Diagnostic Ultrasound - Abdomen and Pelvis

Ascending Cholangitis
Diagnoses: Biliary System
TERMINOLOGY
• Inflammation of intra-/extrahepatic bile duct walls due to
ductal obstruction and infection
IMAGING
• Dilatation of intra- and extrahepatic bile ducts
○ In cases of early cholangitis or intermittent CBD
obstruction, bile ducts may not be dilated
• Circumferential thickening of bile duct wall
• Presence of obstructing choledocholithiasis
• Periportal hypo-/hyperechogenicity adjacent to dilated
intrahepatic ducts
• Presence of purulent bile/sludge
• Multiple small hepatic cholangitic abscesses
TOP DIFFERENTIAL DIAGNOSES
• Cholangiocarcinoma
• Pancreatic ductal carcinoma
• Primary sclerosing cholangitis (PSC)
KEY FACTS
• Recurrent pyogenic cholangitis (RPC)
• Other forms of secondary cholangitis
PATHOLOGY
• Risk factors
○ Choledocholithiasis: Most common
○ Biliary stricture, biliary stent, choledochal surgery, recent
biliary manipulation, sphincter of Oddi dysfunction
CLINICAL ISSUES
• Charcot triad: RUQ pain, fever, jaundice
• Complications: Cholangitic liver abscesses & septicemia,
portal vein thrombosis
• Treatment: Antibiotics + biliary decompression
DIAGNOSTIC CHECKLIST
• Correlate with clinical & laboratory data to achieve accurate
imaging interpretation
(Left) Transverse abdominal
ultrasound in a patient with
ascending cholangitis shows
circumferential markedly
thickened common bile duct
wall with only minimal
luminal distension. (Right)
Transverse color Doppler
ultrasound in the same patient
with ascending cholangitis
shows lack of detectable
vascularity in the thickened
common bile duct wall . In
addition, echogenic debris st
within the CBD is evident on
this image.
(Left) Transverse abdominal
grayscale US in a patient with
ascending cholangitis shows
mildly dilated proximal
intrahepatic duct anterior
to right portal vein ,
consistent with mild degree of
biliary obstruction. (Right)
Transverse abdominal color
Doppler US in the same
patient imaged closer to the
porta hepatis confirms the
tubular structure is a dilated
common bile duct , which
lies anterior to main portal
vein .
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