Assessing Biliary Pathology An Overview Ali N Khan FRCP, FRCR, FRCS

Biliary Tree Normal CBD <8 mm diameter CBD diameter increase with age and after previous biliary surgery For obstructive jaundice US has a sensitivity 70 - 95% and specificity 80 - 100% In future endoscopic ultrasound may become more widely available

Bile Ducts

Sludge ball Obstructive jaundice may occur due to thickened sludge in the biliary tract particularly in women on oral contraceptives.

Air in bile ducts

Choledochal cyst

Mirizzi Mirizzi's syndrome is a rare complication in which a gallstone becomes impacted in the cystic duct, or neck of the GB causing compression of the CBD or the CHD, resulting in obstruction and jaundice. The obstructive jaundice can be caused by direct extrinsic compression by the stone or from fibrosis caused by chronic cholecystitis. A cholecystocholedochal fistula may ensue.

Mirizzi Mirizzi's syndrome is a rare complication in which a gallstone becomes impacted in the cystic duct, or neck of the GB causing compression of the CBD or the CHD, resulting in obstruction and jaundice. The obstructive jaundice can be caused by direct extrinsic compression by the stone or from fibrosis caused by chronic cholecystitis. A cholecystocholedochal fistula may ensue.

Mirizzi Mirizzi's syndrome is a rare complication in which a gallstone becomes impacted in the cystic duct, or neck of the GB causing compression of the CBD or the CHD, resulting in obstruction and jaundice. The obstructive jaundice can be caused by direct extrinsic compression by the stone or from fibrosis caused by chronic cholecystitis. A cholecystocholedochal fistula may ensue.

Mirizzi

Mirizzi

Ductal calculi after LDLT due to biliary stenosis

Biliary stricture LDLT

Biliary sludge syndrome Sludge ball in mid portion of common bile duct producing a filling defect and expanding the duct

Cholangiocarcinoma

Cholangiocarcinoma Ultrasound study show dilated intrahepatic bile ducts (arrow), associated with a hypoechoic mass at the porta hepatis.

Cholangiocarcinoma 75-year old F with CC

Cholangiocarcinoma 75-year old F with CC

Cholangiocarcinoma 75-year old F with CC Extensive arterial/venous encasement precludes resection. Angiography show capillary vascularity at the tumour site (red arrow). The portal vein is encased (red arrow).

Klatskin Tumour Ultrasound study show a Klatskin tumour, which usually is echogenic because of intense fibrotic reaction (arrow).

Assessing Portal Vein Embolization

Biliary Tumours

Worms!

Worms!

The Gallbladder

Gallbladder Anatomy Courtesy Shlomo Gobi

Gallbladder Pathology

Gallbladder Pathology

Images Courtesy Ravi Kadasne

GB Hydrops Images Courtesy Dr.Ravi Kadasne

Courtesy Ravi Kadasne

Courtesy Ravi Kadasne

Courtesy Ravi Kadasne

Courtesy Ravi Kadasne

Acute Cholecystitis Courtesy Ravi Kadasne

Cholecystitis Mimics Courtesy Ravi Kadasne

Cholecystitis Mimics Courtesy Ravi Kadasne

Cholecystitis Mimics Courtesy Durre-Sabih Comet-tail artefact due to cholesterol crystals in Rokitansky-Ascoff sinuses. Courtesy Durre-Sabih

Dengue Fever Courtesy Gunjan Puri

Cholecystitis Mimics: Leukaemia

Cholecystitis Mimics: AIDS Cholangitis

Cholecystitis Mimics-Acute Hepatitis Courtesy Vikas Shukla

Cholecystitis Mimics-Low platelet count! Courtesy Gunjan Puri

Xanthogranulomatous Cholecystitis

Cholecystitis Mimics Perforated DU Courtesy Ravi Kadasne

GB Carcinoma Courtesy Shlomo Gobi

GB Carcinoma Cholangiocarcinoma Cholangiocarcinoma of the gall bladder. Note a complex mass within the GB. The mass is hypervascular. (Images courtesy Durre-Sabih). Images courtesy Durre-Sabih

Endoscopic ultrasonography (EUS) Enables both bile duct visualization and nodal evaluation. Intraductal EUS allows direct evaluation of the lesion EUS-guided FNA results may be positive when other diagnostic tests are inconclusive.

With IOUS, a false-positive diagnosis may occur in 2-4% of cases; however, IOUS-guided biopsy that allows the examination of frozen sections may address this problem.

CBD PV Mass Endoscopic ultrasound show a dilated common bile duct (CBD) and mass it its lower end.

Conclusion US has low specificity but is an excellent screening test for a patient with obstructive jaundice IOUS is the best screening test available for focal liver lesion