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PATHOLOGY OF THE GALLBLADDER AND BILIARY TREE 63 STONE CYSTIC DUCT A B C D E F Figure 3.34 (A) Duodenal gas obscures the cause of obstruction at the lower end of this dilated CBD. (B) Patient positioning can move bowel gas away from the duct, demonstrating the cause of obstruction—a stone at the lower end. (C) TS of a dilated CBD in the head of the pancreas (arrow). (D) Dilated CBD with a hypoechoic ampullary carcinoma at the lower end (arrows). (E) Intrahepatic bile duct dilatation. (F) MRCP, post-cholecystectomy, showing stones in the CBD and cystic duct stump.
64 ABDOMINAL ULTRASOUND CT and MRI are useful for staging purposes if the obstructing lesion is malignant. Cholangiocarcinomas spread to the lymph nodes and to the liver and small liver deposits are particularly difficult to recognize on ultrasound if the intrahepatic biliary ducts are dilated. In hepatobiliary scintigraphy, technetium 99m - labelled derivatives of iminodiacetic acid are excreted in the bile and may help to demonstrate sites of obstruction, for example in the cystic duct, or abnormal accumulations of bile, for example choledochal cysts. Courvoisier’s law, to which there are numerous exceptions, states that if the gallbladder is dilated in a jaundiced patient, then the cause is not due to a stone in the common duct. The reason for this is that, if stones are or had been present, then the gallbladder would have a degree of wall fibrosis from chronic cholecystitis which would prevent it from distending. In fact there are many exceptions to this ‘law’ which include the formation of stones in the duct, without gallbladder stones, and also obstruction by a pancreatic stone at the ampulla. Thus: ● ● Do not assume that obstructive jaundice in a patient with gallstones is due to a stone in the CBD. The jaundice may be attributable to other causes. Do not assume that obstructive jaundice cannot be due to a stone in the CBD if the gallbladder does not contain stones. A solitary stone can be passed into the duct from the gallbladder or stones can form within the duct. Management of biliary obstruction Management of biliary obstruction obviously depends on the cause and the severity of the condition. Removal of stones in the CBD may be performed by ERCP with sphincterotomy. Elective cholecystectomy may take place if gallstones are present in the gallbladder. Laparoscopic ultrasound is a useful adjunct to surgical exploration of the biliary tree and its accuracy in experienced hands equals that of X-ray cholangiography. It is rapidly becoming the imaging modality of choice to examine the ducts during laparoscopic cholecystectomy. 26 Endoscopic ultrasound can also be used to examine the CBD, avoiding the need for laparoscopic exploration of the duct when performed in the immediate preoperative stage. 27 The treatment of malignant obstruction is determined by the stage of the disease. Accurate staging is best performed using CT and/or MRI. If surgical removal of the obstructing lesion is not a suitable option because of local or distant spread, palliative stenting may be performed endoscopically to relieve the obstruction and decompress the ducts (Fig. 3.35). The patency of the stent may be monitored with ultrasound scanning by assessing the degree of dilatation of the ducts. Clinical suspicion of early obstruction should be raised if the serum alkaline phosphatase is elevated, (often more sensitive in the early stages than a raised serum bilirubin). In the presence of ductal dilatation on ultrasound, further imaging, such as CT or MRCP, may then refine the diagnosis. Intrahepatic tumours causing biliary obstruction Focal masses which cause segmental intrahepatic duct dilatation are usually intrinsic to the duct itself, for example cholangiocarcinoma. It is also possible for a focal intrahepatic mass, whether benign or malignant, to compress an adjacent biliary duct, causing subsequent obstruction of that segment. This is not, however, a common cause of biliary dilatation and occurs most usually with hepatocellular carcinomas. 28 Most liver metastases deform rather than compress adjacent structures and biliary obstruction only occurs if the metastases are very large and/or invade the biliary tree. A hepatocellular carcinoma or metastatic deposit at the porta hepatis may obstruct the common duct by squeezing it against adjacent extrahepatic structures. Benign intrahepatic lesions rarely cause ductal dilatation, but occasionally their sheer size obstructs the biliary tree. Choledochal cysts Most commonly found in children, this is associated with biliary atresia, in which the distal ‘blind’ end of the duct dilates into a rounded, cystic mass in response to raised intrahepatic pressure.
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Abdominal Ultrasound
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Abdominal Ultrasound How, Why and W
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v Contents Contributors Preface ix
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vii Contributors Rosemary Arthur FR
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ix Preface Ultrasound continues to
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ABBREVIATIONS xi MHA MHV MI MPV MRA
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Chapter 1 1 Optimizing the diagnost
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OPTIMIZING THE DIAGNOSTIC INFORMATI
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Page 26 and 27: OPTIMIZING THE DIAGNOSTIC INFORMATI
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Page 30 and 31: Chapter 2 17 The normal hepatobilia
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Page 54 and 55: Chapter 3 41 Pathology of the gallb
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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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