Posted on

dilated cbd ultrasound

Her initial presentation was during a consultation made by her
husband. Her symptoms seem relatively minor yet the biochemistry results
are quite abnormal indicating a pattern of obstructive jaundice. Her
ultrasound findings are dramatic with stones seen in the gallbladder and
in the lower common bile duct (CBD). Ultrasound is the first-line
investigation for the gallbladder and biliary tree. The ultrasound scan
should be available with only a short wait for more urgent cases. This
patient should be prioritised for an urgent scan appointment.

Her pancreas was seen to be swollen. The enlargement of the pancreas
may have various causes and if a biliary stone is lodged in the distal
CBD then the patient may develop pancreatitis. With aging, the pancreas
becomes more echogenic and atrophic on ultrasound.

The relationship to ‘pathology’ seen on imaging to ‘disease’ and
clinical symptoms is interesting. Gallstones are common and an incidence
in excess of 10% in the population is described. It is common to find
gallstones in an otherwise asymptomatic patient. My policy is to tell
patients that they have gallstones even if they have no symptoms, however
I am always concerned that patients will then develop symptoms. I am
always surprised how patients can have significant radiological pathology
and have so few symptoms. The patient had obvious gallstones, a thickened
gallbladder wall, biliary dilatation and many CBD stones and yet had only
itching with a history of itching. The story of painless jaundice would be
more suggestive of pancreatic malignancy or a drug reaction rather than
gallstones.

Dilated cbd ultrasound

In 2007, Malik et al[3] retrospectively evaluated a cohort of patients with CBD dilatation and non-diagnostic imaging (TUS, CT or MRCP), previously performed for abdominal pain, weight loss or elevated liver enzymes in serum. These patients underwent EUS, being divided into two groups based on the level of clinical suspicion for biliary pathology (32 patients with normal liver chemistry tests and 15 patients with elevated enzymes)[3]. In the first group, the authors identified two findings on EUS (6%) potentially causative of biliary dilatation, a 7-mm stone of the CBD and a periampullary diverticulum. In the second group, 8 significant findings (53%) were observed: 4 periampullary diverticula, 3 choledocholithiasis and 1 ampullary tumor, not previously detected by TUS and CT.

The biliary system plays a central role in digestive pathophysiology, since it allows bile sterile flow from hepatocytes, through intra- and extra-hepatic ducts, Oddi’s sphincter and Vater’s ampulla, to the duodenum determining lipids absorption and excretion of metabolites and toxins in the small bowel[1]. In case of obstruction of these structures (as observed in choledocholithiasis, Mirizzi’s syndrome, neoplastic or flogistic papillary strictures, parasitic infection, cholangiocellular or pancreatic adenocarcinoma), liver biochemical abnormalities and jaundice, sometimes in association with fever or abdominal pain, usually appear[1].

Article in press: May 28, 2015

IMPACT OF EUS IN THE DIAGNOSTIC WORK UP OF CBD DILATATION

Peer-review started: August 28, 2014

Core tip: Common bile duct dilatation, often without identified causes, in subjects with normal liver function tests and nonspecific abdominal symptoms, and absence of lesions on prior noninvasive imaging tests, is increasingly found in the clinical practice. Since the clinical suspicion for biliary pathology in that setting is usually low, and there are limited literature data, this condition is ignored. However, recent evidences show the existence of pathologies among these patients, often with a non-benign course. In this scenario, endoscopic ultrasound may have a role in the identification of the etiology of dilatation.

Abstract

The authors thank Sharmila Fagoonee (Institute for Biostructures and Bioimages CNR c/o Molecular Biotechnology Center, University of Turin, Turin, Italy) for English revision of the manuscript.

In an abstract published in 2009, based on a retrospective study, 30 patients with biliary dilatation and no evident causes on prior imaging underwent EUS[43]. Four patients had normal biliary system on EUS, 15 patients presented a dilatation of unknown etiology while pathology accounting for CBD dilatation was demonstrated in 11 of them (choledocholithiasis, ampullary adenoma, chronic pancreatitis or cholangiocarcinoma). Similarly to other studies, prevalence of abnormal findings during EUS examination was different between the patients with abnormal and those with normal liver chemistry tests (55% and 33% respectively). Conversely, the number of pathological findings in the latter group differed from percentages reported by other authors[2,3], probably because no details were specified in this study, about clinical presentation and previously used imaging techniques. Notably, none of the patients with unexplained CBD dilatation on EUS was found to have causative lesions after a mean follow-up of 16 mo.