HEPATOBILIARY EMERGENCIES ULTRASOUND

HEPATOBILIARY EMERGENCIES
Ultrasound scanning is invariably the first-line investigation for suspected biliary tract emergencies. These include inflammatory conditions causing right upper quadrant and epigastric pain, mostly acute cholecystitis or gallstone pancreatitis, and the various causes of obstructive jaundice. If possible, interventional treatment should be delayed until a detailed imaging assessment of the cause of biliary obstruction has been made, since the presence of a biliary stent can compromise subsequent imaging by CT, MRI or endoscopic ultrasound.

Similarly, biliary stents frequently cause bile duct wall thickening and may introduce gas into the biliary tree. These will prevent the diagnosis of cholangitis or ductal calculi with ultrasound, and may impede detailed Doppler investigation of, for example, the portal vein. If urgent biliary drainage is required, particularly when the bile is infected, this can quickly be effected by endoscopic stent placement or sphincterotomy.

These less invasive methods are replacing surgery as the treatment of choice in this situation, having a lower mortality rate. Endoscopic sphincterotomy and stone extraction have been found to be preferable to surgery, particularly in cases of severe gallstone pancreatitis where patients may be poor operative risks and in cases of stone-related cholangitis.

Ultrasound-guided bed-side cholecystostomy may also be useful in high-risk patients with infected gallbladders and is an effective treatment for acalculous cholecystitis brought on by prolonged postoperative fasting.

The liver itself may be acutely tender in systemic venous congestion due to cardiac failure, acute hepatitis, or the presence of an intrahepatic abscess. The management of liver abscesses is determined by their size, number and cause. Ultrasound is used to guide diagnostic aspiration and drainage procedures, and most types of hepatic abscess can be treated successfully using these techniques combined with appropriate antibiotic therapy.