A 69-year-old man was admitted in the Emergency Department for jaundice and abdominal pain in the right upper quadrant (RUQ) of the abdomen. He had an unremarkable past medical history. On physical examination he presented abdominal discomfort in the RUQ, without peritoneal reaction and jaundice. Laboratory evaluation showed a normal hemoglobin, leukocytosis of 10500/µL with neutrophilia of 8500/µL and elevation of CRP (50 mg/L), and altered liver function tests (AST 79 UI/L, ALT 141 UI/L, FA 236 UI/L, GGT 1316 UI/L and total bilirubin of 4 mg/dL with 1,30 mg/dL in the unconjugated form). He underwent an abdominal ultrasound that exhibited gallstones, without intra or extrahepatic dilation. To clarify the etiology of the common bile duct (CBD) dilation an endoscopic ultrasonography (EUS) with a linear scope (Pentax) was performed. It showed an echogenic content filling homogeneously all the length of the CBD, suggestive of a dense bile, with no evidence of bile stones; the juxta-papillary portion of the CBD conformed a mass, with 14mm in diameter, and no lumen in its interior (Figure 1). On color-Doppler this mass was hypervascularized (Figure 2).
Figure 1: The mass conformation in the juxta-papillary portion of the CBD.
Figure 2: The mass conformation in the juxta-papillary portion of the CBD – color-Doppler.
The study was complemented with intravenous contrast injection (Sonovue) which demonstrated a quick and homogeneous enhancement of the CBD wall, with 4 mm in thickness, with no enhancement in its interior, forming a regular lumen, with 6 mm in diameter (Figure 3). It maintained the same pattern during all the evaluation (Figure 4 and 5). The pancreas parenchyma was normal and the main pancreatic duct had a regular and non-dilated caliber. The gallbladder had a thin wall with an echogenic content in its lumen. This alterations were more in favor of an inflammatory process rather than a malignant one.
Figure 3: CE-EUS – immediately after Sonovue administration.
Figure 4: CE-EUS – Sonovue administration on minute 00:13.
Figure 5: CE-EUS – Sonovue administration on minute 01:14.
Assuming the diagnosis of a cholangitis the patient was submitted to an ERCP that confirmed the existence of a CBD regular stricture, and a sphincterotomy was performed, with the extraction of CBD dense bile. To confirm the benign etiology of the stricture a brush cytology was done, which was negative for malignancy. The patient progressed with no complications, under intravenous antibiotic, and he was discharged asymptomatic and with normal liver function tests (exception the GGT, of 449 UI/L, but in decrease).
Contrast enhanced-EUS (CE-EUS) permits the differential diagnosis between benign and malignant diseases through a haemodynamic analysis.1 Bile duct thickening is a common feature in both benign and malignant biliary conditions and it has been shown that contrast enhancement in the bile duct wall corresponds to non-neoplastic changes of the bile duct as in cholangitis, as exemplified in this case.2
1. Yip HC, Teoh AYB, Chong CCN, Lau JYW. Current status and future applications of contrast-enhanced endoscopic ultrasonography. World J Gastrointest Endosc. 2014; 6(4): 121–127.
2. Hyodo T, Hyodo N, Yamanaka T, Imawari M. Contrast-enhanced intraductl ultrasonography for thickened bile duct wall. J Gastroenterol 2001; 36(8):557-9.
Joana Carvalho e Branco1, João Dias Pinto2, Ana Caldeira2, Eduardo Pereira2
1. Serviço de Gastrenterologia – Hospital Professor Doutor Fernando da Fonseca, Amadora.
2. Serviço de Gastrenterologia – Hospital Amato Lusitano, Castelo-Branco.