The bile ducts after a fatty meal: further sonographic observations

The sonographic appearance of the response of the common hepatic duct to physiologic stimulation by a fatty meal was assessed in 131 patients referred because of right upper quadrant symptoms or abnormal liver chemical studies. In the determination of the presence or absence of biliary obstruction, the sensitivity of the examination was 84%, the accuracy of a positive test was 84%, and the accuracy of a negative test was 93%. This test proved helpful in several circumstances: equivocal duct caliber (6-10 mm); abnormal caliber (6-14 mm) with normal laboratory values; normal caliber duct with abnormal laboratory values; persistent question of cholelithiasis or asymptomatic pancreatic duct dilatation. Measurements of bile duct caliber alone may be insufficient to ascertain the presence of bile duct obstruction and fatty meal stimulation significantly improves diagnostic accuracy.     

The stilette sign: the appearance of dilated bile ducts in the fatty liver

The appearances of hepatic steatosis and of dilated intrahepatic bile ducts occurring independently are well described. When both conditions occur simultaneously a major sign of biliary obstruction, a double lumen with echogenic walls (the double-barrelled shotgun sign), is modified by the abnormally echogenic liver. The combined appearance is of a tubular structure with no echogenic interface with the liver, containing an echogenic structure at its centre representing echoes from the adjacent bile duct and portal vein walls. We have named this appearance the 'stilette' sign because of its resemblance to a fine needle within a tube. Its importance lies in the fact that it makes dilated intrahepatic bile ducts difficult to recognise by ultrasound.     

Intravenous cholecystokinin octapeptide: its effect on the sonographic appearance of the file ducts in normal subjects

The response of the common hepatic duct to an intravenous injection of sincalide (0.04 mcg/kg over 1 min) was assessed in 15 healthy volunteers. Ultrasound examinations performed at 5-minute intervals for 1 hour revealed a mean maximal decrease in gallbladder volume of 59%. The internal diameter of the duct was unchanged in 13 of 15 subjects, and decreased by 1 mm in the remaining 2 subjects. It is concluded that, in normal subjects, there is no significant change in the internal diameter of the common hepatic duct in response to an intravenous dose of sincalide sufficient to effect gallbladder contraction.     

Sonographic diagnosis of Klatskin tumors

The sonograms of 14 patients with pathologically proven Klatskin tumors presenting between 1974 and 1985 were reviewed. All 14 patients demonstrated dilated intrahepatic bile ducts with a normal-sized extrahepatic biliary tree. In seven patients this was the only finding. The other seven patients demonstrated one or more additional abnormalities. These included an apparent intraductal mass at the confluence of the right and left intrahepatic ducts (four patients), enlarged portal lymph nodes (two patients), and hepatic metastases (one patient). With one exception, these additional findings were seen only in patients scanned after 1980, that is, using real-time sonography and up-to-date scanners. The presence of dilated intrahepatic ducts in a patient with a normal extrahepatic biliary tree should raise the possibility of Klatskin tumor. With high-resolution real-time sonography, further evidence suggestive of malignancy can be demonstrated in at least 50% of patients.     

Fibroadenoma of the breast: sonographic appearance

The sonographic patterns of 100 fibroadenomas, including two giant fibroadenomas and two cystosarcoma phyllodes, were reviewed. The lesions were mostly hypoechoic (92%) and homogeneous in echotexture (72%). Twenty-seven percent of fibroadenomas showed irregular margins. Intratumoral calcifications were noted in 10% of lesions. A marked acoustic shadow without associated calcification was seen in six cases. The mean ratio of the length to the anteroposterior diameter of the tumors was 1.84 +/- 0.52 (standard deviation), indicating an elongation along the general orientation of the breast tissue planes. The ratios of length to anteroposterior diameter calculated in two matching groups of small (less than 1 cm3) fibroadenomas and carcinomas differed significantly. State-of-the-art high-frequency transducers, geometric analysis of tumors, and real-time ultrasound-guided fine-needle aspiration biopsy should help to distinguish between benign and malignant solid breast masses.     

Gaucher disease: sonographic appearance of the spleen

Ultrasonographic (US) examinations of the upper abdomen were performed in 80 patients with Gaucher disease. Of the 49 patients that had not undergone splenectomy, 47 had splenic enlargement. Sixteen patients had multiple lesions in the spleen. Most patients had discrete hypoechoic lesions that corresponded pathologically to focal homogeneous clusters of Gaucher cells. Several patients had similar lesions that were hyperechoic and were composed of Gaucher cells and fibrosis or infarction. A few patients had a geographic pattern of irregular areas of involvement of Gaucher cells among normal splenic parenchyma. The liver was often enlarged but otherwise sonographically unremarkable. Patients with Gaucher disease often have US examinations of the left upper quadrant for abdominal pain. A variety of US findings in the spleen typical for Gaucher disease should be recognized and not interpreted as acute changes.     

Juvenile papillomatosis of the breast: sonographic appearance

Three patients with juvenile papillomatosis of the breast are described. The lesions were apparent clinically as a palpable mass. At mammography, juvenile papillomatosis was not depicted in two patients and was seen as a poorly defined mass in one case. In all patients, high-frequency ultrasound examination showed an ill-defined, inhomogeneous mass with one or several small (up to 0.4 cm), rounded, relatively echo-free areas, which were seen mainly or exclusively near the borders of the lesion.     

Cohen ureteral reimplantation: sonographic appearance

The sonographic records of 27 children who underwent a Cohen ureteroneocystostomy were reviewed. In 13 children (48%) sonograms demonstrated an echogenic, nonacoustically shadowing structure at or just above the trigone that was fixed in position within the bladder wall and covered by intact mucosa. This constellation of sonographic findings, which represent the submucosal segment of the reimplanted ureter, produces a "tunnel sign." Awareness of this appearance will enable the sonographer to better evaluate children who have undergone surgical procedures on the bladder.     

Lingual thyroid gland: sonographic appearance

Thyroid dysgenesis is often manifested by a lingual or sublingual location of the thyroid gland. If radionuclide studies are not readily available or are contraindicated, ultrasound (US) may be used to locate the gland. The US appearance of a lingual thyroid gland and the role of US in the evaluation of suspected thyroid dysgenesis are described.     

Angiography and intervention in tumors of the pancreas, liver and bile ducts

The importance of angiography and of interventional radiology in tumours of the pancreas, liver and bile ducts is discussed. Angiography is performed prior to surgical intervention to assess tumour resectability, for a preoperative visualisation of vascular anatomy, as well as in non-diagnostic findings in ultrasound and computerised tomography. Diagnostic and therapeutic interventional techniques in the liver (fine needle puncture, perfusion, embolisation) and the bile ducts (PTC, ERCP, PTCD, endoprosthesis, stents) are performed selectively in tumour patients in close co-operation with surgeons, radiologists and gastroenterologists.