Back to cited text no. 8    
9.Biliary sonography Steven MC, Alfred BK et al RCNA 1991 Vol 29 No 6 1171-1198  Back to cited text no. 9    
10.Extrahpatic bile duct carcinoma- US characteristic and accuracy in the demonstration tumour. Robeledo T, Muro A, Preito ML  Back to cited text no. 10    
11.The biliary tract John karani A textbook of Radiology and Imaging-Sutton 2003 Vol-1, 711-736  Back to cited text no. 11    
12.The biliary tract Derrik FM, Hans-Ulrich Laush Diagnostic Radiology - R. G. Grainger and D. J. Allison 2001 Vol-2, 1247-1306   Back to cited text no. 12    
13.Non-neoplastic disease of bile duct Baron RL, Campbel WL Alimentary tract radiology-Margulis AR, Burhenne HJ 1994 Vol-2 1295-1324  Back to cited text no. 13    
14.Neoplastic disease of bile duct Parret RS, Thorsen MK, Lausen TL Alimentary tract radiology-Margulis AR, Burhenne HJ 1994 Vol-2 1325-1343  Back to cited text no. 14    
15.Imaging the spectrum of biliary tract disease. Baron RL, Tublin ME, Peterson MS RCNA 2002, 40:1325-1354  Back to cited text no. 15    

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Correspondence Address:
Y M Gohil
Department of Radiology, Gujarat Cancer and Research Institute, Asarwa, Ahmedabad - 380016
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-3026.32250

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    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8], [Figure - 9], [Figure - 10], [Figure - 11], [Figure - 12], [Figure - 13]

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