Biliary tree dilation - and now what?

Biliary tree dilation - and now what? Poster No.: C-1767 Congress: ECR 2012 Type: Educational Exhibit Authors: I. Ferreira, A. B. Ramos, S. Magalhães, M. Certo; Porto/PT Keywords: Pathology, Diagnostic procedure, Ultrasound, MR, CT, Biliary Tract / Gallbladder DOI: 10.1594/ecr2012/C-1767 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 18

Learning objectives - To present a systematic diagnostic approach when biliary tree dilation is found - To review the different causes of biliary tree dilation Background Patients with elevation of bilirubin need to be studied. Investigation normally starts with ultrasound. Ultrasound is a non-invasive and fast technique that can confirm if dilation of biliary tree is or not present, and sometimes can establish its cause. Most of the patients will need further work-up either with Computed Tomography (CT), Magnetic Resonance Cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), and ultrasound endoscopy. Imaging findings OR Procedure details CT is an important tool to confirm ultrasound findings, such as pancreatic carcinoma, enabling at the same time disease staging. In our Hospital, because of time consuming examination and lower availability, MRCP is used for patients with suspicious diseases from the biliary tree, such as Caroli's disease or cholangiocarcinoma. In the presence of a normal CT examination, and/or unclear MRCP findings, which can happens for example in small ampullary tumour, ERCP is usually the next imaging modality to be performed. ERCP is also useful for the treatment of cholelithiasis. Fig. 1 on page 5 summarize our general workup. 1 - Cholelithiasis The formation of stones in the bile duct is far less common than the passage of gallstones from the gallbladder into the common bile duct (CBD). Patients present with abdominal pain in the right upper quadrant, nausea, and vomiting. Fever and jaundice can also be present when cholangitis is superimposed. Page 2 of 18

Ultrasound has a good sensitivity in the evaluation of cholelithiasis, but the distal portion of common bile duct is often difficult to study because of the presence of bowel gas. In this case, MRCP is usually diagnostic and ERCP is useful for treatment. Fig. 2 on page 5 2 - Sphincter of Oddi dysfunction The pathophysiological mechanism of sphincter of Oddi dysfunction is not fully understood. The diagnosis is based on a high index of clinical suspicion in patients with persistent or recurrent biliary pain after cholecystectomy. The presence of abnormal biochemical test of liver function and dilation of CBD is helpful in confirming sphincter of Oddi dysfunction. Noninvasive screening tests such as ultrasound, CT and MRCP studies are also useful Fig. 3 on page 6. Final diagnosis of Sphincter of Oddi dysfunction can be made with sphincter of Oddi manometry, but this is an invasive examination. 3 - Ampullary carcinoma Ampullary carcinoma is rare, although his incidence has increased in the last 30 years. The most common symptom at presentation is obstructive jaundice. Ultrasound can't usually determine the cause of obstruction. CT examination can detect some of these tumors Fig. 4 on page 7 and is important for staging. Small lesions are usually better visualized with ERCP. Most of these tumors are removed surgically, but nowadays, small tumors can be removed endoscopically. 4 - Caroli's disease This congenital disease is characterized by sacular dilation of intra-hepatic bile ducts in a random multifocal pattern. Imaging studies are quite specific for this diagnosis, sparing the patient to a liver biopsy. Although diagnosis can be suspected at ultrasound, MRCP is performed for better characterization Fig. 5 on page 8. Page 3 of 18

5 - Choledochal cyst Choledochal cysts are congenital anomalies of the bile ducts. They consist of cystic dilations of the extra-hepatic biliary tree, intra-hepatic biliary radicles or both. The preferred initial radiologic examination of a choledochal cyst is ultrasound, which can be performed easily in infants since 80% of the patients will present after the age of two. In older patients, other studies are needed, such as CT or MRCP, to exclude other causes of biliary tree dilation Fig. 6 on page 9 Fig. 7 on page 10. 6 - Chronic pancreatitis Patients with chronic pancreatitis usually complain of recurrent abdominal pain. Biliary obstruction Fig. 8 on page 11, pancreatic cancer, pseudocyst, diabetes and splenic vein thrombosis are considered complications of chronic pancreatitis. 7 - Pancreatic carcinoma Patients with pancreatic carcinoma usually complain of vague and unspecific symptoms. About 80% of those with a tumor in the pancreatic head have obstructive jaundice, which can be the first sign of the disease. Ultrasound has a good sensitivity in detecting these lesions, although bowel gas can difficult the observation of the pancreas. The stage of a pancreatic cancer is the most important factor in choosing treatment options and predicting a patient s outlook Fig. 9 on page 12. CT study is usually performed for staging. 8 - Cholangiocarcinoma The incidence of cholangiocarcinoma as increased in the last years and this type of tumor has a poor outcome. The first symptom is frequently painless jaundice. At ultrasound study intra-hepatic tumors can appear as a mass. Peri-hilar and extrahepatic tumors are more difficult to diagnosis at ultrasound. CT and MRCP are the best non-invasive tools to evaluate extension and resectability of these tumors. Fig. 10 on page 13 Fig. 11 on page 14 9 - Gallbladder carcinoma Page 4 of 18

Gallbladder carcinoma is rare and occurs usually in elderly patients, and the prognosis is poor. Biliary tree dilation occurs in advanced cases, when a heterogeneous mass arising from the gallbladder fossa invades and compresses the biliary ducts Fig. 12 on page 15. 10 - Others Liver hilar lymph nodes metastases are relatively common and can cause compression and dilation of the biliary ducts. Tumors arising from surrounding organs can also be a cause of biliary dilation Fig. 13 on page 16. Images for this section: Fig. 1 Page 5 of 18

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Conclusion Biliary tree dilation is a common clinical challenge. Sometimes a long diagnostic workup is needed to find the cause of the obstruction. Personal Information References. Page 18 of 18