Keywords
endosonography - common bile duct - gall bladder stones
Case Report
A 32-year-old man, known case of extrahepatic portal venous obstruction, presented
with upper abdominal pain. Ultrasound abdomen revealed multiple gall bladder stones
with portal cavernoma and common bile duct (CBD) could not be evaluated. Serum bilirubin
as well as alanine and aspartate transaminase levels were normal but alkaline phosphatase
(ALP) was elevated (368 IU/L; N,126 IU/L). Magnetic resonance imaging could not be
done because of patient’s claustrophobia. Endoscopic ultrasound (EUS) was performed
using radial echoendoscope (GF-UE160-AL5; Olympus Corp., Tokyo, Japan) and universal
ultrasound processor EU-ME2 premier plus (Olympus Corp., Tokyo, Japan). EUS performed
from duodenal bulb revealed multiple serpiginous linear anechoic structures in suprapancreatic
region and CBD could not be separately seen ([Fig. 1]). On Doppler EUS, all these serpiginous structures showed flow and in center of
these vascular collaterals small, round, nonvascular, anechoic CBD ([Fig. 2]; arrows) could be seen. However, because of multiple venous collaterals, CBD could
not be properly visualized. Thereafter, contrast-enhanced harmonic EUS (CH-EUS) using
Sonovue (Bracco, Milan, Italy) was done at low mechanical index of 0.12. Contrast-highlighted
venous collaterals 50 seconds after injection of contrast and nonenhancing CBD could
be completely and clearly visualized ([Figs. 3A]
[B] arrows and [Video 1]). The contrast-filled echogenic para-choledochal venous collaterals were clearly
visualized separate from anechoic, noncontrast-filled CBD. The CBD was found to be
normal and patient had low serum vitamin D levels. Serum ALP normalized after correction
of vitamin D levels and patient was referred to surgical services for cholecystectomy.
Fig. 1 Endoscopic ultrasound from duodenal station: multiple serpiginous linear anechoic
structures in suprapancreatic region and common bile duct could not be separately
seen
Fig. 2 On Doppler endoscopic ultrasound, all these serpiginous structures show flow and
in center of these vascular collaterals small, round, nonvascular, anechoic common
bile duct (arrows) could be seen.
Fig. 3 (A and B) Contrast-enhanced harmonic EUS: The contrast-filled echogenic paracholedochal venous
collaterals clearly visualized separate from anechoic, noncontrast-filled common bile
duct.
Take-Home Message
EUS is an excellent imaging modality for the evaluation of CBD because of its close
proximity to the transducer placed in duodenum.[1] In the presence of portal cavernoma, identification and evaluation of CBD become
difficult because of presence of numerous venous collaterals.[1]
[2] In these circumstances, the evaluation of CBD is more difficult if it is nondilated.[2]
[3] CH-EUS seems to be an excellent modality to evaluate nondilated CBD in the presence
of portal cavernoma.
Video 1
Noncontrast endoscopic ultrasound shows multiple serpiginous linear anechoic structures
in suprapancreatic region and common bile duct (CBD) could not be separately seen.
After injection of intravenous contrast, the echogenic paracholedochal venous collaterals
clearly visualized separate from anechoic, noncontrast-filled CBD. The CBD could be
clearly seen throughout its extent.
