Diagnostic Ultrasound - Abdomen and Pelvis
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Diagnostic Ultrasound - Abdomen and Pelvis

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09.07.2019 Views

Biloma TERMINOLOGY Definitions • Encapsulated collection of bile outside biliary tree IMAGING General Features • Location ○ Intrahepatic or extrahepatic, in gallbladder fossa in patients with recent cholecystectomy Ultrasonographic Findings • Grayscale ultrasound ○ Focal collection of fluid within liver or close to biliary tree, e.g. in gallbladder fossa in patient with recent cholecystectomy ○ Round or oval in shape and usually unilocular ○ Thin capsule wall usually not discernible ○ Anechoic fluid content suggests fresh biloma ○ Debris or internal septa suggest infected biloma ○ Posterior acoustic enhancement ○ May see echogenic foci at periphery related to clips from recent surgery • Color Doppler ○ No vascularity within lesion ○ For infected biloma, there may be increased vascularity in adjacent tissue • Needle aspiration under ultrasound guidance usually required to confirm diagnosis (detection of bilirubin in aspirate) CT Findings • Well defined or slightly irregular cystic lesion without identifiable wall • High-attenuation internal debris may be seen • Subcapsular or intrahepatic biloma may result in adjacent transient hepatic attenuation difference (THAD) on arterial phase imaging secondary to mass effect and diminished portal venous flow MR Findings • T1WI: Usually low but variable SI • T2WI: High SI (same as gallbladder),internal debris can be seen as low SI • Delayed phase MR using hepatobiliary contrast agent can determine bile leakage into biloma Radiographic Findings • Cholangiography may delineate leakage site:Extravasation of contrast outside biliary tree Nuclear Medicine Findings • Hepatobiliary scintigraphy may demonstrate continual bile leakage into biloma Imaging Recommendations • Best imaging tool ○ Ultrasound is good at lesion detection and provides information on site & size of lesion for progress monitoring or intervention DIFFERENTIAL DIAGNOSIS Perihepatic Collection/Seroma/Lymphocele • May be anechoic or contain debris or loculations • Thick, irregular wall may be present • Difficult to distinguish from biloma; aspiration biopsy may be required Hepatic Cyst • Variable appearance depending on whether it is sterile, infected, or hemorrhagic Hepatic Abscess • Thick, irregular wall, surrounding vascularity Intrahepatic Hematoma • Echogenicity evolves over time:Echogenic initially, hypoechoic after 4-5 days, internal echoes and septations after 1-4 weeks PATHOLOGY General Features • Etiology ○ Iatrogenic: laparoscopic cholecystectomy, post liver transplantation, ERCP or other instrumentation of biliary tree, liver biopsy ○ Post-traumatic: Blunt trauma, motor vehicle accident ○ Spontaneous rupture of bile duct Gross Pathologic & Surgical Features • Size of biloma depends on difference between leakage rate and reabsorption rate of bile by peritoneum/surroundings CLINICAL ISSUES Presentation • Most common signs/symptoms ○ Vague abdominal pain, nausea and vomiting, fever, leukocytosis in case of infected biloma Natural History & Prognosis • Usually asymptomatic in simple biloma; most gradually decrease in size over weeks Treatment • Percutaneous drainage if large or infected • ERCP stent placement to decrease biliary pressure and control leak • Surgical resection and repair reserved for complicated cases unresponsive to drainage DIAGNOSTIC CHECKLIST Consider • Other causes of fluid collection: Ascites, abscess, hematoma SELECTED REFERENCES 1. Thompson CM et al: Management of iatrogenic bile duct injuries: role of the interventional radiologist. Radiographics. 33(1):117-34, 2013 2. Frydrychowicz A et al: Hepatobiliary MR imaging with gadolinium-based contrast agents. J Magn Reson Imaging. 35(3):492-511, 2012 Diagnoses: Liver http://radiologyebook.com/ 209

Biliary Cystadenoma/Carcinoma Diagnoses: Liver TERMINOLOGY • Rare premalignant or malignant, unilocular or multilocular cystic tumor arising from biliary epithelium • Synonyms: Hepatobiliary cystadenoma/carcinoma, biliary cystic tumor, biliary cystic neoplasm, mucinous cystic neoplasm of liver IMAGING • Solitary, large, well-defined, multiloculated and multilobulated hepatic cyst ○ Thick, irregular wall and enhancing internal septations ○ May show biliary dilation from mass effect • Biliary cystadenoma ○ Thin and smooth septa ○ May have fine calcifications and subtle mural nodularity (< 1 cm) ○ Absence of mural nodularity makes cystadenoma more likely KEY FACTS • Biliary cystadenocarcinoma more commonly associated with ○ Thick and irregular septa ○ Mural and septal nodularity (> 1 cm) and papillary projections ○ Coarse calcifications ○ Hemorrhagic internal fluid • Location ○ Intrahepatic biliary ducts (83%), extrahepatic biliary ducts (13%), gallbladder (0.02%) TOP DIFFERENTIAL DIAGNOSES • Simple/complex/complicated hepatic cyst • Hepatic abscess • Echinococcal (hydatid) cyst • Cystic metastases CLINICAL ISSUES • Primarily occurs in middle-aged Caucasian women (Left) Axial graphic shows a biliary cystadenoma with lobulated contour and multiple irregular, vascularized septations . (Right) Transverse grayscale ultrasound of the liver shows a biliary cystadenoma (with sonographic imaging appearance of a complex cyst) with multiple thickened septations ſt. Most biliary cystadenomas are seen in middle-aged females. (Left) Transverse grayscale ultrasound of the liver shows a large, lobulated, multiseptated biliary cystadenoma with thick septations ſt and layering debris st. (Right) Axial T2- weighted MR with fat saturation of the liver in the same patient shows the large biliary cystadenoma with lobulated contour, multiple thick septations , and associated mild peripheral biliary ductal dilatation st caused by central mass effect. 210 http://radiologyebook.com/

Biliary Cystadenoma/Carcinoma<br />

Diagnoses: Liver<br />

TERMINOLOGY<br />

• Rare premalignant or malignant, unilocular or multilocular<br />

cystic tumor arising from biliary epithelium<br />

• Synonyms: Hepatobiliary cystadenoma/carcinoma, biliary<br />

cystic tumor, biliary cystic neoplasm, mucinous cystic<br />

neoplasm of liver<br />

IMAGING<br />

• Solitary, large, well-defined, multiloculated <strong>and</strong><br />

multilobulated hepatic cyst<br />

○ Thick, irregular wall <strong>and</strong> enhancing internal septations<br />

○ May show biliary dilation from mass effect<br />

• Biliary cystadenoma<br />

○ Thin <strong>and</strong> smooth septa<br />

○ May have fine calcifications <strong>and</strong> subtle mural nodularity<br />

(< 1 cm)<br />

○ Absence of mural nodularity makes cystadenoma more<br />

likely<br />

KEY FACTS<br />

• Biliary cystadenocarcinoma more commonly associated<br />

with<br />

○ Thick <strong>and</strong> irregular septa<br />

○ Mural <strong>and</strong> septal nodularity (> 1 cm) <strong>and</strong> papillary<br />

projections<br />

○ Coarse calcifications<br />

○ Hemorrhagic internal fluid<br />

• Location<br />

○ Intrahepatic biliary ducts (83%), extrahepatic biliary ducts<br />

(13%), gallbladder (0.02%)<br />

TOP DIFFERENTIAL DIAGNOSES<br />

• Simple/complex/complicated hepatic cyst<br />

• Hepatic abscess<br />

• Echinococcal (hydatid) cyst<br />

• Cystic metastases<br />

CLINICAL ISSUES<br />

• Primarily occurs in middle-aged Caucasian women<br />

(Left) Axial graphic shows a<br />

biliary cystadenoma with<br />

lobulated contour <strong>and</strong><br />

multiple irregular,<br />

vascularized septations .<br />

(Right) Transverse grayscale<br />

ultrasound of the liver shows a<br />

biliary cystadenoma (with<br />

sonographic imaging<br />

appearance of a complex cyst)<br />

with multiple thickened<br />

septations ſt. Most biliary<br />

cystadenomas are seen in<br />

middle-aged females.<br />

(Left) Transverse grayscale<br />

ultrasound of the liver shows a<br />

large, lobulated,<br />

multiseptated biliary<br />

cystadenoma with thick<br />

septations ſt <strong>and</strong> layering<br />

debris st. (Right) Axial T2-<br />

weighted MR with fat<br />

saturation of the liver in the<br />

same patient shows the large<br />

biliary cystadenoma with<br />

lobulated contour, multiple<br />

thick septations , <strong>and</strong><br />

associated mild peripheral<br />

biliary ductal dilatation st<br />

caused by central mass effect.<br />

210<br />

http://radiologyebook.com/

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