Review
doi: 10.1259/bjr/60619911.Evaluation of gallbladder and biliary duct disease using microbubble contrast-enhanced ultrasound
Affiliations
- PMID:20603412
- PMCID: PMC3473688
- DOI: 10.1259/bjr/60619911
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Review
Evaluation of gallbladder and biliary duct disease using microbubble contrast-enhanced ultrasound
L M Meacock et al. Br J Radiol.2010 Jul.
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Abstract
Ultrasound examination of the gallbladder is accepted as the primary imaging modality in the assessment of gallbladder disease, with inherent superiority in comparison to other imaging modalities. Contrast-enhanced ultrasound is established as a reliable tool in the detection and characterisation of focal liver lesions. It is less well recognised in gallbladder and biliary disease but can be a valuable complement to baseline ultrasound examination. Contrast-enhanced ultrasound provides the advantages of real-time, repeatable, multiplanar imaging without compromising patient safety or exposing patients to radiation. It can provide specific information as pathology often becomes more conspicuous following the administration of contrast, allowing detailed assessment of benign and malignant conditions arising in the gallbladder and biliary tree. This review illustrates the application of contrast-enhanced ultrasound in the evaluation of a variety of gallbladder and biliary duct diseases. The examination allows clearer delineation of the disease process and more confident diagnosis.
Figures
Biliary sludge. (a) Baseline US image depicts echogenic material within the gallbladder (arrow). This does not exhibit movement on change in patient posture. (b) Colour Doppler US demonstrates no noticeable vascularity. (c) Late arterial-phase CEUS obtained 30 s after administration of microbubble contrast demonstrates that there is no enhancement of the echogenic material,i.e. the contents of the gallbladder remain dark, indicating that it is non-vascular and simply represents adherent biliary sludge. The gallbladder wall enhances (arrow) and is seen separately from the lesion, confirming no mural abnormality.
Acute cholecystitis. (a) (i) Baseline longitudinal US of a 37-year-old female depicts a moderately distended gallbladder, hazy delineation of the thickened (>3 mm) gallbladder wall (small arrow) and echogenic debris within the gallbladder (large arrow). (ii) CEUS 30 s after administration of microbubble contrast depicts an initially hypervascular gallbladder wall. There is improved delineation of pericholecystic fluid (arrow). Note the lack of enhancement of the echogenic sludge within the gallbladder. (iii) CEUS at 86 s. In the late phase, the gallbladder wall shows less enhancement and is hypovascular (between arrowheads) relative to the adjacent liver parenchyma. This enables more accurate measurement of wall thickness. (b) (i) Axial baseline US image of a 30-year-old female with acute cholecystitis; thickening of the gallbladder wall (short arrow) and gallstones are present (long arrow). (ii) CEUS at 80 s shows the differential enhancement of the gallbladder wall (short arrows), allowing accurate assessment of mural thickness. Note the lack of enhancement of biliary sludge and the clear demarcation of the solitary calculus (long arrow).
Adenomyomatosis. (a) Longitudinal baseline US shows segmental mural thickening in a 37-year-old asymptomatic male patient in keeping with a diagnosis of adenomyomatosis. (b) CEUS 23 s after administration of microbubble contrast demonstrates enhancement of the thickened gallbladder wall with anechoic diverticula (arrows).
Gallbladder polyps. (a) Longitudinal baseline US in a 58-year-old male depicts several echogenic lesions arising from the gallbladder wall (arrows). (b) CEUS image at 45 s after administration of microbubble contrast demonstrates vascularity of the lesions (arrows) and a normal adjacent gallbladder wall.
Adenocarcinoma of the gallbladder. (a) Baseline longitudinal US in a 68-year-old woman presenting with pain, depicting gross gallbladder fundus mural thickening contiguous with an intraluminal soft-tissue mass (long arrows). The neck of the gallbladder is normal (short arrow). This may be a florid example of cholecystitis with biliary sludge, but adenocarcinoma of the gallbladder is a possibility. (b) CEUS at 28 s after administration of microbubble contrast demonstrates vascularity of the thickened gallbladder wall with a smooth interface with the liver surface (short arrows). There is a gallbladder lumen (long arrow). (c) Axial contrast-enhanced CT at the level of the gallbladder fossa shows circumferential gallbladder mural thickening without hepatic invasion (short arrows); histology confirmed adenocarcinoma of the gallbladder without infiltration of the liver.
Adenocarcinoma of the gallbladder. (a) Baseline US in a 57-year-old man presenting with obstructive jaundice depicts a soft-tissue mass in an ill-defined gallbladder (long arrow) and evidence of bile duct dilatation (short arrows). (b) CEUS image obtained 90 s after administration of microbubble contrast demonstrates a hypovascular mass centred on the gallbladder fossa, with invasion into the hepatic parenchyma (arrows). The late-phase hypovascularity suggests malignancy and differs from the persistent enhancement in cholecystitis. (c) Axial contrast-enhanced CT at the level of the gallbladder fossa demonstrates a mass with invasion into the adjacent liver parenchyma (arrows), appearances that correlate well with those seen at CEUS.
Biliary duct dilatation. (a) The common hepatic duct is dilated (long arrow) in this 28-year-old female following recent passage of a biliary calculus. Enhancement is seen in the hepatic artery adjacent to the duct (arrowhead). In addition, inflammatory changes in the gallbladder wall are evident (short arrow). (b) Intrahepatic duct dilatation secondary to carcinoma of the head of the pancreas in a 78-year-old male. The portal vein demonstrates enhancement (arrow) with the surrounding dilated bile ducts demonstrating no enhancement. (c) Focal biliary dilatation (arrows) in the graft liver following liver transplantation in a 52-year-old male with an occluded hepatic artery. Ischaemic changes in the bile ducts are probably responsible for this appearance.
Biliary inflammatory disease. (a) Infective cholangitis in a 35-year-old male patient. On the dual-mode image on the right, the greyscale appearance is of increased echogenicity around the bile ducts. More evident areas of bile duct dilatation, probably small communicating biliary abscesses, are visualised following the administration of microbubble contrast (arrow). (b) (i) On the baseline image from this 72-year-old female patient, multiple highly reflective focal lesions are identified in the right lobe of the liver (arrows). (ii) CEUS at 27 s after microbubble contrast administration demonstrates low-reflective focal lesions with septations (arrows), inkeeping with the formation of biliary hepatic abscesses.
Biliary hamartomas. (a) Baseline US examination in an 81-year-old male presenting with liver lesions identified by CT prior to a hemi-colectomy for a bowel malignancy. A number of low-reflective well-circumscribed lesions are visible (arrows). (b) The lesions become more conspicuous (arrows) in the late-phase following microbubble contrast administration (after 90 s). The lesions are indistinguishable from metastatic liver disease but biliary hamartomas were confirmed by biopsy and histology. (c) Contrast-enhanced CT at the level of the coeliac axis confirms multiple low-attenuation lesions throughout the right lobe of the liver (arrows).
Biliary cystadenoma. (a) Transverse US image of the liver of a 64-year-old female patient with a biliary cystadenoma shows a well-defined structure (arrow) demonstrating posterior acoustic enhancement and containing complex internal echoes. (b) CEUS at 30 s after the administration of microbubble contrast demonstrates enhancement of the rim component and a lack of enhancement centrally within the lesion, confirming its cystic nature. (c)T1 coronal MR imaging sequence depicts a high-signal lesion within segment 4 of the liver (arrow) indicative of a cyst with potential mucinous or colloid matrix.
Cholangiocarcinoma. (a) Baseline US illustrates an ill-defined echogenic heterogeneous mass at the porta hepatis (short arrows) with proximal dilatation of the intrahepatic bile ducts (long arrow). (b) CEUS at 20 s after microbubble contrast administration demonstrates peripheral irregular rim-like enhancement (arrows). (c) CEUS at 87 s after microbubble contrast administration demonstrates absence of enhancement within the tumour (arrow). (d) A metallic stent has been placed in the common bile duct for palliative reasons but is not functioning adequately. The CEUS image at 110 s demonstrates evidence of tumour invasion into the biliary stent (arrow).
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