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THE NORMAL HEPATOBILIARY SYSTEM 35 ● ● Jaundice can fall into one of two categories: obstructive (sometimes called posthepatic) in which the bile is prevented from draining out of the liver because of obstruction to the biliary duct(s) non-obstructive (prehepatic or hepatic) in which the elevated bilirubin level is due to haemolysis (the breakdown of the red blood cells) or a disturbance in the mechanism of the liver for uptake and storage of bilirubin, such as in inflammatory or metabolic liver diseases. Naturally, the treatment of jaundice depends on its cause (Table 2.1). Ultrasound readily distinguishes obstructive jaundice, which demonstrates some degree of biliary duct dilatation, from nonobstructive, which does not. Abnormal liver function tests Altered or deranged liver function tests (LFTs) are another frequent cause of referral for abdominal ultrasound. Biochemistry from a simple blood test is often a primary pointer to pathology and is invariably one of the first tests performed as it is quick and easily accessible. Most of these markers are highly unspecific, being associated with many types of diffuse and focal liver pathology. The most frequently encountered LFTs are listed in Table 2.2. Other common reasons for referral In some cases, the presenting symptoms may be organ-specific or even pathognomonic, simplifying the task of ultrasound diagnosis. Often, however, Table 2.2 Test Bilirubin Alkaline phosphatase (ALP) (liver enzyme) Alpha fetoprotein Prothrombin time Gamma glutamyl transferase Alanine aminotransferase (ALT) Aspartate aminotransferase (AST) (liver enzymes) Protein (serum albumin) Common serum liver function tests Association with increased level Obstructive or non-obstructive jaundice. (Differentiation can be made between conjugated and unconjugated bilirubin) Non-obstructive jaundice Metastases Other focal hepatic lesions Hepatocellular carcinoma (HCC) Malignancy Diffuse liver disease (often with portal hypertension) Obstructive jaundice Alcoholic liver disease Obstructive or non-obstructive jaundice Hepatitis Viral infections Other organ failure (e.g. cardiac) Lack of protein is associated with numerous liver diseases. Low levels are associated with ascites, often due to portal hypertension Table 2.1 Common causes of jaundice Non-obstructive Unconjugated hyperbilirubinaemia —haemolysis —haematoma —Gilbert’s disease Mixed hyperbilirubinaemia —hepatitis —alcoholic liver disease —cirrhosis of all types —multiple liver metastases —drug-induced liver disease Obstructive Conjugated hyperbilirubinaemia —stones in the biliary duct —carcinoma of the duct, head of pancreas or ampulla —acute pancreatitis —other masses which compress the common bile duct (e.g. lymph node mass) —biliary atresia (See Chapters 3 and 4 for further information.)
36 ABDOMINAL ULTRASOUND the symptoms are vague and non-specific, requiring the sonographer to perform a comprehensive and knowledgeable search. The non-invasive nature of ultrasound makes it ideal for the first-line investigation. Upper abdominal pain ● ● ● ● ● ● ● Upper abdominal pain, the origin of which could be linked to any of the organs, is one of the most frequent causes of referral. The sonographer can narrow the possibilities down by taking a careful history (see Box 2.1). Is the pain focal? This may direct the sonographer to the relevant organ, for example a thick-walled gallbladder full of stones may be tender on gentle transducer pressure, pointing to acute or chronic cholecystitis, depending on the severity of the pain. Bear in mind that gallstones are a common incidental finding which may be a red herring. Always consider multiple pathologies. Is the pain related to any event which may give a clue? Fat intolerance might suggest a biliary cause, pain on micturition a urinary tract cause, for example. Is it accompanied by other symptoms such as a high temperature? This may be associated with an infective process such as an abscess. Could it be bowel-related? Generalized abdominal pain could be due to inflammatory or obstructive bowel conditions and knowledge of the patient’s bowel habits is helpful. Has the patient had any previous surgery which could be significant? Box 2.1 Always: ● take a verbal history from the patient—don’t just rely on the request card ● obtain the results of any previous investigations, including previous radiology ● consider the possibility of multiple pathologies Palpable right upper quadrant mass A palpable right upper quadrant mass could be due to a renal, hepatobiliary, bowel-related or other cause. The sonographer should gently palpate to get an idea of the size and position of the mass and whether or not it is tender. Specifically targeting the relevant area may yield useful and unexpected results, for example a Reidel’s lobe, colonic carcinoma or impacted faeces, which will help to guide the nature of further investigations. APPENDIX: UPPER-ABDOMINAL ANATOMY Diagrams of sectional upper-abdominal anatomy are reproduced here for quick reference. See Box 2.2 for the abbreviations used here. Box 2.2 AO CBD GB GDA HA HOP IVC LHV LL LPV LRV MHV R Adr RHV RK RL RPV RRA SA SMA SMV SPL ST SV TOP Abbreviations Aorta Common bile duct Gallbladder Gastroduodenal artery Hepatic artery Head of pancreas Inferior vena cava Left hepatic vein Left lobe of liver Left portal vein Left renal vein Middle hepatic vein Right adrenal gland Right hepatic vein Right kidney Right lobe of liver Right portal vein Right renal artery Splenic artery Superior mesenteric artery Superior mesenteric vein Spleen Stomach Splenic vein Tail of pancreas
Page 2 and 3: Abdominal Ultrasound
Page 4 and 5: Abdominal Ultrasound How, Why and W
Page 6 and 7: v Contents Contributors Preface ix
Page 8 and 9: vii Contributors Rosemary Arthur FR
Page 10 and 11: ix Preface Ultrasound continues to
Page 12 and 13: ABBREVIATIONS xi MHA MHV MI MPV MRA
Page 14 and 15: Chapter 1 1 Optimizing the diagnost
Page 16 and 17: OPTIMIZING THE DIAGNOSTIC INFORMATI
Page 30 and 31: Chapter 2 17 The normal hepatobilia
Page 32 and 33: THE NORMAL HEPATOBILIARY SYSTEM 19
Page 54 and 55: Chapter 3 41 Pathology of the gallb
Page 56 and 57: PATHOLOGY OF THE GALLBLADDER AND BI
Page 92 and 93: Chapter 4 79 Pathology of the liver
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PATHOLOGY OF THE LIVER AND PORTAL V
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Chapter 5 121 The pancreas CHAPTER
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THE PANCREAS 123 the patient’s le
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THE PANCREAS 125 Acute pancreatitis
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THE PANCREAS 127 E F G Figure 5.3 c
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A C DISTANCE = 3.43 CM 5%. 13 Over
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THE PANCREAS 131 G H I Figure 5.5 c
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THE PANCREAS 133 head of pancreas.
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THE PANCREAS 135 pancreatic juice i
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Chapter 6 137 The spleen and lympha
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THE SPLEEN AND LYMPHATIC SYSTEM 139
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Chapter 7 153 The renal tract CHAPT
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THE RENAL TRACT 155 As with any oth
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THE RENAL TRACT 157 A B q 0 LRA AO
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THE RENAL TRACT 159 junctions of or
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THE RENAL TRACT 161 A B Figure 7.5
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THE RENAL TRACT 163 carcinomas, the
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THE RENAL TRACT 165 the vesicourete
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THE RENAL TRACT 167 Table 7.1 Sourc
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THE RENAL TRACT 169 A B Figure 7.13
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THE RENAL TRACT 171 Table 7.2 Diffe
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THE RENAL TRACT 173 Ultrasound stil
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THE RENAL TRACT 175 CT is useful fo
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THE RENAL TRACT 177 Xanthogranuloma
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THE RENAL TRACT 179 As with acute t
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THE RENAL TRACT 181 der with increa
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THE RENAL TRACT 183 ● ● Morphol
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THE RENAL TRACT 185 ● ● hydrone
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THE RENAL TRACT 187 A Figure 7.27 A
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THE RENAL TRACT 189 vascular reject
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THE RENAL TRACT 191 B A C Figure 7.
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THE RENAL TRACT 193 computerised ul
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Chapter 8 195 The retroperitoneum a
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THE RETROPERITONEUM AND GASTROINTES
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Chapter 9 215 The paediatric abdome
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THE PAEDIATRIC ABDOMEN 217 A B SPLE
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THE PAEDIATRIC ABDOMEN 219 B A B Fi
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THE PAEDIATRIC ABDOMEN 221 probe de
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THE PAEDIATRIC ABDOMEN 223 When the
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THE PAEDIATRIC ABDOMEN 225 + 78 A 2
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THE PAEDIATRIC ABDOMEN 227 A B C D
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THE PAEDIATRIC ABDOMEN 229 Table 9.
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THE PAEDIATRIC ABDOMEN 231 A LT B C
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THE PAEDIATRIC ABDOMEN 237 mesenter
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THE PAEDIATRIC ABDOMEN 239 E F G Fi
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THE PAEDIATRIC ABDOMEN 241 system i
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Chapter 10 The acute abdomen 243 CH
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THE ACUTE ABDOMEN 245 scan of the p
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THE ACUTE ABDOMEN 247 LIVER LS GB S
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THE ACUTE ABDOMEN 249 D A RT B C E
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THE ACUTE ABDOMEN 251 17. Patlas M,
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Chapter 11 253 Interventional and o
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INTERVENTIONAL AND OTHER TECHNIQUES
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275 Bibliography and further readin
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277 Index A Abdomen, acute gastroin
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INDEX 279 Continuous ambulatory per
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INDEX 281 Intravenous urography (IV
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INDEX 283 Phrygian cap, 29 Pneumobi
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