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Ultrasonography of the hepatobiliary tract

INTRODUCTION

Ultrasound is the least invasive radiologic modality for imaging the liver and biliary tract. Unlike computed tomographic (CT) scanning and magnetic resonance imaging (MRI), the technique is portable, quick, and can be used to guide interventional procedures. Ultrasound uses no ionizing radiation to create the image, and is therefore the technique of choice in pregnant women, in patients with contrast allergies, or in those in whom MRI is contraindicated [1].

This topic will discuss the role of ultrasound in the evaluation of the liver and the intra- and extrahepatic bile ducts. Contrast-enhanced ultrasound and the use of ultrasound for the evaluation of the gallbladder are discussed briefly here and in more detail separately. (See "Acute cholecystitis: Pathogenesis, clinical features, and diagnosis", section on 'Ultrasonography' and "Uncomplicated gallstone disease in adults", section on 'Transabdominal ultrasound' and "Gallbladder cancer: Epidemiology, risk factors, clinical features, and diagnosis", section on 'Ultrasound' and "Gallbladder polyps and cholesterolosis", section on 'Ultrasonography' and "Contrast-enhanced ultrasound for the evaluation of liver lesions".)

TECHNIQUE

Ultrasound relies upon the transmission of targeted sound waves of varying selected frequencies through tissues, with subsequent computerized conversion of the signals from the reflected waves into anatomical images on a screen. The degree of reflection of sound waves depends upon the interface between tissues with different acoustic properties. The degree of echogenicity depends upon the ability of the tissue being evaluated to reflect or absorb the ultrasound waves. A fatty liver will attenuate the ultrasound beam somewhat, limiting full evaluation of the liver parenchyma. Similarly, waves are not transmitted through air; liver lying below interposed loops of bowel therefore will be poorly visualized [1].

Normal measurements on ultrasound — Measurements of components of the hepatobiliary tree depend upon the skill of the ultrasonographer obtaining the measurements, and there is variability in terms of what is considered "normal." However, some general estimates are available regarding the expected sizes of structures in the hepatobiliary tree:

Gallbladder: The gallbladder wall should be less than or equal to 2 mm (in a distended or fasting gallbladder). Collapsed gallbladders, seen when the subject has eaten, typically appear thickened. The maximum dimension of the gallbladder is 5 X 10 cm.

               

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Literature review current through: Aug 2014. | This topic last updated: Aug 5, 2014.
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References
Top
  1. Bennett WF, Bova JG. Review of hepatic imaging and a problem-oriented approach to liver masses. Hepatology 1990; 12:761.
  2. Bowie JD. What is the upper limit of normal for the common bile duct on ultrasound: how much do you want it to be? Am J Gastroenterol 2000; 95:897.
  3. Perret RS, Sloop GD, Borne JA. Common bile duct measurements in an elderly population. J Ultrasound Med 2000; 19:727.
  4. Wu CC, Ho YH, Chen CY. Effect of aging on common bile duct diameter: a real-time ultrasonographic study. J Clin Ultrasound 1984; 12:473.
  5. Kaim A, Steinke K, Frank M, et al. Diameter of the common bile duct in the elderly patient: measurement by ultrasound. Eur Radiol 1998; 8:1413.
  6. Bachar GN, Cohen M, Belenky A, et al. Effect of aging on the adult extrahepatic bile duct: a sonographic study. J Ultrasound Med 2003; 22:879.
  7. Kratzer W, Fritz V, Mason RA, et al. Factors affecting liver size: a sonographic survey of 2080 subjects. J Ultrasound Med 2003; 22:1155.
  8. Kruskal JB, Newman PA, Sammons LG, Kane RA. Optimizing Doppler and color flow US: application to hepatic sonography. Radiographics 2004; 24:657.
  9. Reinhold C, Hammers L, Taylor CR, et al. Characterization of focal hepatic lesions with duplex sonography: findings in 198 patients. AJR Am J Roentgenol 1995; 164:1131.
  10. Tanaka S, Kitamura T, Fujita M, et al. Color Doppler flow imaging of liver tumors. AJR Am J Roentgenol 1990; 154:509.
  11. Nino-Murcia M, Ralls PW, Jeffrey RB Jr, Johnson M. Color flow Doppler characterization of focal hepatic lesions. AJR Am J Roentgenol 1992; 159:1195.
  12. Numata K, Tanaka K, Kiba T, et al. Use of hepatic tumor index on color Doppler sonography for differentiating large hepatic tumors. AJR Am J Roentgenol 1997; 168:991.
  13. Leen E, Angerson WJ, Wotherspoon H, et al. Comparison of the Doppler perfusion index and intraoperative ultrasonography in diagnosing colorectal liver metastases. Evaluation with postoperative follow-up results. Ann Surg 1994; 220:663.
  14. Dodd GD 3rd, Zajko AB, Orons PD, et al. Detection of transjugular intrahepatic portosystemic shunt dysfunction: value of duplex Doppler sonography. AJR Am J Roentgenol 1995; 164:1119.
  15. Foshager MC, Ferral H, Nazarian GK, et al. Duplex sonography after transjugular intrahepatic portosystemic shunts (TIPS): normal hemodynamic findings and efficacy in predicting shunt patency and stenosis. AJR Am J Roentgenol 1995; 165:1.
  16. Sherman SC, Tran H. Pneumobilia: benign or life-threatening. J Emerg Med 2006; 30:147.
  17. Weltman DI, Zeman RK. Acute diseases of the gallbladder and biliary ducts. Radiol Clin North Am 1994; 32:933.
  18. Cooperberg PL, Gibney RG. Imaging of the gallbladder, 1987. Radiology 1987; 163:605.
  19. Simeone JF, Brink JA, Mueller PR, et al. The sonographic diagnosis of acute gangrenous cholecystitis: importance of the Murphy sign. AJR Am J Roentgenol 1989; 152:289.
  20. Brink JA, Kammer B, Mueller PR, et al. Prediction of gallstone composition: synthesis of CT and radiographic features in vitro. Radiology 1994; 190:69.
  21. Laing FC, Jeffrey RB, Wing VW. Improved visualization of choledocholithiasis by sonography. AJR Am J Roentgenol 1984; 143:949.
  22. Pedersen OM, Nordgård K, Kvinnsland S. Value of sonography in obstructive jaundice. Limitations of bile duct caliber as an index of obstruction. Scand J Gastroenterol 1987; 22:975.
  23. Pasanen PA, Partanen KP, Pikkarainen PH, et al. A comparison of ultrasound, computed tomography and endoscopic retrograde cholangiopancreatography in the differential diagnosis of benign and malignant jaundice and cholestasis. Eur J Surg 1993; 159:23.
  24. Lapis JL, Orlando RC, Mittelstaedt CA, Staab EV. Ultrasonography in the diagnosis of obstructive jaundice. Ann Intern Med 1978; 89:61.
  25. Salem S, Vas W. Ultrasonography in evaluation of the jaundiced patient. J Can Assoc Radiol 1981; 32:30.
  26. Gold RP, Casarella WJ, Stern G, Seaman WB. Transhepatic cholangiography: the radiological method of choice in suspected obstructive jaundice. Radiology 1979; 133:39.
  27. Zoli M, Magalotti D, Bianchi G, et al. Efficacy of a surveillance program for early detection of hepatocellular carcinoma. Cancer 1996; 78:977.
  28. Nolten A, Sproat IA. Hepatic artery thrombosis after liver transplantation: temporal accuracy of diagnosis with duplex US and the syndrome of impending thrombosis. Radiology 1996; 198:553.
  29. Owens CA, Bartolone C, Warner DL, et al. The inaccuracy of duplex ultrasonography in predicting patency of transjugular intrahepatic portosystemic shunts. Gastroenterology 1998; 114:975.
  30. Kruskal JB, Kane RA. Intraoperative ultrasonography of the liver. Crit Rev Diagn Imaging 1995; 36:175.
  31. Clarke MP, Kane RA, Steele G Jr, et al. Prospective comparison of preoperative imaging and intraoperative ultrasonography in the detection of liver tumors. Surgery 1989; 106:849.
  32. Wood MM, Romine LE, Lee YK, et al. Spectral Doppler signature waveforms in ultrasonography: a review of normal and abnormal waveforms. Ultrasound Q 2010; 26:83.
  33. John TG, Garden OJ. Laparoscopic ultrasonography: extending the scope of diagnostic laparoscopy. Br J Surg 1994; 81:5.
  34. Goldberg BB, Liu JB, Forsberg F. Ultrasound contrast agents: a review. Ultrasound Med Biol 1994; 20:319.
  35. Balen FG, Allen CM, Lees WR. Ultrasound contrast agents. Clin Radiol 1994; 49:77.
  36. Bartolotta TV, Midiri M, Quaia E, et al. Benign focal liver lesions: spectrum of findings on SonoVue-enhanced pulse-inversion ultrasonography. Eur Radiol 2005; 15:1643.
  37. Choi BI, Lee JY, Han JK, et al. Contrast-enhanced sonography for hepatocellular carcinoma. Intervirology 2004; 47:162.
  38. Nicolau C, Brú C. Focal liver lesions: evaluation with contrast-enhanced ultrasonography. Abdom Imaging 2004; 29:348.
  39. Numata K, Tanaka K, Kiba T, et al. Nonresectable hepatocellular carcinoma: improved percutaneous ethanol injection therapy guided by CO(2)-enhanced sonography. AJR Am J Roentgenol 2001; 177:789.
  40. Blomley MJ, Albrecht T, Wilson SR, et al. Improved detection of metastatic liver lesions using pulse inversion harmonic imaging with Levovist: A multicenter study. Radiology 1999; 213:491.
  41. Bertolotto M, Dalla Palma L, Quaia E, Locatelli M. Characterization of unifocal liver lesions with pulse inversion harmonic imaging after Levovist injection: preliminary results. Eur Radiol 2000; 10:1369.
  42. Leen E, Angerson WJ, Yarmenitis S, et al. Multi-centre clinical study evaluating the efficacy of SonoVue (BR1), a new ultrasound contrast agent in Doppler investigation of focal hepatic lesions. Eur J Radiol 2002; 41:200.
  43. von Herbay A, Vogt C, Häussinger D. Late-phase pulse-inversion sonography using the contrast agent levovist: differentiation between benign and malignant focal lesions of the liver. AJR Am J Roentgenol 2002; 179:1273.
  44. Albrecht T, Blomley MJ, Burns PN, et al. Improved detection of hepatic metastases with pulse-inversion US during the liver-specific phase of SHU 508A: multicenter study. Radiology 2003; 227:361.
  45. Dietrich CF, Kratzer W, Strobe D, et al. Assessment of metastatic liver disease in patients with primary extrahepatic tumors by contrast-enhanced sonography versus CT and MRI. World J Gastroenterol 2006; 12:1699.
  46. Konopke R, Kersting S, Bergert H, et al. Contrast-enhanced ultrasonography to detect liver metastases : a prospective trial to compare transcutaneous unenhanced and contrast-enhanced ultrasonography in patients undergoing laparotomy. Int J Colorectal Dis 2007; 22:201.
  47. Furuse J, Nagase M, Ishii H, Yoshino M. Contrast enhancement patterns of hepatic tumours during the vascular phase using coded harmonic imaging and Levovist to differentiate hepatocellular carcinoma from other focal lesions. Br J Radiol 2003; 76:385.
  48. Westwood M, Joore M, Grutters J, et al. Contrast-enhanced ultrasound using SonoVue® (sulphur hexafluoride microbubbles) compared with contrast-enhanced computed tomography and contrast-enhanced magnetic resonance imaging for the characterisation of focal liver lesions and detection of liver metastases: a systematic review and cost-effectiveness analysis. Health Technol Assess 2013; 17:1.
  49. Rockey DC. Noninvasive assessment of liver fibrosis and portal hypertension with transient elastography. Gastroenterology 2008; 134:8.