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Ultrasonography, traditionally done transabdominally and requiring a period of fasting, provides structural, but not functional, information. It is the least expensive, safest, and most sensitive technique for imaging the biliary system, especially the gallbladder. Ultrasonography is the procedure of choice for

• Screening for biliary tract abnormalities

• Evaluating the hepatobiliary tract in patients with right upper quadrant abdominal pain

• Differentiating intrahepatic from extrahepatic causes of jaundice

• Screening for liver masses

Abdominal Imaging (Gallstones)

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The kidneys, pancreas, and blood vessels are also often visible on hepatobiliary ultrasounds. Ultrasonography can measure spleen size and thus help diagnose splenomegaly, which suggests portal hypertension.

Ultrasonography can be difficult in patients with intestinal gas or obesity and is operator-dependent. Endoscopic ultrasonography may provide improved resolution to hepatobiliary abnormalities. Endoscopic ultrasonography incorporates an ultrasound transducer into the tip of an endoscope and thus provides greater image resolution even when intestinal gas is present.

Gallstones cast intense echoes with distal acoustic shadowing that move with gravity. Transabdominal ultrasonography is extremely accurate (sensitivity > 95%) for gallstones > 2 mm in diameter (1). Endoscopic ultrasonography can detect stones as small as 0.5 mm (microlithiasis) in the gallbladder or biliary system. Transabdominal and endoscopic ultrasonography can also identify biliary sludge (a mixture of particulate material and bile) as low-level echoes that layer in the dependent portion of the gallbladder without acoustic shadowing.

Cholecystitis findings typically include

• A thickened gallbladder wall (> 3 mm)

• Pericholecystic fluid

• An impacted stone in the gallbladder neck

• Tenderness when the gallbladder is palpated with the ultrasound probe (ultrasonographic Murphy sign)

Extrahepatic obstruction is indicated by dilated bile ducts. On transabdominal and endoscopic ultrasounds, bile ducts stand out as echo-free tubular structures. The diameter of the common duct is normally < 6 mm, increases slightly with age, and can reach 10 mm after cholecystectomy. Dilated ducts are virtually pathognomonic for extrahepatic obstruction in the appropriate clinical setting. Ultrasonography can miss early or intermittent obstruction that does not dilate the ducts. Transabdominal ultrasonography may not reveal the level or cause of biliary obstruction (eg, sensitivity for common duct stones can be as low as 40%) (2). Endoscopic ultrasonography has a better yield.

Focal liver lesions > 1 cm in diameter can usually be detected by transabdominal ultrasonography. In general, cysts are echo-free; solid lesions (eg, tumors, abscesses) tend to be echogenic. Carcinoma appears as a nonspecific solid mass. Ultrasonography has been used to screen for hepatocellular carcinoma in patients at high risk (eg, with chronic hepatitis B, cirrhosis, or hemochromatosis). Because ultrasonography can localize focal lesions, it can be used to guide aspiration and biopsy.

Diffuse disorders (eg, cirrhosis, fatty liver) can be detected with ultrasonography.

Ultrasound elastography can measure liver stiffness as an index of hepatic fibrosis. In this procedure, the transducer emits a vibration that induces an elastic shear wave. The rate at which the wave is propagated through the liver is measured; liver stiffness speeds this propagation. Elastography is often used in combination with blood tests to assess hepatic fibrosis, particularly in patients with chronic hepatitis C and nonalcoholic fatty liver disease.

This noninvasive method is used to assess direction of blood flow and patency of blood vessels around the liver, particularly the portal vein. Clinical uses include

• Detecting portal hypertension (eg, indicated by significant collateral flow and the direction of flow, increased diameter of the portal vein to >13 to 15 mm)

• Assessing the patency of liver shunts (eg, surgical portacaval, percutaneous transhepatic)

• Evaluating portal vein patency before liver transplantation and detecting hepatic artery thrombosis after transplantation

• Evaluating hepatic vein patency (Budd-Chiari syndrome)

• Detecting unusual vascular structures (eg, cavernous transformation of the portal vein)

• Assessing tumor vascularity before surgery

CT is commonly used to identify hepatic masses, particularly small metastases, with a specificity of ~ 80% (3). CT with IV contrast is accurate for diagnosing cavernous hemangiomas of the liver as well as differentiating them from other abdominal masses. Neither obesity nor intestinal gas obscures CT images. CT can detect hepatic steatosis and the increased hepatic density that occurs with iron overload. CT is less helpful than ultrasonography in identifying biliary obstruction but often provides the best assessment of the pancreas.

MRI is used to image blood vessels (without using contrast), ducts, and hepatic tissues. MRI is superior to CT and ultrasonography for diagnosing diffuse liver disorders (eg, fatty liver, hemochromatosis) and for clarifying focal defects (eg, liver tumors, hemangiomas). MRI also shows blood flow and therefore complements Doppler ultrasonography and CT angiography in the diagnosis of vascular abnormalities and in vascular mapping before liver transplantation.

Magnetic resonance cholangiopancreatography (MRCP) is more sensitive than CT or ultrasonography in diagnosing common bile duct abnormalities, particularly stones. Its images of the biliary system and pancreatic ducts are comparable to those obtained with endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography, which are more invasive. Thus, MRCP is a useful screening tool when biliary obstruction is suspected and before therapeutic ERCP (eg, for simultaneous imaging and stone removal) is done and has largely supplanted the use of HIDA (hydroxy or diisopropyl iminodiacetic acid) scans. MRCP is the screening test of choice for primary sclerosing cholangitis.

Abdominal Imaging (Normal MRCP)

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ERCP combines endoscopy through the second portion of the duodenum with contrast imaging of the biliary and pancreatic ducts. The papilla of Vater is cannulated through an endoscope placed in the descending duodenum, and the pancreatic and biliary ducts are then injected with a contrast agent.

Endoscopic Retrograde Cholangiopancreatography (ERCP)

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ERCP provides detailed images of much of the upper gastrointestinal tract and the periampullary area, biliary tract, and pancreas. ERCP can also be used to obtain tissue for biopsy. ERCP is the best test for diagnosis of ampullary cancers. ERCP is as accurate as endoscopic ultrasonography for diagnosis of common duct stones. Because it is invasive, ERCP is used more for treatment (including simultaneous diagnosis and treatment) than for diagnosis alone. ERCP is the procedure of choice for treating biliary and pancreatic obstructing lesions, and for

• Removal of bile duct stones

• Stenting of strictures (inflammatory or malignant)

• Sphincterotomy (eg, for papillary stenosis, also called sphincter of Oddi dysfunction)

Morbidity from a diagnostic ERCP with only injection of contrast material is about 1%. Adding sphincterotomy raises morbidity to 4 to 9% (mainly related to pancreatitis and bleeding). ERCP with manometry to measure sphincter of Oddi pressure causes pancreatitis in up to 25% of patients.

With fluoroscopic or ultrasound guidance, the liver is punctured with a needle, the peripheral intrahepatic bile duct system is cannulated above the common hepatic duct, and a contrast agent is injected.

PTC is highly accurate in diagnosing biliary disorders and can be therapeutic (eg, decompression of the biliary system, insertion of an endoprosthesis). However, ERCP is usually preferred because PTC causes more complications (eg, sepsis, bleeding, bile leaks).

A radiopaque contrast agent is directly injected during laparotomy to image the bile duct system.

Operative cholangiography is indicated when jaundice occurs and noninvasive procedures are equivocal, suggesting common duct stones. The procedure can be followed by common duct exploration for removal of biliary stones. Technical difficulties have limited its use, particularly during laparoscopic cholecystectomy.

With the increasing availability of MRCP, the usefulness of HIDA scan has decreased significantly. Cholescintigraphy is done after the patient fasts. An IV technetium-labeled iminodiacetic compound (eg, hydroxy or diisopropyl iminodiacetic acid [HIDA or DISIDA]) is injected; these substances are taken up by the liver and excreted in bile, then enter the gallbladder.

HIDA Scan

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In acute calculous cholecystitis, which is usually caused by impaction of a stone in the cystic duct, the gallbladder does not appear on a scintigraphic scan because the radionuclide cannot enter the gallbladder. Such nonvisualization is diagnostically quite accurate (except for false-positive results in some critically ill patients). However, cholescintigraphy is rarely needed clinically to diagnose acute cholecystitis.

If acalculous cholecystitis is suspected, the gallbladder is scanned before and after administration of cholecystokinin (used to initiate gallbladder contraction). The decrease in scintigraphic counts indicates the gallbladder ejection fraction. Reduced emptying, measured as the ejection fraction, suggests acalculous cholecystitis.

Cholescintigraphy also detects bile leaks (eg, after surgery or trauma) and anatomic abnormalities (eg, congenital choledochal cysts, choledochoenteric anastomoses). After cholecystectomy, cholescintigraphy can quantitate biliary flow; biliary flow helps identify papillary stenosis (sphincter of Oddi dysfunction).

However, in acute or chronic cholestatic hepatic disorders, cholescintigraphy is not accurate as a diagnostic test because, with cholestasis, hepatocytes excrete lower amounts of the radiotracer into the bile.

Ultrasonography and CT have largely supplanted radionuclide scanning, which had been used to diagnose diffuse liver disorders and mass lesions of the liver. Radionuclide scanning shows the distribution of an injected radioactive tracer, usually technetium (^99mTc sulfur colloid), which distributes uniformly within the normal liver. Space-occupying lesions > 4 cm, such as liver cysts, abscesses, metastases, and tumors, appear as defects. Diffuse liver disorders (eg, cirrhosis, hepatitis) decrease liver uptake of the tracer, with more appearing in the spleen and bone marrow. In hepatic vein obstruction (Budd-Chiari syndrome), liver uptake is decreased except in the caudate lobe because its drainage into the inferior vena cava is preserved.

Plain x-rays are not usually useful for diagnosis of hepatobiliary disorders. They are insensitive for gallstones unless the gallstones are calcified and large. Plain x-rays can detect a calcified (porcelain) gallbladder. Rarely, in gravely ill patients, x-rays show air in the biliary tree, which suggests emphysematous cholangitis.

1. 1. McIntosh DM, Penney HF: Gray-scale ultrasonography as a screening procedure in the detection of gallbladder disease. Radiology. 136(3):725-727, 1980. doi: 10.1148/radiology.136.3.7403554

2. 2. Gurusamy KS, Giljaca V, Takwoingi Y, et al: Ultrasound versus liver function tests for diagnosis of common bile duct stones. Cochrane Database Syst Rev2015(2):CD011548, 2015. doi: 10.1002/14651858.CD011548

3. 3. Freitas PS, Janicas C, Veiga J, et al: Imaging evaluation of the liver in oncology patients: A comparison of techniques. World J Hepatol 13(12):1936-1955, 2021. doi: 10.4254/wjh.v13.i12.1936