Bile Duct Hamartomas: US, CT and MR Findings in Eight Patients, Focusing on the US Findings

PURPOSE: To describe the US, CT and MR findings in eight patients with bile duct hamartomas. MATERIALS AND METHODS: Bile duct hamartomas were diagnosed in eight patients (5 men and 3 women; age range, 41-69 years; mean age, 56 years) by liver biopsy. The US, CT and MR findings were retrospectively reviewed. RESULTS: Ultrasonographically, the bile duct hamartomas presented diffuse inhomogeneous and coarse echo texture with focal lesions, including bright spotty echoes or small hyperechoic nodules (n=7), hypoechoic nodules (n=7) and comet-tail echo (n=3) in seven patients. 16 of the 39 definable hypoechoic nodules that ranged in size from 5 mm to 16mm showed posterior enhancement. CT revealed innumerable hypodense nodules measuring 2-5 mm (n=3), 2-13 mm (n=1), 2-15 mm (n=2) and 2-18 mm (n=1) in seven patients. They were usually irregular in shape and showed no enhancement, but became more apparent after the administration of intravenous contrast medium. The innumerable hypodense nodules on enhanced CT scans were uniformly (n=5) or nonuniformly (n=2) distributed throughout the liver. In four patients, MR images showed multiple small cyst-like lesions 2-13 mm in diameter. These small cystlike lesions were much more apparent on T2-weighted images or MR cholangiography. The diagnosis was made by either core-needle or wedge biopsy. In one patient, a small single lesion on the liver surface was not visible on the imaging studies. Pathologic examination revealed multiple bile duct hamartomas of varying size or microhamartomas. CONCLUSION: Although the bile duct hamartomas on CT and MR presented as numerous intrahepatic, small cyst-like lesions, they on US showed variable findings consisting of inhomogeneous and coarse echo texture with focal lesions, including bright spotty echoes or small hyperechoic nodules, hypoechoic nodules, and comet-tail echoes.

Radiological Spectrum of Intraductal Papillary Tumors of the Bile Ducts

Papillary tumor of the bile duct is characterized by the presence of an intraductal tumor with a papillary surface comprising innumerable frondlike infoldings of proliferated columnar epithelial cells surrounding slender fibrovascular stalks. There may be multiple tumors along the bile ducts (papillomatosis or papillary carcinomatosis), which are dilated due to obstruction by a tumor per se, by sloughed tumor debris, or by excessive mucin. Radiologically, the biliary tree is diffusely dilated, either in a lobar or segmental fashion, or aneurysmally, depending on the location of the tumor, the debris, and the amount of mucin production. A tumor can be depicted by imaging as an intraductal mass with a thickened and irregular bile duct wall. Sloughed tumor debris and mucin plugs should be differentiated from bile duct stones. Cystically or aneurysmally, dilated bile ducts in mucin-hypersecreting variants (intraductal papillary mucinous tumors) should be differentiated from cystadenoma, cystadenocarcinoma and liver abscess.

US-guided Percutaneous Transhepatic Biliary Drainage: Comparative Study of Right-sided and Left-sided Approach

PURPOSE: To compare the feasibility and safety of US-guided right and left percutaneous transhepatic biliary drainage (PTBD). MATERIALS AND METHODS: Between March 1998 and May 1999, 32 patients underwent 36 US-guided right or left PTBD in referred order, alternatively. The causes of biliary obstruction were bile duct stone (n=2), bile duct carcinoma (n=10), carcinoma of the pancreas (n=9), GB carcinoma (n=7), metastasis to the porta hepatis (n=3), and carcinoma of the ampulla of vater (n=1). Technical success, procedure time, fluoroscopic time, and complications were evaluated. RESULTS: PTBD was successful in 94% of both right and left approach. The average procedure time was 9.7+/-3.8 min. in the right approach and 9.6+/-3.1 min. in the left approach, respectively (p=0.794). The average fluoroscopic time were 3.9+/-2.4 min. in the right approach and 3.8+/-2.2 min. in the left approach (p=0.892). A major complication, bile peritonitis, occurred in one of 16 patient with right-sided approach. Minor complications occurred in six right (2 hemobilia, 3 tube malfunction, 1 cholangitis) and three left (1 hemobilia, 1 fever, 1 cholangitis) PTBD. There were no significant difference in the complication rates between right and left PTBD (p=0.729). CONCLUSION: There were no significant differences in feasibility and safety in US-guided right and left PTBD.

US-guided Left-sided Percutaneous Biliary Drainage: Analysis of the Technical Factors Related to Procedure

PURPOSE: To evaluate the factors affecting procedure related technical difficulties of US-guided left sidedPTBD and the complications involved in the use of this method. MATERIAL AND METHODS: We prospectively evaluatedUS-guided left PTBD in 26 patients with malignant biliary obstructions. The causes of underlying malignancy werebile duct carcinoma(n=10), adenocarcinoma of the pancreas(n=8), GB carcinoma(n=4), metastasis to the portahepatis(n=2), duodenal carcinoma(n=1), hepatocellular carcinoma(n=1). We divided the procedure into four steps forthe evaluation of technical difficulties, and we measured procedure time and fluoroscopic exposure time. And weevaluated the incidence of procedure related complications. RESULTS: US-guided left PTBD was successful in allattempted cases. The average procedure time and fluoroscopic exposure time involved were 14.2 min. and 5.5 min.,respectively. From the first step to the fourth step, the average time required was 4.4 min, 2.3 min., 1.9 min.,5.6 min., respectively. One major complication involved sepsis(3.8%), and ten minor complications including fivetransient hemobilia(19.2%), three tube malfunction(11.5%), and two fever(7.6%). CONCLUSION: US-guided left PTBDwas easy to perform and a relatively safe method. The total procedure time was short, and as the radiologistbecomes more experienced, this could be further reduced.

Choledochal Cysts in Children: Pre- and Postoperative Radiological Evaluation

PURPOSE: To review the type, incidence and radiologic findings and to evaluate the clinical significance of intrahepatic duct dilatation of choledochal cysts in children. MATERIALS AND METHODS: Ultrasonography and operative cholangiography of 49 consecutive children with surgically confirmed choledochal cyst were reviewed and classified according to the Todani's classification. Patients with intrahepatic duct dilatation in preoperative evaluation were routinely followed by ultrasonography after surgery of extrahepatic bile duct. The status of bileduct was evaluated by comparing with the preoperative ultrasonography. RESULTS: According to the preoperative evaluation, there were 19 cases(39%) of type Ia, three cases(6%) of type Ib, ten cases(20%) of type Ic, 15 cases(31%) of type IVa, two cases(4%) of type V, but no case of the type II, III, IVb in Todani's classification.In twelve of 13 patients (five cases of type I and eight cases of type IVa) who had been followed up after surgery of choledochal cyst, the previously noted intrahepatic ductal dilatation were no longer seen. CONCLUSION: The incidence of the types of choledochal cysts by Todani's classification shows no significant difference between our result and the other authors'. The intrahepatic ductal dilatation seems to be reversible and mainly secondary to extrahepatic obstruction by choledochal cyst. Thus, postoperative follow up examination is more important than preoperative classification of bile duct dilatation.