real-time high quality echography

The UOEH Association of Health Sciences

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The UOEHAssociation ofHealth Sciences

J. UOEH, 2(2): 179-192 (1980) 179

(Original]

Real-Time High Quality Electronic Linear Scanning Echography

for Biliary Tract Disease

Toshiji KoBAyAsHI and Minoru HAyAsHI .

DePartntent ef Centrat Clinicag Laboratory, Schooi of Medicine, Ubeiversity of OccuPational and

Environmental Hbalth, JaPan. Kitaleyushu 807, faPan

Abstract: As the recently developed ultrasonography by electronic linear scanning can provide refined

high quality images in real-time fashion for many important target organs, this techni-

que was applied to visualization oi biliary tract disease. Special attention was paid to

the scanning methocls incltrding optimal direction and plane in visualizing the portal venous system, the hepatic veneus system and intrahepatic bile ducts to see ii any dis-

placement or distortion oi these normal anatomical landmarks could contribute important

diagnostic information on Tnany biliary tract diseases. Special ernphases were focused

upon specific echographic signs derived from many typical echograms including the gall-

bladder stone, common bile duct stone, intrahepatic bile duct stone, smal] liver metastases

and cancer of the gallbladder,

Key zvords: ultrasonography, electronic linear scanning, biliary tract disease.

(Received 15 February 1980)

In the past few years many technical amendments have been achievecl in the refine-

ment of ultrasonographic images and its clinical application jn many fields of target

organs.

Since the introduction of the linear eiectronic scanner (Bom, 1971) into clinical ultra-

sonography, the norrnal hepatic and portal veins can be easily visualized and distinguished

from each other. Normal-sized intrahepatic bile ducts are usually invisible by contact

scanning, although the normal extrahepatic biliary tract can be visualized. Hewever, the

recently developed high quality electronic linear scanner (Iinuma et al. , 1976) can visualize

it clearly. Therefore, we investigated its modality in various biliary tract diseases, and

this paper deals with the technique and important landmarks to approach the best visu-

alization of biliary tree changes and the demonstration of typical echograms of various

diseases of a biliary tree.

Materials and Methods

The ultrasonograms of 10 normal adults were carried out to establish the maneuver

in scanning technique to visualize the normal hepatic and portal veins and also to measure

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180 T. KoBAyAsHI&M. HAyASHI

the normal size of intra- and extrahepatic bile ducts as important anatomical landmarks

fer echographic diagnosis of hepatobiliary diseases,

Ult.rasonographic examinations were carried out on 631 patients listed in Table 1 during

the period of 7 months from July 9, 1979 to January 31, 1980. All examinations were

performecl by the high quality elect,ronic linear scanner with the focused transducer of

3.5 MHz (Toshiba SAL-10A).

The abnormal echograms of the patients with proven intrahepatic or extrahepatic bile

duct dilatation ancl focal liver diseases were subjected to this analysis, and surgery,

cholangjography, ERCP and postmortem findings were used as the proof of presence Qf

dilated bile ducts and other changes,

Table 1. 0rgans echographically exarnined during

the period of 7 menths

9-rgal --.. ."-. ..C.a$e -.r

Live'r' 134

Gallbladder and biliary trees 109

Pancreas 33

Spleen 47

Kidney 71

Uterus 154

Ovary 36

Urinary bladder 9

.f)t.RPoln.l!Li.gi-!Limgr .... -- . -m.- 3s.

-

Total -- .- 931--m

Results

L Techniques in maneuver to visuali2e the normal luminal structures

(IntrahePatic Portal and hePatic veins and bilia7cy tract)

In order to obtain the best visualization of intrahepatic luminal structures, the supine

or the left decubitus position is employed,

i) Visualigation of Portal venous system

The abdominal aorta can be first visualized by placing the transducer transversely on

the upper epigastrium, then the important. Iandmarks can be seen, that is, the superior

mesenteric artery (SMA), the splenic vein and the head and body of the pancreas just

above the aorta, as seen in Fig. 1 A. Then, moving the transducer right-clownward,

the splenic vein can be merged into the main portal trunk as seen in Fig. 1 B.

In order te visualize the peripheral branches of the portal veneus systern, that is, the

right and the left port.al branches, the linear transducer is firmly pressed against the

abdominal wa]l at. the subcostal margin at the deep inspiratery phase, deeply tilting it




Real-TirneEchography in Biliary

Fig. 1.Visualization ei the portalAe: Aorta P: PancreasSMA: Superior mesenteric

TractDisease

IB IA

=;"r-----.--t -.-

..t-t:t+N--

-----1--kl'''

･':'Llverg-stt-------;-t--ti---+-r-t---',,s"---t---'-j-.--.i.4Tt-;--1-:+--

'olt･･

-e-----r

:::::-;le-:-:ST--:i"it-----T----"--ttLr--t---:----

-,.-.;.-'.-SSM'A

,-.-.-'xS.PEK-----

1;･,i･lj`I,･i･'e--T-t-:i'---t--t-F-

---lJt.

::n.b;'.

-tI.･':t.:;c::r.

.:-:.:"tHi",l--I..p-tl--

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:t;sJ..--.--..--

r.''--'(:"t:"1:t:'

----'-t:...:';･:'.ktv. Ao

t.---ttt--------t-t-F.-sN-r,-

J.

venous

PV:

artery

system.Main

portal vein

SV: Splenic vein

UP

/t

181

Fig. 2. The peripheral branches of the portal venous system,

GB: Gallbladder !VC: Inferior vena cava

PV: Portal vein UP: Umbilical point

toward the abdominal wall.

The junction of three main branches, that is, the main porLal trunk, the right portal

branch, called the "umbilical

poinV', can be clearly yisualized by following the rnain trunk

peripherally. This echogram can be optimally obtained by the subcostal scanning (Fig. 2).

ii) Visuali2ation of hePatic venous system

By placing 'the

linear transducer at the left upper hypochondrinni, that. is, the scann-



The UOEHAssociation of Health Sciences

182 T. KoBAyAsHI & M.HAyAsHI

Moving tlie transduccr

Hepatic vein

Portal vein

margin, the inferior vena cava

heart, as seen in Fig. 3A. Then

of inferior vena cava and then the

Fig. 3B and 3 C.

venous system and the hepatic

to describe the location of any

' lesions and the biliar}r tree

as preoperative information by

intrahePatic bile duct

the branches of the portal venous

This finding was first demonstrated

et al., ]978) and the "Shotgun

size of the right and left biliary ducts

by the resolution power of the

can be identifiecl as the fine linear

(Fig. 5).

divided into three parts; the- and the lower duodenal portiQn

Fig. 3, Visualization ef hepatic venous systein.

from 3A to 3C,

H: Right side of tbe heart HV: IVC: Inferior vena cava PV:

ing plane direction slightly upward at the left subcostal

can be idenLified at the right-posterior aspect of the

moving the transducer rightward gradually, the tr"nk

hepatic venous branches can be visualized, as seen in

The distribution pattern ol these vessels; the portal

venous system, is a very important anatomical landmark

changes in the liver, Lhat is, the IocaLion of space-occupying

abnormalities.

These echographic signs may be highly appreciated

surgeons who will perform the partial hepatectomy.

iii) Identification and visualization of the normal

Intrahepatic bile ducts run parallel cranially to

system in the normal structure as shown in Fig. 4.

echographically as the ``Paralle]

Channnel Sign'' (ConradSign" (Weill et al., 1978),

After bifurcation from the timbilical point, the

are estimated approximately 4.0 mm in average diameter

linear transducer used in our study. These bile ducts

or luminal struetures just cranially to the portal vein

iv) Techniq"es to visualixe the common bile duct

The comrnon bile duct or choledocus is anaLomically

upper duodenal portion, the posterior duodenal portion




Real-TinieEchographyin Biliary Tract Disease

Fig. 4,Normal anatomical

BD: Biliary tree

HA: Hepatic artery

distribution of various

HV: Hepatic vein

PV: Portal vein

luminalstructures.

183

Fig. 5. Visualization of normal intrahepatic biEe duct. Its bile duct runs parallel to

the portal vein,

BD: Bile duct PV: Portal vein

ending at the Vater orfice in the duodenum as schematically shown in Fig. 6.

The cornmon bile duct runs parallel to the main trunk of the portal venous system,

and can be best visualized at the scanning direction perpendicular to the costal margin,

illustrating its duct closer to the abdominal wall and the porta.1 vein just underneath, as

shown in Fig. 7 as an example, a dilated bile duct.



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184

Fig. 6,

T, KoBAyASHI & M, HAyASHI

Normal anatomyof the common bile duct.

Fig. 7, Dilatation of the cotntnon bile duct.

BD: Dtlated cominon bile duct (Upper duodenal purtion) PV: Portal vein

IL Demonstration of tyPical echograms

i) A tyPical echogram of dilatation of the common bild duct

In this echogram recordecl by the linear electronic scanner at the subcostal margin in

the scanning plane perpendicularly, the dilated comrnon bile duct is clearly shown frorn

the upper duodenal portion to the posterior duodenal portion as shown in Fig. 8.

ii) A tyPical echogram of intrahePatic bile d"ct dilatation

Intrahepatic bile duct dilatation is clearly visualized in the case of cancer of the gall-

biadder with abnormal biochemical data (Total bilirubin 32 mg/dl, GOT 61 I.U., GPT

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The UOEHAssociation ofHealthSclences

Fig. 8.

Real-TimeEchography in BiliaryTract

Dilatation of the common bile duct,CBD: Dilated common bile duct (Upper &BD: Dilated intrahepaLic bile ducts PV:

Fig, 9,Marked dilatation of

(By lincar clectronic

Disease 185

v

posterior duodenalPortal vein

portions)

the inLrahepatic bilescanner)

ducts

x

46 I. U., ALP (K-A) 54 U., and LDH 418 I. U.).

The echograms by the linear scanner (Fig. 9) and by the compound contact scanner

(Fig. 10) show marked dilatation of intrahepatic bile ducts in varying sizes.

a) Dilated intrahepatic bile ducts can be depicted even at the peripheral portion of the

liver parenchym.

b) Acoustic accentuatien is observed underneath the dilated bile ducts.

c) The dilated bile ducts are visualized as anechoic areas.

d ) Normal intrahepatic luminal structures such as the portal or hepatic veins are obscured.

e) Diaphragmatic echo is rather accentuated as compared with that of the normal echo-

gram due te high transmission of ultrasonic energy or reverberation phenomenon

through the dilated bile ducts.




186 T. KoB,xyAsHI & M. HAyAsHI

x

Fig. 10, M[arked dilatation uf the intrahepatic bile duct.

(By compound contacL scanner)

The above-mentioned echographic characteristics are important findings when

diagnosis of the dilatation of common bile duct and intrahepatic bile ducts is made.

iii) 71yPical echograms of common bile duct stone (Choledocholithiasis) The common bile duct stone and its dilatation were clearty demonstrated in Fig.

The location of the linear transducer is markedi at the right upper corner. Dilated

ducts and acoustic shadowing from the stune are also illustrated.

In another case of the common bile duct stene, there was a diagno$tic puzzle

Fig. 11.

the

ILbile

to

itE!ii- "" ' J""'-zz--

Choledocholithiasis (Common bile duct stone)CBD: Dilatecl common bile ductShadow: Acoustic s.hadowing from stone

x




Real-TimcEchography in

Fig. 12.

BiiiaryTractDisease

Choledocholithiasis,12A: Stone ls seen

Cap sign

12B: Confirmation

A

within gallbladder

o[ stone within the

B

187

x

inimicking Phrygian

dirated common bile duct

Fig. 13.Visualization

Arrow: Stoncof the

ecbointrahepaticblle

duct stone.

whether this stone was within the "Phrygian

Cap" sign (Edell, 1978) or a stone within

the common bile duct at the time of examination. In the echogram recorded by the

costal rnargin scanning, whether the gallbladder with Phrygian Cap sign or the gallbaldderwith dilated cornmon bile duct was uncertain, therefore, the tarnsducer was moved to

the perpendicular direction to the costal margin and it was identified that the stone was

within the dilated common bite duct as shown in the right echogram in Fig. 12.




188

Fig, 14,

T. KoBAyAsHI & M.HAyAsHI

Cholecystogram showing thepresenceof thestone.

Fig. 15,Multiple stones in the left hepatic

BD: Dilated bile duct Shadew:

vi}i.tnvs.

'

ii'f,lillf.Siit'li.l,//rS;it:'

lf･}i,ill.,s:'i--tJ-t---::+t'th..t

--- a.:t-tt E-L:tv

:.･ SF:/ t･;ZS:i

iij;'

BD.･:,･:.;.,,g'::I･:':::'il.:･ild

.,tEpt

t'--

$K. i

ge ptss"sk,/'::･' n :L

s es>,-1

--==.

bile duct,Acoustic shadow

multiple stonesfrom

x

iv) A typical echogram ef a intrahePatic bile duct stone

Typical echograms oi a intrahepatic bile duct $tolle are shown in Fig. 13. A high

echo-level fine stone is cleariy shown wiLh acoustic shadowing underneath. Cholecysto-

gram by the drip infusion technique shows a intrahepatic bile duct stone in this patient

(Fig. 14).

v) MultiPle small stones in the left hePatic bile duct

Multipie small stones with acoustic shadowing underneath are clearly demonstrated

within the left intrahepatic bile duct as shown in Fig. ]5.

vi) Dilatation and the narrowing of the common bile duct

The comrnon bile duct is dilated at the upper duodenal portion and its lower duodenal

portion is narrowed in the case of cancer of the Papilla Vaterii. Its echogram shows




Real-TimeEchography

Fig, 16,Echogramfromcancer

in Biliary Tract Disease

of PapillaVaterii. Dilatation and .narrowmg.

189

Fig. 17. Chlecystogram in Lhc case of cancer of Papilla VaLerii. Dilated

common bile duct and sudden disappearance of radiopaque

material at the lower portion.

dilated and then narrowed portions in the cornmon bile duct (Fig. 16). Its cholecysto-

gram shows a dillated common bile duct and sudden disappearance of radiopaque material

at t/he lower portion as shown in Fig. 17.

vii) Liver metastases and the dilatation of common bile duct

Large rnetastatic foci from cancer of the gallbladder are demonstrated with the dilata-

tion of the intrahepatic bile duct underneath in Fig. I8. Two separate foci with central

necroses are shown on the echograms taken by linear transducer (Fig. 19).



The UOEHAssociation of

19e

HealthSclences

T, KoBAyASHI

Fig. 18.

& M, HAyAsHI

iocal necroses (By infiltration showed

are clearly

from cancer of

scanner)

1976; Hill et al,,

; Taylor et al.,

rnost of the '

Liver metasta6es with central

Shrinked gallbladder by cancerous

ultrasonic beam as shown

rnetastatic foci with central

Fig. 19. Liver metastases

(By linear

T: Tumor

The same

Discussion

The echographic examinations for the

& Filly, 1975; Filly & Laing, 1978; Goldberg,

Lee et al., 1977; Sample, ]977; Taylor

(Malini & Sabel, 1977; Stone et al.,

have been widely reported so far, however,

by contact scanner, namely the single or

real-time scanning using 2.4 MHz transducer

diseases (Takehara et al,, 1976).

Present investigation was carried out

scanner, ancl various advantages in clinical

compound contact scanner)

strong attenuation of

by dilatataon of bile duct and

necroses demonstrated.

gallbladder.electronic

masscase

Fig, 18.

diagnosis biliary tract diseases (Carlsen

1978; Laing et aL, 1978;

& including obstructive jaundice1975 1974; Weill et al., 1975)

exammations were carried out

compound scanning techniques, and the

was first reported for the hepato-biliary

by the real-titne high quality electronic linear

application are discussed in this paper.

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Real-Time Echography jn Biljary Tract Disease 191

There was no limitation in respiratory movement while using the linear electronic scanner,

as is seen when using contact scanning. One merit using the linear electronic scanner

is that one can find any pathological lesion in a short time thus eliminating time-consum-

ing examinations and allowing the doctor to examine rnany patients during the day.

The identification of hepatic ]uminal structures such as the portal venous system,

hepatic venous system ancl biliary tract trees can be easily done by both contact scanning

and electronic scanning, but it seems to be better in the Iinear scanning at any given

plane or angle, and this linear scanning is rather superior than computed tomography

where the tomographic plane is limited only to the horizontal one. Furthermore the

pursuit of luminal structure toward the periphery can be mure easily performed by the

linear electronic scanner as documented in this paper. The parallel channel sign (Conradet al., 1978) or the shotgun sign (Weili et al. , 1978) can be also easily identified by this

scanning technique.

Further advantage of this scanner is that the percutaneous transhepatic cholangio-

graphy can be done by using the Iinear electronic scanner with an aspiration hole in

center.

''

When compared with other approaches in echography, the dilatation of the commQn

bile duct is the easiest one to be visualized by the linear electronic scanning. Its

posterior duodenal portion can also be visuaiized by this approach, although this visualiza-

tion is rather diMcult by compound or single contact scanning.

Small gallstone Iess than 3 mm in size can be also identified within the intrahepatic

bile duct as shown in Fig. 18.

In summary, the real-time high quality linear electronic scanning technique can be

used for the visualization of small intrahepatic bile duct stones, any patholegy in the

common bile duct, any pathologies related with the portal venous system, the hepatic

venous system and the biliary tract tree and the space-occupying lesions within the liver

parenchym, and its clinical applicability is emphasized by the demonstration of typical

echograms.

Reference

Borrt, N. 0971): Ultrasenic viewer for cross-sectional analyses of moving cardiac structures. Bio-

Medical Engineering, 6: 500-505,

Car}sen, E. N. & Filly, R. A. (1975): Newer ultrasonographic anatomy in upper abdomen: I. The

porta] and hepatic venous anatomy. J. Clin. Ultrasound, 4: 85-90.

Conrad, M. R., Landay, M, J. & Janes, J. O, (1978): Sonographic "Parallel Chamiel" sign of biliary

tree enlargement in mild to mederate obstructive jaundice. Am. J, Roentgenol., 130: 279 286.

Edefl, S, (1978) : A comparison of the "Phrygian

Cap" deiorrnity with bi6table and gray scale ultra-

sound. ･J. Clin. Ultrasound, 6: 34 35.Filly, R. A. & Laing, F. C. (1978): Anatomic variation of portal venous anatomy in the porta

hepatis: Ultrasonic evaluaLion. J. Clin. Ultrasound, 6: 83--89.

Goldberg, B. B, (1976) : Ultrasonic cholangiography: Gray seale evaluation of the common bile duct.

Radiology, 118: 401-404,



The 　 UOEH 　 Assooiation 　 of 　 Health 　 Soienoes

192 T ．KOBAYASHI ＆ M ．　 HAYA9 ．　HI

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高性能実時間表示電子りニァ走査法による胆道系疾患の超音波診断

小林　利次・林　　　実

産業医科大学病院中央臨旅検査部

要旨：近年，開発された高性能実時閥表示竜子リニア超音波断層装置により各種胆道疾愚の診断

を行った．本装置は従来の断層法に比較し映像がすこぶる鮮明であ 1），門脈系，肝静脈系

わよび肝内胆管系の描写が 1耳能であり，これら肝内管腔構造の描出は胆石症，総腿管結石，

肝内胆管結石，肛のう癌および肝内占居性病変の診断にすこぶる有用であった．病変描出

のテクニックおよび典型的なエコ

ー一ゲラムの提示により本診断法の有用性を強調した．

J，UOEH （産業医大誌），2 （2 ）： 179．．・192（1980）

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