Jaundice

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6.9 Renal Insufficiency and Acute Renal Failure

Diagnosis:

Laboratory findings : frequent hyperlipidemia and bacteriuria

Sonography

Sonographic findings :

Small kidneys

Increased echogenicity

Bulging renal surface

Parenchymal thinning

Calculi

Accuracy of sonographic diagnosis: Ultrasound is very accurate when laboratory

tests show elevated uric acid and other clinical manifestations of gout are present.

Renal Lithiasis

..............................................................................................................

See Upper Abdominal Pain, Renal Colic, p. 65; Kidney, Renal calyceal or pelvic stone, p. 288; Urogenital Organs, Urinary stone colic, p. 380.

Note: Renal insufficiency may develop in long-standing cases of lithiasis with

recurrent episodes of colic.

Polycystic Kidney

..............................................................................................................

6.10 Jaundice

Basic Principles

..............................................................................................................

Principal signs and symptoms:

Cholestasis with elevated liver values (AP, g-glutamate transferase [GGT], bilirubin, etc.)

Yellowish discoloration of the skin (jaundice when bilirubin i 3 mg/dL), pruritus, pale stool, dark urine, fatigue

Note: Painless jaundice has a malignant etiology in more than 95 % of cases.

Sonographic findings. Particular attention is given to the following aspects :

Size and configuration of the liver:

– Smooth or nodular surface – Nodular parenchymal changes – Truncation or displacement of portal vessels – Increased hepatic echogenicity, visual texture – Impression of left hepatic lobe by cardiac pulsations

Increased hepatic arterial perfusion (on CDS) indicating cirrhosis

Dilated bile ducts: dilatation due to biliary outflow obstruction caused by increased intraductal pressure (segmental intrahepatic or affecting one half of the lobe p no jaundice). With loss of parenchymal elasticity (as in cirrhosis), very little dilatation of the intrahepatic bile ducts can occur.

Accuracy of sonographic diagnosis: A parenchymal cause of biliary outflow

obstruction can almost always be identified. Ultrasound can also define the level of the obstruction and disclose a lithogenic or malignant cause. Jaundice due to acute hepatitis or hemolysis is not associated with sonographic abnormalities.

Differential diagnosis: The possible diagnoses are listed in Table 25 in order of

their frequency in the general hospital setting.

Principal Signs and Symptoms

Table 25.Differential diagnosis of jaundice

yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy

Diagnosis Sonographic signs

yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy

Common

yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy

yyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyy

Hepatitic or toxic cirrhosis of the liver (p. 236, 238)

Cholelithiasis (p. 332) Shadowing stone, possible duct occlusion with prestenotic

ductal dilatation

Biliary obstruction or tumor (p. 330)

yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy

Less common

yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy

Hepatic tumor (p. 249, 250)

Dilated bile ducts with possible obstruction of the pancreatic duct; other findings depend on the cause

yyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyy

Intrahepatic mass, with or without biliary obstruction; anechoic fluid in the abdominal cavity

Cholangitis (p. 331) Signs of PSC and inflammation, wall thickening, lymph

nodes; causative lesion may be definable (purulent cholangitis, stone, tumor, abscess)

139

6.10 Jaundice

Table 25.Differential diagnosis of jaundice – continued

yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy

Diagnosis Sonographic signs

yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy

Fatty liver hepatitis (toxic liver disease, NASH, p. 146)

Cholecystitis (p. 147)

yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy

Rare

yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy

yyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyy

Enlarged liver, homogeneously increased echogenicity, rounded border, acoustic shadowing

yyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyy

Budd-Chiari syndrome (p. 147)

Secondary biliary cirrhosis (p. 147)

Helminthiasis

Principal Signs and Symptoms

(ascariasis, p. 331)

Signs of hepatic cirrhosis, detectable cause of the biliary obstruction

Luminal obstruction by ascarids

Papillomatosis (p. 328) Hypoechoic, immobile intraluminal flow void with ill-defined

margins

Caroli syndrome (p. 141) Cystic dilatation of intrahepatic bile ducts, possible signs of

cholangitis, gallstones

Bile duct compression or infiltration (p. 143)

Biliary atresia (p. 147)

Conditions that cannot be diagnosed with ultrasound

Less common: Epidemic hepatitis, primary biliary hepatic cirrhosis, cholestatic liver disease, juvenile jaundice (Meulengracht disease) Rare: Galactosemia, Dubin–Johnson syndrome, Rotor disease, spherocytic anemia, thalassemia, paroxysmal hemoglobinuria, hemoglobin anomaly, erythrocyte enzyme disorder, autoimmune forms of hemolysis, toxic isoimmune hemolysis, neonatal jaundice, hemolytic disease of the newborn, neonatal infection, congenital hemolysis, reactive hepatitis due to infections, toxic liver damage, Crigler–Najjar disease

Hepatitic or Toxic Hepatic Cirrhosis (Fig. 181)

..............................................................................................................

See also Ascites, Hepatic Cirrhosis, p. 156; Liver, Hepatic Cirrhosis, p. 236; Severe chronic hepatitis with structural change or cirrhosis p. 238.

Fig. 181 Hepatic cirrhosis: echogenic necrotic foci. Multiple needle biopsies showed no evidence of tumor

140

6.10 Jaundice

Cholelithiasis (Figs. 182 and 183)

..............................................................................................................

See also Upper Abdominal Pain, Biliary Colic, p. 64; Bile Ducts, Gallstones, p. 332; Biliary Cysts, p. 326.

Fig. 182a, b Intrahepatic cholelithiasis. a Caroli syndrome: pronounced cholelithiasis (1) with a dilated intrahepatic bile duct (2). b Hepatolithiasis

Principal Signs and Symptoms

Fig. 183a–d Common duct stone disease (choledocholithiasis). a Large occlusive stone (ST) in the common hepatic duct (CHD) with prestenotic ductal dilatation extending into the intrahepatic divisions of the ducts (arrows). b Four gallstones (arrows), nonocclusive (normal caliber of intrahepatic duct). c Two prepapillary stones with distal shadowing (S). Arrow: papillary region on the posterior wall of the duodenum (DUO). d ERCP of the case in c demonstrates the two prepapillary stones noted on ultrasound

141

6.10 Jaundice

Occurrence:

Intrahepatic (Fig. 182) : Caroli syndrome (cystic dilatation of intrahepatic bile ducts) leads to recurrent episodes of cholangitis with abscess formation and predisposes to lithiasis and other diseases. It must be differentiated from hepatolithiasis.

Extrahepatic (Fig. 183): common hepatic duct, common bile duct, prepapillary

Biliary Obstruction or Tumor (Fig. 184)

..............................................................................................................

See also Bile Ducts, Biliary papillomatosis, p. 328; intrahepatic biliary carcinoma, p. 329; Ductal dilatation due to compression or invasion by metastases, p. 143, 145, 329; Anechoic ductal dilatation due to obstructive cholestasis, p. 330.

Clinical manifestations :

Painless jaundice, or jaundice with colicky pain

Principal Signs and Symptoms

Diagnosis:

History

Laboratory findings : elevated conjugated direct bilirubin

Sonography

ERCP

Percutaneous biopsy is done only if the diagnosis is uncertain, not to confirm a tumor.

Sonographic findings: dilated bile ducts, depending on the site of the obstruction;

possible obstruction of the pancreatic duct

Stone (Fig. 184): relatively echogenic mass that moves with position changes, usually with a partial acoustic shadow (Stones that form intraductally are mostly pigment stones containing little calcium.)

Biliary papillomatosis (multiple mucus-producing epithelial tumors): hypoechoic, immobile intraluminal voids with ill-defined margins; see also p. 328

Ascariasis: luminal obstruction by ascarids; see also p. 331

Klatskin tumor: dilated intrahepatic bile duct near the bifurcation of the hepatic duct and distal, hypoechoic bile duct obstruction with ill-defined margins; see also p. 329

Accuracy of sonographic diagnosis: The dilated bile ducts can be clearly visua-

lized. Occasionally the cause cannot be determined even with further tests and is not definitely established until operative exposure and histologic examination.

Fig. 184 Large gallstone (arrow; incomplete sh adow, S) partially obstructing the bile duct (BD)

142

6.10 Jaundice

Bile Duct Compression or Infiltration (Figs. 185–190)

..............................................................................................................

Note: Rarely, jaundice is caused by the compression of bile ducts by lymph nodes,

a pseudocyst, duodenal diverticulum, Mirizzi stone, or in Caroli syndrome. The infiltration of bile ducts by an invasive tumor is somewhat more common.

Mirizzi syndrome (Fig. 185): Morphological variant of the cystic duct, which has

a low termination and runs parallel to the hepatic duct. An impacted stone in the cystic duct or gallbladder neck may lead to compression of the hepatic duct. Mirizzi syndrome is marked by chronic biliary tract stenoses due to recurrent episodes of cholangitis. Four grades of severity are distinguished based on the circumference of the common hepatic duct and common bile duct.

Caroli syndrome (Fig. 182a, p. 141): cystic dilatation of the intrahepatic bile duct,

diffuse or localized. Children are predominantly affected and often present with upper abdominal pain and jaundice. Cholangitis, lithiasis, and renal and pancreatic cysts are common. Frequently coexists with congenital periportal hepatic fibrosis. Inspissated bile in the dilated ducts may be mistaken for a tumor.

Fig. 185 Mirizzi stone (arrow) with an acoustic shadow (S) causing minimal ductal dilatation; no common duct stone

Principal Signs and Symptoms

Fig. 186a, b Small lymph node metastases (arrow) compressing the common hepatic duct; dilatation of the right and left duet (DHD, DHS). The hilar ductal caliber is increased, and conspicuous tubular structures are visible in the perihilar parenchyma (b)

143

6.10 Jaundice

Principal Signs and Symptoms

Fig. 187 Compression of the bile duct (BD) by inflamed lymph nodes (LN, arrows). GB = gallbladder, VC = vena cava. Clinical findings raised suspicion of malignant papillary stenosis, prompting operative treatment. Histology showed no malignancy, only inflammation and fibrosis of the papilla with enlarged lymph nodes

Fig. 188 Compression of the bile duct (BD) by a duodenal diverticulum (D), which could be mistaken for a cyst

Fig. 189 Truncated duct pattern typical of a malignant tumor. The tumor (T) has infiltrated only the hepatic duct (HD) in the absence of hydrops and has encased the hepatic artery (HA), which is in a typical location. PV = portal vein

Fig. 190a, b Treatment with a stent. a Stent and stone in the obstructed bile duct. b Stent in the bile duct, which is completely occupied by papillomatous carcinoma

144

6.10 Jaundice

Hepatic Tumor (Fig. 191)

..............................................................................................................

See also Liver, Primary hepatic carcinoma, p. 249; Metastases, p. 250.

Clinical manifestations: painless jaundice; possible known tumor disease; pos-

sible abdominal distension with ascites

Note: Painless jaundice is often the initial sign and sole indicator of a primary

hepatic tumor.

Diagnosis: history; laboratory tests; sonography; CT angiography (if required);

FNAB

Sonographic findings :

Anechoic fluid in the abdominal cavity

Mass of highly variable echogenicity and shape (see also Chap. 21, Search for Occult Tumors): – Discrete outflow obstruction with associated biliary stasis – Diffuse lesion with functional loss of liver parenchyma and jaundice, even in

the absence of biliary obstruction

Accuracy of sonographic diagnosis: A careful examination can detect round

lesions as small as 1–2 cm in 80 % of cases.

Principal Signs and Symptoms

Fig. 191a–c Tumor-related cholestasis. a Intrahepatic cholestasis due to cho-

langiocellular carcinoma. b Extrahepatic cholestasis due to a gallbladder tumor (T) that has infiltrated and obstructed the bile duct (arrow)

Cholangitis (Fig. 192)

..............................................................................................................

See also Bile Ducts, Biliary sludge and pus, p. 331; Sclerosing cholangitis, p. 327.

Classification:

Acute suppurative cholangitis

Primary sclerosing cholangitis (PSC): associated with chronic inflammatory

bowel diseases; leads to biliary hepatic cirrhosis

Chronic, nonsuppurative destructive cholangitis (precursor of primary biliary cirrhosis [PBC]) : cannot be diagnosed with ultrasound, which is used only to

145

6.10 Jaundice

Fig. 192a, b a Cholangitis due to chronic obstruction by an impacted stone. The bile duct is expanded and shows marked wall thickening to 4 mm. b Chronic sclerosing cholangitis with the development of hepatic cirrhosis. Magnified view of

Principal Signs and Symptoms

the left hepatic lobe: “three-lane highway” pattern; the central red-encoded vessel is a dilated artery

exclude other causes of jaundice. Typically, mitochondrial antibodies are positive in 96 % of cases.

Vascular cholangitis

Clinical manifestations of acute suppurative cholangitis: severe illness ranging

to septic shock, fever, jaundice, right upper quadrant pain

Diagnosis: history, associated disease; laboratory tests; sonography; ERCP :

In PSC: irregular luminal width of the bile ducts; biopsy, histology

In PBC: markedly fine intra- and extrahepatic bile ducts

Sonographic findings :

Signs of sclerosis in PSC (see also Fig. 479, p. 327): – Bile duct walls are thickened and echogenic – Luminal irregularities of the intra- or extrahepatic bile ducts with circum-

scribed dilatations

– Prominence of the portal tract arteries and intrahepatic bile ducts (“three-

lane highway”)

– Development of cirrhosis: initial vascular changes followed by changes in the

liver contours

Inflammatory signs in suppurative cholangitis:

– Thickening and layering of the duct wall – Echogenic material in the duct lumen

Causes of inflammation: stone, abscess, obstructing tumor

Accuracy of sonographic diagnosis: Ultrasound can suggest the correct diagnosis,

which is confirm ed by endoscopic retrograde cholangiography (ERC), biopsy, and the clinical findings.

Fatty Liver Hepatitis, Chronic Toxic Liver Disease, Nonalcoholic steatohepatatis (NASH)

..............................................................................................................

See also Liver, toxic fatty liver, toxic chronic liver disease, p. 234, 238.

Clinical manifestations: right upper quadrant abdominal pain, anorexia, nausea,

Diagnosis: history; clinical findings; laboratory findings: elevated transaminases,

glutamate dehydrogenase (GLDH); sonography; liver biopsy and histology

146

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