Computed tomography in obstructive jaundice. Part I: The level of obstruction

Ultrasonography and Computed Tomography in Diffuse Liver Disease with Cholestasis

Ultrasonography (US) and computed tomography (CT) were performed on respectively 67 and 42 (altogether 72) patients, for the assessment of intrahepatic cholestasis. The diagnostic ability to differentiate between malignant (17 patients) and benign (55 patients) liver disease was analyzed. Coarse echogenicity of the liver led to inconclusive results in differentiating between cirrhosis (2 out of 29 patients) and malignant infiltration (4 out of 15 patients) by US. Other benign liver diseases in 23 patients, including acute hepatitis, chronic active hepatitis, fatty liver, and liver congestion, were correctly interpreted as benign. CT correctly disclosed malignant liver disease in all cases. A false positive diagnosis of malignancy was encountered in 4 (out of 17) patients with decompensated hepatic cirrhosis because of non-homogeneous expansive areas on CT in 3 cases. The true cause was in 2 patients non-uniform fatty infiltration, and in one patient with acute hepatitis A, small hypodense lesions. Among cholestatic patients, decompensated cirrhosis and malignant liver infiltration could not always be differentiated on US or CT.

Value and Accuracy of Multidetector Computed Tomography in Obstructive Jaundice

BACKGROUND

Objective; To find out the role of MDCT in the evaluation of obstructive jaundice with respect to the cause and level of the obstruction, and its accuracy. To identify the advantages of MDCT with respect to other imaging modalities. To correlate MDCT findings with histopathology/surgical findings/Endoscopic Retrograde CholangioPancreatography (ERCP) findings as applicable.

MATERIAL/METHODS

This was a prospective study conducted over a period of one year from August 2014 to August 2015. Data were collected from 50 patients with clinically suspected obstructive jaundice. CT findings were correlated with histopathology/surgical findings/ERCP findings as applicable.

RESULTS

Among the 50 people studied, males and females were equal in number, and the majority belonged to the 41-60 year age group. The major cause for obstructive jaundice was choledocholithiasis. MDCT with reformatting techniques was very accurate in picking a mass as the cause for biliary obstruction and was able to differentiate a benign mass from a malignant one with high accuracy. There was 100% correlation between the CT diagnosis and the final diagnosis regarding the level and type of obstruction. MDCT was able to determine the cause of obstruction with an accuracy of 96%.

CONCLUSIONS

MDCT with good reformatting techniques has excellent accuracy in the evaluation of obstructive jaundice with regards to the level and cause of obstruction.

Segmental liver hyperintensity in malignant biliary obstruction on diffusion weighted MRI: associated MRI findings and relationship with serum alanine aminotransferase levels

OBJECTIVES

Segmental liver hyperintensity can be observed in malignant biliary obstruction on diffusion weighted MRI (DW-MRI). We describe MRI findings associated with this sign and evaluate whether DW-MRI segmental hyperintensity has any relationship with serum alanine aminotransferase (ALT) levels.

METHODS

The DW-MRI T(1) weighted, T(2) weighted and gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced T(1) weighted images obtained in 21 patients with hepatic malignancy, who demonstrated biliary obstruction and segmental hyperintensity on DW-MRI (b=0-750 s mm(-2)), were retrospectively reviewed by 2 readers blinded to clinical results. DW-MRI hyperintense liver segments were recorded as hypointense, isointense or hyperintense relative to normal liver on T(1)/T(2) weighted imaging. It was also noted whether contrast enhancement was similar to that observed in normal liver or diminished in the hepatocellular phase. The mean apparent diffusion coefficient (ADC) value (×10(-3) s mm(-2)) of DW-MRI hyperintense segments, normal liver and tumour were compared using Student's t-test. The frequency of MRI findings was corroborated with serum ALT levels, which reflect hepatocyte injury.

RESULTS

DW-MRI hyperintense segments frequently showed T(1) hyperintensity (10/21), T(2) hyperintensity (19/21) and/or diminished contrast enhancement (15/21). Tumours showed significantly lower mean ADC values than liver (1.23 ± 0.08 vs 1.43 ± 0.05; p=0.013). Segments showing concomitant T(1) hyperintensity had lower mean ADC values than liver (1.30 ± 0.05 vs 1.43 ± 0.05; p=0.023). The patients (8/10) with concomitant T(1) and DW-MRI segmental hyperintensity showed elevated ALT levels (p=0.030, Fisher's exact test).

CONCLUSION

Concomitantly high T(1) weighted and DW-MRI signal in liver segments was associated with lower ADC values and abnormal liver function tests, which could reflect underlying cellular swelling and damage.

Magnetic resonance cholangiopancreatography in obstructive jaundice

GOALS

To determine the ability of magnetic resonance cholangiopancreatography (MRCP) to diagnose the level and cause of obstruction in patients with obstructive jaundice.

BACKGROUND

The limitations of available imaging modalities have led to the increasing use of MRCP, which is a noninvasive and highly accurate technique in evaluating patients with biliary obstruction.

STUDY

Thirty patients were included in this study. MRCP was done using a fat suppressed, heavily T2 weighted fast spin echo sequence. The MRCP findings were confirmed on surgical exploration or clinical follow-up.

RESULTS

MRCP could correctly identify ductal dilatation and the level of obstruction in all cases, except one. All causes of obstruction, except three, were detected. It failed to detect a common bile duct calculus in a minimally dilated ductal system and misdiagnosed a case of focal chronic pancreatitis as carcinoma head pancreas and a small pancreatic head mass as cholangiocarcinoma. It had a sensitivity of 94.44%, specificity of 81.81%, positive predictive value of 89.47%, and negative predictive value of 90% for the detection of malignant causes. The overall diagnostic accuracy for detection of level and cause of obstruction was 96.3% and 89.65%, respectively.

CONCLUSION

The high diagnostic accuracy of MRCP in evaluating patients with obstructive jaundice indicates that it has the potential to become the diagnostic modality of choice in such patients.

Liver imaging. A hepatologist's perspective

Numerous diagnostic modalities may be employed in the assessment of liver disease. In this article we outline radiologic approaches to several clinical problems including the evaluation of abnormal liver function tests and jaundice, evaluation of liver masses, and management of the patient with cirrhosis and portal hypertension.

Acute biliary disease: initial CT and follow-up US versus initial US and follow-up CT

PURPOSE

To evaluate the utility of ultrasonography (US) versus that of computed tomography (CT) for assessment of acute biliary disease.

MATERIALS AND METHODS

Radiologic reports and clinical charts were reviewed in all patients who underwent US and CT within 48 hours of each other for evaluation of acute right upper quadrant pain. Radiologic findings and clinical outcome were correlated.

RESULTS

CT was the initial imaging study in 57 patients, and CT findings resulted in underdiagnosis or misdiagnosis of acute biliary disease in eight of 11 patients. Follow-up US results were suggestive of the correct diagnosis and provided additional clinical information in seven of these eight patients. US findings resulted in altered clinical treatment in six of 11 patients with acute biliary disease. US was the initial study in 66 patients, and US findings were suggestive of biliary disease or the correct diagnosis in seven of seven patients with acute biliary disease. Follow-up CT did not result in changes in clinical treatment in any patient with acute biliary disease.

CONCLUSION

Initial US is better than initial CT in patients suspected of having acute biliary disease. Follow-up CT provides no additional information regarding the biliary system, and its use should be limited to those patients with a wider differential diagnosis or with confusing clinical symptoms and signs.

Arterial dynamic appearance of common bile duct carcinoma by helical CT on angiography (angio-HCT): four operated cases

We present four cases of common bile duct carcinoma in which both angiographic helical CT (angio-HCT) and pancreatoduodenectomy were done in the 3 years since 1995. Angio-HCT was performed with direct infusion of the contrast medium through the gastroduodenal artery inserted on angiography. Angio-HCT displayed the tumors as lower density areas in contrast to the strong enhancement of the circumferential nontumorous areas, including the pancreas and duodenum.

Computed tomography of the bile ducts

Although not typically a first-line test for patients with suspected biliary tract disease, improvements in CT technology have resulted in an increased ability for CT to detect and characterize causes of biliary obstruction and other biliary diseases. As with other abdominal neoplastic disease, CT is the most common imaging procedure for staging biliary tract malignancies. Attention to optimizing CT techniques and an awareness of subtle CT imaging findings can increase the efficacy of CT in evaluating the biliary tract.

Utilization pattern and efficacy of nonsurgical techniques to establish drainage for high biliary obstruction

PURPOSE

To review the frequency and success of percutaneous and endoscopic techniques in the relief of high biliary obstruction.

MATERIALS AND METHODS

A search of the radiologic achieves was performed identifying 70 patients with cholangiographic demonstration of high biliary obstruction defined as proximal to the distal third of the extrahepatic bile duct. Record review determined the frequency and success rates of percutaneous and endoscopic techniques in providing biliary decompression for obstructive jaundice.

RESULTS

Endoscopic retrograde cholangiopancreatography was performed in 35 of 70 patients, providing initial endoscopic biliary decompression (EBD) in six patients (two subsequently required percutaneous intervention). Percutaneous biliary drainage (PBD) was attempted in 60 of 70 patients, providing initial decompression in 55 patients. PBD provided decompression after failed endoscopic biliary drainage in 18 of 26 patients. Endoscopic drainage was never attempted after failed percutaneous drainage. Overall EBD success was 23% and overall PBD success was 95%. The complication rate attributed to EBD was 26%; that attributed to PBD was 25%. For those patients who underwent attempts at both EBD and PBD, the complication rate was 16%.

CONCLUSION

At an institution with well-developed gastrointestinal medical services and interventional radiologic services, PBD was more successful in providing initial biliary decompression than endoscopic techniques for high biliary obstruction.

Obstructive jaundice in gastric carcinoma: cause, site, and relationship to the primary lesion

OBJECTIVE

Obstructive jaundice is frequently present in patients with advanced gastric carcinoma. The purpose of this study was to assess the cause and preferential site of bile duct obstruction in patients with gastric carcinoma and to evaluate correlativity of biliary obstruction with the nature of the primary gastric lesion.

METHODS

Cholangiographic findings of 54 patients with metastatic gastric carcinoma presenting with obstructive jaundice were reviewed retrospectively. The level of the bile duct obstruction was divided into four segments: segment 1, from an individual intrahepatic duct to the biliary hilum; segment 2, common hepatic duct (CHD) involvement from the biliary hilum to the level of the cystic duct; segment 3, the proximal half of the common bile duct (CBD); segment 4, the distal half of the CBD. To evaluate the characteristics of the primary gastric lesion, operative records and pathologic findings were reviewed.

RESULTS

Obstruction sites were segment 1 in eight patients (15%), segment 2 in 25 (46%), segment 3 in 17 (32%), and segment 4 in four (7%). The causes of obstruction were metastatic lymphadenopathy in the hepatoduodenal ligament (50 of 54) and direct invasion of the primary or recurrent tumor (four of 54). The location of the primary gastric lesions was the antrum, antrum and body, and body in 36 (67%), 17 (31%), and 1 (2%), respectively. Borrmann type 3 lesions were present in 72% of cases, and type 2 lesions in the remaining 24%. Histologic type was undifferentiated adenocarcinoma in 91% of patients, and differentiated adenocarcinoma in the remaining. Serosal invasion was shown in 96% of the patients.

CONCLUSION

Our results show that the cause of bile duct obstruction in advanced gastric carcinoma is predominantly metastatic lymphadenopathy in the hepatoduodenal ligament, and its preferential site is around the level of the cystic duct. Obstructing lesions showed characteristic cholangiographic findings.

Diagnosis of choledocholithiasis by endoscopic ultrasonography

BACKGROUND/AIMS

Endoscopic ultrasonography is a promising procedure for the diagnosis of extrahepatic cholestasis. Accuracy for the diagnosis of choledocholithiasis by ultrasonography and computed tomography were prospectively compared with endoscopic ultrasonography in 62 consecutive patients.

METHODS

Final diagnosis was determined by endoscopic retrograde cholangiography with or without sphincterotomy or intraoperative cholangiography with or without choledochoscopy. All of the patients had abdominal ultrasonography, computed tomography, endoscopic ultrasonography, and either an endoscopic retrograde (n = 40) or intraoperative cholangiography (n = 32) performed.

RESULTS

Choledocholithiasis was confirmed in 22 patients. Thirteen patients had a stone with a diameter < 1 cm, and 14 had a nonenlarged common bile duct. Endoscopic ultrasonography was more sensitive (97%) than ultrasonography (25%; P < 0.0001) and computed tomography (75%; P < 0.02). Specificity and positive predictive value were not significantly different. Negative predictive value of endoscopic ultrasonography (97%) was better than that of ultrasonography (56%; P < 0.0001) and computed tomography (78%; P < 0.02). Results were unchanged after six patients in whom the absence of choledocholithiasis was considered probable after follow-up were excluded. Endoscopic ultrasonography results did not depend on stone diameter or common bile duct dilatation.

CONCLUSIONS

Endoscopic ultrasonography appears to be the best diagnostic tool for the diagnosis of choledocholithiasis compared with other noninvasive procedures.

Case report: massive biliary dilatation mimicking cystic retroperitoneal masses on computed tomography

An unusual case is presented in which a massively dilated common bile duct produced a confusing CT image of multiple cystic areas within the abdominal cavity. Cholangiography and CT-cholangiography were useful in establishing the correct diagnosis. The differential diagnosis of cystic retroperitoneal masses is discussed.

Endosonography: promising method for diagnosis of extrahepatic cholestasis

Endosonography, ultrasonography, and computed tomography (CT) were carried out prospectively in 52 patients with extrahepatic cholestasis. 35 patients had extrahepatic biliary obstructions (21 tumorous, 14 non-tumorous) and 17, with recent gallstone migration within the bile duct, had no extrahepatic obstruction at the time of investigation. The definitive diagnosis was established by surgery (in 39 patients), by transendoscopic sphincterotomy (11 patients), or by retrograde biliary opacification (2 patients). Endosonography was significantly more sensitive than ultrasonography or CT (100% vs 80% and 83%, respectively) in making a positive diagnosis of obstruction. Endosonography was also significantly more accurate than ultrasonography or CT (97% vs 49% and 66%) in diagnosing the cause of the obstruction and more effective in the assessment of the locoregional spread of tumorous obstructions (75% vs 38% and 62%). Thus, endosonography was superior to ultrasonography and CT in the diagnosis and staging of biliary obstructions.

Radiologic evaluation of the jaundiced patient. Diagnostic and therapeutic role of current procedures

Radiologic evaluation of the jaundiced patient generally begins with ultrasound. Computed tomography may provide better information regarding the exact level of obstruction, but it is more expensive and time-consuming than ultrasound and carries the risk associated with intravenous contrast. It thus should be used only when ultrasound findings are likely to be inadequate. Percutaneous transhepatic cholangiography and endoscopic retrograde cholangiopancreatography are both relatively safe, reliable procedures for direct opacification of the biliary tree. The choice depends on clinical and ultrasound findings. Percutaneous transhepatic cholangiography provides a foundation for percutaneous drainage if necessary. Cholescintigraphy in the jaundiced patient provides physiologic information but poor anatomic detail. It is useful in establishing common duct functional patency.

Appraisal of the management of bile duct stones

This review discusses the natural history, diagnosis and treatment of stones in the bile ducts. A rational plan of management is outlined.

Contrast-enhanced computed tomography of the normal and abnormal gallbladder

One hundred and fourteen upper abdominal computed tomography examinations performed before and after intravenous contrast were reviewed. In 48 patients who had no evidence of biliary or pancreatic disease, the mean gallbladder wall attenuation before contrast was 25 +/- 13 HU and after contrast 42 +/- 18 HU, with a wall thickness of 1.9 +/- 0.43 mm. In 14 patients with chronic pancreatitis these values were 24 +/- 10.5 HU, 44 +/- 25 HU and 2.0 +/- 0.54 mm, respectively. In a further group of 15 patients with chronic biliary disease, the values were 34 +/- 15 HU, 53 +/- 18 HU and 2.3 +/- 0.9 mm. The degree of wall enhancement was statistically significant in each group. There was no statistical difference in the attenuation characteristics or wall enhancement between normal patients and those with chronic pancreatitis. Patients with chronic biliary disease had a thicker gallbladder wall with higher attenuation before contrast but a similar degree of enhancement.

Computed tomography of obstructive jaundice secondary to duodenal hematoma

Duodenal hematoma is an unusual condition, usually secondary to blunt abdominal trauma. Even more unusual is the rare development of obstructive jaundice and the attendant computed tomography findings. Nontraumatic causes of duodenal hematoma are also discussed.

Intrahepatic versus extrahepatic cholestasis. Discrimination with biliary scintigraphy combined with ultrasound

Biliary scintigraphy and ultrasound imaging were performed in 52 patients with suspected biliary tract pathology. Results were correlated with the findings of direct cholangiography. Several new innovations in scintigraphic technique were used. The combination of ultrasound imaging and scintigraphy correctly identified biliary tract obstruction in 17 of 19 patients, 12 of whom had dilated bile ducts on ultrasonography. Intrahepatic cholestasis was correctly diagnosed in 11 of 13 patients. Accurate discrimination between intrahepatic and extrahepatic cholestasis was achieved in 28 of 32 patients (88%) with the combined studies. Scintigraphy also provided a correct diagnosis of acute cholecystitis in all 9 patients with surgically confirmed disease. Eleven additional patients with gallbladder or pancreatic disease had normal bile ducts at scintigraphy, which was confirmed with cholangiography. When combined with ultrasound imaging, modern biliary scintigraphy can (a) provide excellent discrimination between intrahepatic and extrahepatic cholestasis and (b) help determine the need for subsequent invasive diagnostic studies in selected patients.

Intravenous cholangiography in the CT era

With the availability of computed tomography (CT), ultrasonography (US), percutaneous transhepatic cholangiography (PTC), and endoscopic retrograde cholangiopancreatography (ERCP), the use of intravenous cholangiography (IVC) has waned. A retrospective study of 69 intravenous cholangiograms performed from 1979 through 1982 assessed the utility of intravenous cholangiography, as well as its effect on patient management, at an institution where CT was highly developed. In no case after normal findings on CT and/or ultrasound examination did IVC make a positive pathologic diagnosis. After abnormal results on CT and/or US examinations, in no case did IVC add to the diagnosis. Finally, after technically suboptimal results of CT and/or US examinations, IVC made only 1 positive pathologic diagnosis. Overall, IVC correctly demonstrated only 5 of 9 cases of common duct stones or strictures. Of the 26 cases with anatomical correlation there were a total of 7 false-positive and -negative IVC examinations. In this series, IVC was rarely useful in the diagnosis of biliary tract disease. Given the high inaccuracy rate of IVC in this study, its use for the exclusion of biliary tract disease is discouraged.

Obstructive jaundice. Diagnostic and therapeutic considerations

The diagnostic approach to obstructive jaundice must be individualized on the basis of the sensitivity and specificity of the various procedures available. No single diagnostic approach is optimal in all patients. The physician must be guided by knowledge of the yield, complications, and cost of the tests available. In addition, interventional endoscopic and radiologic techniques add a new therapeutic dimension to the standard surgical approach.

Intrahepatic bile duct dilatation shown by computed tomography--predilection for the left lobe?

Dilated biliary duct radicles were most obvious within the left lobe of the liver in 30 out of 42 patients with obstructive jaundice in whom intrahepatic duct dilatation was satisfactorily demonstrated by computed tomography. In 19 of these 30 patients the level of obstruction was at the lower end of the common bile duct. Recognition of this finding may prevent the erroneous diagnosis of intrahepatic or multiple obstructing lesions.

Imaging of the liver, biliary tract, and pancreas

The interaction between the various noninvasive and invasive imaging modalities used to evaluate the liver, biliary tract, and pancreas is demonstrated in this article. By understanding this interaction and correlating noninvasive studies, the clinician will avoid diagnostic redundancy and the need for invasive testing may be reduced.

Computed tomography of the liver

Computed tomography (CT) has been in clinical use for nearly a decade. The capabilities and potentials of this tool in evaluating disease of various organs are continuously being explored. A number of articles have been published focusing on its clinical applications in hepatic disorders and comparing its efficacy with other imaging modalities. This review presents hepatic CT findings and their utility in clinical practice.

Current concepts in diagnosis. Approach to the patient with cholestatic jaundice

On the basis of clinical evaluation, the physician should decide whether extrahepatic biliary obstruction is highly unlikely, possible, or very likely. If it is highly unlikely, no further workup for obstruction is indicated unless the clinical picture is altered on follow-up examination. Further evaluation of the biliary tree is warranted in other patients. Ultrasonography is currently the noninvasive imaging technique of first choice. Computed tomography is indicated if ultrasonography has yielded technically inadequate results or in special circumstances when it is anticipated that decisions regarding further diagnostic evaluation or treatment will be importantly influenced by the results. Negative findings obtained in a technically adequate examination may represent a logical stopping point in the workup of patients in whom obstruction is considered merely a possibility to be excluded, but they should not dissuade the clinician from further diagnostic evaluation if obstruction is considered very likely. Indeed, in selected circumstances, such as cases in which choledocholithiasis is suspected after cholecystectomy, direct cholangiography is appropriate as an initial test. If evidence of obstruction is obtained by noninvasive imaging, direct cholangiography will be required in many patients before treatment, and the choice between percutaneous or retrograde cholangiography should be made on an individual basis. The challenge to the clinician is to minimize the risk, expense, and time involved in obtaining sufficient information for a definitive diagnosis and treatment.