There are many diagnostic studies which can evaluated the state of biliary tract and gall bladder diseases which facilitated to reach proper diagnosis these diagnostic measures can be classified as follow

Laboratory diagnostic study

When patients with suspected diseases of the gallbladder or the extrahepatic biliary tree are evaluated by

Complete blood count CBC
An elevated white blood cell (WBC) count may indicate or raise suspicion of chole­cystitis
Liver function tests
 .  An elevation of bilirubin, alkaline phos­phatase, and aminotransferase cholangitis should be suspected
Cholestasis: an obstruction to bile flow is characterized by an elevation of bilirubin (i.e , the conjugated form), and a rise in alkaline phosphatase
Serum aminotransferases may be normal or mildly el­evated. in patients with biliary colic
Important for detection if there is urobiliurolgin or biliurbin
Radiological study

Abdominal ultrasonography

All ultrasound is the initial investigation of any patient suspected of disease of the biliary tree
It is noninvasive painless does not submit the patient to radiation, and can be performed on critically ill patients
 It is dependent upon the skills and the experience of the operator and it is dynamic (i.e., static images do not give the same information as those obtained during the ultrasound investi­gation itself
Adjacent organs can frequently be examined at the same time. Obese patients, patients with ascites, and patients with distended bowel may be difficult to examine satisfactorily with an ultrasound.

All ultrasound will show stones in the gallbladder Stones are acoustically dense and reflect the ultrasound waves back to the ultrasonic transducer, Because stones block the passage of sound waves to the region behind them, they also produce an acoustic shadow
Stones also move with changes in position
 Polyps may be cal­cified and reflect shadows, but do not move with change in pos­ture
 Some stones form a layer in the gallbladder; others a sediment or sludge
A thickened gallbladder wall and local tenderness in­dicate cholecystitis
The patient has acute cholecystitis if a layer of edema is seen within the wall of the gallbladder or between the gallbladder and the liver
 When a stone obstructed the neck of the gallbladder the gallbladder may become very large but thin walled
 A contracted thick-walled gallbladder indicates chronic cholecystitis

The extrabepatic bile ducts are also well visualized by ultra­sound, except for the retroduodenal portion
 Dilation of the ducts in a patient with jaundice establishes an extrahepatic obstruction as a cause for the jaundice
. Frequently the site, and sometimes the cause of obstruction, can be determined by ultrasound

Small stones in the common bile duct frequently get lodged at the distal end of it, behind the duodenum, and are therefore difficult to detect

 A dilated common bile duct on Ultrasound small stones in the gallbladder, and the clinical presentation allow one to assume that a stone or stones are causing the obstruction

Periampullary tumors can be difficult to diagnose on ultrasound, but beyond the retroduodenal portion, the level of obstruction and the cause may be visualized quite well

 Ultrasound can be helpful in evaluating tumor invasion and flow in the porta1 vein. an important guideline for resectability of periampullary tumors

Biliary Radionuclide Scanning HIDA Scan

Biliary scintigraphy provides a noninvasive evaluation of the liver. gallbladder, bile ducts, and duodenum with both anatomic and func­ tional information

 99m-Technetium-labeled derivatives of dimethyl iminodiacetic acid (HIDA) are injected intravenously, cleared by the Kupffer cells in the liver, and excreted in the bile

Uptake by the liver is detected within 10 minutes, and the gallbladder, the bile ducts, and the duodenum are visualized   within 60 minutes in fasting subjects

The primary use of biliary scintigraphy is in the diagnosis of acute cholecystitis, which appears as a nonvisualized gallblad­der, with prompt filling of the common bile duct and duodenum

 Evidence of cystic duct obstruction on biliary scintigraphy is highly diagnostic for acute cholecystitis

 False-positive results nay seen in patients with gallbladder stasis, as in critically ill patients and in patients receiving parenteral nutrition

 Filling of the gallbladder and common bile duct with delayed or absent filling of the duodenum indicates an obstruction at the ampulla

,Biliary leaks as a complica­tion of surgery of the gallbladder or the biliary tree can be confirmed and frequently localized by biliary scintigraphy.

Computed Tomography CT scanning

Abdominal CT scans are inferior to ultrasonography in diagnosing­ gallstones

The major application of CT scans is to define the course and status of the extrahepatic biliary tree and adjacent struc­tures

 It is the test of choice in evaluating the patient with suspected malignancy of the gallbladder, the extrahepatic biliary system, or nearby organs, in particular the head of the pancreas

Use of CT scan is an integral part of the differential diagnosis of obstructive jaundice

 Spiral CT scanning provides additional staging
information, including vascular involvement in patients with peri
ampullary tumors

Percutaneous Transhepatic Cholangiography PTC

An intrahepatic bile duct is accessed percutaneously with a small needle under fluoroscopic guidance

Once the position in a bile duct has been confirmed, a guidewire is passed and subsequently a catheter passed over the wire

 Through the catheter, a cholangiogram can be performed and therapeutic interventions done, such as biliary drain insertions and stent placements

 Percu­taneous transhepatic cholangiography (PTC) has little role in the management of patients with uncomplicated gallstone disease, but is particularly useful in patients with bile duct strictures and tumors, as it defines the anatomy of the biliary tree proximal to the affected segment

As with any invasive procedure, there are potential risks for PTC these are mainly bleeding, cholangitis, bile leak, and other catheter related problems

Magnetic Resonance Imaging MRI scanning

MRI provides anatomic details of the liver, gallbladder, and pancreas similar to those obtained from CT

Using MRI with newer techniques and contrast materials, accurate anatomic images can be obtained of the bile ducts and the pancreatic duct

It has a sensitivity and specificity of 95 and 89%, respectively, at detecting choledocholithiasis

MRI with magnetic resonance cholangiopancreatography (MRCP) offers a single non­ invasive test for the diagnosis of biliary tract and pancreatic disease

Endoscopic Retrograde Cholangiopancreatography (ERCP

Using a side-viewing endoscope, the common bile duct can be
canulated and a cholangiogram performed using fluoroscopy

The procedure requires intravenous-sedation for the patient

The advantages of endoscopic retrograde cholangiography (ERC) include direct visualization of the ampullary region and direct access to the distal common bile duct, with the possibility of therapeutic intervention

The test is rarely needed for uncomplicated gallstone disease, but for stones in the common bile duct, in par­ticular when associated with obstructive jaundice, cholangitis, or gallstone pancreatitis

 ERC is the diagnostic and often therapeu­tic procedure of choice. Once the endoscopic cholangiogram has shown ductal stones. sphincterotomy and stone extraction can be performed, and the common bile duct cleared of stones

 Complications of diagnostic ERC include pancreatitis and cholangitis. and occur in up to % of patients

Endoscopic Ultrasound

 requires a special endoscope with an ultrasound transducer at its tip

The results are operator dependent, but offer noninvasive imaging of the bile ducts and adjacent struc­tures

It is of particular value in the evaluation of tumors and their resectability

 The ultrasound endoscope has a biopsy channel, al­lowing needle biopsies of a tumor under ultrasonic guidance

Endo­scopic ultrasound also has been used to identify bile duct stones, and although it is less sensitive than ERC, the technique is less invasive

Oral Cholecystography

 Oral chole­cystography has largely been replaced by ultrasonography

 It in­volves oral administration of a radiopaque compound that is ab­sorbed, excreted by the liver, and passed into the gallbladder. Stones are noted on a film as filling defects in a visualized, opacified gall­ bladder

Oral cholecystography is of no value in patients with in­testinal malabsorption, vomiting. obstructive jaundice, and hepatic failure

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