Abstract
Paediatric biliary tract and gallbladder diseases include a variety of entities with a wide range of clinical presentations. Cholestasis represents an impaired secretion of bilirubin by hepatocytes, manifesting with high blood levels of conjugated bilirubin and jaundice. Various causes may be involved, which can be recognised analysing blood tests and hepatobiliary imaging, while sometimes liver biopsy or surgery may be necessary. High-resolution real-time ultrasonography is an important tool for differentiation of obstructive and non-obstructive causes of jaundice in infants and children. In this paper, we briefly review the normal anatomy and the ultrasound aspects of main pathologies affecting gallbladder and biliary tree in neonatal and paediatric age.
Similar content being viewed by others
References
Behrman RE (ed) (1992) Nelson textbook of pediatrics, 14th edn. Saunders, Philadelphia, p 478
Frank SJ, Kurian J (2016) Three-dimensional sonography of biliary tract disorders. J US Med 35(4):791–804
Zhang Y, Wang XL, Li SX, Bai YZ, Ren WD, Xie LM et al (2013) Ultrasonographic dimensions of the common bile duct in Chinese children: results of 343 cases. J Pediatr Surg 48:1892–1896
Di Serafino M, Severino R, Gioioso M et al (2019) Pediatric liver ultrasound: a pictorial essay. J Ultrasound. https://doi.org/10.1007/s40477-018-0352-z
Hernanz-Schulman M, Ambrosino MM, Freeman PC, Quinn CB (1995) Common bile duct in children: sonographic dimensions. Radiology 195:193–195
Di Serafino M, Vitale V, Severino R, Barbuto L, Vezzali N, Ferro F, Rossi E, Caprio MG, Raia V, Vallone G (2018) Pediatric ultrasonography of the pancreas: normal and abnormal findings. J Ultrasound 25:8. https://doi.org/10.1007/s40477-018-0348-8
Jeon J, Song SY, Lee KT, Lee KH, Bae MH, Lee JK (2013) Clinical significance and long-term outcome of incidentally found bile duct dilatation. Dig Dis Sci 58:3293–3299
Tas A, Koklu S (2012) Unusual cause of common bile duct dilatation in asymptomatic elderly patient: right hepatic artery syndrome. Ann Hepatol 11:150–151
Gore RM, Levine MS (2007) Textbook of gastrointestinal radiology, 3rd edn. Elsevier, Philadelphia
Oppong KW, Mitra V, Scott J, Anderson K, Charnley RM, Bonnington S et al (2014) Endoscopic US in patients with normal liver blood tests and unexplained dilatation of common bile duct and or pancreatic duct. Scand J Gastroenterol 49:473–480
Kim JE, Lee JK, Lee KT, Park DI, Hyun JG, Paik SW et al (2001) The clinical significance of common bile-duct dilatation in patients without biliary symptoms or causative lesions on ultrasonography. Endoscopy 33:495–500
Carroll BA, Oppenheimer DA, Muller HH (1982) High-frequency real-time US of the neonatal biliary system. Radiology 145:437–440
Teele RL, Share JC (1991) The liver. In: Teele RL, Share JC (eds) Ultrasonography of infants and children. Saunders, Philadelphia, pp 416–451
Soares KC, Arnaoutakis DJ, Kamel I et al (2014) Choledochal cysts: presentation, clinical differentiation, and management. J Am Coll Surg 219:1167–1180
Lin SF, Lee HC, Yeung CY, Jiang CB, Chan WT (2014) Common bile duct dilatations in asymptomatic neonates: incidence and prognosis. Gastroenterol Res Pract. https://doi.org/10.1155/2014/392562
Sato M, Ishida H, Konno K et al (2001) Choledochal cyst due to anomalous pancreatobiliary junction in the adult: sonographic findings. Abdom Imaging 26:395–400
Naji O, Hussain A, Baker D, Habib N, El-Hasani S (2009) Obstructive jaundice due to autoimmune cholangiopathy. BMJ Case Rep. https://doi.org/10.1136/bcr.11.2008.1291
Riederer J (2000) Obstructive jaundice du to sludge in the common bile duct. Dtsch Med Wochenschr 125:11–14
Todani Takuji et al (1977) Congenital bile duct cysts. Am J Surg 134(2):263–269
Ohashi T, Wakai T, Kubota M et al (2013) Risk of subsequent biliary malignancy in patients undergoing cyst excision for congenital choledochal cysts. J Gastroenterol Hepatol 28:243–247
Ahuja AT, Griffith JF et al (2007) Caroli disease. In: Amirsys (ed) Diagnostic imaging: ultrasound, vol 1, pp 36–37
Shah OJ, Shera AH, Zargar SA et al (2009) Choledochal cysts in children and adults with contrasting profiles: 11-year experience at a tertiary care center in Kashmir. World J Surg 33:2403–2411
Di Serafino M, Mercogliano C, Vallone G (2015) US evaluation of the enteric duplication cyst: the gut signature. J Ultrasound 19(2):131–133
Di Serafino M, Severino R, Mercogliano C, Lisanti F, Martino C, Rocca R, Abate R, Salata M, Vallone G, Maroscia D (2016) A complicated ileal duplication cyst in a young adult: the value of the “Gut Signature”. Open J Radiol 6:100–104
Segal SR, Sherman NH, Rosenberg HK et al (1994) Ultrasonographic features of gastrointestinal duplications. J US Med 13:863–870
Mack CL, Sokol RJ (2005) Unraveling the pathogenesis and etiology of biliary atresia. Pediatr Res 57:87R–94R
Bezerra JA (2005) Potential etiologies of biliary atresia. Pediatr Transplant 9:646–651
Valayer J (1996) Conventional treatment of biliary atresia: long-term results. J Pediatr Surg 31:1546–1551
Balistreri WF, Grand R, Hoofnagle JH, Suchy FJ, Ryckman FC, Perlmutter DH et al (1996) Biliary atresia: current concepts and research directions. Summary of a symposium. Hepatology 23:1682–1692
Ikeda S, Sera Y, Ohshiro H, Uchino S, Akizuki M, Kondo Y (1998) Gallbladder contraction in biliary atresia: a pitfall of US diagnosis. Pediatr Radiol 28:451–453
Nicotra JJ, Kramer SS, Bellah RD, Redd DC (1997) Congenital and acquired biliary disorders in children. Semin Roentgenol 32:215–227
Choi SO, Park WH, Lee HJ, Woo SK (1996) ‘Triangular cord’: a sonographic finding applicable in the diagnosis of biliary atresia. J Pediatr Surg 31:363–366
Iorio R, Liccardo D, Di Dato F, Puoti MG, Spagnuolo MI, Alberti D, Vallone G (2013) US scanning in infants with biliary atresia: the different implications of biliary tract features and liver echostructure. Ultraschall Med 34(5):463–467
Giannattasio A, Cirillo F, Liccardo D, Russo M, Vallone G, Iorio R (2008) Diagnostic role of US for biliary atresia. Radiology 247(3):912
Visrutaratna P (2003) Biliary atresia: making the diagnosis by the gallbladder ghost triad. Pediatr Radiol 33:902 (author reply 903)
Park WH, Choi SO, Lee HJ, Kim SP, Zeon SK, Lee SL (1997) A new diagnostic approach to biliary atresia with emphasis on the ultrasonographic triangular cord sign: comparison of ultrasonography, hepatobiliary scintigraphy, and liver needle biopsy in the evaluation of infantile cholestasis. J Pediatr Surg 32:1555–1559
Lee HJ, Lee SM, Park WH, Choi SO (2003) Objective criteria of triangular cord sign in biliary atresia on US scans. Radiology 229:395–400
Choi SO, Park WH, Lee HJ, Woo SK (1996) ‘Triangular cord’: a sonographic finding applicable in the diagnosis of biliary atresia. J Pediatr Surg 31:363–366
Di Serafino M, Esposito F, Mercogliano C, Vallone G (2016) The triangular cord sign. Abdom Radiol (NY). 41(9):1867–1868
Azuma T, Nakamura T, Nakahira M, Harumoto K, Nakaoka T, Moriuchi T (2003) Pre-operative ultrasonographic diagnosis of biliary atresia–with reference to the presence or absence of the extrahepatic bile duct. Pediatr Surg Int 19:475–477
Kim WS, Cheon JE, Youn BJ, Yoo SY, Kim WY, Kim IO et al (2007) Hepatic arterial diameter measured with US: adjunct for US diagnosis of biliary atresia. Radiology 245:549–555
Lee MS, Kim MJ, Lee MJ, Yoon CS, Han SJ, Oh JT et al (2009) Biliary atresia: color doppler US findings in neonates and infants. Radiology 252:282–289
El-Guindi MA, Sira MM, Konsowa HA, El-Abd OL, Salem TA (2013) Value of hepatic subcapsular flow by color Doppler ultrasonography in the diagnosis of biliary atresia. J Gastroenterol Hepatol 28:867–872
Burton EM, Babcock DS, Heubi JE, Gelfand MJ (1990) Neonatal jaundice: clinical and ultrasonographic findings. South Med J 83:294–302
Kirks DR, Coleman RE, Filston HC, Rosenberg ER, Merten DF (1984) An imaging approach to persistent neonatal jaundice. AJR Am J Roentgenol 142:461–465
Takamizawa S, Zaima A, Muraji T, Kanegawa K, Akasaka Y, Satoh S et al (2007) Can biliary atresia be diagnosed by ultrasonography alone? J Pediatr Surg 42:2093–2096
Park WH, Choi SO, Lee HJ (1999) The ultrasonographic ‘triangular cord’ coupled with gallbladder images in the diagnostic prediction of biliary atresia from infantile intrahepatic cholestasis. J Pediatr Surg 34:1706–1710
Lee SY, Kim GC, Choe BH, Ryeom HK, Jang YJ, Kim HJ et al (2011) Efficacy of US-guided percutaneous cholecystocholangiography for the early exclusion and type determination of biliary atresia. Radiology 261:916–922
Kanegawa K, Akasaka Y, Kitamura E, Nishiyama S, Muraji T, Nishijima E et al (2003) Sonographic diagnosis of biliary atresia in pediatric patients using the “triangular cord” sign versus gallbladder length and contraction. AJR Am J Roentgenol 181:1387–1390
Mittal V, Saxena AK, Sodhi KS, Thapa BR, Rao KL, Das A et al (2011) Role of abdominal sonography in the preoperative diagnosis of extrahepatic biliary atresia in infants younger than 90 days. AJR Am J Roentgenol 196:W438–W445
Han SJ, Kim MJ, Han A, Chung KS, Yoon CS, Kim D et al (2002) Magnetic resonance cholangiography for the diagnosis of biliary atresia. J Pediatr Surg 37:599–604
Liu B, Cai J, Xu Y, Peng X, Zheng H, Huang K et al (2014) Three-dimensional magnetic resonance cholangiopancreatography for the diagnosis of biliary atresia in infants and neonates. PLoS One 9:e88268
Lee SM, Cheon JE, Choi YH, Kim WS, Cho HH, Kim IO, You SK (2015) Ultrasonographic diagnosis of biliary atresia based on a decision-making tree model Korean. J Radiol 16(6):1364–1372
Ikeda S, Sera Y, Ohshiro H, Uchino S, Akizuki M, Kondo Y (1998) Gallbladder contraction in biliary atresia: a pitfall of US diagnosis. Pediatr Radiol 28(6):451–453
Han SJ, Kim MJ, Han A, Chung KS, Yoon CS, Kim D, Hwang EH (2002) J magnetic resonance cholangiography for the diagnosis of biliary atresia. Pediatr Surg. 37(4):599–604
Tang ST, Li SW, Ying Y, Mao YZ, Yong W, Tong QS (2009) The evaluation of laparoscopy-assisted cholangiography in the diagnosis of prolonged jaundice in infants. J Laparoendosc Adv Surg Tech A 19(6):827–830
Bălănescu RN, Bălănescu L, Drăgan G, Moga A, Caragaåã R (2015) Biliary lithiasis with choledocolithiasis in children. Chirurgia (Bucur). 110(6):559–561
Jeanty C, Derderian SC, Courtier J, Hirose S (2015) Clinical management of infantile cholelithiasis. J Pediatr Surg 50(8):1289–1292
Wesdorp I, Bosman D, de Graaff A et al (2000) Clinical presentations and predisposing factors of cholelithiasis and sludge in children. JPGN 31:411–417
Della Corte C, Falchetti D, Nebbia G et al (2008) Management of cholelithiasis in Italian children: a national multicenter study. World J Gastroenterol 14:1383–1388
Matos C, Avni EF, Van Gansbeke D, Pardou A, Struyven J (1987) Total parenteral nutrition (TPN) and gallbladder diseases in neonates. Sonographic assessment. J Ultrasound Med 6(5):243–248
Poffenberger C, Gausche-Hill M, Ngai S et al (2012) Cholelithiasis and its complications in children and adolescents. Pediatr Emerg Care 28:68–79
Svensson J, Makin E (2012) Gallstone disease in children. Semin Pediatr Surg 21:255–265
Rothstein D, Harmon CM (2016) Gallbladder disease in children. Sem Ped Surg 25:225–231
Amedee-Manesme O, Bernard O, Brunelle F, Hadchouel M, Polonovski C, Baudon JJ, Beguet P et al (1987) Sclerosing cholangitis with neonatal onset. J Pediatr 111:225–229
Baker AJ, Portmann B, Westaby D, Wilkinson M, Karani J, Mowat AP (1993) Neonatal sclerosing cholangitis in two siblings: a category of progressive intrahepatic cholestasis. J Pediatr Gastroenterol Nutr 17:317–322
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no conflict of interest.
Informed consent
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, and its late amendments. Additional informed consented was obtained from all patients for which identifying information is not included in this article.
Human and animal rights
This article does not contain any studies with human or animal subjects performed by any of the authors.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Di Serafino, M., Gioioso, M., Severino, R. et al. Ultrasound findings in paediatric cholestasis: how to image the patient and what to look for. J Ultrasound 23, 1–12 (2020). https://doi.org/10.1007/s40477-019-00362-9
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s40477-019-00362-9