Diagnostic Ultrasound - Abdomen and Pelvis

Ascending Cholangitis
Diagnoses: Biliary System
Pancreatic Ductal Carcinoma
• Infiltrative hypoechoic mass in pancreatic head
• Dilatation of intra- and extrahepatic bile ducts and
pancreatic ducts
• Vascular encasement
• Regional nodal and liver metastases
Primary Sclerosing Cholangitis (PSC)
• Segmental strictures, beaded and pruned ducts
• Involves both intrahepatic & extrahepatic ducts
• End-stage: Lobular liver, hypertrophy, and atrophy
Recurrent Pyogenic Cholangitis (RPC)
• Intra-/ and extrahepatic biliary pigmented stones
• Lateral segment of left lobe and posterior segment of right
lobe are more commonly involved
• Presence of multifocal intrahepatic ductal strictures with
segmental dilatation
• Clinical information of ethnic origin and recurrent attacks of
cholangitis help in suggesting etiology
Other Forms of Secondary Cholangitis
• AIDS-related cholangitis
• Chemotherapy-induced cholangitis
• Ischemic cholangitis
PATHOLOGY
General Features
• Etiology
○ Pathogenesis: Stone/stricture → obstruction → bile stasis
→ increased biliary pressure → infection
○ Source of infection: Usually ascending from duodenum;
rarely hematogenous
○ Risk factors
– Choledocholithiasis and hepatolithiasis (most
common)
– Biliary stricture: In setting of PSC or malignancy
– Biliary stents: Can act as nidus of infection
– Choledochal surgery
– Recent manipulation: ERCP, PTC
– Sphincter of Oddi dysfunction or stenosis
○ Bacteriology
– Escherichia coli, Klebsiella, Enterococcus species,
Enterobacter species
– Anaerobes in mixed infections
• Associated abnormalities
○ Gallstone disease
Staging, Grading, & Classification
• Severity of disease
○ Mild: Responsive to antibiotics and supportive therapy
○ Moderate: Not responsive to medical therapy, but no
organ dysfunction
○ Severe: Organ dysfunction
Microscopic Features
• Acute inflammatory infiltrates involving ductal
mucosa/submucosa
• Periductal aggregates of leukocytes with edema
• Liquefied necrosis in cholangitic abscesses
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Charcot triad: RUQ pain, fever, jaundice
• Other signs/symptoms
○ Septicemia, septic shock
○ Lethargy, mental confusion
– Especially in elderly patients
• Lab data
○ Increased WBC count & bilirubin levels
○ Increased alkaline phosphatase and GGT
○ Transaminitis
○ Positive blood cultures in toxic phase
Demographics
• Age: More common in middle age or elderly
• Epidemiology: Most common type of cholangitis in Western
countries
Natural History & Prognosis
• Complications: Cholangitic liver abscesses & septicemia,
portal vein thrombosis
• Majority improve with antibiotic treatment
• High mortality if not decompressed
• Overall mortality significantly improved with antibiotic
treatment and biliary decompression
Treatment
• Antibiotics to cover gram-negative organisms
• Biliary decompression for uncontrolled sepsis and failed
medical therapy
○ ERCP: Sphincterotomy + stone extraction, internal stent
○ PTC: External biliary drainage via percutaneous
transhepatic biliary drainage (PTBD)
○ Surgical decompression: Fulminant cases and failed
nonoperative decompression
DIAGNOSTIC CHECKLIST
Consider
• Correlate with clinical & laboratory data to achieve accurate
imaging interpretation
○ Due to overlap in US features of various cholangitis
Image Interpretation Pearls
• Biliary ductal dilatation and thickening related to
obstructing choledocholithiasis in appropriate clinical
setting
SELECTED REFERENCES
1. Spârchez Z et al: Role of contrast enhanced ultrasound in the assessment of
biliary duct disease. Med Ultrason. 16(1):41-7, 2014
2. Kiriyama S et al: TG13 guidelines for diagnosis and severity grading of acute
cholangitis (with videos). J Hepatobiliary Pancreat Sci. 20(1):24-34, 2013
3. Patel NB et al: Multidetector CT of emergent biliary pathologic conditions.
Radiographics. 33(7):1867-88, 2013
4. Eun HW et al: Assessment of acute cholangitis by MR imaging. Eur J Radiol.
81(10):2476-80, 2012
5. Kim SW et al: Diagnostic performance of multidetector CT for acute
cholangitis: evaluation of a CT scoring method. Br J Radiol. 85(1014):770-7,
2012
340