477

3-55

Ultrasonography in Obstructive Jaundice - A Pictorial Essay

YM GOHIL, SB PATEL, KG GOSWAMI, S SHAH, H SONI

Ind J Radiol Imag 2006 16:4:477-481

Key words : Obstructive Jaundice, Ultrasonography

Introduction calculus are gas or particulate material in the adjacent

duodenum or gas in biliary tract, pancreatic calcification,
Jaundice is a symptoms complex, characterized by yellow post-cholecystectomy surgical clips.
coloration of tissues and body fluids due to an increase
in bile pigments. Jaundice is classified in hemolytic,
hepatic and obstructive. Ultrasonography in obstructive
jaundice is useful to differentiate non obstructive from
obstructive jaundice by demonstration of dilatation of
intrahepatic and extrahepatic biliary ducts, to
demonstrate level and cause of obstructive jaundice, to
assess resectability of tumour by giving information about
local invasion, liver metastasis, distant lymphadenopathy,
vascular invasion and peritoneal metastasis.

Fig 2

Fig 1

PATHOLOGY
(A) BENIGN LESIONS:
1. Choledocholithiasis

Stone in CBD is may be primary resulted from bile stasis

and infection or secondary from gallbladder. On
sonography If CBD is dilated then calculus is seen as an
echogenic nodule with acoustic shadowing. But if CBD
is minimal dilated or of normal caliber, acoustic shadowing Fig 3
is usually not seen. Possible source of confusion with

From the Department of Radiology, Gujarat Cancer and Research Institute, Asarwa, Ahmedabad - 380016

Request for Reprints: Dr. Yogesh M. Gohil, Department of Radiology, Gujarat Cancer and Research Institute, Asarwa, Ahmedabad
- 380016

Received 10 March 2006; Accepted 10 July 2006

478

478 YM Gohil et al IJRI, 16:4, November 2006

Fig 4
Fig 7

Fig 5
Fig 8

Fig 6 Fig 9
 479

IJRI, 16:4, November 2006 Ultrasonography in Obstructive Jaundice 479

Fig 13
Fig 10

2. Mirrizi's syndrome

Mirrizi's syndrome is uncommon cause for extra hepatic

biliary obstruction due to an impacted stone in the cystic
duct creating extrinsic mechanical compression of the
common hepatic duct. Not uncommonly, the stone
penetrates into the common hepatic duct or the gut,
resulting in a cholecystobiliary or cholecystenteric fistula.
Sonographic findings include intrahepatic bile duct dilation,
a normal size CBD, and a large stone in the neck of the
gallbladder or cystic duct.

3. Post operative biliary strictures

Majority of the strictures are the result of injury to the

bile duct at the time of biliary tract surgery. ERCP and
PTC are investigation of choice. On sonography smooth
Fig 11 tapering stenosis with proximal dilation of CBD, abrupt
cut off of CBD, the presence Of echogenic nodule without
acoustic shadowing are findings.

4. Post- inflammatory strictures

Inflammatory strictures caused by cholangitis, chronic

pancreatitis, gallstones and penetrating or perforating
duodenal ulcer. The most frequent findings are smooth,
concentric, often tapered narrowing of the CBD. Strictures
may be single or multiple and may involve any portion of
the biliary tree.

5. Primary sclerosing cholangitis and AIDS

cholangitis

Primary sclerosing cholangitis is chronic progressive

disorder of unknown etiology that occurs commonly in
young men. In about 50 % cases it is associated with
Fig 12 ulcerative colitis. In AIDS, causes of abnormalities are
infection with HIV virus and opportunistic organisms have
480
480 YM Gohil et al
been implicated. Sonography shows patchy smooth or
irregular wall thickening of the intrahepatic bile ducts.
Dilatation of biliary radicles is usually mild.
6. Recurrent pyogenic cholangitis
Recurrent pyogenic cholangitis is endemic in Southeast
Asia. Recurrent nature of the disease leads to progressive
biliary strictures with marked ductal dilatation and stone
formation. The disease often progresses to cirrhosis.
Sonographic shows combination of marked extrahepatic
bile duct dilatation and intrahepatic bile duct dilatation
limited to segmental branches with acute peripheral
tapering ("pruned-tree" appearance), with associated
biliary calculi and debris.
7. Parasitic diseases
Ascaris lumbricoides-It normally inhabits the small
intestine and have propensity to migrate through the
ampulla of Vater to lodge in the gallbladder and biliary
tract. On USG, the worms can be recognized as tubular
non-shadowing, echogenic structures in the dilated biliary
tract. When they alive, the movement of the worms can
be seen, and it is usually possible to seen a sonolucent
inner tube within the echogenic tubular structure, which
represents the alimentary canal of the worm. In transverse
section, a "bull's eye" image may be seen caused by the
worm inside a dilated bile duct. Ultrasound may also reveal
hepatic abscesses complicating biliary ascariasis.
Biliary Hydatid- Hydatid disease can affect any organ of
the body and liver is involved most commonly. Rupture is
an important complication of Hydatid cyst of liver. In a
patient with rupture into the biliary system, daughter cysts
and membranes pass into the common bile duct producing
surgical jaundice. Sonography shows Findings of Hydatid
cyst in liver (cyst with daughter cyst), with connection of
Hydatid cyst with CBD and linear echogenic material due
to laminated Hydatid membranes, rounded small cysts
due to Hydatid daughter cysts and debris due to a mixture
of Hydatid membranes and daughter cysts in CBD.
8. Choledochal cysts
Choledochal cysts are uncommon congenital cysts of
the bile ducts. The cysts usually manifest in childhood,
and the triad of jaundice, pain and palpable sub costal
mass is diagnostic. Sonographic findings reflect specific
types of choledochal cysts. Todani et al classified
choledochal cysts into five types.
Type I Fusiform cystic dilatation of
extrahepatic CBD.
Type II Eccentric fluid filled cyst may be seen
which may appear separate from the
IJRI, 16:4, November 2006
CBD, as its neck may be narrow.
Type III Choledochal cyst or choloedochocele
represents localized cystic dilatation
of the distal intramural duodenal portion
of the CBD and is difficult to diagnose
on US.
Type IV A Multiple cyst involving intrahepatic and
extrahepatic bile ducts.
Type IV B There are multiple cysts involving the
extrahepatic bile duct only.
Type V Also called Caroli's diseases includes
single or multiple intrahepatic bile duct
cysts.
Complications are choledocholithiasis, changes due to
pancreatitis and /or biliary cirrhosis, portal vein thrombosis,
hepatic abscess, and malignant neoplasm within the cyst
wall and gallbladder.
(B) MALIGNANT LESION CAUSING OBSTRUCTIVE
JAUNDICE
1.Carcinoma of gallbladder
Carcinoma of the gallbladder is the most common biliary
tract malignancy. The patient usually an elderly female.
Majority of tumours are inoperable at the time of diagnosis.
Lymphnodes and liver invasion and local spread to
duodenum, stomach, and colon is common. Three major
patterns have been described on sonography. In type I,
the gallbladder is surrounded or replaced by hypoechoic
or heterogenous mass. In type II, there is focal or diffuse,
irregular and asymmetrical wall thickening. In type 3, which
is less common, a polypoid, and fungating intraluminal
mass, is seen. Gall stones seen in majority of patients.
Biliary obstruction in the form of dilated intrahepatic biliary
radicles and CBD may seen because of direct extension
via hepato-duodenal ligament or compression by
lymphadenopathy. On ultrasonography differential
diagnosis includes complicated cholecystitis and
xanthogranulomatous cholecystitis.
2.Cholangiocarcinoma
It is uncommon tumour. It is commoner in males with
peak incidence in sixth or seventh decade. High incidence
is associated with sclerosing cholangitis, Caroli's disease,
choledochal cysts, and ulcerative colitis. The prognosis
of distally placed tumour is better than proximally placed
tumours. Local and distant metastases are uncommon.
Cholangiocarcinoma can be classified according to
location as,(1) Intrahepatic tumour (2) Hilar lesions (the
most common location) referred to as Klatskin tumour
and (3) Distal ductal tumour. Cholangiocarcinoma may
occur in between these general locations.
Intrahepatic Cholangiocarcinoma -They are usually
large at presentation due to early asymptomatic course.

IJRI, 16:4, November 2006
Sonographic findings are nonspecific and may be seen
as hypo or iso echoic masses, which may be
homogenous or heterogenous. Focal intrahepatic biliary
ductal dilatation and atrophy of the segment of the liver
drained by these duct with retraction of overlying liver
capsule may also be seen.
Hilar Cholangiocarcinoma -The most common location
is either at the confluence of right and left hepatic ducts,
or the proximal common hepatic duct, and has been
termed Klatskin tumour. Hilar Cholangiocarcinoma are
graded according to Bismuth classification. Type 1 lesion
involves common hepatic duct only; type 2 lesion involves
right and left hepatic ducts at confluence. First order
branches are involved of either (type 3) or both (type 4) of
the hepatic ducts. Ultrasound demonstrates dilatation of
intrahepatic biliary radicles without any evidence of
extrahepatic dilatation. Tumours may be small and difficult
to visualize on sonography. Occasionally moderately
echogenic tumour may be seen at confluence. Some time
no mass seen at confluence except non-union of right
and left hepatic biliary radicles.
Distal duct Cholangiocarcinoma -The least common
location for Cholangiocarcinoma is the distal duct.
Ultrasound demonstrates biliary dilatation proximal to an
abrupt obstruction. Site of lesion will determine the
gallbladder distention. There may be seen intraluminal
polypoid lesion within bile duct. The bile duct at the level
of obstruction in Cholangiocarcinoma is narrowed if the
process is primarily desmoplastic and widened if there is
an obstructing intraluminal mass.
3. Carcinoma of head of pancreas
Carcinoma of head of pancreas is usually presented with
obstructive jaundice.
Most common ultrasonographic finding in pancreatic
carcinoma is a poorly defined, homogenous or
inhomogeneous hypoechoic mass in the pancreas or
pancreatic fossa. When an isoechoic mass is identified,
attention should be given to the size of the pancreas and
nodularity of its contour. Other findings include dilation of
the pancreatic duct and CBD proximal to obstruction.
4. Carcinoma of duodenum
Carcinoma of duodenum may involve CBD with direct
extension or by nodal mass. Patient presents with gastric
outlet problems more commonly than icterus. On
sonography there may be circumferential diffuse or focal
hypoechoic thickening noted with adjacent nodes.
481
Ultrasonography in Obstructive Jaundice 481
5. Ampullary tumour
On ultrasound it is seen as polypoid mass at region of
ampulla or abrupt dilatation of common duct or double
duct sign. In double duct sign Common bile duct and
pancreatic duct dilated without any obvious mass.
References
1. The Gallbladder and Bile duct Laing FC Diagnostic
Ultrasound-Rumack CM, 1998 vol-1 175-223
2. High resolution real time ultrasound in the evaluation of
the normal and obstructed biliary tract. Cooperberg PL
et al Radiology, 129: 477-480
3. The accuracy of sonography in the differential diagnosis
of obstructive jaundice: A comparison with
cholangiography.Koenigsberg M, Weiner SN, Walzer A
et al Radiology 1979, 133: 157-165.
4. Biliary dilatation: Defining the level and cause by Real
time US.Laing FC, Jeffrey RB Jr, Wing VW Radiology
1986, 160: 39-42
5. Ultrasonography of carcinoma of the Gallbladder: an
analysis of 80 cases.Kumar A, Agrarwal S, Berry M, et al
J Clin Ultrasound 18: 1990; 715-720
6. Cholangiocarcinoma at hepatic hilus: sonographic
findings Hann LE, Greatrex KV et al. AJR; 1997:168:985-
989
7. Bile duct obstruction: Radiological evaluation of level,
cause and tumour resectibility Robert N, Gibson et al.
Radiology 1986; 160:43-47
8. Ultrasound diagnosis of rupture Hydatid cyst of liver with
biliary obstruction Camunez F et al. Gastrointest Radiol
1986; 11: 330-333
9. Biliary sonography Steven MC, Alfred BK et al RCNA
1991 Vol 29 No 6 1171-1198
10. Extrahpatic bile duct carcinoma- US characteristic and
accuracy in the demonstration tumour. Robeledo T, Muro
A, Preito ML
11. The biliary tract John karani A textbook of Radiology and
Imaging-Sutton 2003 Vol-1, 711-736
12. The biliary tract Derrik FM, Hans-Ulrich Laush
Diagnostic Radiology - R. G. Grainger and D. J. Allison
2001 Vol-2, 1247-1306
13. Non-neoplastic disease of bile duct Baron RL, Campbel
WL Alimentary tract radiology-Margulis AR, Burhenne
HJ 1994 Vol-2 1295-1324
14. Neoplastic disease of bile duct Parret RS, Thorsen MK,
Lausen TL Alimentary tract radiology-Margulis AR,
Burhenne HJ 1994 Vol-2 1325-1343
15. Imaging the spectrum of biliary tract disease. Baron
RL, Tublin ME, Peterson MS RCNA 2002, 40:1325-1354
482

Anita Medical