1979, British Journal of Radiology, 52, 276-280
Ultrasound in the evaluation and diagnosis of jaundice By K. C. Dewbury, B.Sc, F.R.C.R., A. E. A. Joseph, M.Sc, F.R.C.R., S. Hayes and C. Murray, M.R.C.P. Radiology Department, Southampton General Hospital, Southampton {Received July, 1978) ABSTRACT
Our experience in the evaluation and diagnosis of jaundice by ultrasound in a consecutive series of patients examined in the past year is reported. A final diagnosis is available in 49 patients with obstructive jaundice and 41 patients with nonobstructive jaundice. The accuracy of separation into these two groups is 97% in this series. We would like to stress the value of ultrasound as a complete investigation in many jaundiced patients. In this series a full diagnosis of the cause of jaundice was achieved in 58% of patients.
In the past few years the ultrasound diagnosis of obstructive jaundice has been shown to be accurate in experienced hands. The positive diagnosis of extrahepatic obstruction approaches 100% (Taylor etal.y 1974; Conrad et al, 1978; Malini and Sabel, 1977). The basis for making the diagnosis is the identification of a dilated biliary tree in the jaundiced patient. We report our experience over a twelvemonth period in which a series of 111 consecutive patients presenting with jaundice were examined. We would like to emphasize the value of ultrasound imaging not only as a screening procedure to separate obstructive jaundice from other causes of jaundice but in the accurate specific diagnosis of jaundice in many instances. SUBJECTS AND METHODS
It has become the practice in our hospital for most jaundiced patients to have an ultrasound examination as soon as possible after presenting. Over a twelve-month period a series of 111 consecutive patients have been examined. All patients had a bilirubin level greater than 3 mg% (50 milliosmoles/ litre). A final diagnosis is available in 90 patients, obtained by review of the patients' records. In all patients shown to have obstructive jaundice the final diagnosis was reached at laparotomy or in a few instances at post mortem. Biopsy results are available in most patients with non-obstructive jaundice. However, six patients with infective hepatitis have been included without biopsy proof, as in these instances the biochemical studies, auto-immune studies and clinical course were so typical for there to be no reasonable doubt as to the diagnosis. Twenty-one cases had to be excluded where proof of diagnosis was not available (refusal of biopsy, laparotomy or post mortem). All examinations were performed using a commercially available grey-
scale unit and a 2.25 MHz 19 mm long internally focused transducer. Initially a series of longitudinal and transverse scans were done at 2 cm intervals using the standard single sweep technique, where possible in suspended inspiration. Transverse oblique scans were taken to maximize pancreatic visualization. In all cases of obstructive jaundice it is our practice to rotate the patient 30 deg into the right anterior oblique position to maximize visualization of the full length of the common bile duct, with a series of closely spaced longitudinal scans. A common bile duct measurement of over 8 mm by ultrasound was considered dilated (Behan and Kazam, 1978). This technique has proved particularly valuable in demonstrating both the level and cause of obstruction. The left lateral position may occasionally be of value in demonstrating the lower end of the common bile duct. This position is also used for intercostal scans when the liver is obscured by bowel gas in other positions. In these circumstances only limited views of the liver parenchyma may be obtained, however this is often sufficient to confirm or exclude obstruction as a cause of jaundice. In all cases with no evidence of obstruction initially we now make a positive search for the main left and right hepatic ducts lying adjacent to the portal veins. Even when of normal calibre these are quite frequently demonstrated (Fig. 1). RESULTS
In the full series of 111 patients there were two scan failures due to excessive bowel gas. This failure rate of 2% is surprisingly low. The possible explanation for this lies in the fact that many jaundiced patients have enlarged livers which are more easily demonstrated and also in the value of intercostal scans in the left lateral position. Although for most other situations a fairly comprehensive view of the liver is required for a successful study in the patient with obstructive jaundice, limited views of the liver will often be adequate to confirm the presence of dilated ducts. A positive final diagnosis is available in 90 patients, 49 of whom had obstructive jaundice and 41 nonobstructive jaundice. Details are given in Tables I
276
APRIL
1979
Ultrasound in the evaluation and diagnosis of jaundice TABLE I OBSTRUCTIVE JAUNDICE
Patients
Ultrasound diagnostic
Ultrasound helpful
Ultrasound failed
Carcinoma of the pancreas
18
12(66%)
1(6%)
—
Stones in common bile duct
19
11(58%)
5(26%)
—
1
—
—
—
Diagnosis
3
Carcinoma of gall-bladder
1
Cholangiocarcinoma and infiltrating lesions at porta hepatis
3
3(100%)
Ampullary carcinoma
3
2(66%)
1(33%)
—
Non-malignant stricture CBD
3
—
3(100%)
—
Dilated CBD — no stones found
2
1(50%)
1(50%)
—
49
29(59%)
12(24%)
3
Totals
TABLE II NON-OBSTRUCTIVE JAUNDICE
Diagnosis
Ultrasound diagnostic
Hepatitis
20
4 (all severe changes)
Cirrhosis and fatty infiltration
13
11(84%)
Cardiac cirrhosis
3
3(100%)
Metastases
5
5(100%)
Totals
FIG. 1. A transverse scan showing the main right portal vein (PV) and above it the main right hepatic duct (HD).
Patients
41
23(56%)
and II. There were no false positives and three false negatives. All the false negatives were in patients with intermittent biliary obstruction due to gallstones. In two cases calculi were demonstrated in the gall-bladder but dilated ducts were not seen. Laparotomy was, however, three weeks later in one instance and five weeks later in the second, when in both cases calculi were found in a dilated common bile duct. The third failure is described in more detail later. The accuracy of separation into two main groups was 97% in this series. When the ultrasound report records the precise cause of jaundice these results are classified as diagnostic. In obstructive jaundice a further category is identified in which
277
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52, No. 616 K. C. Dewbury, A. E. A. Joseph, S. Hayes and C. Murray
the ultrasound report indicated the level of obstruction or contributed other helpful, but non-diagnostic information about the nature of the obstruction. These are classified as helpful. Diagnostic results were obtained in a total of 52 patients (58%), and helpful results in a further 13%. In the series there were 18 cases of pancreatic carcinomas, 12 of which (66%) were demonstrated. There were 19 patients with stones in the common bile duct which were identified in 11 cases (58%). All the five patients with metastases were correctly identified. In 15 cases of non-obstructive jaundice a bright liver echo pattern was identified. We consider this indicative of cirrhosis, fatty infiltration or severe hepatitis (Dewbury et al, 1979). Biopsy in these cases indicated one of these pathologies in all instances. In three patients a bright liver echo pattern was identified in association with enlargement of the IVC and hepatic veins. All these patients were in severe congestive heart failure, one came to post mortem within two weeks and the liver showed the typical changes of cardiac cirrhosis. Two patients with cirrhosis had normal ultrasound images as did the majority of patients with hepatitis. Casei
FIG. 2A.
Longitudinal scan showing the full length of the common bile duct (CBD) with an irregular heterogenous mass at its lower ends (arrowheads) typical of a pancreatic tumour.
ILLUSTRATIVE CASE REPORTS
A 72-year-old man presented with a three-week history of progressive jaundice. On physical examination, the liver and gall-bladder were enlarged. The bilirubin was 12 mg% and the liver function tests suggested an obstructive aetiology. An ultrasound examination was performed within 48 hours of admission. This confirmed the presence of enlarged ducts within the liver (Fig. 2A and B). The common bile duct was identified measuring 20 mm in diameter and this was traced down to its lower end where it terminates in a large pancreatic mass. Multiple metastases were also demonstrated in the liver. The ultrasound diagnosis was of extrahepatic biliary obstruction secondary to a large pancreatic carcinoma with liver metastases. These findings were all confirmed at laparotomy. Case 2 A 56-year-old woman presented with a ten-day history of jaundice initially associated with pain. An ultrasound examination was performed. This showed moderate dilatation of intrahepatic biliary radicles and marked enlargement of the common bile duct (Fig. 3). This measured 18 mm in diameter. At the lower end of the common bile duct a 2 cm calculus is demonstrated with distal acoustic shadowing. These findings were confirmed at laparotomy. Case 3 A 43-year-old man with several months history of vague abdominal discomfort and a five-day history of jaundice was admitted to hospital for further investigation. He was a publican and admitted to a large alcohol intake. Physical examination revealed an enlarged, slightly tender liver. The bilirubin level was 5 mg%. An ultrasound examination demonstrated considerable hepatic enlargement with no evidence of dilated biliary ducts. The liver echo pattern was brightly reflective suggesting fatty infiltration and/or cirrhosis (Fig. 4A and B). A liver biopsy confirmed an established mixed pattern cirrhosis with a minor degree of fatty deposition.
FIG. 2B.
Transverse scan in the same patient showing the full extent of the pancreatic mass (P). Dilated ducts (D) within the liver and metastases (M) are also shown. K = Kidney; S = Spine; Ao=Aorta. DISCUSSION
The value of ultrasound imaging as a tool for separating obstructive jaundice from other causes of jaundice is confirmed in our series with an accuracy of97%. We would like to stress that in over half the patients a further step can be taken in making a definitive diagnosis by ultrasound. This compares favourably with the experience of other workers (Taylor and Rosenfield, 1977). In obstructive jaundice this will obviate the need for further investigatory procedures such as PTC and ERCP prior to laparotomy. The commonest causes of obstructive jaundice are carcinoma of the pancreas and common bile duct stones. We were able to make
278
APRIL 1979
Ultrasound in the evaluation and diagnosis of jaundice
FIG. 3. Longitudinal scan showing the dilated common bile duct (CBD) with a calculus (C) at its lower end. The acoustic shadowing (AS) is readily visible.
positive diagnoses in 66% and 58% respectively of these conditions. Two of the pancreatic carcinomas not visualized were under 3 cm in diameter. The key to the making of a complete diagnosis in obstructive jaundice is the good visualization of the common bile duct. We have noted during this study that our ability to visualize the common bile duct has increased since we have adopted the technique of rotating the patient into the right anterior oblique position to obtain optimal results. For this reason we anticipate that our diagnostic accuracy will increase. The regular identification of the normal calibre common bile duct is more difficult. It is well recognized that in a small number of patients with obstructive jaundice the common bile duct may not be enlarged. In our series we had one such patient (the third false negative) with a history of several attacks of typical biliary colic over a six-month period, culminating in jaundice in the last attack. Jaundice had been present for over two weeks when the ultrasound examination was done and this did not show any evidence of dilated ducts. The presence of calculi in a non-dilated common bile duct was demonstrated by ERCP and these were later removed at laparotomy. This case emphasizes the point that in the presence of a clinical history of obstructive jaundice with biochemical findings also pointing to an obstructive aetiology, further diagnostic studies may need to be carried out in the presence of a negative ultrasound examination. This can either be a HIDA isotope scan or the more invasive procedures of endoscopic retrograde cannulation of the papilla (ERCP) or percutaneous transhepatic cholangiography (PTC). In non-obstructive jaundice the ability to make a
FIG. 4A.
A longitudinal scan through the right lobe of the liver. This shows hepatic enlargement and a brightly reflective echo pattern. Compare appearances with Fig. 4B.
FIG. 4B.
Normal liver for comparison.
positive diagnosis rests essentially in the detection of either metastases or the bright liver echo pattern corresponding to cirrhosis, fatty infiltration or severe hepatitis. In this series 23 positive diagnoses were made (56%). Not surprisingly all the patients with metastatic replacement were correctly identified. The overall accuracy achieved will obviously depend on the proportion of such cases in the series. If this group contained mainly cases of moderately severe infective hepatitis the diagnostic possibilities are more limited. Some of the patients with longstanding hepatitis showed a relatively non-reflective echo pattern in the liver. We have begun to recognize this since completion of data for this study. Its significance and its cause are not yet clear. We have shown that the non-reflective halo in the target metastasis is associated with sinusoidal ectasia in post mortem liver studies. Attention to this finding of a relatively
279
V O L . 5 2 , No. 616
K. C. Dewbury, A. E. A. Joseph, S. Hayes and C. Murray non-reflective transonic liver may help in positively identifying the patient with hepatitis. We are at present evaluating this rinding more fully.
REFERENCES BEHAN, M. and KAZAM, E., 1978. Sonography of the com-
mon bile duct: value of the right anterior oblique view. American Journal of Roentgenology, 130, 701-709. CONRAD, M. R., LANDAY, M. J. and JAMES, J. O., 1978.
Sonographic "parallel channel" sign of biliary tree enlargement in mild to moderate obstructive jaundice. American Journal of Roentgenology, 130, 279-286.
CONCLUSION
Ultrasound accurately categorizes jaundice into two main groups and should undoubtedly be the screening method of choice, performed as early as possible in the assessment of the jaundiced patient. In over half the patients a definitive diagnosis may be reached. This is of considerable importance in the management of the patient with obstructive jaundice. In these instances more invasive procedures such as PTC and ERCP need not be performed. Where appropriate, laparotomy may be proceeded to with no further investigatory delay.
JOSEPH, A. E. A., DEWBURY, K. C. and MCGUIRE, P., 1979.
Ultrasound in the detection of chronic liver disease (the "bright liver"). British Journal of Radiology, 52,184^88. MALINI, S. and SABEL, J., 1977. Ultrasonography in ob-
structive jaundice. Radiology, 123, 429—433. TAYLOR, K. J. W., CARPENTER, D. A. and MCCREADY, V.,
1974. Ultrasound and scintigraphy in the differential diagnosis of obstructive jaundice. Journal of Clinical Ultrasound, 2,105-116. TAYLOR, K. J. W. and ROSENFIELD, A. T., 1977. Grey-scale
ultrasonography in the differential diagnosis of jaundice. Archives of Surgery, 112, 820-825.
Book reviews Recent Advances In Ultrasound Diagnosis. Edited by Asim Kurjak, pp. iii + 330, 1978 (Excerpta Medica, The Netherlands), $52.25. This book is the Proceedings of the International Symposium on Recent Advances in Ultrasound Diagnosis held in Dubrovnik in October, 1977. The book consists of photo copies of the precis submitted by the authors together with pictures which appear to have reproduced well. The contents vary in quality more than most books with multiple authors, because of the absence of any editorial alteration in the submissions. Some have quaint English and spelling. Despite the variations in type face, it is easily read. The quality of pictures from the various centres is remarkably wide, varying from the virtually incomprehensible to the superb examples provided by Kossoff and his colleagues in Australia, and one must agree with Donald in his introduction, who points out that "No diagnostic technique can be better than the diagnostic ability of the clinician." There seems no doubt that the important part of an ultrasound examination remains the operator who carries out the procedure and interprets the results. There are 39 articles in all, of which 16 are on obstetrics and gynaecology. The liver attracted little attention. Poor results are again reported in ultrasound of the breast, which is disappointing considering the superficial nature of the organ, and the wide application this examination would have if it were successful. Striking results are reported in the assessment of blood vessels, from Drs. White and Curry from Ontario, and other workers also report their experience in this field. The book will be read with interest by workers developing ultrasound techniques. It contains a fair number of up-todate references, and is recommended for the libraries of ultrasound departments carrying out research. J. G. B. RUSSELL.
Prevention and detection of cancer. Part I: Prevention Vol. 1: Etiology. Edited by H. E. Nieburgs, pp. xx+1193, illus., 1977 (Marcel Dekker Inc., New York), Sw.Fr.190. This volume on the aetiology of cancer is the first of four which will present the contributions to the Third International Symposium on Detection and Prevention of Cancer held in New York City from April 26 to May 1, 1976. The preface states that the four volumes aim to "provide a comprehensive review of our current state of knowledge on the role of experimental and human oncogenesis and of host and environmental factors for primary and secondary prevention," constituting a "multidisciplinary approach to cancer control that bridges fundamental research and clinical oncology." With such ambitious aims, it is to be expected that the first volume devoted to the important and basic subject of aetiology should be lengthy and expensive. And, at about 1200 pages and priced at over Sw.Fr.190, it is both of these. It is disappointing, therefore, to find that this work is not comprehensive and includes little that is not available elsewhere. The chapter on radiation is the shortest in the book with only three contributions. Of these, two report small series of radiation-related malignancies. The third paper by C. E. Land and D. H. McGregor deals with the induction period of radiation-induced malignancy. Whereas radiationinduced leukaemia occurs at an earlier age than the average, no such tendency is shown by the radiation-induced cancers of the lung and breast. The suggestion is made that the increased incidence of lung and breast cancer following radiation exposure depends on the additional operation of factors similar to those that influence the development of these cancers in the general (non-exposed) population. Most of the book is devoted to laboratory work and not to the epidemiology of cancer in man as the title might suggest to many readers. L. KINLEN.
280
Ultrasound in the evaluation and diagnosis of jaundice By K. C. Dewbury, B.Sc, F.R.C.R., A. E. A. Joseph, M.Sc, F.R.C.R., S. Hayes and C. Murray, M.R.C.P. Radiology Department, Southampton General Hospital, Southampton {Received July, 1978) ABSTRACT
Our experience in the evaluation and diagnosis of jaundice by ultrasound in a consecutive series of patients examined in the past year is reported. A final diagnosis is available in 49 patients with obstructive jaundice and 41 patients with nonobstructive jaundice. The accuracy of separation into these two groups is 97% in this series. We would like to stress the value of ultrasound as a complete investigation in many jaundiced patients. In this series a full diagnosis of the cause of jaundice was achieved in 58% of patients.
In the past few years the ultrasound diagnosis of obstructive jaundice has been shown to be accurate in experienced hands. The positive diagnosis of extrahepatic obstruction approaches 100% (Taylor etal.y 1974; Conrad et al, 1978; Malini and Sabel, 1977). The basis for making the diagnosis is the identification of a dilated biliary tree in the jaundiced patient. We report our experience over a twelvemonth period in which a series of 111 consecutive patients presenting with jaundice were examined. We would like to emphasize the value of ultrasound imaging not only as a screening procedure to separate obstructive jaundice from other causes of jaundice but in the accurate specific diagnosis of jaundice in many instances. SUBJECTS AND METHODS
It has become the practice in our hospital for most jaundiced patients to have an ultrasound examination as soon as possible after presenting. Over a twelve-month period a series of 111 consecutive patients have been examined. All patients had a bilirubin level greater than 3 mg% (50 milliosmoles/ litre). A final diagnosis is available in 90 patients, obtained by review of the patients' records. In all patients shown to have obstructive jaundice the final diagnosis was reached at laparotomy or in a few instances at post mortem. Biopsy results are available in most patients with non-obstructive jaundice. However, six patients with infective hepatitis have been included without biopsy proof, as in these instances the biochemical studies, auto-immune studies and clinical course were so typical for there to be no reasonable doubt as to the diagnosis. Twenty-one cases had to be excluded where proof of diagnosis was not available (refusal of biopsy, laparotomy or post mortem). All examinations were performed using a commercially available grey-
scale unit and a 2.25 MHz 19 mm long internally focused transducer. Initially a series of longitudinal and transverse scans were done at 2 cm intervals using the standard single sweep technique, where possible in suspended inspiration. Transverse oblique scans were taken to maximize pancreatic visualization. In all cases of obstructive jaundice it is our practice to rotate the patient 30 deg into the right anterior oblique position to maximize visualization of the full length of the common bile duct, with a series of closely spaced longitudinal scans. A common bile duct measurement of over 8 mm by ultrasound was considered dilated (Behan and Kazam, 1978). This technique has proved particularly valuable in demonstrating both the level and cause of obstruction. The left lateral position may occasionally be of value in demonstrating the lower end of the common bile duct. This position is also used for intercostal scans when the liver is obscured by bowel gas in other positions. In these circumstances only limited views of the liver parenchyma may be obtained, however this is often sufficient to confirm or exclude obstruction as a cause of jaundice. In all cases with no evidence of obstruction initially we now make a positive search for the main left and right hepatic ducts lying adjacent to the portal veins. Even when of normal calibre these are quite frequently demonstrated (Fig. 1). RESULTS
In the full series of 111 patients there were two scan failures due to excessive bowel gas. This failure rate of 2% is surprisingly low. The possible explanation for this lies in the fact that many jaundiced patients have enlarged livers which are more easily demonstrated and also in the value of intercostal scans in the left lateral position. Although for most other situations a fairly comprehensive view of the liver is required for a successful study in the patient with obstructive jaundice, limited views of the liver will often be adequate to confirm the presence of dilated ducts. A positive final diagnosis is available in 90 patients, 49 of whom had obstructive jaundice and 41 nonobstructive jaundice. Details are given in Tables I
276
APRIL
1979
Ultrasound in the evaluation and diagnosis of jaundice TABLE I OBSTRUCTIVE JAUNDICE
Patients
Ultrasound diagnostic
Ultrasound helpful
Ultrasound failed
Carcinoma of the pancreas
18
12(66%)
1(6%)
—
Stones in common bile duct
19
11(58%)
5(26%)
—
1
—
—
—
Diagnosis
3
Carcinoma of gall-bladder
1
Cholangiocarcinoma and infiltrating lesions at porta hepatis
3
3(100%)
Ampullary carcinoma
3
2(66%)
1(33%)
—
Non-malignant stricture CBD
3
—
3(100%)
—
Dilated CBD — no stones found
2
1(50%)
1(50%)
—
49
29(59%)
12(24%)
3
Totals
TABLE II NON-OBSTRUCTIVE JAUNDICE
Diagnosis
Ultrasound diagnostic
Hepatitis
20
4 (all severe changes)
Cirrhosis and fatty infiltration
13
11(84%)
Cardiac cirrhosis
3
3(100%)
Metastases
5
5(100%)
Totals
FIG. 1. A transverse scan showing the main right portal vein (PV) and above it the main right hepatic duct (HD).
Patients
41
23(56%)
and II. There were no false positives and three false negatives. All the false negatives were in patients with intermittent biliary obstruction due to gallstones. In two cases calculi were demonstrated in the gall-bladder but dilated ducts were not seen. Laparotomy was, however, three weeks later in one instance and five weeks later in the second, when in both cases calculi were found in a dilated common bile duct. The third failure is described in more detail later. The accuracy of separation into two main groups was 97% in this series. When the ultrasound report records the precise cause of jaundice these results are classified as diagnostic. In obstructive jaundice a further category is identified in which
277
VOL.
52, No. 616 K. C. Dewbury, A. E. A. Joseph, S. Hayes and C. Murray
the ultrasound report indicated the level of obstruction or contributed other helpful, but non-diagnostic information about the nature of the obstruction. These are classified as helpful. Diagnostic results were obtained in a total of 52 patients (58%), and helpful results in a further 13%. In the series there were 18 cases of pancreatic carcinomas, 12 of which (66%) were demonstrated. There were 19 patients with stones in the common bile duct which were identified in 11 cases (58%). All the five patients with metastases were correctly identified. In 15 cases of non-obstructive jaundice a bright liver echo pattern was identified. We consider this indicative of cirrhosis, fatty infiltration or severe hepatitis (Dewbury et al, 1979). Biopsy in these cases indicated one of these pathologies in all instances. In three patients a bright liver echo pattern was identified in association with enlargement of the IVC and hepatic veins. All these patients were in severe congestive heart failure, one came to post mortem within two weeks and the liver showed the typical changes of cardiac cirrhosis. Two patients with cirrhosis had normal ultrasound images as did the majority of patients with hepatitis. Casei
FIG. 2A.
Longitudinal scan showing the full length of the common bile duct (CBD) with an irregular heterogenous mass at its lower ends (arrowheads) typical of a pancreatic tumour.
ILLUSTRATIVE CASE REPORTS
A 72-year-old man presented with a three-week history of progressive jaundice. On physical examination, the liver and gall-bladder were enlarged. The bilirubin was 12 mg% and the liver function tests suggested an obstructive aetiology. An ultrasound examination was performed within 48 hours of admission. This confirmed the presence of enlarged ducts within the liver (Fig. 2A and B). The common bile duct was identified measuring 20 mm in diameter and this was traced down to its lower end where it terminates in a large pancreatic mass. Multiple metastases were also demonstrated in the liver. The ultrasound diagnosis was of extrahepatic biliary obstruction secondary to a large pancreatic carcinoma with liver metastases. These findings were all confirmed at laparotomy. Case 2 A 56-year-old woman presented with a ten-day history of jaundice initially associated with pain. An ultrasound examination was performed. This showed moderate dilatation of intrahepatic biliary radicles and marked enlargement of the common bile duct (Fig. 3). This measured 18 mm in diameter. At the lower end of the common bile duct a 2 cm calculus is demonstrated with distal acoustic shadowing. These findings were confirmed at laparotomy. Case 3 A 43-year-old man with several months history of vague abdominal discomfort and a five-day history of jaundice was admitted to hospital for further investigation. He was a publican and admitted to a large alcohol intake. Physical examination revealed an enlarged, slightly tender liver. The bilirubin level was 5 mg%. An ultrasound examination demonstrated considerable hepatic enlargement with no evidence of dilated biliary ducts. The liver echo pattern was brightly reflective suggesting fatty infiltration and/or cirrhosis (Fig. 4A and B). A liver biopsy confirmed an established mixed pattern cirrhosis with a minor degree of fatty deposition.
FIG. 2B.
Transverse scan in the same patient showing the full extent of the pancreatic mass (P). Dilated ducts (D) within the liver and metastases (M) are also shown. K = Kidney; S = Spine; Ao=Aorta. DISCUSSION
The value of ultrasound imaging as a tool for separating obstructive jaundice from other causes of jaundice is confirmed in our series with an accuracy of97%. We would like to stress that in over half the patients a further step can be taken in making a definitive diagnosis by ultrasound. This compares favourably with the experience of other workers (Taylor and Rosenfield, 1977). In obstructive jaundice this will obviate the need for further investigatory procedures such as PTC and ERCP prior to laparotomy. The commonest causes of obstructive jaundice are carcinoma of the pancreas and common bile duct stones. We were able to make
278
APRIL 1979
Ultrasound in the evaluation and diagnosis of jaundice
FIG. 3. Longitudinal scan showing the dilated common bile duct (CBD) with a calculus (C) at its lower end. The acoustic shadowing (AS) is readily visible.
positive diagnoses in 66% and 58% respectively of these conditions. Two of the pancreatic carcinomas not visualized were under 3 cm in diameter. The key to the making of a complete diagnosis in obstructive jaundice is the good visualization of the common bile duct. We have noted during this study that our ability to visualize the common bile duct has increased since we have adopted the technique of rotating the patient into the right anterior oblique position to obtain optimal results. For this reason we anticipate that our diagnostic accuracy will increase. The regular identification of the normal calibre common bile duct is more difficult. It is well recognized that in a small number of patients with obstructive jaundice the common bile duct may not be enlarged. In our series we had one such patient (the third false negative) with a history of several attacks of typical biliary colic over a six-month period, culminating in jaundice in the last attack. Jaundice had been present for over two weeks when the ultrasound examination was done and this did not show any evidence of dilated ducts. The presence of calculi in a non-dilated common bile duct was demonstrated by ERCP and these were later removed at laparotomy. This case emphasizes the point that in the presence of a clinical history of obstructive jaundice with biochemical findings also pointing to an obstructive aetiology, further diagnostic studies may need to be carried out in the presence of a negative ultrasound examination. This can either be a HIDA isotope scan or the more invasive procedures of endoscopic retrograde cannulation of the papilla (ERCP) or percutaneous transhepatic cholangiography (PTC). In non-obstructive jaundice the ability to make a
FIG. 4A.
A longitudinal scan through the right lobe of the liver. This shows hepatic enlargement and a brightly reflective echo pattern. Compare appearances with Fig. 4B.
FIG. 4B.
Normal liver for comparison.
positive diagnosis rests essentially in the detection of either metastases or the bright liver echo pattern corresponding to cirrhosis, fatty infiltration or severe hepatitis. In this series 23 positive diagnoses were made (56%). Not surprisingly all the patients with metastatic replacement were correctly identified. The overall accuracy achieved will obviously depend on the proportion of such cases in the series. If this group contained mainly cases of moderately severe infective hepatitis the diagnostic possibilities are more limited. Some of the patients with longstanding hepatitis showed a relatively non-reflective echo pattern in the liver. We have begun to recognize this since completion of data for this study. Its significance and its cause are not yet clear. We have shown that the non-reflective halo in the target metastasis is associated with sinusoidal ectasia in post mortem liver studies. Attention to this finding of a relatively
279
V O L . 5 2 , No. 616
K. C. Dewbury, A. E. A. Joseph, S. Hayes and C. Murray non-reflective transonic liver may help in positively identifying the patient with hepatitis. We are at present evaluating this rinding more fully.
REFERENCES BEHAN, M. and KAZAM, E., 1978. Sonography of the com-
mon bile duct: value of the right anterior oblique view. American Journal of Roentgenology, 130, 701-709. CONRAD, M. R., LANDAY, M. J. and JAMES, J. O., 1978.
Sonographic "parallel channel" sign of biliary tree enlargement in mild to moderate obstructive jaundice. American Journal of Roentgenology, 130, 279-286.
CONCLUSION
Ultrasound accurately categorizes jaundice into two main groups and should undoubtedly be the screening method of choice, performed as early as possible in the assessment of the jaundiced patient. In over half the patients a definitive diagnosis may be reached. This is of considerable importance in the management of the patient with obstructive jaundice. In these instances more invasive procedures such as PTC and ERCP need not be performed. Where appropriate, laparotomy may be proceeded to with no further investigatory delay.
JOSEPH, A. E. A., DEWBURY, K. C. and MCGUIRE, P., 1979.
Ultrasound in the detection of chronic liver disease (the "bright liver"). British Journal of Radiology, 52,184^88. MALINI, S. and SABEL, J., 1977. Ultrasonography in ob-
structive jaundice. Radiology, 123, 429—433. TAYLOR, K. J. W., CARPENTER, D. A. and MCCREADY, V.,
1974. Ultrasound and scintigraphy in the differential diagnosis of obstructive jaundice. Journal of Clinical Ultrasound, 2,105-116. TAYLOR, K. J. W. and ROSENFIELD, A. T., 1977. Grey-scale
ultrasonography in the differential diagnosis of jaundice. Archives of Surgery, 112, 820-825.
Book reviews Recent Advances In Ultrasound Diagnosis. Edited by Asim Kurjak, pp. iii + 330, 1978 (Excerpta Medica, The Netherlands), $52.25. This book is the Proceedings of the International Symposium on Recent Advances in Ultrasound Diagnosis held in Dubrovnik in October, 1977. The book consists of photo copies of the precis submitted by the authors together with pictures which appear to have reproduced well. The contents vary in quality more than most books with multiple authors, because of the absence of any editorial alteration in the submissions. Some have quaint English and spelling. Despite the variations in type face, it is easily read. The quality of pictures from the various centres is remarkably wide, varying from the virtually incomprehensible to the superb examples provided by Kossoff and his colleagues in Australia, and one must agree with Donald in his introduction, who points out that "No diagnostic technique can be better than the diagnostic ability of the clinician." There seems no doubt that the important part of an ultrasound examination remains the operator who carries out the procedure and interprets the results. There are 39 articles in all, of which 16 are on obstetrics and gynaecology. The liver attracted little attention. Poor results are again reported in ultrasound of the breast, which is disappointing considering the superficial nature of the organ, and the wide application this examination would have if it were successful. Striking results are reported in the assessment of blood vessels, from Drs. White and Curry from Ontario, and other workers also report their experience in this field. The book will be read with interest by workers developing ultrasound techniques. It contains a fair number of up-todate references, and is recommended for the libraries of ultrasound departments carrying out research. J. G. B. RUSSELL.
Prevention and detection of cancer. Part I: Prevention Vol. 1: Etiology. Edited by H. E. Nieburgs, pp. xx+1193, illus., 1977 (Marcel Dekker Inc., New York), Sw.Fr.190. This volume on the aetiology of cancer is the first of four which will present the contributions to the Third International Symposium on Detection and Prevention of Cancer held in New York City from April 26 to May 1, 1976. The preface states that the four volumes aim to "provide a comprehensive review of our current state of knowledge on the role of experimental and human oncogenesis and of host and environmental factors for primary and secondary prevention," constituting a "multidisciplinary approach to cancer control that bridges fundamental research and clinical oncology." With such ambitious aims, it is to be expected that the first volume devoted to the important and basic subject of aetiology should be lengthy and expensive. And, at about 1200 pages and priced at over Sw.Fr.190, it is both of these. It is disappointing, therefore, to find that this work is not comprehensive and includes little that is not available elsewhere. The chapter on radiation is the shortest in the book with only three contributions. Of these, two report small series of radiation-related malignancies. The third paper by C. E. Land and D. H. McGregor deals with the induction period of radiation-induced malignancy. Whereas radiationinduced leukaemia occurs at an earlier age than the average, no such tendency is shown by the radiation-induced cancers of the lung and breast. The suggestion is made that the increased incidence of lung and breast cancer following radiation exposure depends on the additional operation of factors similar to those that influence the development of these cancers in the general (non-exposed) population. Most of the book is devoted to laboratory work and not to the epidemiology of cancer in man as the title might suggest to many readers. L. KINLEN.
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