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

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

3. Bile Ducts

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

5. Air in bile ducts

6. Choledochal cyst

7. 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.

8. 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.

9. 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.

10. Mirizzi

11. Mirizzi

12. Ductal calculi after LDLT due to biliary stenosis

13. Biliary stricture LDLT

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

15. Cholangiocarcinoma

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

17. Cholangiocarcinoma
75-year old F with CC

18. Cholangiocarcinoma
75-year old F with CC

19. 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).

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

21. Assessing Portal Vein Embolization

23. Biliary Tumours

24. Worms!

25. Worms!

26. The Gallbladder

27. Gallbladder Anatomy
Courtesy Shlomo Gobi

28. Gallbladder Pathology

29. Gallbladder Pathology

30. Images Courtesy Ravi Kadasne

31. GB Hydrops
Images Courtesy Dr.Ravi Kadasne

32. Courtesy Ravi Kadasne

33. Courtesy Ravi Kadasne

34. Courtesy Ravi Kadasne

35. Courtesy Ravi Kadasne

36. Acute Cholecystitis
Courtesy Ravi Kadasne

37. Cholecystitis Mimics
Courtesy Ravi Kadasne

38. Cholecystitis Mimics
Courtesy Ravi Kadasne

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

40. Dengue Fever
Courtesy Gunjan Puri

41. Cholecystitis Mimics: Leukaemia

42. Cholecystitis Mimics: AIDS Cholangitis

43. Cholecystitis Mimics-Acute Hepatitis
Courtesy Vikas Shukla

44. Cholecystitis Mimics-Low platelet count!
Courtesy Gunjan Puri

45. Xanthogranulomatous Cholecystitis

46. Cholecystitis Mimics Perforated DU
Courtesy Ravi Kadasne

47. GB Carcinoma
Courtesy Shlomo Gobi

48. 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

49. 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.

50. 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.

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

52. 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