Ultrasonography of the hepatobiliary tract

HUAuthorsUH
HUUmaprasanna S Karnam,
MD UH
HUJ onathan B Kruskal, MD,
PhD UH
HUK Rajender Reddy, MD UH
HUSection EditorUH
HUSanjiv Chopra, MD UH
HUDeputy EditorUH
HUAnne C Travis, MD, MSc UH

Last literature review version 17.3: September 2009 | This topic last updated: J uly 29,
2009 HU(More)UH
INTRODUCTION Ultrasound is the least invasive radiologic modality for imaging the
liver and biliary tract. Unlike 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 [ HU1UH] .
TECHNIQUE Ultrasound relies upon the transmission of targeted sound waves of
varying selected frequencies though 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 [ HU1UH] .
Gallbladder wall measurements on ultrasound 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.
Common hepatic duct (inner wall to inner wall) is usually measured at the level of hepatic
artery. In the normal fasting state it should be <7 mm in patients <60 years, and <10 mm in
patients older than 60.
The CBD is commonly up to 10 mm in patients who have undergone a cholecystectomy.
Color flow Doppler ultrasound Vessel patency and flow direction can be determined
by assigning color flow properties to the ultrasound image. The transducer detects moving
blood which is arbitrarily assigned a red or blue color depending upon whether flow is
towards or away from the transducer, respectively. Much variation exists in flow velocities,
which are further influenced by fasting or eating. The range of normal velocities in the
hepatic artery and portal veins is 30 to 60 cm/second and 20 to 30 cm/second, respectively
[ HU2UH] .
Color flow is an important tool in evaluating the vascular supply of hepatic masses,
although no sensitive or specific flow features have been described that allow the lesions to
be differentiated [ HU3-5UH] . Most hepatocellular carcinomas have internal vascularity which
can be detected by color flow Doppler, although a number of metastatic lesions also ha
internal vascularity, limiting the usefulness of this technique for distinguishing between
ve
these two entities [ HU5UH] .
Color flow Doppler imaging primarily is used in the following circumstances:
It is very accurate when evaluating tumor-induced occlusion of major hepatic
vessels, and is quite sensitive for documenting the direction of flow within the
vessel being interrogated [ HU3-5UH] . This is particularly useful in planning surgery for
patients with cirrhosis in whom flow direction may be reversed in the main portal
vein.
It is routinely used to evaluate patients prior to liver transplantation since portal vein
patency is an important technical issue for the transplant surgeon.
Color flow is used to document the flow direction and patency of surgically created
portosystemic shunts.
Color flow is frequently used to demonstrate lack of flow in dilated intrahepatic
ducts, thereby distinguishing dilated ducts from adjacent intrahepatic vessels.
Duplex Doppler ultrasonography Duplex Doppler ultrasound converts an audible
signal reflected from a selected region of interest on the ultrasound image into a continuous
waveform which includes data concerning frequency, amplitude, and flow direction [ HU6,7UH] .
Thus, flow rate can be accurately measured, the characteristics of flow demonstrated, and
flow direction determined. These features may be important in the following circumstances:
Flow rate is particularly important in the follow-up of patients following a
transjugular intrahepatic portosystemic shunt (TIPS) insertion ( HUsee "Follow-up of
TIPS" belowUH) [ HU8,9UH] .
Flow characteristics, such as increased resistance to flow in rejecting livers (with
peaking of the systolic wave and lack of antegrade diastolic flow), or characteristic
waveforms associated with hepatic artery stenosis (the Tardus-Parvus pattern), are
used to evaluate the newly transplanted liver.
The duplex to-and-fro waveform has a characteristic diagnostic pattern in
suspected arteriovenous fistulae following liver biopsies.
Vascular indices and ratios Attempts have been made to document different vascular
indices and ratios for differentiating various hepatic lesions, including hepatic metastases,
hemangiomas, and hepatocellular carcinoma [ HU6,7UH] . These flow indices are not widely
available at present, and are currently used in experimental settings only.
The Doppler perfusion index (DPI) is the ratio of hepatic arterial to total liver blood
flow. DPI is elevated in the presence of intrahepatic tumors, and may therefore be
useful in screening patients with suspected metastases. DPI is also increased in
patients with cirrhosis, probably due to elevation of portal pressure and augmented
hepatic arterial flow; this limits its diagnostic potential in evaluating mass lesions in
patients with cirrhosis.
The portal vein congestive index (PVCI) is the ratio of cross sectional area of the
portal vein to time averaged velocity of blood flow in the portal vein. The PVCI is
higher in cirrhotic livers when compared to livers containing metastases. These
findings have been explained by data from animal studies in which there has been
an increased hepatic artery flow and decreased portal vein flow in the presence of
liver metastases.
Tumor peak systolic velocity (TPSV) is another criteria used to characterize hepatic
lesions. For lesions larger than 2 cm, a tumoral peak systolic velocity of >0.4
cm/sec has a moderate sensitivity and specificity in distinguishing malignant tumors
from hemangiomas. However, the TPSV is not helpful in distinguishing
hepatocellular carcinoma from metastases.
The hepatic tumor index (HTI) is the ratio of tumoral peak systolic velocity to peak
systolic velocity in the right or left hepatic artery. The HTI has potential use in
determining the nature of a liver mass. The HTI of masses >1 cm has a moderate
sensitivity and specificity distinguishing hepatocellular carcinoma from metastatic
lesions and hemangiomas. When both TPSV and HTI are used in combination
(TPSV >0.4 cm/sec and HTI >1.0), there is a high sensitivity (91 percent) and
specificity (83 percent) for distinguishing hepatocellular carcinomas from metastatic
lesions and hemangiomas [ HU6UH] .
CLINICAL USE Ultrasound is very sensitive for differentiating cystic from solid lesions,
and for delineating septations within cystic lesions such as biliary cystadenomas.
Ultrasound will identify solid lesions, but the imaging characteristics are usually nonspecific,
requiring careful clinical or biochemical correlation, additional imaging studies, or biopsy.
Certain lesions, such as hemangiomas, have a characteristic sonographic appearance and
require no additional imaging when identified. Similarly, focal fatty infiltration or sparing is
easily identified on ultrasound [ HU1UH] .
This section will briefly describe some of the major clinical uses of ultrasound in patients
with suspected hepatobiliary disease. The use of ultrasound and other imaging studies in
the individual disorders is discussed in detail on the appropriate topic reviews.
Evaluation of right upper quadrant pain Ultrasound is the diagnostic procedure of
choice for imaging the hepatobiliary system in patients who present with acute right upper
quadrant pain [ HU10UH] . The sensitivity of ultrasound for detecting gallstones is >95 percent (
HUshow radiograph 1UH), and other adjacent structures can be simultaneously evaluated [ HU11UH] .
Ultrasound may also identify gallbladder wall thickening and localized tenderness over the
gallbladder (Murphy's sign), findings which are consistent with the presence of acute
cholecystitis ( HUshow radiograph 2

UH) [ HU12UH] . ( HUSee "Clinical features and diagnosis of acute
cholecystitis"UH). CT scanning is not as accurate for detecting gallbladder wall abnormalities
or gallstones; cholesterol stones can have the same density as bile [ HU13UH] .
Ultrasound has similar sensitivity to CT for detecting choledocholithiasis (75 percent in the
presence of dilated ducts, 50 percent for nondilated ducts); gas in the duodenum can
obscure visualization of the distal common bile duct [ HU14UH] . Cholangiography or magnetic
resonance cholangiopancreatography (MRCP) may be preferred in these circumstances. (
HUSee "Magnetic resonance cholangiopancreatography"UH).
Evaluation of obstructive jaundice The sensitivity of ultrasound for the detection of
dilated bile ducts and biliary obstruction ranges in various studies from 55 to 91 percent [
HU15-18UH] . The sensitivity increases with the serum bilirubin concentration and the duration of
jaundice [ HU19UH] .
Screening for hepatocellular carcinoma Ultrasound has been used for screening
patients with cirrhosis at three- to six-month intervals for the presence of hepatocellular
carcinoma. In a study of 164 patients with cirrhosis, for example, ultrasound identified
hepatocellular carcinoma in 26 of 34 cases (76 percent) while the lesion was still single and
small (<4 cm) [ HU20UH] . However, all imaging modalities remain insensitive for detecting small
hepatomas in a cirrhotic liver since tumors may be infiltrative and not differ from
surrounding abnormal parenchyma, and are indistinguishable from regenerative nodules. (
HUSee "Clinical features and diagnosis of primary hepatocellular carcinoma"UH).
Evaluation before and after liver transplantation As mentioned above,
ultrasonography provides important information regarding the patency and size of the portal
vein. It can also detect spontaneous or surgically created portosystemic shunts, which
could affect the outcome of the transplant.
Doppler ultrasonography is an accurate, noninvasive modality to screen for vascular
complications after orthotopic liver transplant. Hepatic artery thrombosis should be
considered in patients with fulminant hepatic necrosis after liver transplantation and those
with bile collections and recurrent bacteremia. Impending hepatic artery thrombosis can
also be predicted based upon the Doppler wave form [ HU21UH] .
Follow-up of TIPS TIPS is a percutaneously placed intrahepatic shunt between the
hepatic and portal veins designed to decompress the portal system. The shunt is being
increasingly used for management of bleeding varices and intractable ascites. ( HUSee
"Treatment of active variceal hemorrhage"UH and HUsee "Treatment of diuretic-resistant ascites
in patients with cirrhosis"UH). Ultrasound is the modality of choice for evaluating shunt
patency following TIPS insertion [ HU8,9UH] .
Doppler ultrasonography is very sensitive and specific for measuring blood flow velocity
within the stent and for predicting stent stenosis; it is the procedure of choice for follow-up
and surveillance for complications associated with TIPS. ( HUSee "Complications of
transjugular intrahepatic portosystemic shunts"UH). Sonographic criteria for stent stenosis
include [ HU8,9UH] :
Low velocity flow (<60 cm/sec) within any portion of the stent
Low flow velocity with a focal velocity increase, usually identified at the hepatic
venous end of the stent
Flow gradient increases greater than 100 percent from portal to hepatic venous
ends
A temporal change in peak flow velocity of >50 cm/sec from the post TIPS baseline
sonogram
Identification of new hepatopedal flow in the left portal vein or a newly recanalized
periumbilical vein are indirect evidence for stent malfunction since left portal venous
flow usually reverses towards the stent
In one report, nearly all complications of TIPS were detected by using three criteria: no flow
for thrombosis; a temporal change in peak stent velocity greater than 50 cm/sec for stent
and/or hepatic vein stenosis; and reversal of flow from hepatofugal to pedal in the
contralateral non-stented portal vein for hepatic vein and stent stenosis [ HU8UH] .
However, the previously reported high sensitivity and specificity of duplex Doppler
ultrasonography was recently questioned in a prospective double-blind study of 38 patients
who had undergone TIPS [ HU22UH] . In this report, ultrasonography correctly predicted shunt
occlusion or stenosis in only 11 of 31 cases, incorrectly suggesting patency in 21 instances.
Compared with venography, ultrasonography had a sensitivity and specificity for predicting
TIPS stenosis or occlusion of 35 and 83 percent, respectively.
Liver tumor staging and treatment Assessment of portal vein patency is important for
staging patients with hepatocellular carcinoma [ HU23UH] . Doppler ultrasound is a sensitive
technique for distinguishing between tumor-induced thrombus occluding a portal or hepatic
vein and tumor thrombus invading a vein. The neovascularity of tumor thrombus is
detectable as an arterial signal within the thrombus; ultrasound can also be used to guide
biopsy of these thrombi, if indicated [ HU23UH] .
Ultrasound is used to identify and localize tumors to specific liver segments, facilitating
surgical planning if resection is being considered. Similarly, the size, number, and exact
location of liver tumors is easily determined with ultrasound. Extracapsular spread of tumor,
or diaphragmatic invasion also are well evaluated by ultrasound. The sensitivity of
ultrasound for detecting metastatic disease to the liver is similar to CT scanning, around 85
percent [ HU24UH] .
Biopsy of hepatic lesions can be performed under ultrasound guidance. In addition, in some
centers, ultrasound-guided cryo or radiofrequency ablation of tumors is now being
performed; use is expected to increase.
Diagnosis of ascites Ultrasound easily detects ascitic fluid in the peritoneal cavity and
is commonly used for guiding paracentesis. Unlike CT and MRI, ultrasound provides useful
additional information concerning the nature of the fluid, such as the presence of
septations, loculations, hematoma, and peristalsing loops of bowel. Bedside guidance can
be provided for the sick patient unable to come to the radiology department since
ultrasound is mobile. No imaging technology can differentiate between a transudate or
exudate. ( HUSee "Initial therapy of ascites in patients with cirrhosis"UH).
Intraoperative and laparoscopic ultrasound Intraoperative ultrasound of the liver is a
versatile adjunct to surgical inspection and palpation; it is being used with increased
frequency to identify small (2 to 5 mm) metastases in patients undergoing segmental liver
resections [ HU23UH] . Specially developed ultrasound probes are used on standard diagnostic
ultrasound machines. The technique is more sensitive than CT, MRI, and regular
ultrasound, routinely detecting unexpected tumors in approximately 5 percent of patients. In
clinical series, the surgical procedure is modified in 51 percent of patients based upon
intraoperative ultrasound findings alone [ HU23UH] .
Diagnostic laparoscopic ultrasound has extended the role of standard staging laparoscopy
by being able to detect small peritoneal and hepatic lesions easily missed by other staging
methods [ HU25UH] . It is particularly well suited for imaging the biliary system. The technique is
not widely performed; it requires separate insertion sites to evaluate the left and right lobes
of the liver unless the falciform ligament is resected. A complete scan of the liver is
performed to exclude small lesions using small (<1 cm) flexible transducers incorporated
into the tip of a fiberoptic endoscope; biopsy guidance can also be provided if necessary.
The porta hepatis is easily imaged to identify enlarged nodes for staging purposes.
Contrast agents Ultrasound contrast agents modify the basic physical interactions
between ultrasound waves and body tissues and amplify the signal produced by flowing
blood. These agents may be useful for detecting subtle flow abnormalities and for
distinguishing areas of abnormal flow relative to normal background parenchymal
perfusion. As a result, they may improve the detection of neoplasms, tumor vascularity,
vascular stenosis and focal liver lesions [ HU26-30UH] .
Three contrast phases can be differentiated due to the specific blood supply of the liver:
The arterial phase (hepatic artery) starts 10 to 20 seconds after intravenous
injection and lasts for 10 to 15 seconds
The venous phase (portal vein) extends from 30 to 35 seconds and lasts up to 120
seconds
The late phase starts at 120 seconds and lasts up to five minutes post-injection with
the disappearance of bubbles
Several agents have been developed to enhance sonographic differences between tissues
and to improve the characterization of vascular flow of liver lesions.
Carbon dioxide microbubbles injected into the hepatic artery of patients with small
(<3 cm) hepatocellular carcinomas enhance most tumors, with a greater sensitivity
for hypervascular lesions than conventional ultrasonography, angiography, or CT [
HU31UH] . One commercially available contrast agent (Levovist, Schering, AG, Berlin)
consists of microbubbles adsorbed onto galactose particles and palmitic acid.
Delayed post vascular scanning with Levovist has shown promise in detecting liver
lesions (especially malignancy) [ HU32,33UH] . Levovist is available in more than 60
countries, but is currently unavailable in the United States.
Perfluorochemicals are promising compounds with a high sonographic density and
compressibility, which allows them to act as highly reflective ultrasound contrast
agents [ HU26UH] . They are normally phagocytosed by the reticuloendothelial system
and remain in the spleen and liver for a least two days, resulting in a rim-like region
of increased echogenicity around tumors. A preliminary clinical trial demonstrated
that a large quantity of these compounds was needed to produce adequate tumor
enhancement, and that they may cause allergic reactions and transient elevation of
liver enzymes. This presents a potential problem for their future clinical use.
Additional agents now in clinical trials rely upon the targeted sound wave to disrupt small
contrast-containing vesicles, thereby enhancing the signal produced by flowing blood.
Additional imaging techniques that are contrast-specific (eg, harmonic and pulse-inversion
imaging) are also in development.
Patterns seen with common hepatic lesions include the following:
Hemangiomas have a peripheral globular contrast pooling in the early phase (a
cotton wool appearance), with the globules becoming larger and more numerous
(centripetal fill-in).
Focal nodular hyperplasia has a centrifugal stellate branching in early arterial phase
followed by an intense homogenous uptake (spoke wheel pattern). Rapid washout
occurs thereafter and an iso- or hyperechoic lesion is seen in portal venous phase.
Hepatocellular carcinoma shows strong enhancement during the arterial phase and
one or more feeding arteries can be seen entering the lesions periphery. Intense
global pooling in late arterial phase is followed by a rapid washout in the portal
venous phase.
The accuracy of contrast enhanced ultrasonography compared with other imaging
modalities is incompletely understood, although it appears to improve sensitivity and
specificity compared with standard ultrasonography in patients with a variety of liver lesions
[ HU34,35UH] , and certain sonographic characteristics appear to correlate well with specific
tumor types [ HU36UH] . In a prospective study of 67 patients with a focal liver lesion that was
confirmed to be benign or malignant based upon other imaging studies and/or histology,
the sensitivity and specificity of contrast enhanced ultrasonography for discrimination of
benign versus malignant lesions was 100 and 63 percent, respectively [ HU35UH] . These values
were better than for standard ultrasonography (sensitivity 85 percent and specificity 30
percent). Sensitivity improved from 94 to 98 percent and specificity improved from 60 to 88
percent in another study comparing contrast enhanced with standard ultrasonography for
detection of hepatic metastases [ HU37UH] . Contrast US detects more liver metastases than
conventional US [ HU38,39UH] . It is especially useful to detect small (<1 cm) lesions, lesions in
the subcapsular or ventral locations, or those around the ligamentum teres. Findings
appeared to be complementary to CT and MRI since one imaging modality or another
appeared to better characterize lesions in individual patients. Contrast enhanced
ultrasonography had good concordance with MRI in diagnosis of hepatic hemangiomas in
another report [ HU40UH] .
The utility of contrast US is markedly reduced in patients with severe steatosis or deep
seated lesions. In those with multiple liver lesions, arterial and early portal phases cannot
be investigated simultaneously.
Noninvasive assessment of hepatic fibrosis and portal hypertension by transient
elastography is an exciting newer application of ultrasound that needs to be explored
further before widespread use [ HU41UH] .

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