Diagnostic Ultrasound - Abdomen and Pelvis
Dilated Gallbladder Mucocele/Hydrops Mucocele/Hydrops (Left) Longitudinal oblique ultrasound of the gallbladder in a patient with obstructive jaundice from a pancreatic head carcinoma shows a distended but otherwise normal gallbladder st, the Courvoisier sign. (Right) Axial CECT of the same patient after placement of a metal bile duct stent ſt to relieve biliary obstruction. There is now edema of the gallbladder wall and pericholecystic stranding st from acute cholecystitis which later perforated. Differential Diagnoses: Biliary System Mucocele/Hydrops Mucocele/Hydrops (Left) Longitudinal oblique ultrasound of the gallbladder in an elderly patient with jaundice shows a dilated gallbladder with stones st and sludge ſt. The wall was normal. The common bile duct was dilated secondary to a pancreatic lesion. (Right) CECT of the same patient better demonstrates the obstructing multicystic serous cystadenoma in the head of pancreas st obstructing the bile duct ſt and causing gallbladder distension . Acute Hemorrhagic Cholecystitis Acute Hemorrhagic Cholecystitis (Left) Longitudinal oblique ultrasound shows a markedly abnormal gallbladder filled with bright echoes ſt in a patient with a dropping hematocrit and signs of infection. Shadowing is noted st but the stone is indistinct. (Right) Axial CECT of the same patient shows a perforated gallbladder with gallstones st and luminal hemorrhage ſt. There is an adjacent hematoma . Active bleeding was treated by embolization. 915
Intrahepatic and Extrahepatic Duct Dilatation Differential Diagnoses: Biliary System DIFFERENTIAL DIAGNOSIS Common • Choledocholithiasis • Ascending Cholangitis • Recurrent Pyogenic Cholangitis • Pancreatic Ductal Carcinoma • Cholangiocarcinoma • Choledochal Cyst Less Common • Sludge • Periampullary Tumor • Sclerosing Cholangitis • Parasitic Infestation • AIDS-Related Cholangiopathy • Biliary Intraductal Papillary Mucinous Neoplasm ESSENTIAL INFORMATION Helpful Clues for Common Diagnoses • Choledocholithiasis ○ Most common location is in common bile duct (CBD) ○ Round echogenic focus with marked posterior acoustic shadowing • Ascending Cholangitis ○ Imaging may reveal biliary duct wall thickening, intraluminal debris, or obstructing biliary stone ○ Periportal inflammatory hypo-/hyperechogenicity may be seen • Recurrent Pyogenic Cholangitis ○ Bacterial colonization of brown pigment stones in both intrahepatic and extrahepatic bile ducts ○ Densely packed intrahepatic stones ○ Atrophy of involved lobe/segment of liver in later stages • Pancreatic Ductal Carcinoma ○ Ill-defined, solid mass in pancreatic head ○ Pancreatic duct dilatation that abruptly tapers at point of pancreatic carcinoma ○ Vascular encasement ± regional nodal/liver metastases • Cholangiocarcinoma ○ Extrahepatic cholangiocarcinoma involves biliary ducts in hepatoduodenal ligament – Intra- and extrahepatic biliary dilatation – May see: Irregular soft tissue thickening of extrahepatic bile duct or polypoidal mass within CBD ○ Intrahepatic cholangiocarcinoma: Ill-defined, infiltrative, iso-/hyperechoic mass often with capsular retraction • Choledochal Cyst ○ Congenital biliary malformation characterized by fusiform duct dilatation ○ Most commonly involves CBD ○ Cystic extrahepatic mass separated from gallbladder and communicating with CHD or intrahepatic ducts ○ Fusiform dilatation of extra- ± intrahepatic bile ducts ○ Abrupt change in caliber at junction of dilated segment to normal ducts Helpful Clues for Less Common Diagnoses • Sclerosing Cholangitis ○ Autoimmune disease that causes multiple intra- and extrahepatic biliary strictures with dilatation • Biliary Intraductal Papillary Mucinous Neoplasm ○ Ductal intraluminal mass with frond-like papillary projections ○ Hypersecretion of mucin as well as anatomic obstruction leads to markedly dilated intra- and extrahepatic biliary ducts SELECTED REFERENCES 1. Plentz RR et al: Clinical presentation, risk factors and staging systems of cholangiocarcinoma. Best Pract Res Clin Gastroenterol. 29(2):245-252, 2015 2. Raman SP et al: Abnormalities of the Distal Common Bile Duct and Ampulla: Diagnostic Approach and Differential Diagnosis Using Multiplanar Reformations and 3D Imaging. AJR Am J Roentgenol. 203(1):17-28, 2014 3. Attasaranya S et al: Choledocholithiasis, ascending cholangitis, and gallstone pancreatitis. Med Clin North Am. 92(4):925-60, x, 2008 4. Lim JH et al: Biliary intraductal papillary-mucinous neoplasm manifesting only as dilatation of the hepatic lobar or segmental bile ducts: imaging features in six patients. AJR Am J Roentgenol. 191(3):778-82, 2008 (Left) Grayscale ultrasound of the liver shows mild biliary ductal dilatation of the common bile duct as well as mildly prominent intrahepatic biliary ducts creating subtle double ducts . The cause of mild biliary ductal dilatation was due to an obstructing stone in the common bile duct (not shown). (Right) Longitudinal oblique grayscale US of the liver shows a markedly dilated common duct with layering debris st in a patient with ascending cholangitis. Choledocholithiasis Ascending Cholangitis 916
- Page 886 and 887: PART III SECTION 1 Liver Hepatomega
- Page 888 and 889: Hepatomegaly - Firm consistency (du
- Page 890 and 891: Hepatomegaly Lymphoma Lymphoma (Lef
- Page 892 and 893: Diffuse Liver Disease Acute/Chronic
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- Page 918 and 919: Irregular Hepatic Surface Subcapsul
- Page 920 and 921: Portal Vein Abnormality Bland Porta
- Page 922 and 923: PART III SECTION 2 Biliary System
- Page 924 and 925: Diffuse Gallbladder Wall Thickening
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- Page 952 and 953: PART III SECTION 4 Spleen Focal Spl
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Dilated Gallbladder<br />
Mucocele/Hydrops<br />
Mucocele/Hydrops<br />
(Left) Longitudinal oblique<br />
ultrasound of the gallbladder<br />
in a patient with obstructive<br />
jaundice from a pancreatic<br />
head carcinoma shows a<br />
distended but otherwise<br />
normal gallbladder st, the<br />
Courvoisier sign. (Right) Axial<br />
CECT of the same patient<br />
after placement of a metal<br />
bile duct stent ſt to relieve<br />
biliary obstruction. There is<br />
now edema of the gallbladder<br />
wall <strong>and</strong> pericholecystic<br />
str<strong>and</strong>ing st from acute<br />
cholecystitis which later<br />
perforated.<br />
Differential Diagnoses: Biliary System<br />
Mucocele/Hydrops<br />
Mucocele/Hydrops<br />
(Left) Longitudinal oblique<br />
ultrasound of the gallbladder<br />
in an elderly patient with<br />
jaundice shows a dilated<br />
gallbladder with stones st<br />
<strong>and</strong> sludge ſt. The wall was<br />
normal. The common bile duct<br />
was dilated secondary to a<br />
pancreatic lesion. (Right) CECT<br />
of the same patient better<br />
demonstrates the obstructing<br />
multicystic serous<br />
cystadenoma in the head of<br />
pancreas st obstructing the<br />
bile duct ſt <strong>and</strong> causing<br />
gallbladder distension .<br />
Acute Hemorrhagic Cholecystitis<br />
Acute Hemorrhagic Cholecystitis<br />
(Left) Longitudinal oblique<br />
ultrasound shows a markedly<br />
abnormal gallbladder filled<br />
with bright echoes ſt in a<br />
patient with a dropping<br />
hematocrit <strong>and</strong> signs of<br />
infection. Shadowing is noted<br />
st but the stone is indistinct.<br />
(Right) Axial CECT of the same<br />
patient shows a perforated<br />
gallbladder with gallstones st<br />
<strong>and</strong> luminal hemorrhage ſt.<br />
There is an adjacent<br />
hematoma . Active bleeding<br />
was treated by embolization.<br />
915
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