Contrast enhanced ultrasound (CEUS) in gallbladder and bile duct pathology: technique, interpretation and clinical applications

Contrast enhanced ultrasound (CEUS) in gallbladder and bile duct pathology: technique, interpretation and clinical applications Poster No.: C-2099 Congress: ECR 2011 Type: Scientific Exhibit Authors: E. Casula, E. Romá de Villegas, M. J. Cerverón, T. Ripollés, 1 1 2 3 1 2 2 2 M. J. martinez, L. Navarro Vilar ; VALENCIA, sp/es, Valencia/ 3 ES, valencia/es Keywords: Pathology, Neoplasia, Inflammation, Comparative studies, Ultrasound, Biliary Tract / Gallbladder, Abdomen DOI: 10.1594/ecr2011/C-2099 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 24

Purpose To evaluate the utility of CEUS in the diagnosis of gallbladder and biliary duct pathology, using as reference the CT scan, MRI and histological studies whenever possible. Methods and Materials We performed a retrospective analysis of patients studied in the period between March 2006 and May 2010 for suspected lesions in gallbladder or biliary duct; 37 patients (24 men and 13 women), aged between 56 and 90 years, met the following criteria: - Conventional ultrasonography studies before and after administrating secondgeneration intravenous contrast (Sonovue ) - Aged over 18 years. - No history of previous adverse reaction to ultrasound contrast. Of 37 patients, 29 had also additional imaging (CT, MRI) and/or pathological studies (diagnostic FNA or postoperative biopsy). Technique: Toshiba Aplio 80 ultrasound. Convex sector (3.5-7 MHz) and linear (5-10 MHz) ultrasound transducer Gray-scale and colour Doppler evaluation. Sonovue ultrasound contrast (2.4 ml of sulfur hexafluoride bolus intravenous + 10 cm3 of saline bolus), lasting each study 3 minutes; occasionally a second study with the same characteristics was performed. CEUS parameters evaluated: enhancement pattern and wall involvement, loss of continuity of the gallbladder wall, wash-out time and delayed enhancement. Page 2 of 24

Results Ultrasound imaging and subsequent CEUS showed a pattern of recruitment and sonographic findings which provided a diagnostic approach of the following conditions: adenomyomatosis (2 cases), acute or chronic cholecystitis (17 cases), cholangiocarcinoma (11), gallbladder neoplasia (4), perivesicular isolated abscess without cholecystitis (1) and infiltration of bile ducts by hepatocellular carcinoma (1). Adenomyomatosis Also known as adenomatous hyperplasia, it is usually an incidental finding consisting of an epithelial proliferation and hypertrophy of the muscle layer with mucosal invaginations (Rokitansky-Aschoff sinuses) B-mode Ultrasonography Wall thickening (three types): - Focal (in fundus) - Segmental (body or body-fundus) - Fuzzy (diffuse thickening of the entire wall) Cystic intramural spaces (Rokitansky-Aschoff sinuses) Small echogenic foci with artefact in "comet tail" for cholesterol crystals Frequent or concurrent cholelitiasis. CEUS Adenomyomatosis shows diffuse contrast enhancement, similar to the gallbladder mucosa. Homogeneous enhancement in arterial and portal phase. Late wash-out Page 3 of 24

Acute cholecystitis B-mode ultrasound Wall thickening > 3 mm Distension of lumen (> 5 cm) Positive sonographic's Murphy sign Hyperemia of the gallbladder wall on Doppler Cholelitiasis, stones placed in cystic duct or gallbladder neck. Pericholecystic fluid. Alteration of echogenicity of the adjacent fat Dilatation of intra and extrahepatic biliary duct Cholecystitis complicated with abscesses on page 10: - Hypoechoic perivesicular collections Perforated cholecystitis: - Avascular areas in the gallbladder wall - Wall thinning CEUS Its utility lies mainly in the detection of wall perforation and perivesicular collections: o Homogeneous uptake of the gallbladder wall in the arterial phase o Progressive wash-out. o Abscess or gangrenous cholecystitis: - Non-enhancement of the perivesicular area - Wall continuity loss on page and communication with abscesses o Perforated cholecystitis: - Solution of continuity of the gallbladder wall - Unenhanced wall foci (necrosis) Page 4 of 24

Chronic cholecystitis. B-mode ultrasound Gallbladder wall thickening Gallstones Contracted gallbladder Absence of signs suggesting acute episode: vesicular distension, hyperemia, Eco-Murphy sign...) CEUS Mural thickening with enhancement in arterial phase similar to the rest of the gallbladder Late-stage hypoatenuation No signs of infiltration in adjacent hepatic parenchyma Gallbladder neoplasm Rare neoplasm, predominantly in the elderly, with the highest percentage in women; 98% of them correspond to adenocarcinomas. B-mode ultrasound: Three presentation types are described: Intravesicular mass: Mass with gallbladder obliteration and invasion of adjacent liver parenchyma. Focal or diffuse irregular wall thickening Intraluminal polypoid lesion Nodular areas Dilatation of intrahepatic biliary tree. CEUS - Arterial phase enhancement of the gallbladder wall and the mass. - Tortuous intratumoral vessels may be seen. Page 5 of 24

- Rapid Wash-out (portal phase) with decreased uptake in portal and late phases - Destruction of the gallbladder wall on page Cholangiocarcinoma B-mode ultrasound Intrahepatic cholangiocarcinoma: - Hypoechoic mass - Difficult differentiation from liver metastases or HCC infiltration. Hilar cholangiocarcinoma or Klatskin tumour: - Intrahepatic biliary tree dilatation - Bad defined hypoechoic mass, infiltrating the porta hepatis Distal cholangiocarcinoma: - Asymmetric thickening of the biliary duct wall - Irregular or nodular biliary duct stenosis - Irregular intraluminal echogenic material in bile duct - Associated dilatation of intra and extra hepatic CEUS Intrahepatic cholangiocarcinoma on page 18 - The enhancement pattern in the arterial phase depends on the size of the lesion: * Peripheral and irregular ring-shaped * diffuse heterogeneous uptake * diffuse homogeneous uptake - Rapid Wash-out Page 6 of 24

Hilar cholangiocarcinoma: - Enhancement may be: * affecting the whole mass on arterial phase * only peripherally * or hypovascular lesion without enhancement - Rapid Wash-out - Possible extension to gallbladder, hepatic flexure of colon, and so on. Extrahepatic cholangiocarcinoma. - Heterogeneous and peripheral enhancement on arterial phase - Enhancement of intraluminal tumour tissue in biliary duct - Rapid wash-out 6. OTHER CASES: - Isolated perivesicular abscess without cholecystitis (1) - Infiltration of bile duct by hepatocellular carcinoma (1). CEUS showed intense arterial phase enhancement of both the mass and adjacent liver parenchyma. Of the 37 cases reported, 29 were also provided with CT, MRI and/or histopathology. Thus, a "matching or percentage of agreement" between CEUS and other studies was calculated, resulting to be of 86'2%. Images for this section: Page 7 of 24

Fig. 1 Page 8 of 24

Fig. 2: Gangrenous cholecystitis. B-mode US: signs of emphysematous cholecystitis; gas in the gallbladder lumen (arrow), cholelihiasis (curved arrow), pericholecystic fluid (curved arrow). CEUS: Gallblader wall foci of necrosis (arrows) with lack of enhancement representing devitalized wall confirmed at surgery Page 9 of 24

Fig. 3: Gangrenous cholecystitis. CEUS: Gallblader wall necrosis (arrows) with lack of enhancement. Confirmatory CT. Page 10 of 24

Fig. 4: Perichoclecystic abscess in acute cholecystitis. CEUS: Hypoechoic pericholecystic collection (arrow). Wall interruption with communication with the abscess. Page 11 of 24

Fig. 5: Usefulness of contrast for differentiation between biliary sludge and Gallbladder carcinoma. CEUS: Biliary sludge does not enhance with the contrast Page 12 of 24

Fig. 6: Hyperechoic polypoid mass into the gallbladder. CEUS: hyperenhancement of the mass. Page 13 of 24

Fig. 7: B-mode US: large heterogenous hypoechoic mass obliterating the gallbladder. Note gallstone. CEUS: Hyper-enhancement of a nodular thickened wall representing tumor. Biliary sludge located into the lumen does not enhance with the contrast. Page 14 of 24

Fig. 8: CEUS: Hypervascular fundal mass (arrow) representing a gallbladder carcinoma. Page 15 of 24

Fig. 9: CEUS: Nonenhanced fundal mass (arrow) representing biliary sludge Page 16 of 24

Fig. 10: CEUS: Gallbladder carcinoma. Hyperenhancing polypoid mass (arrow) arising from the gallbladder wall that invades the adjacent liver (curved arrows). Page 17 of 24

Fig. 11: B-mode US: Both patients show a contracted lithiasic gallbladder with a hypoechoic pericholecystic mass. CEUS: chronic cholecystitis (case 1) shows an intact gallbladder wall (arrow). Destruction of the gallbladder wall (arrow) is seen in gallbladder carcinoma (case 2). Page 18 of 24

Fig. 12: Intrahepatic cholangiocarcinoma (Klatskin tumor). B-mode US: dilatation of the intrahepatic ducts with a doubtful poorly defined mass in the porta hepatis. Portal phase of CEUS: small hypoechoic nodule hypoenhanced representing the hilar tumor. Page 19 of 24

Fig. 13: Hilar cholangiocarcinoma. B-mode US: hilar hypoechoic mass. CEUS: during the arterial phase (16s) the lesion shows peripheric enhancement, and it becomes hypoenhanced during the portal phase (112s). CT scan shows the same findings as CEUS. Page 20 of 24

Fig. 14: Extrahepatic cholangiocarcinoma. B-mode US: common hepatic duct dilatation with intrabiliary mass (arrow) with homogenous echogenicity. CEUS: enhancement of an intraluminal tumour tissue. Page 21 of 24

Fig. 15: Extrahepatic cholangiocarcinoma. B-mode US: marked dilatation of the common hepatic duct with soft tissue into the lumen (arrow). CEUS: enhancement of the intraluminal content representing tumoral tissue Page 22 of 24

Fig. 16: B-mode US: marked dilatation of the left intrahepatic duct with a mass into the lumen (arrow). PV: left portal vein. CEUS: non-enhancement of the intraluminal mass representing biliary sludge. Biliary obstruction was due to a distal choledocholithiasis (nor shown). Page 23 of 24

Conclusion CEUS promises to be an easy, simple and useful imaging tool for detecting gallbladder and biliary tree disorders, including their complications. References -Carol M. Rumack, S.Wilson, J.Charboneau. "Diagnostic Ultrasound", Elvesier Mosby -Kazushi Numata, MD, Hiroyuki Oka, MD, Manabu Morimoto, MD. "Differential Diagnosis of Gallbladder Diseases With Contrast-Enhanced Harmonic Gray Scale Ultrasonography;", J Ultrasound Med 2007 -LM Meacock, MBcHB, MRCS, FRCR M E Sellars, MBBS, FRCR. "Evaluation of gallbladder and biliary duct disease using microbubble contrast-enhanced ultrasound", British Journal of Radiology 2010 -Ren Mao, MD, Er-Jiao Xu, MD, Kai Li, MD. "Usefulness of Contrast-Enhanced Ultrasound in the Diagnosis of Biliary Leakage Following T-Tube Removal", Journal of Clinical Ultrasound 2009 -Xiao-Long Ren, Rui-Ling Yan, Xiao-Hui Yu. "Biliary cystadenocarcinoma diagnosed with real-time contrast-enhanced ultrasonography: report of a case with diagnostic features", Word Journal of Gastroenterology 2010 -Korosh Khalili1, Ur Metser, Stephanie Wilson. "Hilar Biliary Obstruction: Preliminary Results with Levovist-Enhanced Sonography" Am. J. Roentgenol. 2003 -Hui-Xiong Xu. "Contrast-enhanced ultrasound in the biliary system: Potential uses and indications", World J Radiol. 2009 Personal Information Page 24 of 24