Imaging of the Jaundiced Adult

8/18/2019 Imaging of the Jaundiced Adult

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AbstractSection:

There are many techniques for imaging the jaundiced patient – the rationale for

investigation depends on the history, examination and biochemistry.

Transabdominal ultrasound (TAU! is the initial technique of choice, and "ill differentiate

bet"een obstructive and non#obstructive causes in the majority of cases, and can

demonstrate the cause of obstruction in some cases.

The role of $%& and in particular magnetic resonance cholangiopancreatography ($%'!

is rapidly increasing

&nvasive techniques, such as endoscopic retrograde cholangiopancreatography ()%'!should be reserved for therapeutic purposes.

Section:

Jaundice manifests as yellow discolouration of the skin, mucous membranes and sclerae. It is due to a rise in serum

bilirubin and is usually detected at serum bilirubin levels of approximately 40 mol l!"

.

#auses of $aundice can be classified as pre%hepatic, hepatic and post%hepatic. &ilirubin is formed as a breakdown

product of haem molecules. In the pre%hepatic phase there is increased non%water soluble 'uncon$u(ated) bilirubin in

the blood bound to plasma albumin. *his is taken up by the liver hepatocytes where there is (lucuronide

con$u(ation of the bilirubin to form a water soluble 'con$u(ated) bilirubin. In the post%hepatic phase the water soluble

bilirubin is passed into the (ut via the bile ducts where some is excreted in the stool, and the remainder metabolised

and reabsorbed and passed out in the urine as urobilino(en.

&lood biochemistry is useful in establishin( the presence of abnormal liver function tests and evaluatin( the bilirubin

level. +hilst it is said to be possible to try and establish whether a patient presentin( with $aundice has a pre%hepatic,

hepatic or post%hepatic abnormality from the type of bilirubin elevation in the blood, in the ma$ority of patients there is

a mixed picture with elevation of both con$u(ated and uncon$u(ated bilirubin.

*he important findin( of bilirubin in the urine indicates the presence of con$u(ated bilirubinaemia.

*he clinical approach to investi(atin( the $aundiced patient is based on two main biochemical factors. If bilirubin is

absent in the urine the causes are due to pre%hepatic patholo(y and radiolo(ical ima(in( has a limited role. If present

in the urine then the cause is likely to be due to obstruction of the excretion of bile from the normal route and is either

hepatic or post%hepatic and radiolo(ical ima(in( plays a crucial role in the evaluation.

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*he second factor depends on the liver function tests. In a $aundiced patient with normal liver biochemistry the

causes are likely to be pre%hepatic and ima(in( is not usually performed. If the liver function tests are abnormal,

radiolo(ical ima(in( is appropriate to evaluate liver parenchyma and ducts.

*he primary aims of radiolo(y are to assess whether the cause of $aundice is obstructive and to determine the cause

of obstruction when present. *he role of the different ima(in( modalities will be addressed below. owever, it is best

practice to perform the ima(in( with a de(ree of ur(ency so that appropriate plans can be made if further interventionis needed. *he presence of biliary prostheses and drains can make assessment of the level and causes of

obstruction much more difficult.

Ima(in( in this situation is most readily based upon two pathways:

#ross%sectional ima(in(, to depict the anatomical appearance of the biliary system in order to evaluate the level

and ima(e the cause of the obstruction, or the functional assessment of the lack of draina(e of bile, which is best

appreciated on nuclear scinti(raphy or cholan(io(raphy, althou(h the latter also depicts the anatomy and sometimes

the cause of obstruction.

-ew advances in transabdominal ultrasound '*/S), #* and 1 scannin( offer a safe, timely and cost effective

method of investi(atin( these patients. +hilst the presence of dilatation of the bile ducts in radiolo(y is su((estive ofobstruction, there are three basic caveats or pitfalls to remember.

*here may be obstruction without dilatation seen early in the course of disease. 2xtrahepatic bile duct dilatation

precedes intrahepatic duct dilatation by up to 4 or 3 days, and intrahepatic duct dilatation may not be apparent in the

early sta(es ", 56. *his picture may also occur with intermittent impaction of calculi or reduced pliability of the liver.

7ilatation without obstruction can be seen in patients with a choledochal cyst or in patients in whom a stone has been

passed. dilated duct may take 80930 days to revert to normal calibre 86. In repeated obstruction the duct may not

return to a normal calibre. 7ysmotility syndromes may also cause dilatation without obstruction 46. It is not

uncommon to see a persistently dilated duct in the elderly patient particularly with a history of previous

cholecystectomy 'i(ures " and 5).

-on%biliary mimics of obstruction 46 such as portal vein thrombosis 'i(ure 8) or periportal oedema 'i(ure 4) could

be mistaken for dilated bile ducts.

Cross-sectional imagingSection:

Ultrasound

*/S of the upper abdomen is universally established as the most useful first line ima(in( study in the $aundiced

adult 3, ;6. It has been accepted as a of patients bowel (as can obscure

the duct or the body habitus, and ad$acent abdominal structures can render the ima(in( of the distal common bile

duct '#&7) difficult 5, ? 9@6.

*he appearance of dilated intrahepatic ducts is of tubular structures with a branchin( or stellate pattern ad$acent to

the vessels in the portal triads 'i(ure 3). Aeft lobe ducts often appear more prominent and seem to dilate at an

earlier sta(e than the ri(ht hepatic ducts "06.

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-ormal intrahepatic ducts are barely visible, althou(h with modern e

accuracy in the dia(nosis of bile duct obstruction ?6. alse positive dia(noses are rarely seen "06. *he sensitivity of

ultrasound in definin( the level of obstruction and cause can be wide ran(in( from 5?> to @3> ?, "0 9"56 and 58> to

CC> ?, "0, ""6, respectively, and depends on operator skill as well as the differences in patient population "6.

In many clinical settin(s, the combination of history, examination, blood biochemistry and */S is sufficient todistin(uish between $aundice due to obstructive causes and those due to non%obstructive causes. In patients with

obstruction, */S may inform the type of intervention re


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1#D has been shown to have an overall @;9"00> accuracy for level of obstruction and @0> accuracy for the

cause of obstruction ", "@6 'i(ure ?). #omparisons have mostly been made with direct cholan(io(raphy, usually

endoscopic retro(rade cholan(iopancreato(raphy '21#D), in cases of biliary obstruction, particularly in stone

disease, but also for the evaluation of mali(nant obstruction 50 9556. combination of T " and T 5 wei(hted (radient

echo axial, heavily T 5 wei(hted thin section scans in coronal and coronal obli


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investi(ations which are si(nificantly operator dependent with a relatively hi(h morbidity of "9?> for 21#D "@, 5@6

and 893> for D*# ?, "3, 806. 21#D has an unsuccessful cannulation rate of 89"0> "@, 5@, 806. 21#D has a

sensitivity of @09@;> and specificity of @C> in detectin( #&7 stones 8", 856, althou(h it has been recently

su((ested that 1#D demonstrates intrahepatic stones better than 21#D 886. /se in mappin( of the duct system

pre%operatively for choledochal cysts can be suboptimal if the duct si=e is lar(e with contrast bein( diluted, and

studies su((est that 1#D ima(in( is as (ood as cholan(io(raphy in these cases 5;, 5?6. D*# (ives

excellentima(in( with a success rate of up to @@> ", 846, althou(h this is dependent on the presence of biliarydilatation. 7irect cholan(io(raphy does not demonstrate abnormalities extrinsic to the duct lumen.

s the dia(nostic role of 1#D evolves, the role of both 21#D and D*#, and their most si(nificant advanta(e, is

primarily therapeutic with the ability to extract stones, biopsy intraductal lesions and place stents easily. D*# and

intervention is now reserved for mana(ement of patients with obstructive $aundice in whom 21#D has failed or may

not be possible 'e.g. previous bilioenteric anastamosis).

Pathological processes causing jaundiceSection:

Gnce the presence of obstruction has been detected, accurate evaluation of the level of obstruction is important in

definin( the cause and in plannin( treatment. Harious disease processes are associated with different levels of

obstruction, and in a clinical settin( this classification is more relevant in arrivin( at the correct dia(nosis "6.

Gbstruction at the intrahepatic level may be due to space%occupyin( diseases of the liver or primary sclerosin(

cholan(itis 'DS#). t the porta hepatis level, DS# and mali(nancies such as cholan(iocarcinoma, metastases and

invasive (allbladder carcinoma are the most relevant causes. t the suprapancreatic bile duct level, iatro(enic

causes, mostly post cholecystectomy, pancreatitis and mali(nancies such as cholan(iocarcinoma, metastatic nodes

and pancreatic carcinoma are important. Impacted stone can obstruct at this level, termed iri==is syndrome.

t the pancreatic and ampullary level, calculi are the most common cause of obstruction "0, 836, althou(h

neoplasms and pancreatitis can also cause obstruction. Dancreatic carcinoma is the most likely cause but in addition,at this level, ampullary carcinoma, althou(h uncommon, is also important ", 8;6.

eneral principles of differentiatin( beni(n from mali(nant strictures apply to all the ima(in( modalities. &eni(n bile

duct strictures can usually be differentiated on cross%sectional ima(in( techni


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that in the presence of cirrhosis and duct distortion this can lead to false positive and false ne(ative dia(noses. *he

complication of cholan(iocarcinoma is raised by the appearance of a new dominant stricture 'particularly if there is

proximal bile duct dilatation) or a liver mass. Gne of the problems in makin( the dia(nosis of cholan(iocarcinoma

complicatin( DS# is that with both contrast enhanced #* and contrast enhanced 1, a focally thickened, enhancin(

bile duct wall can be detected. In such cases it is impossible to distin(uish between beni(n chan(es and a small

cholan(iocarcinoma on ima(in( (rounds alone 'i(ure ""). 21#D and brushin( the bile duct wall for cytolo(ical

analysis may be helpful.

eoplastic disease

Jaundice is usually a late feature in hepatocellular carcinoma '##) and is related to compression of the bile duct by

tumour or direct extension into the bile ducts 8?6. *he features are very variable on */S, with either unifocal or

multifocal lesions, commonly hypoechoic when small, often with a soft tissue capsule around them but more complex

mixed low and hi(h echo lesions when lar(er 8?6. 7oppler can show disordered blood flow in these lesions and can

also assess vascular invasion "8, 83, 8?6.

#* is more useful in the dia(nosis and, in particular, the sta(in( of ## and aids in mappin( for treatment. ##

shows variable density and enhancement patterns on #*. It is usually hypodense compared with the liver

parenchyma unless present in a diffusely fatty liver where it appears hyperdense in comparison. Gn post%

contrastima(in(, enhancement is best seen peripherally on the arterial phase. #apsular enhancement, if present, can

be seen on delayed ima(in( 8?6.

## on 1I has a variety of si(nal patterns dependin( on si=e and histolo(ical type, but as with #*, the

enhancement is seen on the arterial phase with rapid ima(in( immediately after an intravenous contrast infusion "86

with later capsular enhancement. 'See chapters on K1I of the cirrhotic liverL 8@6 and K1I of the non%cirrhotic liverL

406 in this issue for further details).

#holan(iocarcinoma is the most common tumour of the bile ducts, but can be difficult to detect at any level on

ultrasound. *he morpholo(ical types are classified as mass formin( 9 commonly intrahepatic and poorly

differentiated, periductal infiltratin( 9 usually hilar lesions that are well differentiated and intraductal 9 the least

common type usually is the papillary type 46.

Intrahepatic mass formin( cholan(iocarcinomata are less common than hilar lesions "0, 8;, 4"6. Gccasionally, a

hyperechoic soft tissue mass is identified. 7isordered blood flow and vascular infiltration may be apparent on 7uplex

and contrast enhanced #* ima(in( "0, "5, 8;6.

*he appearances of intrahepatic cholan(iocarcinoma on #* can be very non%specific with a variable enhancement

pattern often more fre


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is of variable si=ed rounded hypoechoic lesions with a peripheral rin( of increased echo(enicity described as a Kbulls

eye or tar(etL lesion 83, 446. s with hepatocellular carcinoma, 7oppler scannin( has some value in showin( the

abnormal blood flow pattern in the metastatic lesions "86.

#ontrast enhanced ultrasound has been introduced in recent years whereby intravenous 'IH) microbubbles are

in$ected and produce arterial phase enhancement of liver lesions, particularly mali(nancies, and is useful in

differentiatin( beni(n from mali(nant lesions 8?6. *he limitations of this are primarily of cost and of the time involvedin performin( the in$ection and scan.

Gn 1, liver specific contrast a(ents, such as hepatocyte selective a(ents, which are not taken up by abnormal

metastatic lesions, can aid in the dia(nosis of metastases. ## can show variable enhancement with this contrast

a(ent "86. 1eticuloendothelial specific a(ents which are not usually taken up by either metastases or ## can be

used, but the time of examination and re


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"ile duct injury

Jaundice is rarely caused by beni(n, intrinsic bile duct lesions, but the most common of these are iatro(enic,

predominantly due to bile duct in$ury durin( (allbladder sur(ery.

Pancreatic le!el pathologies

Section:

Stone disease

*he most common cause of distal duct obstruction is calculi. &iliary calculi predominantly arise in the (allbladder,

althou(h some calculi can arise in the intrahepatic or extrahepatic ducts. /ltrasound is one of the most effective

methods for visuali=in( stones in the (allbladder with a sensitivity of @39@@> 5, ?, 436. allbladder stones are less

well seen on other ima(in( modalities, althou(h these patients present with pain rather than $aundice. *he presence

of (allbladder stones is not indicative of distal stone obstruction without the clear demonstration of intraduct calculi.

lthou(h there is continuin( improvement in ultrasound e and

specificity of up to "00> 5", 54, 5C, 4C6 'i(ure "C). alse ne(ative examinations are more often related to factors

such as patient movement and si=e of calculi, with poor detection of calculi less than 5 mm in diameter 4C6. alse

positive results are related to si(nal voids from bile flow, ad$acent vessel compression and air in the biliary tree 4@6.

If calculi are seen in intrahepatic dilated ducts, on ultrasound or 1, then a dia(nosis of oriental cholan(iohepatitis

should be considered. *his is a recurrent pyo(enic cholan(itis due to strictures and duct stones that are often

intrahepatic. *he ducts appear much dilated and patients can present with liver abscesses which can help raise the

suspicion of the dia(nosis 836.

#holan(itis as a cause of $aundice fre


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Carcinoma

Dancreatic carcinoma is the most common mali(nant cause of distal obstructive $aundice. 7#* is excellent in

sta(in( the disease and influencin( the mana(ement, 1 bein( reserved for selective cases in problem solvin(. *his

topic is considered in detail elsewhere in this issue 'see K-eoplasms of the pancreasL 306).

+ith a (ood #* techni


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Figure #$ xial #* ima(e throu(h the upper abdomen in a @5%year%old female showin( dilated bile duct in the head ofthe pancreas and the (allbladder containin( (allstones. *he patient had normal liver function tests and bilirubin levels.

Figure %$ 'a,b) /ltrasound ima(es at the same level in the epi(astric re(ion of a ;C%year%old female patient with previouscholecystectomy showin( a dilated common bile duct '#&7). *his patient also had normal liver function tests and bilirubinlevels. 'b) *he usefulness of colour flow mappin( in differentiatin( dilated duct 'arrow) from the portal vein 'arrowhead).

Figure &$ xial #* ima(e throu(h the abdomen in a 83%year%old female with sclerosin( peritonitis. *he ima(e showsthrombosis of the ri(ht portal vein 'arrow) and branches.

Figure '$ 'a,b) xial #* ima(es throu(h the liver in a ;C%year%old male patient with cholan(itis showin( periportal oedema.-ote the periportal low density is ill%defined and circumferential 'arrows), which helps in differentiation from intrahepaticducts.

Figure ($ 'a,b) /ltrasound ima(es throu(h the liver in a ?3%year%old female showin( dilated intrahepatic ducts.

Figure )$ 'a,b) #* ima(es throu(h the liver in the same patient as i(ure 3 showin( dilated intrahepatic ducts.

Figure *$ a(netic resonance cholan(iopancreato(raphy '1#D) ima(e in a 83%year%old female showin( a dilated ductupstream to an intraductal stone 'arrow).

Figure +$ 'a) 2ndoscopic retro(rade cholan(iopancreato(raphy '21#D) and 'b) ma(netic resonancecholan(iopancreato(raphy '1#D) ima(es in the same patient with a hilar cholan(iocarcinoma. *he 1#D ima(e shows

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the entire biliary tree above and below the stricture compared with the 21#D, which only shows some of the cannulated ductabove the stricture.

Figure ,$ 2ndoscopic retro(rade cholan(iopancreato(raphy '21#D) ima(e in a 83%year%old female with previouscholecystectomy. *he ima(e shows sur(ical clips indentin( the bile duct causin( a stricture.

Figure #$ 'a,b) a(netic resonance cholan(iopancreato(raphy '1#D) ima(es in a 30%year%old female with lon(standin(ulcerative colitis. *hese show the beaded appearance of the intra and extrahepatic ducts due to multiple, short se(mentstrictures representin( sclerosin( cholan(itis.

Figure ##$ xial 1 ima(es throu(h the liver in the same patient as in i(ure "0. 'a,b) Dre contrastima(es and 'c,d) postcontrast ima(es at the same level showin( thickened, enhancin( bile duct walls 'arrowheads).

Figure #%$ xial #* ima(e throu(h the liver in an C0%year%old female. *his shows focal retraction of the liver capsule 'arrow)with an underlyin( mass formin( cholan(iocarcinoma.

Figure #&$ xial 1 ima(e throu(h the liver post%contrast of a ;?%year%old female. *his also shows focal retraction ofthe liver capsule 'arrow) and also shows enhancement of thecholan(iocarcinoma.

Figure #'$ 'a,b) xial #* ima(es throu(h the porta hepatis with 'c,d) coronal reconstructions throu(h the same area in a

male patient presentin( with $aundice. 'a) and 'c) show solid enhancin( common duct 'arrows) and 'b) and 'd) show thereappearance of a low density fluid filled duct 'arrowheads).

Figure #($ xial #* ima(es throu(h the upper abdomen in a female patient with infiltrative (allbladder carcinoma. 'a)Deriportal infiltration with enlar(ed nodes. 'b) lower level shows asymmetrically thickened (allbladder wall and anintraluminal stone.


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Figure #)$ xial #* ima(es throu(h the upper abdomen in a patient with painless $aundice. 'a,b) 7ilated intrahepatic andcommon hepatic ducts. 'c) lower level, showin( a non%dilated common bile duct '#&7) in the head of the pancreas.Irre(ularly thickened (astric antrum 'arrow), representin( a primary carcinoma, is seen on 'b) with peritoneal nodules'arrowheads) on ima(es 'a) and 'c).

Figure #*$ xial #* ima(es throu(h the upper abdomen at the level of the head of the pancreas. 'a) pre%contrast ima(e showin( a hi(h density fillin( defect in the distal duct 'arrow). *his is not readily seen on 'b) a post%contrast ima(e at the same level. *here was dilatation of the biliary duct system proximal to the calculus.

Figure #+$ #oronal ma(netic resonance cholan(iopancreato(raphy '1#D) ima(e in a 8;%year%old $aundiced femalepatient. Intraluminal fillin( defect in the distal common bile duct '#&7) representin( calculi.

Figure #,$ xial #* ima(e throu(h the upper abdomen in a 43%year%old male patient with painless $aundice showin( a solidampullary mass and dilated common bile duct '#&7) and pancreatic duct.

Figure %$ low chart for the ima(in( pathway in the $aundiced patient.

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Imaging of the Jaundiced Adult

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