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Abdominal Ultrasound
Biliary tree
 Mohamed Zaitoun

Radiology assistant lecturer

Faculty of medicine , Zagazig university
 The Biliary tree
Anatomy-1
Congenital diseases-2
Choledicholithiasis-3
Mirrizi syndrome-4
Hemobilia-5
Pneumobilia-6
Inflammation-7
Malignancy-8
Anatomy-1
In biliary terminology , proximal denotes the portion -
of the biliary tree that is in relative proximity to the
liver & hepatocytes , where as distal refers to the
caudal end closer to the bowel
The term branching order applies to the level of -
division of the bile ducts starting from the CHD with
1st order branches being the RT & LT hepatic ducts ,
2nd order branches , their respective divisions ( also
known as 2ry biliary radicals ) and so on
Central specifies proximity to the porta hepatis , -
whereas peripheral refers to the higher order branches
of the intrahepatic biliary tree extending into the
hepatic parenchyma
The intrahepatic ducts aren’t in a fixed relation to the -
portal vein within the portal triads , and can be
anterior or posterior to the vein or even tortuous
about the vein
The RT & LT hepatic ducts , that is the 1st order -
branches of the CHD are routinely seen on US and it
is not uncommon to visualize normal 2nd order
branches
Visualization of 3rd or higher order branches is often -
an abnormal finding & requires a search for the cause
of dilatation
Normal diameter of the 1st & higher order branches of -
the CHD has been suggested to be 2 mm or less and
no more than 40 % of the diameter of the adjacent PV
The normal caliber of the common hepatic / bile duct -
in patients without history of biliary disease has been
quoted as up to 6 mm
There is a controversy about whether there is normal -
widening of the duct with increasing age , similarly ,
the literature is inconclusive with regard to an
association between cholecystectomy and a large
caliber CBD
Although diameters of up to 10 mm have been -
recorded in an asymptomatic normal population , the
great majority of the diameters lie under 7 mm ,
therefore , a ductal diameter of 7 mm or greater
should prompt further further investogations
Congenital diseases-2

a) Choledochal cysts
b) Caroli’s disease
a) Choledochal cysts
Represents a heterogenous group of diseases that may manifest -
as congenital , focal or diffuse cystic dilatation of the biliary
tree
The most widely used classification system divides choledochal -
>> cysts into 5 types
Type I -1
Fusiform dilatation of the CBD ( 80 % )*
Type II -2
Are true diverticuli of the bile ducts ( very rare )*
Type III -3
Are called choledochoceles , confined to the intraductal portion*
of the CBD
 Type IVa -4
Are multiple intra- and extrahepatic biliary*
dilations
Type IVb -5
Are confined to the extrahepatic biliary tree*
Type V -6
Caroli’s disease has been classified , but it is of *
different embryonic origin and therefore it is
not a true choledochal cyst
>> U/S-
A cystic structure is identified which may contain*
internal sludge , stones or even solid neoplasm
In some cases , the cyst is large enough that its*
connection to the bile duct is not immediately
recognized
ERCP is necessary to ensure that the dilatation is not a*
result of distal neoplasm , especially in the case of
type I choledochal cysts , because there is a proven
risk of cholangiocarcinoma with all choledochal cysts
, surgical resection is advocated
 b) Caroli’s disease
A rare congenital disease of the intahepatic biliary tree that -
forms as a result of malformation of the ductal plates , the
primordial cells that give rise to the intrahepatic bile ducts
>> There are 2 types -
The simple , classic form-1
Caroli’s syndrome ( more common form , which occurs with-2
periportal hepatic fibrosis )
The disease has associated cystic renal disease , most -
,commonly renal tubular ectasia ( medullary sponge kidney )
However both forms may also be seen in patients with
autosomal recessive polycystic kidney disease
U/S -
Saccular or less often , fusiform dilatation of the*
intrahepatic biliary tree resulting in biliary stasis ,
stone formation & bouts of cholangitis & sepsis
The disease most often diffusely affects the*
intrahepatic biliary tree , but it may be focal
The central dot corresponds to the portal vein *
that is surrounded by dilated bile ducts
If associated with congenital hepatic fibrosis , *
finding of cirrhosis & portal hypertension is
also present
Cholangiocarcinoma develops in 7 % of*
patients with Caroli’s disease
Choledocholithiasis-3
>> Can be classified into -
: a) Primary form
Denotes de novo formation of stones*
Etiology ( are often related to diseases causing*
strictures or dilatation of the bile ducts , leading to
>> stasis , as follows
Sclerosing cholangitis-1
Caroli’s disease-2
Parasitic infections of the liver ( Clonorchis , -3
Fasciola & Ascaris )
Chronic hemolytic diseases , such as sickle -4
cell disease
Prior biliary surgery , such as biliary enteric -5
anastomosis
: b)Secondary form
Migration of stones from the gall bladder into *
the CBD
Common than the primary form*
Bile duct stones are found in 8 to 18 % of*
patients with symptomatic gall stones
: Intrahepatic stones -
The appearance of stones depends on their size *
& texture
Most stones are highly echogenic with posterior *
acoustic shadowing
Small < 5 mm or soft pigment stones in the *
setting of recurrent pyogenic cholangitis may
not shadow
When the affected ducts are filled with stones , the*
individual stones may not be seen , instead , a bright
echogenic linear structure with posterior acoustic
shadowing is seen
Stones should be always be suspect if discrete or linear*
echogenicities with or without shadowing are seen in
the region of the portal triads paralleling the course of
the portal vein within the liver
: CBD stones -
The majority of the stones in the CBD will be in the*
distal duct right at the ampulla of vater , therefore ,
sonographic evaluation should include assessment of
the entire duct with detailed effort focused on the
periampullary region , however this exact area is
often the most difficult to see as it may be hidden by
bowel gases , making detection of distal CBD stones
most difficult
The classic appearance of CBD stones is that of a*
rounded echogenic lesion with posterior acoustic
shadowing
It should be recognized that there will not be a fluid*
rim around an impacted distal CBD stone because it
is compressed against the duct wall , the lateral
margins of the stone are therefore not seen , however
in the stones seen in the GB or proximal duct , likely
to be surrounded by bile
Small stones may lack good acoustic shadows and*
appear only as a bright linear echogenicity either
straight or curved
: Pitfalls in the diagnosis of choledocholithiasis include*
a) Blood clot ( hemobilia )
b) Papillary tumors
c) Biliary sludge ( non of these will shadow )
d) Surgical clips in the porta hepatis , mostly due to previous
cholecystectomy appear as linear echogenic foci with
shadowing
The short length , relative high degree of echogenicity , lack of
ductal dilatation , and absence of the GB should allow
differentiation of surgical clips from stones
Sludge
Surgical clips
: Mirrizi syndrome-4
Describes a clinical syndrome of jaundice with pain &-
fever resulting from obstruction of the common hepatic
duct by a stone impacted in the cystic duct
It occurs most commonly when the cystic duct &-
common hepatic ducts run in parallel course
The stone is often impacted in the distal cystic duct , and-
the accompanying inflammation & edema result in the
obstruction of the adjacent common hepatic duct
The obstruction of the cystic ducts results in recurrent-
bouts of cholecystitis , and the impacted stone may
erode into the common hepatic duct resulting in a
cholecysto-choledochal fistula and biliary obstruction
, identification of this complication ( called Mirizzi
type II ) is important because the treatment requires
surgical repair of the fistula ,acute cholecystitis ,
cholangitis and even pancreatitis may occur
U/S-
Mirrizi syndrome should be considered on sonography*
when biliary obstruction with dilatation of the biliary
ducts to the level of the common hepatic duct is seen
in conjunction with a picture of acute or chronic
cholecystits , thus the GB has features of acute
cholecystitis , but may or may not be distended
A stone impacted in the cystic duct with surrounding*
edema at the level of the obstruction is confirmatory
Hemobilia-5
: Causes-
a) Iatrogenic biliary trauma , mostly due to
percutaneous biliary procedures or liver biopsies ( 65
%)
b) Cholangitis & cholecystitis ( 10 % )
C) Vascular malformations & aneurysms
)%7(
d) Abdominal trauma ( 6 % )
e) Malignancies especially HCC & cholangiocarcinoma
( 7%)
: C/P-
Pain , bleeding and biochemical jaundice
: Complications-
Apart from the blood loss , which occasionally is severe
, complications are rare ( cholecystitis , cholangitis &
pancreatitis )
: U/S-
Most often the blood is echogenic or of mixed*
echogenicity and retractile , conforming to the shape
of the duct
Occasionally it may appear tubular with a *
central hypoechoic area
Acute hemorrhage will appear as fluid with low *
level internal echoes
Blood clots may be mobile*
Extension into the GB is common*
The clinical history is often very useful in *
assisting with the diagnosis
Pneumobilia-6
: Causes-
: Air within the biliary tree is most commonly seen as a result of*
a) Previous biliary intervention
b) Biliary enteric anastomosis
c) Common bile duct stent
In the acute abdomen , pneumobilia may be caused primarily by-
>> three entities
Emphysematous cholecystits-1
Choledocho-doudenal fistula ( inflammation caused by an-2
impacted stone in the CBD may cause erosion of the duct wall )
Cholecysto-enteric fistula ( prolonged acute -3
cholecystits may lead to erosion into an
adjacent loop of bowel , most commonly the
duodenum or transverse colon , stones may
then pass from the GB into the bowel and can
cause bowel obstruction called gall stone
ileus )
: U/S-
Air in the bile ducts has a characteristic appearance ,*
bright echogenic linear structures following the portal
triads are seen
Posterior dirty shadowing & reverbation artifact*
are seen with large quantities of air ) ringdown (
Movement of the air bubbles , best seen just after*
changing the patient’s position is diagnostic
Extensive arterial calcifications seen especially in*
diabetics , can mimic pneumobilia
: Inflammation-7

Acute ( bacterial ) cholangitis)1

Recurrent pyogenic cholangitis)2
Ascaris)3
Primary sclerosing cholangitis)4
 Acute ( bacterial ) cholangitis-1
Biliary obstruction is an essential component of-
bacterial cholangitis , associated in 85 % of cases
with CBD stones , other causes of obstruction include
biliary stricture as a result of trauma or surgery ,
congenital abnormalities such as choledochal cyst and
partially obstructive tumors
Intrinsic or extrinsic neoplasms causing complete-
biliary obstruction rarely cause pyogenic cholangitis
prior to biliary intervention
C/P : Charcot’s triad-
a) Fever ( 90 % )
b) RT upper quadrant pain ( 70 % )
c) Jaundice ( 60 % )
It is a medical emergency-
: U/S-
Is the 1st imaging modality to determine the cause and*
level of obstruction , and to exclude other diseases
such as cholecystitis , acute hepatitis or Mirrizi
syndrome
Dilatation of the biliary tree ( CBD > 6 mm ) *
Choledocholithiasis & possibly sludge *
Bile duct wall thickening*
Hepatic abscesses*
Recurrent pyogenic cholangitis-2
Has been known by other names including -
hepatolithiasis & oriental cholangio-hepatitis
It is a disease characterized by chronic biliary -
obstruction , stasis & stone formation leading to
recurrent episodes of acute pyogenic cholangitis
Any segment of the liver may be affected but the -
lateral aspect of the left lobe is most often
involved
Acute complications of the disease , namely -
sepsis , may be fatal & may need urgent
percutaneous biliary decompression or surgery
The chronic stasis & inflammation eventually -
leads to severe atrophy of the affected segment
, biliary cirrhosis & cholangiocarcinoma are
long term complications
: U/S-
Dilated ducts filled with sludge & stones confined to one or*
more segments of the liver
Patients may also present with multiple echogenic masses in the*
liver and recognizing that these in fact , lie within markedly
dilated ducts requires care
When dilated ducts are identified , their contents may be*
hypoechoic or echogenic
With severe atrophy of the affected segment , very little*
parenchyma may be present and the crowded stone filled ducts
may appear as a single heterogenous mass
Ascaris-3
More common in children-
The worm is active within the small bowel & may enter-
the biliary tree retrogradely through the ampulla of
Vater , causing acute biliary obstruction
: C/P-
Infected patients are asymptomatic but may present*
with biliary colic , cholangitis , acalculous
cholecystitis or pancreatitis
: U/S-
Most commonly a single worm is identified , which*
appears as a tube or as parallel echogenic lines within
the bile ducts , the appearance is quite similar to a
biliary stent , which should be excluded on clinical
history
On the transverse view , the rounded worm surrounded*
by the duct wall gives a target appearance
The worm may be folded into itself or occupy any portion of the*
ductal system , including far out into the liver parenchyma ,
close to the capsule or within the GB
Movement of the worm during the scan facilitates the diagnosis*
When the infestation is heavy , multiple worms may lie adjacent*
to each other within a distended duct giving a spaghetti like
appearance
Occasionally , the worms may appear as an amorphous ,*
echogenic filling defect , making the diagnosis more difficult
Primary sclerosing cholangitis-4
Sclerosing cholangitis ( SC ) is a chronic inflammatory-
disease process affecting the entire biliary tree
If the etiology is unknown , the term primary-
sclerosing cholangitis is used
: Causes of secondary SC-
a) AIDS cholangiopathy
b) Bile duct neoplasm
c) Biliary tract surgery , trauma
d) Choledocholithiasis
e) Congenital abnormalities of the biliary tract
f) Ischemic stricturing of bile ducts
g) Post treatment for hydatid cyst
PCS is a chronic disease affecting the entire biliary tree-
, the process involves a fibrosing inflammation of the
small & large bile ducts leading to biliary strictures
and cholestasis and eventually to biliary cirrhosis ,
portal hypertension & hepatic failure
It occurs most commonly in men , with median age of 39 years-
at diagnosis
About 80 % of patients have concomitant inflammatory bowel-
disease , typically ulcerative cholitis , it may also occur in
conjunction with retroperitoneal fibrosis
: U/S-
Most patients diagnosed are asymptomatic*
Irregular , circumferential bile duct wall thickening of varying*
degree , encroaching on and narrowing the lumen
In advanced cases , finding of cirrhosis are also present*
: Malignancy-8

Primary ( Cholangiocarcinoma )*
Secondary ( Mets )*

Cholangiocarcinoma
:Classification (based on anatomic location)-
% a) Intrahepatic ( peripheral ) 10
% b) Hilar ( Klatskin’s ) 60
% c) Distal 30
A) Intrahepatic choangiocarcinoma
(peripheral) ( 10 % )
The least common location for-
cholangiocarcinoma but they represent the 2 nd
most common primary malignancy of the liver
The incidence has been dramatically rising in -
the past two decades due to increase in the
number of patients with liver cirrhosis and
long term hepatitis C infection
: U/S-
Hypovascular solid mass with heterogenous*
echotexture and it may appear hypo , iso or
hyperechoic
A clue to differentiation from HCC is a much higher*
incidence of ductal obstruction than in HCC ,
however mets to the liver not uncommonly may cause
intrahepatic ductal obstruction and therefore may be
indistinguishable
A more unusual manifestation is that of purely*
intraductal mass , these are polypoid masses
distending the affected ducts , often 3rd or 4th order
branches spreading within the duct and filling it with
mucin , the most common appearance of the
intraductal intrahepatic cholangiocarcinoma is one or
more polypoid masses confined to the bile ducts , a
less common form may present as a solid mass within
a cystic structure , representing tumor within a
markedly distended duct that doesn’t communicate
with the biliary tree
: In CT*
>> The key findings to look for are
Delayed enhancement-1
Peripheral biliary dilatation-2
Capsular contraction-3
B) Hilar cholangiocarcinoma( Klatskin ) ( 60 % )
Often begins in either the RT or LT bile ducts & extend-
both proximally into higher order branches and
distally into the common hepatic duct & contra-
lateral bile ducts
The tumors also extend outside of the ducts to involve-
adjacent portal vein and arteries
Chronic obstruction , especially if accompanied with-
PV involvement leads to atrophy of the involved lobe
Nodal disease often begins in the porta hepatis -
and within the hepatoduodenal ligament ( local
nodes ) and extending to celiac , superior
mesenteric , peripancreatic , and posterior
pancreatico-duodenal stations ( distant nodes )
Metastases are usually to the liver & peritoneal -
surfaces
: U/S-
: Assessment of*
a) The level of obstruction
b) The presence of a mass
c) Lobar atrophy
d) Patency of main , RT , & LT PV
e) Encasement of hepatic artery
f) Local & distant adenopathy
g) Distant mets
Dilatation of the higher order intrahepatic bile*
ducts with non-union of the RT & LT ducts is the
classic appearance , when dilated ducts are
encountered , they should be followed centrally
toward the hepatic hilum to determine which order
branching ( segmental ducts & higher or RT/LT
hepatic ducts ) is involved with tumor , tumor
extension into segmental ducts bilaterally precludes
resection
The obstructing tumor is not always visualized by*
sonography , when a mass isnot directly visualized ,
its presence can be inferred based on the level of
obstruction , though this often underestimates the
tumor extent
Lobar atrophy leads to crowding of the dilated bile*
ducts and if longstanding , a shift of in the axis of the
liver due to hypertrophy of the contra-lateral side , the
atrophy of the lobe is often accompanied by
obliteration of its PV
Differences in lobar echogenicity due to the*
varying degree of ductal & vascular
obstruction between the two lobes , is an
uncommon finding
Narrowing of the RT or LT PV leading to*
compensatory increased flow in the
accompanying hepatic artery
Klatskin Tumor - Bismuth-classification
Bismuth-Corlette type I
-A type I tumor is a lesion limited of the
common hepatic duct, i.e. below the
.confluence
Bismuth-Corlette type II

A type II tumor is a lesion that extends to the

confluence
Bismuth-Corlette type IIIa and IIIb

A IIIa-tumor extends into the right and a IIIb -

tumor extends into the left hepatic duct
Bismuth-Corlette type IV

Type IV-tumor with extention into the right

and left duct
C) Distal cholangiocarcinoma ( 30 % )
: U/S-
A polypoid tumor appears as a duct expanding , well*
defined intra-ductal mass often with no internal
vascularity
The nodular sclerosing subtype causes focal irregular*
ductal constriction & duct wall thickenind
In more advanced disease , the tumor appears as a*
hypoechoic , hypovascular mass with poorly defined
margins invading adjacent structures
: Secondary ( Mets )
Mets to the biliary tree mimic the different -
appearances of cholangiocarcinoma , affecting
both intra and extrahepatic ducts
The history of past or concurrent malignancy , -
along with multiplicity should raise the
possibility of mets
Breast , colon and melanoma constitute the -
majority of primary sites of malignancy