Pitfalls and

Differential Diagnosis
in Biliary Sonography1
StantonJ. Rosenthal, MD
Glendon G. Cox, MD
Louis H. Wetzel, MD
Solomon Batnitzky, MD

Ultrasonography has a primary role in the imaging of biliary disease.

Most cases are straightforward, but the authors emphasize unusual
manifestations, uncommon diseases, and artifacts that may present di-
agnostic challenges. Issues in differential diagnosis are discussed for
the following findings: internal gallbladder echoes (calculi vs tume-
factive sludge, air, hematobilia, parasitic infestation, cholecystosis,
neop!asia, and artifacts) , gallbladder wall thickening (acute cholecys-
titis vs acalculous cholecystitis, artifacts, ascites, hypoalbuminemia,
hepatitis, and scierosing cholangitis) , pericholecystic fluid (chole-
cystitis vs ascites, perforated ulcer, and trauma) , bile duct dilata-
tion (biliary obstruction vs sclerosing cholangitis, biliary air, anoma-
bus portal system, biliary atresia, Caroli disease, and cholangiocar-
cinoma), perinatal and neonatal biliary disease, and sclerosing chol-
angitis.

U INTRODUCTION
Investigation of disease of the bibiary tract and liver has been an important focus of
scientific inquiry from ancient times to the present. Babylonian priests practicing
divination studied hepatobiliary pathologic specimens from sacrificial sheep for
important clues to the future. Clay models of sheep livers and gabbbladders pro-
duced over 4,000 years ago (Fig 1) are highly accurate and detailed depictions of
hepatobiliary anatomy and represent some of the earliest known anatomic studies.
As imaging techniques have improved, diagnostic radiologists have increasingly
studied images of the bibiat-y tract. Plain radiography, oral cholecystography, intra-
venous cholangiognaphy, ultnasonography (US) , computed tomography (CT) , per-
cutaneous cholangiography, endoscopic retrograde pancreaticocholangiography

Abbreviations: AIDS acquired immunodelicienc) syndrome. RAO right anterior oblique, WES wall, echo,
shadow.

Index terms: Bile ducts. abnormalities, 76. 14 Bile

#{149} ducts, calculi, 76.28 Bile
#{149} ducts, diseases, 76.28 Bile ducts,
#{149}

enlarged. 76.28 Bile

#{149} ducts, neoplasms, 76.3 Bile
#{149} ducts, stenosis or obstruction, 76.28 Bile
#{149} ducts, US studies,
76. 1 298 Cholangitis,
#{149} 76.288 Cholecystitis.
#{149} 76.285

RadioGraphics 1990; 10:28-311

I From the Department of Diagnostic Radiology. University of Kansas Medical Center, Rainbow Boulevard at 39th St.
Kansas City, KS 66103. From the 1988 RSNA annual meeting. Received April F7, 1989; accepted and revision re
questedjune 2 1 ; revision received September 1 1 . Address reprint requests to SiR.
C RSNA, 1990

285
 (ERCP) , and magnetic resonance (MR) irnag-
ing all have been or are used in evaluation of
biliary tract disease. Of these, sonography is
most often employed as the primary imaging
tool because it has high sensitivity for the
presence of gallstones, it enables accurate
evaluation of the status of the intra- and cx-
trahepatic biliary ducts, and the examination
can be performed relatively rapidly and at
bow cost (1-3). In most cases, the US evabua-
lion is straightforward, but occasionally irn-
aging pitfalls or unusual presentations may
complicate the sonographic evaluation.
These potential problems form the basis of
this article.

U CHOLELITHIASIS Figure 1. Babylonian clay model of sheep liver

The US diagnosis of cholebithiasis is usually and gallbladder (circa 2000 Bc) . (Reprinted, with
one of the most straightforward in medical permission.)
imaging. High-amplitude echoes within the
lumen of the gallbladder that produce
“clean,” sharply defined, anechoic shadows
that move with change in patient position
are virtually always gallstones. The concept
of clean shadowing produced by calculi yen-
sus “dirty” shadowing (multiple internal
echoes within the shadowed area, poorly de-
fined margins, or a curtainbike effect) has
been used to differentiate calculi from gas in
bowel loops adjacent to the gallbladder, par-
ticularby the first portion of the duodenum.
Although this differentiating point is useful
in many cases, the degree of absorption and
reflection of the sound increases with fre-
quency and may vary from stone to stone,
even within the same patient. As a result, cal-
culi may produce both clean and dirty shad-
owing (Fig 2) . Variations in the angle of mci-
dence between the ultrasound beam and the
calculi may also contribute to these differ-
ences (1 ,3). Occasionally, intense reverbera-
tions within stones produce typical dirty
Figure 2. Sonogram of a straightforward case of
shadows and may closely mimic the effect of
cholelithiasis demonstrates four well-defined cal.
duodenab gas compressing the gallbladder culi that produce clean (arrow) and dirty (arrow-
(Fig 3) . In interpreting a case of this sort, head) shadowing.
careful real-time observation of the move-
ment of the stone with change in patient po-
sition will result in a correct diagnosis (Figs positions is critically important to minimize
4 , 5). Examination of the gallbladder with false-negative diagnoses (Fig 6).
the patient in prone, decubitus, and upright If the patient has not fasted, the gallblad-
den may appear contracted or absent on sono-
grams. Bright, irregular echoes in the gall-
bladder fossa associated with an intense, usu-
ally clean shadow indicate the presence of
multiple calculi in a contracted gallbladder
(Fig 7) . This appearance can be closely mirn-

286 U RadioGrapbics U Rosenthal et a! Volume 10 Number 2

 . . #{149}.‘ .w

# - -.----

a. b.
Figure 3. (a) Sonogram of gallbladder calculus (arrows) demonstrates dirty shadows that mimic duode-
nal gas compressing the gallbladder. (b) Oral cholecystogram reveals true nature of the single, large,
transparent crystalline stone (arrows).

4a. 4b.
Figures 4, 5. (4a) Sonogram shows hypenechoic
foci strongly resembling gallstones that were
caused by an irregular impression of duodenal gas
(arrow) on the posterior aspect of the gallblad-
den. (4b) Another sonognam obtained moments
later after a peristaltic wave shows a normal gall-
bladder. (5) Sonogram of another case demon-
-:7-,. . . .#“a
.-
#{149} strates gas (arrow) mimicking a gallstone. The dif-
V 4c: > ference in size between the large shadow and the
smaller hyperechoic reflector (arrow) and the in-
constancy of these findings during real-time scan-
.- . . ,

fling indicate the source of the echoes is not a cal-

culus.
,

; .

5.

March 1990 Rosenthal et a! U RadioGrapbics U 287

 a. b.
Figure 6. (a) Sonogram obtained with the patient supine reveals an apparently normal gallbladder.
(b) Another sonogram taken with the same patient standing clearly shows multiple calculi.

‘
-.
. -I
..
.‘a.:
. :
#{149}
.

-. . . . 4

--
.- -
.- . -..-.-
‘--
.1
..
:
:
. - .

#{149}: - -

I:
.±-

7. 8.
Figures 7, 8. (7) Sonogram demonstrates the WES (wall, echo, shadow) triad (arrows)-a specific sign
for a contracted, stone-filled gallbladder. The WES sign is composed of two parallel echogenic arcs pro-
duced by the leading edge of the gallbladder wall and the stones. Bile creates a thin, echopenic zone be-
tween the arcs, and the stones produce a posterior shadow (4) . (8) Sonogram demonstrates a hyperechoic
structure with a shadow, but the WES triad is not present. In this case, gas in the bowel occupying the gall-
bladder fossa mimicked the appearance of gallstones.

288 U Ra4ioGrapbics U Rosenthal et a! Volume 10 Number 2

 res 9, 10. (9) Sonogram demonstrates pol-
tnnow) projecting into the gallbladder lumen.
ILongitudinal (a) and transverse (b) scans ob-
I in another case reveal a round artifact (an-
caused by dust within a multiformat camera
tlosely mimics a polyp.

icked by gas-containing bowel in the gall- festation, gallbladder empyerna, and carcino-
bladder fossa if the gallbladder is contracted ma. Gallbladder polyps, either adenomas or
due to a recent fatty meal (Fig 8) . The dirty papilbornas, are nonshadowing, nonrnobibe
shadow seen in Figure 8 is helpful but not in- soft-tissue masses projecting into the lumen.
fallible evidence that gallstones are not They are usually less than 1 cm in diameter
present. Observing the passage of water (1 -3) (Fig 9) . We encountered a case in
through the duodenum on noting a WES triad which a camera artifact mimicked the ap-
may clarify this situation. pearance of a polyp (Fig 10).

U NONCALCULUS STRUCTURES
WITHIN THE GALLBLADDER
Many entities other than calculi produce
echoes within the gallbladder, including ad-
enomatous polyps, hyperplastic cholecysto-
sis, bibiary sludge, hematobilia, parasitic in-

March 1990 Rosenthal et a! U RadioGrapbics U 289

 _v.. ‘ ‘ - ..
,,V#{149}:..

Frb%.., . . .;. r..

13. 14.
Figures 11-14. Sonognams demonstrate biliary sludge (arrows in 11), partial volume artifact resembling
sludge (arrows in 13) , and collections of pus that appear similar to sludge (14). Sonogram of a patient re-
ceiving hyperalimentation (12) shows sludge filling the entire gallbladder.

Gallbladder sludge is viscous bile, usually Artifact from partial volume averaging may
with a high bilirubin content, that is fre- produce an appearance resembling sludge
quently seen in cases of biliary stasis (Fig (Fig 13), but in general, the echogenicity
1 1) . This may be a normal finding accompa- within the gallbladder decreases with in-
flying prolonged fasting, particularly in pa- creasing distance from the adjacent bright re-
tients undergoing hyperalimentation. In flector that contributes to the artifact. Patho-
these cases, the entire gallbladder may be logic biliary stasis, such as that accompany-
filled with sludge (3) (Fig 1 2). ing acalcubous cholecystitis, produces
collections of pus or dense bile that are simi-
bar to sludge found in fasting patients (5)
(Fig 1 4) . Milk-of-calcium bile may also re-

290 U RadioGrapbics U Rosenthal et a! Volume 10 Number 2

a. b.
Figure 15. Sonognam (a) and CT scans (b) obtained in a case of cholelithiasis and cholecystitis show
milk-of-calcium bile that resembles sludge (arrows) (cf Fig 1 1).

.m T: T

Figure
sludge
16.
(arrows)
Sonogram
, associated
demonstrates tumefactive
with both gallstones veals
-‘#{149}. - 7. Sonogram
sludgebike material
of a case
within
of hematobilia
the gallbladder
and thickening of the gallbladder wall secondary (GB) ; however, the septations in the mass are
to acute cholecystitis. suggestive of the true diagnosis.

semble sludge (Fig 1 5) However, . milk-of- that may simulate the sonographic appear-
calcium bile is usually somewhat more echo- ance of sludge on pus. Septations or other cv-
genic than sludge and is frequently associat- idence of organization within the gallbladder
ed with calculi and cholecystitis. Tumefac- and the presence of dilated bile ducts, which
tive sludge is also commonly associated with are frequently associated with hematobibia,
cholelithiasis (Fig 1 6) and has been ob- are findings suggestive of this potentially be-
served to evolve into calcium bilirubinate thai condition (Fig 17).
stones in many patients (3).
Hematobilia can result in accumulation of
echogenic material within the gallbladder

March 1990 Rosenthal et a! U Ra4ioGrapbics U 291

 a. b.
Figure 18. Sonogram (a) shows phrygian cap configuration. This radiologic finding was so named be-
cause of its similarity to the “cap of liberty” bestowed on freed slaves in ancient Phrygia (b). The appear-
ance is produced by a sharp fold in the lower portion of the gallbladder, which causes the fundus (arrows
in a) to lie anterior to the body of the gallbladder.

U GALLBLADDER VARIATIONS This appearance must also be differentiated

There are many variations in the shape of the from that caused by a layer of small calculi
gallbladder, most of which are only anatomic suspended between bile of differing viscosi-
curiosities. One of the best known is the ties (Fig 20) . The floating calculi can be con-
phrygian cap (Fig 1 8), which is produced by nectby diagnosed by noting that the layer ne-
a sharp fold in the lower portion of the gall- mains horizontal, despite changes in patient
bladder. This configuration has no clinical position. True septations do occur within the
significance. A more common fold occurs in gallbladder (Fig 2 1), but they are seldom as-
the proximal portion of the gallbladder, re- sociated with symptoms.
sulting in a sharp angubation of the gablbbad- Variations in the shape and position of the
den body on its neck. This variation is usually gallbladder may become clinically signifi-
best seen in longitudinal scans (Fig 1 9a). cant when they act to obscure diagnostic in-
The same fold in a transverse view often has formation. Figure 22 is an axial scan of a
the false appearance of a septum (Fig 1 9b). transversely oriented gallbladder in a patient
with acute chobecystitis. Wall thickening was
noted in many scans, but the large calculus
could be identified only in transverse views.

292 U RadioGraphics U Rosenthal et a! Volume 10 Number 2

Figures 19-21. (19a) Longitudinal US scan shows fold (arrow) in proximal gallbladder (GB). (19b) On
transverse scan of the same case, the fold could be confused with a septum (arrow) in the posterior aspect
of the gallbladder. (20) Sonogram of another case reveals layer of suspended calculi (arrows) that appears
similar to the proximal fold. Compare these images with that of actual septa in the gallbladder (21).

Figure 22. Transverse sonogram reveals large

calculus (arrow) obstructing the neck of the gall-
bladder that was missed on scans obtained in oth-
en planes.

March 1990 Rosenthal et a! U Ra4ioGrapbics U 293

 23. 24.

Figures 23-25. (23) Sonogram shows thicken-

ing of the gallbladder wall (arrows) caused by
acute cholecystitis induced by a single calculus
(arrowhead) impacted in the neck of the gallblad-
den. (24) Gallbladder wall thickening seen on this
sonogram of a patient with ascites is at least in
part an artifact caused by the presence of closely
apposed strong reflecting surfaces at the ascites-
gallbladder wall interface and the immediately
adjacent gallbladder wall-bile interface (arrows).
(25) Sonogram shows a thickened gallbladder
wall (arrows), produced by hypoalbuminemia
and alcoholic hepatitis, and a penicholecystic
halo in a chronic alcoholic without ascites.

U GALLBLADDER WALL THICKENING

Evaluation of gallbladder wall thickness
plays an important role in the sonographic
study of the biliary system. The gallbladder cholelithiasis. Many patients with acute cho-
wall is no more than 2 mm thick in 97% of becystitis will not have all these charactenis-
healthy subjects, provided that the short axis tics. Nevertheless, the diagnosis can be sus-
of the gallbladder is at beast 2 cm in diame- pected due to the presence of gallstones,
ten. Acute cholecystitis is a major cause of moderate wail thickening, and focal tender-
wall thickening (Fig 23) and is the most like- ness. In these cases, confirmation of cystic
by diagnosis if the wall thickness exceeds 5 duct obstruction by means of hepatobiliary
mm. The confident US diagnosis of chobecys- scintigraphy is often useful (3).
titis is based on the criteria of wail thickness Other important causes of gallbladder wall
of greater than 4 mm and a round or oval thickening include hepatitis, artifacts in-
gallbladder distended to a transverse diame- duced by the presence of penicholecystic flu-
ten of at least 5 cm. Other important criteria id, hypoalbuminernia, right-sided heart fail-
are gallbladder wall lucency or “halo” and une, and incomplete gallbladder distention.
In addition, focal thickening occurs in gall-
bladder carcinoma and adenornyornatosis
(1-3,6).

294 U Ra4ioGrapbics U Rosenthal et a! Volume 10 Number 2

 of findings in patients with viral perichole-
cystitis. Findings resemble those of acalcu-
bus chobecystitis, except that the gallblad-
den tends to be contracted rather than dilated.
The degree of contraction is greatest in those
cases with the most marked wall thickening
and penicholecystic organization. Despite
the wall thickening, internal gallbladder
echoes were absent in all cases. All of our pa-
tients with viral penicholecystitis were under
35 years of age, and none had a history of re-
cent surgery, trauma, or burns. All presented
with right upper quadrant pain and tender-
ness. Hepatobiliary scintigraphy demonstrat-
T ‘
1
ed patency of the cystic duct in all cases.
.. Gallbladder wall thickening has also been
observed in patients with acquired immuno-
:-
deficiency syndrome (AIDS) (Fig 27) . Grurn-
tx., -‘- bach et al (7) reported gallbladder wall
Figure 27. Sonogram shows thickened gallblad- thickening in 55% of 22 patients with AIDS.
den wall in a patient with AIDS. There was an increased prevalence of extra-
biliary cytomegabovirus infestation and intes-
final cryptosponidiosis in this group as well
Gallbladder wall thickening in the pres- as in other AIDS patients with dilated bile
ence of ascites is primarily artifactual. ducts (7).
Hypoalbuminernia and chronic liver dis-
ease may also contribute to this appearance

March 1990 Rosenthal et al U Ra4ioGrapbics U 295

 Figures 28, 29. (28) Sonogram shows soft-tissue mass in the gallbladder fundus (arrow) that proved to
be carcinoma. Multiple calculi were also present. (29) In a sonogram of a large aneurysm (A) of the hepat-
ic artery, thrombus (arrows) appears similar to the mass seen in Figure 28.

Focal thickening of the gallbladder wall

occasionally occurs in cholecystitis, but it is
more commonly associated with adenomyo-
matosis, gallbladder carcinoma (Fig 28), and
adherent turnefactive sludge (3 ,8) We en-
.

countered a case in which thrombus in an

hepatic artery aneurysm mimicked the ap-
pearance of a gallbladder mass (Fig 29).
.

:;
Figure 30 Sonogram of a patient with cholecys-
titis shows areas of increased reflection in the
gallbladder wall (arrows) . This appearance was
caused by focal calcium deposits.

296 U Ra4ioGrapbics U Rosenthal et a! Volume 10 Number 2

Figure 31. Longitudinal (a) and transverse (b) scans of a 60-year-old man with emphysematous chole-
cystitis demonstrate extensive gas collections in the gallbladder wall (arrows). (c) Radiograph helped
confirm the findings, and the diagnosis of porcelain gallbladder was ruled out. Biliary air (arrows) is also
seen.

U GALLBLADDER WALL ECHOES Emphysematous chobecystitis is generally

Irregular thickening of the gallbladder wall caused by occlusion of the cystic artery with
and surface epitheliurn in adenornyomatosis secondary gallbladder infarction. There is a
may give rise to areas of increased reflection, high potential for perforation, peritonitis,
reverberation artifacts, or faint shadowing and sepsis. Twenty percent of the patients
(3 ,8) Occasionally,
. focal calcium deposits are diabetic, and men are affected three
in cb.olecystitis may have a similar appear- times more often than women. Clostridium,
ance (Fig 30) . More extensive calcium de- Enterobacter aerogenes, and Escbericbia
posits produce a “porcelain gallbladder,” in coli are the most commonly associated or-
which acoustic shadowing from the calcified ganisms (1,3).
wall obscures the detail of the rest of the or-
gan. Sonographically, these findings are diffi-
cult to distinguish from the extensive mural
and intra!uminal air collections of emphyse-
matous cholecystitis (Fig 31).

March 1990 Rosenthal et a! U Ra4ioGrapbics U 297

 32. 33.

Figures 32-35. (32) Sonogram of a case of early rupture of a gangrenous gallbladder reveals small pen-
cholecystic fluid collection (arrows) . (33) Right longitudinal scan of a case of perforated duodenal ulcer
shows a similar fluid collection (arrows) around a normal gallbladder. (34) Sonognam of a different pa-
tient demonstrates a penicholecystic abscess (A) produced by a perforated ulcer and thickening of the ad-
jacent wall of an otherwise normal gallbladder (GB) . (35) Sonogram of another patient shows a penichole-
cystic abscess (A) secondary to gallbladder (G) perforation that appears similar to the abscess seen in Fig-
une 34.

U PERICHOLECYSTIC FLUID U EXTRAHEPATIC BILE DUCT

Gangrene on rupture of an acutely inflamed DILATATION
gallbladder may produce penicholecystic flu- US is an excellent method for evaluating the
id collections or frank abscesses (Figs 32, size of the extrahepatic bile ducts. Longitu-
35). Such fluid collections appear similar to dinal scans obtained with the patient in the
the lucent halo seen in many cases of chole- right anterior oblique (RAO) position are
cystitis (Fig 32) . Perforated ulcers may mirn- particularly useful and may reveal not only
ic this appearance (Figs 33, 34). the diameter of an enlarged bile duct but at

298 U RadioGrapbics U Rosenthal et a! Volume 10 Number 2

36 37.
Figures 36, 37. (36) Sonogram clearly shows dilated extrahepatic bile duct (arrows) and an obstructing
calculus (arrowhead) in the common bile duct with a definite acoustic shadow. (37) Transverse scan
shows a calculus impacted in the intrapancreatic portion of the common bile duct. No bile surrounds the
obstructing stone (arrow) . This produces decreased stone echogenicity and reduced shadowing, since
there is a much lesser degree of acoustic mismatch between the calculus and surrounding pancreas than
would be the case if the stone were still suspended in bile.

times the cause of the enlargement as well

(Fig 36) In the case illustrated
. in Figure 36,
the obstructing calculus that caused the dila-
tation was easily seen; however, sonographic
detection of common bile duct stones can of-
ten be more difficult, as in the case shown in
Figure 37.
Although a dilated common bile duct usu-
ally implies obstruction, a previously dilated
duct may not return to normal caliber de-
spite relief of the obstruction. Such was the
case for the patient in Figure 38. Occasional-

-
who underwent
- t longitudinal
cholecystectomy
scan of a patient
demonstrates
a persistent dilated common bile duct (arrows).
Because the intrahepatic bile ducts were not en-
barged, the radiologist suspected no acute ob-
struction was present. This was confirmed by
means of ERCP.

March 1990 Rosenthal et a! U Ra4ioGrapbks U 299

 a. b.
Figure 39. (a) RAO longitudinal scan of a patient with acute cholecystitis shows a massively dilated cys-
tic duct (CD) . An enlarged common hepatic duct was suspected initially; however, there was no concomi-
rant dilatation of the intrahepatic bile ducts. GB = gallbladder. (b) Another longitudinal scan reveals a
common hepatic duct of normal size (arrows).

ly, an enlarged cystic duct may be mistaken zyrnes to weaken the bile duct in most cases
for a dilated common bile duct (Fig 39) . A that are found after birth. Sonographically,
careful US examination, and correlation with the cysts may resemble an enlarged gallblad-
the size of the intrahepatic ducts, should den. However, they are commonly found
help establish the correct diagnosis. close to the head of the pancreas and are fre-
Choledochab cysts usually form as an aneu- quently (50% of cases) associated with intra-
rysm or diverticuburn of the common bile hepatic bile duct dilatation. These facts are
duct. Anomalous union of the common bile helpful in the differential diagnosis (1-3).
and pancreatic ducts allows pancreatic en- Stasis of bile may result in stone formation
within the cyst. Figures 40 and 4 1 illustrate
various appearances of choledochab cysts.

300 U RadioGrapbks U Rosenthal et a! Volume 10 Number 2

 .

-- _ ..

40c. 41.
Figures 40, 41. (40) Transverse (a) and longitudinal (b) sonograms of a child with intermittent pain in
the right upper quadrant show a choledochal cyst (C). The cyst deforms the pancreatic head (F) and con-
tains a calculus (arrow in b) . (c) ERCP image of the same patient shows the large cyst (C) to the left of a
normal-sized gallbladder. (41) Sonogram of a choledochal cyst in a 35-year-old woman with moderately
severe dilatation of the intrahepatic bile ducts. In this case, the cyst is a large fluid-containing mass (C)
anterior to the night kidney and lateral to the pancreas.

March 1990 Rosenthal et a! U RadioGrapbics U 301

 Figures 42, 43. (42) Right transverse scan of a
child with rhabdomyosarcoma of the porta hepa-
tis shows tubular, fluid-containing structures in
the periphery of the liver, characteristic of major
intrahepatic bile duct dilatation. (43a) Transverse
scan of a patient without biliary disease demon-
strates an anomalous H-type branching of the right !:
portal vein (A = anterior branch, P posterior
. 4 t.
branch) . This appearance should not be confused
with the parallel track sign formed by the dilated Ii.. iiQ-:t

right hepatic duct. (43b) Duplex Doppler image

definitively demonstrates the venous nature of
both the anterior and posterior tubular structures.

, ;-- .
:.
-V.

I.

. . ,#{149}..

.. ?1-T
I.

..
#{149}‘
‘.

Mi

...#{149};,
I
;:-:

43a.

Figure 44. Transverse scan of a patient who

underwent a Whipple operation shows typical,
brightly echogenic, branching ducts containing
air (arrows) , which are usually most apparent in
the nondependent portion of the liver.

302 U Ra4ioGrapbks U Rosenthal et a! Volume 10 Number 2

a. b.
Figure 45. (a) Sonogram shows typical findings of biliary air (arrows) in a patient with clinical chole-
cystitis. The gallbladder is not visualized. (b) Image from an upper gastrointestinal study of the same pa-
tient shows a fistula (arrow) between a severely contracted gallbladder and the duodenal cap. A large
stone (S) is present within the duodenum, and there is a duodenal stricture (arrowhead) , which prevents
passage of the stone distally.

U INTRAHEPATIC BILE DUCT of the sphincter of Oddi or a surgical bibiary-

DILATATION entenic anastomosis (Fig 44) . Bouveret syn-
Major intrahepatic bile duct dilatation pro- drome is another rare cause of bile duct air.
duces obvious, large, tubular, fluid-contain- In this syndrome, a large gallstone erodes
ing structures in the periphery of the liver into the distal stomach or proximal duode-
(Fig 42) The
. bile duct walls are often mildly num, producing gastric outlet obstruction
irregular, and they tend to have associated (Fig45) (1).
posterior acoustic enhancement. Dilatation Rarely, extensive calcification of the intra-
of the right hepatic duct as it courses anteni- hepatic arteries closely mimics the sono-
or to the portal vein often produces a “paral- graphic appearance of biliary air (Fig 46).
lel track” sign on transverse scans near the
hilurn of the liver. However, this appearance
should not be confused with that of anorna-
bus branching patterns of the night portal
vein (Fig 43).
Air within a dilated intrahepatic biliary
system is usually secondary to incompetence

March 1990 Rosenthal et a! U RadioGrapbics U 303

 !.,
--.
L.
. 2
‘#{149}
.. : -

_..._%t’.

r ‘ ‘

#{149}‘#{149}‘lIllbI . .Tc! .
p..
.
.
..
5.
.
.
.

p.: -

‘:
p #{149}1

‘ 4..,” :d..T ,-
. . . .#{149}. , . #{149}..

.- .*‘. #{149} 4%.

..- -... . 0

-.. I. : #{149}

--

I.. ..

. .:
r

. 1
.:_ - .

a. b.
Figure 46. (a) Sonognam demonstrates brightly echogenic areas similar in appearance to biliary air in a
patient with chronic renal failure and severe secondary hyperparathyroidism. (b) Noncontrast CT scan re-
veals that these areas are extensive calcification of the intrahepatic arteries.

Intrahepatic bile duct dilatation is usually r -

secondary to obstruction of the extrahepatic

biliary system. When the extrahepatic ducts
are normal, the intrahepatic obstruction is I
usually secondary to cholangitis or liven neo- ::
#{149}p .. jd
plasia, either primary or metastatic (Fig 47).
In Minizzi syndrome, the mass obstructing
the biliary tract is a large impacted calculus
in the cystic duct, which compresses the
common hepatic duct (1 ,3). Figure 48 illus- 541_. 4
trates the various radiobogic findings in Mm- .

izzi syndrome. #{149}

:-: .
..

.,

Figure 47. Transverse scan of a patient with a

diffusely infiltrating cholangiocarcinoma in the
lateral segment of the left hepatic lobe (arrows).
The presence of focally dilated bile ducts (arrow-
heads) is a useful clue to the presence of the
mass.

304 U Ra4ioGrapbics U Rosenthal et a! Volume 10 Number 2

 . . .

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Figure 48 (a) Right longitudinal sonogram of a patient with Minizzi syndrome shows moderate dilata-
tion of the intrahepatic bile ducts. (b) Sonogram obtained more medially shows a large calculus (arrow)
casting an acoustic shadow across the ports hepatis. The gallbladder (GB) is contracted and thick walled.
(c) Right parasagittal MR image demonstrates findings similar to those in a and b. (d) Percutaneous chol-
angiogram reveals severe narrowing of the common hepatic duct (arrow).

March 1990 Rosenthal et a! U RadioGraphics U 305

 Figure 51 Sonogram of a patient with polycys-
Figure 49. (a) Right longitudinal sonogram of a tic liven disease shows no tubular connections be-
patient with Canoli disease shows multiple con- tween the cysts, unlike sonographic findings in
necting tubular structures (arrows) in the liver. Canoli disease.
(b) Transverse scan shows a large poorly echo-
genic calculus (arrow) in the common bile duct.
(c) Cholangiogram demonstrates the stone (S). U PERINATAL AND NEONATAL
BILIARY DISEASE
Cholelithiasis in the fetus is extremely rare
Caroli disease is a rare form of intrahepatic (Fig 52) . Although fetal cholelithiasis may
bile duct dilatation characterized by marked be idiopathic, there is an association with
saccular enlargement of the intrahepatic bile hernolytic anemia, such as that associated
ducts and renal disease, usually tubular ecta- with Rh incompatibility, and enzyme defects
sia or other cystic disease (Figs 49, 50). He- (10,11).
patic fibrosis and biliary calculi are common Although distinctly uncommon, choleli-
(1 -3 ,9) . The absence of tubular connections thiasis is being recognized more frequently
between the cysts helps in the differentiation in premature infants undergoing prolonged
of autosomal dominant polycystic liver dis- treatment for respiratory distress syndrome
ease (Fig 5 1) from Caroli disease. and bronchopulmonary dysplasia in inten-

306 U RadioGrapbics U Rosenthal et a! Volume 10 Number 2

C. d.
Figure 50. Radiologic studies of a 1 7-year-old patient with Caroli disease and osteogenesis imperfecta
demonstrate less massive biliary dilatation than that seen in Figure 49. Right longitudinal sonograms (a, b)
show multiple communicating hepatic cystic structures. These findings are confirmed on a CT scan (c)
and cholangiognam (d).

Figure 52. Oblique coronal scan of the night

side of a 39-week-old fetus shows multiple,
brightly echogenic calculi (arrow) in a normal-
sized gallbladder.

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i:

53. 54.
Figures 53, 54. (53) Sonogram of a 4-month-old premature infant, who had a birth weight of 1 kg,
shows typical findings of cholelithiasis (arrows). (54) Right longitudinal scan of an infant with meconium
peritonitis who had recently eaten shows what appears to be a stone-filled or diffusely calcified galiblad-
den (arrow) . Scans obtained after fasting revealed a normal gallbladder and widespread penitoneal calcifi-
cation.

sive care units. Prolonged total parenteral tool, since passage of the radionuclide into
nutrition and frequent administration of fur- the intestinal tract rules out biliary atresia.
osernide may combine with the immaturity However, because this finding may not be
of the hepatocellular enzyme system to pre- demonstrated in some cases of severe hepati-
dispose these infants to gallstone formation tis, US may be useful to evaluate the pres-
(3) (Fig 53) . Although these stones may ence of the gallbladder, to visualize portions
spontaneously resolve with institution of a of the extrahepatic bibiary system, and to
normal diet and discontinuation of diuretics, rube out bile duct dilatation. Failure to visu-
while they are present, the patients are at abize the gallbladder on sonograrns in a fast-
risk of chobecystitis and bibiary obstruction. ing jaundiced neonate is presumptive cvi-
If sonography is performed in an infant dence of biliary atresia. The converse is not
whose gallbladder is contracted due to a ne- true, however, since the gallbladder is
cent meal, the penitoneal plaques of meconi- present in up to 20% of patients with extra-
urn peritonitis may closely mimic the ap- hepatic biliary atresia (1 ,3) (Fig 55).
pearance of a small gallbladder filled with
calculi or a diffusely calcified gallbladder U SCLEROSING CHOLANGITIS
(Fig 54) . US visualization of a normal gall- Primary sclerosing chobangitis is an idiopath-
bladder after fasting as well as sonographic ic cholestatic syndrome characterized by in-
and radiographic evidence of calcific tra- and extrahepatic biliary fibrosis and bile
plaques elsewhere in the penitoneal cavity duct obliteration. Eventually, progressive
can clarify this situation. biliary cirrhosis and hepatic failure occur.
US has an adjunctive role in the noninva- The disease occurs in 1 %-4% of patients
sive differentiation of neonatal hepatitis and with chronic ulcerative colitis. There are
biliary atresia in jaundiced infants. Hepato- weaker associations with Riedel disease,
biliary scintigraphy is the primary imaging Crohn disease, and retnoperitoneal fibrosis.
The most common etiobogic link in these
conditions is most likely bacterial or meta-
bolic alteration of bile acids. Clinically, the
diagnosis is one of exclusion, after congeni-

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si..
1
-- . . ‘ .

b.
Figure 55. (a) Right longitudinal scan of a 2-
month-old infant with biliany atresia jaundiced
since 2 days of age shows a normal gallbladder
(G) and common hepatic duct (arrow) . (b) Hep-
atobiliary scintiscan shows activity in the liver
and bladder but not the gallbladder on bowel,
findings suggestive of biliary atresia. (c) Intraop-
erative cholangiogram opacifies the gallbladder
and a small patent common bile duct but shows
no filling of the common hepatic or intrahepatic
ducts, despite transient clamping of the proximal
common bile duct. The diagnosis of intrahepatic
biliary atresia was confirmed.

ings include focal thickening of the gallblad-

den wall, concentric thickening of the intra-
and extrahepatic biliary system, irregularity
of the bile duct, and focal dilatation of the
C. bile duct (1 6- 1 9) . We encountered eight
patients with a surgically or cholangiograph-
ically proved diagnosis of primary sclerosing
tal biliary disease, choledocholithiasis, pre- cholangitis. The patients ranged in age from
vious surgical stricture, and cancer have 23 to 60 years, with an average of 40 years.
been ruled out. These patients have an in- Two had past histories of chronic ulcerative
creased propensity to develop gallstones as colitis. No sonographic abnormalities were
well as benign and malignant gallbladder
neoplasms (1,12-15).
Although the results of sonographic exam-
ination of some patients with primary scbe-
nosing cholangitis are normal, reported find-

March 1990 Rosenthal et a! U RadioGrapbics U 309

 a. b. c.

Figure 56. Longitudinal (a) and transverse (b) sonograms of a 23-year-old man with primary sclerosing
cholangitis show striking thickening (arrows) of the gallbladder (GB) wall.
(c, d) Longitudinal and trans-
verse scans show thickening, irregularity, and focal dilatation of the common hepatic duct (arrow in C)
and in the left lobe intrahepatic ducts (arrows in d) . (e) ERCP image demonstrates multiple areas of steno-
sis and dilatation.

present in three. Mild to marked gallbladder U REFERENCES

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ing, irregularity, or focal dilatation of intra- tract, pancreas, and spleen. Baltimore: Wil-
hepatic bile ducts in three; and focal thick- hams & Wilkins, 1987.
2. Kane RA. The biliary system. In: Kurtz AB,
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Goldberg B, eds. Gastrointestinal ultraso-
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310 U RadioGrapbics U Rosenthal et a! Volume 10 Number 2

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‘... -‘ ...
-
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#{149} . pp..,
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7
58.
Figures 57-59. (57) Sonogram of a 46-year-old
man with primary sclerosing cholangitis reveals
thickening and dilatation of the intrahepatic bile
ducts (arrows) and moderate thickening of the
gallbladder wall (arrowheads). (58) Longitudinal
scan ofa 32-year-old woman with primary scleros-
ing cholangitis demonstrates thickening and irreg-
ularity of the common hepatic duct (arrows).
(59) Longitudinal sonogram of a 4 1 -year-old man
with ulcerative colitis and primary sclerosing
cholangitis depicts mild dilatation and slight
thickening of the intrahepatic bile ducts (an-
rows).

59-

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