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Role of US in the Detection, Characterization, and Staging of Cholangiocarcinoma¹

¹ From the Departments of Medical Imaging (C.M.B., S.R.W.) and General Surgery (B.L.), Toronto Hospital, University of Toronto, 200 Elizabeth St, Toronto, Ontario, Canada M5G 2C4. Received August 18, 1998; revision requested October 7 and received December 15; accepted December 15. Address reprint requests to S.R.W.

View larger version (89K): [in a new window]   Figure 1.   Couinaud's functional segmental anatomy. The liver is divided into nine segments. The longitudinal boundaries (right, middle, left scissurae) are three hepatic veins. The transverse plane is defined by the right main and left main portal pedicles. (Adapted and reprinted, with permission, from reference 10.)

View larger version (165K): [in a new window]   Figures 2-5.   (2) Recumbent H view of the left portal vein bifurcation. On a subcostal US scan, the left portal vein (p), the ascending branch of the left portal vein (a), and the branches to three segments of the left lobe of the liver (2, 3, and 4) suggest a recumbent H. (3) Recumbent H view of the right portal vein bifurcation. Intercostal oblique US scan shows the branches to the anterior (5 and 8) and posterior (6 and 7) segments of the right lobe of the liver. rpv = right portal vein. (4) Hepatoduodenal ligament view. Sagittal US scan shows the common hepatic duct and common bile duct (CBD) anterior to the main portal vein (MPV). (5) Pancreatic head view. Transverse US scan shows the common bile duct (arrow) along the posterolateral aspect of the pancreatic head. The gastroduodenal artery (arrowhead) courses along the anterolateral aspect of the pancreatic head. PV = portal vein, SV = splenic vein.

View larger version (154K): [in a new window]   Figures 2-5.   (2) Recumbent H view of the left portal vein bifurcation. On a subcostal US scan, the left portal vein (p), the ascending branch of the left portal vein (a), and the branches to three segments of the left lobe of the liver (2, 3, and 4) suggest a recumbent H. (3) Recumbent H view of the right portal vein bifurcation. Intercostal oblique US scan shows the branches to the anterior (5 and 8) and posterior (6 and 7) segments of the right lobe of the liver. rpv = right portal vein. (4) Hepatoduodenal ligament view. Sagittal US scan shows the common hepatic duct and common bile duct (CBD) anterior to the main portal vein (MPV). (5) Pancreatic head view. Transverse US scan shows the common bile duct (arrow) along the posterolateral aspect of the pancreatic head. The gastroduodenal artery (arrowhead) courses along the anterolateral aspect of the pancreatic head. PV = portal vein, SV = splenic vein.

View larger version (147K): [in a new window]   Figures 2-5.   (2) Recumbent H view of the left portal vein bifurcation. On a subcostal US scan, the left portal vein (p), the ascending branch of the left portal vein (a), and the branches to three segments of the left lobe of the liver (2, 3, and 4) suggest a recumbent H. (3) Recumbent H view of the right portal vein bifurcation. Intercostal oblique US scan shows the branches to the anterior (5 and 8) and posterior (6 and 7) segments of the right lobe of the liver. rpv = right portal vein. (4) Hepatoduodenal ligament view. Sagittal US scan shows the common hepatic duct and common bile duct (CBD) anterior to the main portal vein (MPV). (5) Pancreatic head view. Transverse US scan shows the common bile duct (arrow) along the posterolateral aspect of the pancreatic head. The gastroduodenal artery (arrowhead) courses along the anterolateral aspect of the pancreatic head. PV = portal vein, SV = splenic vein.

View larger version (155K): [in a new window]   Figures 2-5.   (2) Recumbent H view of the left portal vein bifurcation. On a subcostal US scan, the left portal vein (p), the ascending branch of the left portal vein (a), and the branches to three segments of the left lobe of the liver (2, 3, and 4) suggest a recumbent H. (3) Recumbent H view of the right portal vein bifurcation. Intercostal oblique US scan shows the branches to the anterior (5 and 8) and posterior (6 and 7) segments of the right lobe of the liver. rpv = right portal vein. (4) Hepatoduodenal ligament view. Sagittal US scan shows the common hepatic duct and common bile duct (CBD) anterior to the main portal vein (MPV). (5) Pancreatic head view. Transverse US scan shows the common bile duct (arrow) along the posterolateral aspect of the pancreatic head. The gastroduodenal artery (arrowhead) courses along the anterolateral aspect of the pancreatic head. PV = portal vein, SV = splenic vein.

View larger version (163K): [in a new window]   Figure 6.   Parallel channel sign of biliary obstruction secondary to cholangiocarcinoma. Sagittal US scan through the right lobe of the liver shows parallel tubes representing a portal vein (pv) and its accompanying dilated bile duct (bd). This US feature is also known as the shotgun sign.

View larger version (139K): [in a new window]   Figure 7.   Infiltrating Klatskin tumor. Subcostal oblique US scan through the porta hepatis shows a soft-tissue mass (m) in the common hepatic duct with invasion of adjacent liver tissue. The invasive component is inferred from the separation of the dilated central bile ducts (bd). pv = portal vein.

View larger version (157K): [in a new window]   Figures 8, 9.   Papillary variant of Klatskin tumor. (8) Sagittal US scan through the common hepatic duct shows an oval, well-defined, soft-tissue intraductal mass filling the lumen and "poking" upward into the right main duct (arrow). (9a) Subcostal oblique US scan through the right (RT) and left (L) hepatic ducts shows nodular intraductal tumor filling both ducts. pv = portal vein. (9b) Endoscopic retrograde cholangiopancreatogram also demonstrates tumoral invasion of both hepatic ducts (arrowheads).

View larger version (160K): [in a new window]   Figures 8, 9.   Papillary variant of Klatskin tumor. (8) Sagittal US scan through the common hepatic duct shows an oval, well-defined, soft-tissue intraductal mass filling the lumen and "poking" upward into the right main duct (arrow). (9a) Subcostal oblique US scan through the right (RT) and left (L) hepatic ducts shows nodular intraductal tumor filling both ducts. pv = portal vein. (9b) Endoscopic retrograde cholangiopancreatogram also demonstrates tumoral invasion of both hepatic ducts (arrowheads).

View larger version (138K): [in a new window]   Figures 8, 9.   Papillary variant of Klatskin tumor. (8) Sagittal US scan through the common hepatic duct shows an oval, well-defined, soft-tissue intraductal mass filling the lumen and "poking" upward into the right main duct (arrow). (9a) Subcostal oblique US scan through the right (RT) and left (L) hepatic ducts shows nodular intraductal tumor filling both ducts. pv = portal vein. (9b) Endoscopic retrograde cholangiopancreatogram also demonstrates tumoral invasion of both hepatic ducts (arrowheads).

View larger version (154K): [in a new window]   Figure 10a.   Cholangiocarcinoma in a preexisting choledochal cyst. (a) Sagittal US scan through the right lobe of the liver shows a soft-tissue mass (M) within a focal sacculation of the common hepatic duct. gb = gallbladder. (b) Coronal magnetic resonance (MR) cholangiopancreatogram helps confirm the presence of the mass (m).

View larger version (163K): [in a new window]   Figure 10b.   Cholangiocarcinoma in a preexisting choledochal cyst. (a) Sagittal US scan through the right lobe of the liver shows a soft-tissue mass (M) within a focal sacculation of the common hepatic duct. gb = gallbladder. (b) Coronal magnetic resonance (MR) cholangiopancreatogram helps confirm the presence of the mass (m).

View larger version (119K): [in a new window]   Figures 11, 12.   Nodular ductal cholangiocarcinoma. (11) Subcostal oblique US scan through the ductal confluence shows diffuse, shelflike thickening of the proximal right hepatic duct (arrowheads). A small residual lumen remains visible. (12) Sagittal (a) and transverse (b) US scans through the common duct show sheetlike thickening of the common hepatic duct (shouldering of tumor [s and arrowheads in a]) with a corresponding "bull's-eye" appearance of the common hepatic duct on the transverse scan (arrows in b). Histopathologic findings helped confirm nodular cholangiocarcinoma. ha = hepatic artery, pv = portal vein.

View larger version (110K): [in a new window]   Figures 11, 12.   Nodular ductal cholangiocarcinoma. (11) Subcostal oblique US scan through the ductal confluence shows diffuse, shelflike thickening of the proximal right hepatic duct (arrowheads). A small residual lumen remains visible. (12) Sagittal (a) and transverse (b) US scans through the common duct show sheetlike thickening of the common hepatic duct (shouldering of tumor [s and arrowheads in a]) with a corresponding "bull's-eye" appearance of the common hepatic duct on the transverse scan (arrows in b). Histopathologic findings helped confirm nodular cholangiocarcinoma. ha = hepatic artery, pv = portal vein.

View larger version (117K): [in a new window]   Figures 11, 12.   Nodular ductal cholangiocarcinoma. (11) Subcostal oblique US scan through the ductal confluence shows diffuse, shelflike thickening of the proximal right hepatic duct (arrowheads). A small residual lumen remains visible. (12) Sagittal (a) and transverse (b) US scans through the common duct show sheetlike thickening of the common hepatic duct (shouldering of tumor [s and arrowheads in a]) with a corresponding "bull's-eye" appearance of the common hepatic duct on the transverse scan (arrows in b). Histopathologic findings helped confirm nodular cholangiocarcinoma. ha = hepatic artery, pv = portal vein.

View larger version (176K): [in a new window]   Figure 13a.   Subtle Klatskin tumor. (a) Subcostal oblique US scan shows a small segment of dilated right hepatic duct (r) with an adjacent, extremely subtle isoechoic mass (m). The mass is further suggested by compression and bowing of the portal vein (PV) and by the separation of the biliary stent (two echogenic lines) from the anterior edge of the portal vein. (b) Subcostal US scan obtained with slight angulation of the transducer provides optimal visualization of the mass (m), which has slightly increased echogenicity and a hypoechoic rim (arrows). PV = portal vein, r = right hepatic duct.

View larger version (158K): [in a new window]   Figure 13b.   Subtle Klatskin tumor. (a) Subcostal oblique US scan shows a small segment of dilated right hepatic duct (r) with an adjacent, extremely subtle isoechoic mass (m). The mass is further suggested by compression and bowing of the portal vein (PV) and by the separation of the biliary stent (two echogenic lines) from the anterior edge of the portal vein. (b) Subcostal US scan obtained with slight angulation of the transducer provides optimal visualization of the mass (m), which has slightly increased echogenicity and a hypoechoic rim (arrows). PV = portal vein, r = right hepatic duct.

View larger version (182K): [in a new window]   Figure 14.   Mural extension of tumor. Subcostal oblique US scan through the porta hepatis shows an invasive Klatskin tumor with an extensive intraductal lobar component (large arrow). Subtle nodularity along the inferior wall of the left main duct (small arrows) is caused by tumor infiltration.

View larger version (168K): [in a new window]   Figure 15a.   Lobar atrophy. (a) Subcostal oblique US scan of the liver shows atrophy and ductal crowding of the left lobe. A mass (M) is inferred from the separation of the dilated ducts. (b) Axial CT scan helps confirm the presence of the mass.

View larger version (136K): [in a new window]   Figure 15b.   Lobar atrophy. (a) Subcostal oblique US scan of the liver shows atrophy and ductal crowding of the left lobe. A mass (M) is inferred from the separation of the dilated ducts. (b) Axial CT scan helps confirm the presence of the mass.

View larger version (150K): [in a new window]   Figure 16.   Lobar atrophy. Sagittal US scan shows a segmentally dilated duct to segment 6 in an atrophic right lobe. The obstructed duct touches the liver surface. k = kidney.

View larger version (144K): [in a new window]   Figure 17a.   Geographic alteration in lobar echotexture secondary to a Klatskin tumor. (a) Intercostal oblique US scan through the liver shows marked lobar atrophy of the right lobe (rt). In addition, there is geographic alteration in lobar echotexture, with the right lobe substantially less echogenic than the left lobe (lt). (b) Axial US scan through the left lobe and porta hepatis shows segmentally dilated ducts with nonunion, echotexture variation, and a subtle Klatskin tumor (arrowheads). Segments 2, 3, and 4 are clearly marked.

View larger version (150K): [in a new window]   Figure 17b.   Geographic alteration in lobar echotexture secondary to a Klatskin tumor. (a) Intercostal oblique US scan through the liver shows marked lobar atrophy of the right lobe (rt). In addition, there is geographic alteration in lobar echotexture, with the right lobe substantially less echogenic than the left lobe (lt). (b) Axial US scan through the left lobe and porta hepatis shows segmentally dilated ducts with nonunion, echotexture variation, and a subtle Klatskin tumor (arrowheads). Segments 2, 3, and 4 are clearly marked.

View larger version (152K): [in a new window]   Figures 18-20.   (18) Involvement of the main portal vein. Sagittal gray-scale US scan shows an infiltrative mass in the common bile duct. A nodular component (arrowheads) is seen invading the main portal vein (pv). An indwelling stent is also visible (arrow). (19) Hepatic artery encasement. Subcostal oblique gray-scale US scan through the porta hepatis shows incomplete encasement of the hepatic artery (*) by a mass in the ductal confluence (arrowheads). The hepatic artery is incompletely circumscribed by tumor tissue; there is an intact tissue plane between the artery and the adjacent portal vein (pv). (20) Involvement of the right portal vein. Subcostal oblique gray-scale US scan through the porta hepatis shows an abrupt narrowing (arrow) with complete obliteration of the right portal vein (rpv) secondary to an isoechoic infiltrating Klatskin tumor (m). A biliary stent appears as two parallel echogenic lines within the tumor.

View larger version (173K): [in a new window]   Figures 18-20.   (18) Involvement of the main portal vein. Sagittal gray-scale US scan shows an infiltrative mass in the common bile duct. A nodular component (arrowheads) is seen invading the main portal vein (pv). An indwelling stent is also visible (arrow). (19) Hepatic artery encasement. Subcostal oblique gray-scale US scan through the porta hepatis shows incomplete encasement of the hepatic artery (*) by a mass in the ductal confluence (arrowheads). The hepatic artery is incompletely circumscribed by tumor tissue; there is an intact tissue plane between the artery and the adjacent portal vein (pv). (20) Involvement of the right portal vein. Subcostal oblique gray-scale US scan through the porta hepatis shows an abrupt narrowing (arrow) with complete obliteration of the right portal vein (rpv) secondary to an isoechoic infiltrating Klatskin tumor (m). A biliary stent appears as two parallel echogenic lines within the tumor.

View larger version (140K): [in a new window]   Figures 18-20.   (18) Involvement of the main portal vein. Sagittal gray-scale US scan shows an infiltrative mass in the common bile duct. A nodular component (arrowheads) is seen invading the main portal vein (pv). An indwelling stent is also visible (arrow). (19) Hepatic artery encasement. Subcostal oblique gray-scale US scan through the porta hepatis shows incomplete encasement of the hepatic artery (*) by a mass in the ductal confluence (arrowheads). The hepatic artery is incompletely circumscribed by tumor tissue; there is an intact tissue plane between the artery and the adjacent portal vein (pv). (20) Involvement of the right portal vein. Subcostal oblique gray-scale US scan through the porta hepatis shows an abrupt narrowing (arrow) with complete obliteration of the right portal vein (rpv) secondary to an isoechoic infiltrating Klatskin tumor (m). A biliary stent appears as two parallel echogenic lines within the tumor.

View larger version (187K): [in a new window]   Figures 21, 22.   (21) Left portal vein thrombosis secondary to ductal cholangiocarcinoma. Axial color Doppler US scan through the porta hepatis shows complete thrombosis of the left main and ascending branches (AP) of the portal vein from adjacent tumor invasion. Patent prominent hepatic arterial branches (yellow) run parallel to the thrombosed portal vein. Blue area indicates flow in the main portal vein. No flow is seen in the ascending left portal vein. bd = bile duct. (22) Hepatic artery encasement. Color Doppler US scan through the hepatoduodenal ligaments shows complete encasement of the proximal right lobar branch of the hepatic artery by a tumor mass. ha = hepatic artery, P = portal vein.

View larger version (170K): [in a new window]   Figures 21, 22.   (21) Left portal vein thrombosis secondary to ductal cholangiocarcinoma. Axial color Doppler US scan through the porta hepatis shows complete thrombosis of the left main and ascending branches (AP) of the portal vein from adjacent tumor invasion. Patent prominent hepatic arterial branches (yellow) run parallel to the thrombosed portal vein. Blue area indicates flow in the main portal vein. No flow is seen in the ascending left portal vein. bd = bile duct. (22) Hepatic artery encasement. Color Doppler US scan through the hepatoduodenal ligaments shows complete encasement of the proximal right lobar branch of the hepatic artery by a tumor mass. ha = hepatic artery, P = portal vein.

View larger version (157K): [in a new window]   Figure 23.   Polypoid mass in the distal common bile duct. Axial US scan through the pancreatic head shows a nodule with frondlike surface excrescences in the distal common bile duct (arrow). PV = portal vein.

View larger version (154K): [in a new window]   Figure 24.   Mural thickening of the entire common bile duct due to stent placement. Sagittal US scan through the hepatoduodenal ligaments shows a circumferentially thickened common hepatic duct (arrowheads) with preservation of luminal patency. This thickening is difficult to differentiate from a nodular cholangiocarcinoma or cholangitis. A stent is present but is not seen on this view. PV = portal vein.

View larger version (144K): [in a new window]   Figure 25.   Sclerosing cholangitis mimicking nodular ductal cholangiocarcinoma. Sagittal US scan through the hepatoduodenal ligaments shows thickening and nodularity of the common hepatic duct (arrowheads). PV = portal vein.

View larger version (132K): [in a new window]   Figure 26a.   Ductal cholangiocarcinoma in a patient with preexisting sclerosing cholangitis. (a) Axial US scan through the porta hepatis shows a thick-walled common bile duct (diameter, 2.2 cm) with an indwelling stent. (b) Axial US scan through the porta hepatis obtained 3 months later shows marked enlargement of the common bile duct (diameter, 3.1 cm). Cholangiocarcinoma was proved at histopathologic analysis. Cross-hatch calipers in each image indicate the lateral margins of the duct.

View larger version (161K): [in a new window]   Figure 26b.   Ductal cholangiocarcinoma in a patient with preexisting sclerosing cholangitis. (a) Axial US scan through the porta hepatis shows a thick-walled common bile duct (diameter, 2.2 cm) with an indwelling stent. (b) Axial US scan through the porta hepatis obtained 3 months later shows marked enlargement of the common bile duct (diameter, 3.1 cm). Cholangiocarcinoma was proved at histopathologic analysis. Cross-hatch calipers in each image indicate the lateral margins of the duct.

View larger version (139K): [in a new window]   Figure 27a.   Invasive gallbladder cancer mimicking a Klatskin tumor. (a) Sagittal US scan through the gallbladder fossa shows a solid mass (m) containing trapped stones. (b) Axial US scan through the porta hepatis shows the tumor (m) extending up to and obstructing the common bile duct (cbd).

View larger version (133K): [in a new window]   Figure 27b.   Invasive gallbladder cancer mimicking a Klatskin tumor. (a) Sagittal US scan through the gallbladder fossa shows a solid mass (m) containing trapped stones. (b) Axial US scan through the porta hepatis shows the tumor (m) extending up to and obstructing the common bile duct (cbd).

View larger version (135K): [in a new window]   Figure 28a.   Papillary adenoma in a preexisting choledochal cyst. (a) Sagittal US scan through the porta hepatis shows an eccentric mass (m) within a biliary diverticulum. (b) Coronal MR cholangiopancreatogram helps confirm the presence of the mass (m). Cholangiocarcinoma in a choledochal cyst was proved at histopathologic analysis.

View larger version (112K): [in a new window]   Figure 28b.   Papillary adenoma in a preexisting choledochal cyst. (a) Sagittal US scan through the porta hepatis shows an eccentric mass (m) within a biliary diverticulum. (b) Coronal MR cholangiopancreatogram helps confirm the presence of the mass (m). Cholangiocarcinoma in a choledochal cyst was proved at histopathologic analysis.

View larger version (144K): [in a new window]   Figures 29, 30.   (29) Metastasis mimicking papillary cholangiocarcinoma of the intrahepatic bile duct. Transverse US scan through the left lobe of the liver shows a papillary intraductal mass (arrow) obstructing a segmental bile duct (s). Metastatic rectal cancer was proved at histopathologic analysis. (30) Metastasis mimicking papillary cholangiocarcinoma of the extrahepatic bile duct. Sagittal US scan through the common bile duct (cbd) shows a polypoid intraluminal mass (m) causing bile duct obstruction. Metastatic melanoma was proved at histopathologic analysis.

View larger version (152K): [in a new window]   Figures 29, 30.   (29) Metastasis mimicking papillary cholangiocarcinoma of the intrahepatic bile duct. Transverse US scan through the left lobe of the liver shows a papillary intraductal mass (arrow) obstructing a segmental bile duct (s). Metastatic rectal cancer was proved at histopathologic analysis. (30) Metastasis mimicking papillary cholangiocarcinoma of the extrahepatic bile duct. Sagittal US scan through the common bile duct (cbd) shows a polypoid intraluminal mass (m) causing bile duct obstruction. Metastatic melanoma was proved at histopathologic analysis.

View larger version (159K): [in a new window]   Figure 31a.   Mirizzi syndrome mimicking a Klatskin tumor. (a) Sagittal US scan through the porta hepatis shows a large gallstone (S) in the region of the common bile duct and common hepatic duct dilating the latter (cd). GB = gallbladder. (b) Subcostal US scan obtained cephalad to a shows an infiltrative "mass" (arrowheads) obstructing the proximal right and left bile ducts, thereby mimicking a Klatskin tumor. (c) Endoscopic retrograde cholangiopancreatogram helps confirm the diagnosis. Inflammatory tissue was proved at surgery.

View larger version (142K): [in a new window]   Figure 31b.   Mirizzi syndrome mimicking a Klatskin tumor. (a) Sagittal US scan through the porta hepatis shows a large gallstone (S) in the region of the common bile duct and common hepatic duct dilating the latter (cd). GB = gallbladder. (b) Subcostal US scan obtained cephalad to a shows an infiltrative "mass" (arrowheads) obstructing the proximal right and left bile ducts, thereby mimicking a Klatskin tumor. (c) Endoscopic retrograde cholangiopancreatogram helps confirm the diagnosis. Inflammatory tissue was proved at surgery.

View larger version (162K): [in a new window]   Figure 31c.   Mirizzi syndrome mimicking a Klatskin tumor. (a) Sagittal US scan through the porta hepatis shows a large gallstone (S) in the region of the common bile duct and common hepatic duct dilating the latter (cd). GB = gallbladder. (b) Subcostal US scan obtained cephalad to a shows an infiltrative "mass" (arrowheads) obstructing the proximal right and left bile ducts, thereby mimicking a Klatskin tumor. (c) Endoscopic retrograde cholangiopancreatogram helps confirm the diagnosis. Inflammatory tissue was proved at surgery.

View larger version (135K): [in a new window]   Figure 32a.   Common bile duct stone mimicking papillary cholangiocarcinoma. Sagittal (a) and axial (b) US scans through a dilated common bile duct show a round, "polypoid" intraluminal lesion (s). Faint acoustic shadowing is seen in a. A stone was proved at endoscopic retrograde cholangiopancreatography.

View larger version (139K): [in a new window]   Figure 32b.   Common bile duct stone mimicking papillary cholangiocarcinoma. Sagittal (a) and axial (b) US scans through a dilated common bile duct show a round, "polypoid" intraluminal lesion (s). Faint acoustic shadowing is seen in a. A stone was proved at endoscopic retrograde cholangiopancreatography.

View larger version (128K): [in a new window]   Figures 33-36.   (33) Common bile duct stone suggestive of papillary cholangiocarcinoma in a patient with a stricture and long-standing sclerosing cholangitis. Sagittal US scan through the porta hepatis shows a well-defined, nonshadowing, avascular echogenic mass in the extrahepatic bile duct (arrows). Lack of shadowing makes differentiation of the impacted stone from a tumor particularly difficult. (34) Hemobilia mimicking ductal cholangiocarcinoma in a patient who had undergone liver biopsy. Sagittal US scan through the porta hepatis shows an ill-defined, echogenic soft-tissue mass (arrow) filling the dilated extrahepatic bile duct. Blood was extracted at endoscopic retrograde cholangiopancreatography. (35) Bile duct rejection in a liver transplant recipient. Sagittal oblique US scan through the porta hepatis shows diffuse circumferential thickening of the right hepatic ducts with only a small residual central lumen (arrowheads). The patient had undergone transplantation 3 weeks earlier and had demonstrated a sudden elevation in liver enzyme levels. Differential diagnosis included recurrent sclerosing cholangitis, which is highly unusual given the timing of this event. (36) Postoperative stricture mimicking a ductal cholangiocarcinoma. Sagittal US scan through the porta hepatis shows abrupt tapering of a dilated common hepatic duct (arrowhead) secondary to previous laparoscopic gallbladder surgery. No mass is present.

View larger version (150K): [in a new window]   Figures 33-36.   (33) Common bile duct stone suggestive of papillary cholangiocarcinoma in a patient with a stricture and long-standing sclerosing cholangitis. Sagittal US scan through the porta hepatis shows a well-defined, nonshadowing, avascular echogenic mass in the extrahepatic bile duct (arrows). Lack of shadowing makes differentiation of the impacted stone from a tumor particularly difficult. (34) Hemobilia mimicking ductal cholangiocarcinoma in a patient who had undergone liver biopsy. Sagittal US scan through the porta hepatis shows an ill-defined, echogenic soft-tissue mass (arrow) filling the dilated extrahepatic bile duct. Blood was extracted at endoscopic retrograde cholangiopancreatography. (35) Bile duct rejection in a liver transplant recipient. Sagittal oblique US scan through the porta hepatis shows diffuse circumferential thickening of the right hepatic ducts with only a small residual central lumen (arrowheads). The patient had undergone transplantation 3 weeks earlier and had demonstrated a sudden elevation in liver enzyme levels. Differential diagnosis included recurrent sclerosing cholangitis, which is highly unusual given the timing of this event. (36) Postoperative stricture mimicking a ductal cholangiocarcinoma. Sagittal US scan through the porta hepatis shows abrupt tapering of a dilated common hepatic duct (arrowhead) secondary to previous laparoscopic gallbladder surgery. No mass is present.

View larger version (152K): [in a new window]   Figures 33-36.   (33) Common bile duct stone suggestive of papillary cholangiocarcinoma in a patient with a stricture and long-standing sclerosing cholangitis. Sagittal US scan through the porta hepatis shows a well-defined, nonshadowing, avascular echogenic mass in the extrahepatic bile duct (arrows). Lack of shadowing makes differentiation of the impacted stone from a tumor particularly difficult. (34) Hemobilia mimicking ductal cholangiocarcinoma in a patient who had undergone liver biopsy. Sagittal US scan through the porta hepatis shows an ill-defined, echogenic soft-tissue mass (arrow) filling the dilated extrahepatic bile duct. Blood was extracted at endoscopic retrograde cholangiopancreatography. (35) Bile duct rejection in a liver transplant recipient. Sagittal oblique US scan through the porta hepatis shows diffuse circumferential thickening of the right hepatic ducts with only a small residual central lumen (arrowheads). The patient had undergone transplantation 3 weeks earlier and had demonstrated a sudden elevation in liver enzyme levels. Differential diagnosis included recurrent sclerosing cholangitis, which is highly unusual given the timing of this event. (36) Postoperative stricture mimicking a ductal cholangiocarcinoma. Sagittal US scan through the porta hepatis shows abrupt tapering of a dilated common hepatic duct (arrowhead) secondary to previous laparoscopic gallbladder surgery. No mass is present.

View larger version (134K): [in a new window]   Figures 33-36.   (33) Common bile duct stone suggestive of papillary cholangiocarcinoma in a patient with a stricture and long-standing sclerosing cholangitis. Sagittal US scan through the porta hepatis shows a well-defined, nonshadowing, avascular echogenic mass in the extrahepatic bile duct (arrows). Lack of shadowing makes differentiation of the impacted stone from a tumor particularly difficult. (34) Hemobilia mimicking ductal cholangiocarcinoma in a patient who had undergone liver biopsy. Sagittal US scan through the porta hepatis shows an ill-defined, echogenic soft-tissue mass (arrow) filling the dilated extrahepatic bile duct. Blood was extracted at endoscopic retrograde cholangiopancreatography. (35) Bile duct rejection in a liver transplant recipient. Sagittal oblique US scan through the porta hepatis shows diffuse circumferential thickening of the right hepatic ducts with only a small residual central lumen (arrowheads). The patient had undergone transplantation 3 weeks earlier and had demonstrated a sudden elevation in liver enzyme levels. Differential diagnosis included recurrent sclerosing cholangitis, which is highly unusual given the timing of this event. (36) Postoperative stricture mimicking a ductal cholangiocarcinoma. Sagittal US scan through the porta hepatis shows abrupt tapering of a dilated common hepatic duct (arrowhead) secondary to previous laparoscopic gallbladder surgery. No mass is present.

View larger version (152K): [in a new window]   Figure 37a.   Peripheral cholangiocarcinoma. (a) Axial US scan through the left lobe of the liver (lt) shows a large, poorly defined hepatic mass with diffuse flecks of increased echo-genicity that are suggestive of micro-calcifications. (b) Sagittal US scan shows a massively dilated common bile duct (CBD). (c) CT scan helps confirm the diagnosis. Peripheral cholangiocarcinoma with abundant ductal mucin was proved at histopathologic analysis.

View larger version (132K): [in a new window]   Figure 37b.   Peripheral cholangiocarcinoma. (a) Axial US scan through the left lobe of the liver (lt) shows a large, poorly defined hepatic mass with diffuse flecks of increased echo-genicity that are suggestive of micro-calcifications. (b) Sagittal US scan shows a massively dilated common bile duct (CBD). (c) CT scan helps confirm the diagnosis. Peripheral cholangiocarcinoma with abundant ductal mucin was proved at histopathologic analysis.

View larger version (117K): [in a new window]   Figure 37c.   Peripheral cholangiocarcinoma. (a) Axial US scan through the left lobe of the liver (lt) shows a large, poorly defined hepatic mass with diffuse flecks of increased echo-genicity that are suggestive of micro-calcifications. (b) Sagittal US scan shows a massively dilated common bile duct (CBD). (c) CT scan helps confirm the diagnosis. Peripheral cholangiocarcinoma with abundant ductal mucin was proved at histopathologic analysis.

View larger version (144K): [in a new window]   Figure 38.   Colon metastasis mimicking peripheral cholangiocarcinoma. Sagittal US scan of the right lobe of the liver shows a large, echogenic mass (m) obstructing the peripheral part of the bile duct. Metastatic colon cancer was proved at histopathologic analysis.