Percutaneous US-guided Cholecystocholangiography with Microbubbles for Assessment of Infants with US Findings Equivocal for Biliary Atresia and Gallbladder Longer than 1.5 cm: A Pilot Study

Abstract

Purpose To evaluate the feasibility of ultrasonographically (US) guided percutaneous cholecystocholangiography (PCC) for early exclusion of biliary atresia (BA) in infants suspected of having BA with equivocal US findings or indeterminate type of BA and a gallbladder longer than 1.5 cm at US. Materials and Methods This study was approved by the ethics committee; written informed parental consent was obtained. From February 2016 to December 2016, nine infants (four boys, five girls; mean age, 60.2 days; median age, 57 days; age range, 23-117 days) with conjugated hyperbilirubinemia and gallbladder longer than 1.5 cm at US were referred for US-guided PCC after US findings were equivocal for BA (n = 7) or the type of BA was unclear (n = 2). PCC was performed with a US machine with incorporated contrast pulse sequencing, contrast-specific software, and a linear transducer by injecting diluted contrast material via an 18-gauge needle. Images from US and US-guided PCC were evaluated in consensus by two radiologists. US criteria for BA were fibrotic cord sign (>2 mm) and gallbladder length-to-width ratio greater than 5.2. BA was excluded at PCC when contrast material was visualized in the gallbladder, common hepatic ducts, and common bile duct and during passage to the duodenum. Patients in whom BA was diagnosed after PCC underwent surgery or liver biopsy as the reference standard. Nonparametric and Fisher exact tests were used. Results US-guided PCC was successful in all patients. There were no procedural-related complications. BA was excluded in five of the nine patients. The median serum direct bilirubin level in these patients slightly decreased 1 week after PCC, from 91.1 μmol/L (interquartile range [IQR], 81.6-113.8 μmol/L) to 65.3 μmol/L (IQR, 57.8-74.7 μmol/L); however, this difference was not statistically significant (P = .062). BA was diagnosed in four patients, with the diagnosis confirmed at surgery (n = 2) or liver biopsy (n = 2). BA in two patients with unclear type of BA was defined as type III without patency of the common bile duct in one patient and as type III with patency of the common bile duct in the other. Conclusion In this highly selected group of infants with indeterminate type of BA or inconclusive US findings, US-guided PCC enabled the diagnosis of BA in four infants and the exclusion of BA in five. US-guided PCC may be a safe and effective tool to exclude BA early in infants with equivocal US findings. RSNA, 2017.

The prognosis of type III biliary atresia with a hilar cyst on ultrasonography might not be better than that without

“…Kaplan-Meier survival curves indicated that the overall survival time with a native liver after KPE between two groups was also not significantly different. SWE value, which is widely used to measure liver stiffness and has the possibility for predicting native liver survival after KPE surgery in patients with isolated BA [11,16,17], was also similar between two groups. And our analyses revealed that most USG characteristics were similar between two groups.…”

“…For patients with small gallbladder (shorter than 1.5 cm, n = 6) and absence of gallbladder on USG (n = 5), whether the cyst communicated with the gallbladder wasn't confirmed by intraoperative cholangiography, because it is generally impossible to perform intraoperative cholangiography in these patients. In addition, two patients with cyst communicated with the gallbladder were confirmed by the percutaneous ultrasound-guided cholecystocholangiography with microbubbles, a mature technology in our center [11]. Figure 1 shows a 9-day-old female with a 28 mm × 16 mm porta cyst that was communicated with the gallbladder from a small tube (approximately 2 mm diameter) ( Fig.…”

Ultrasound Evaluation of Biliary Atresia Based on Gallbladder Classification: Is 4 Hours of Fasting Necessary?

“…As one of the most widely used ultrasound features for the diagnosis of BA, gallbladder abnormalities have been greatly emphasized by many investigators, due to their high sensitivity in distinguishing BA from other neonatal jaundice conditions . Most features would require infants to be fasted for at least 4 hours before being examined via ultrasonography to more clearly detect and measure the gallbladder . However, our previous studies have shown that an incompletely filled gallbladder, detected via ultrasonography, can also help in excluding BA.…”

“…The diagnoses of the 100 infants with BA were confirmed by using surgical exploration (n = 90), liver biopsy (n = 7), or intraoperative cholangiography under laparoscopy (n = 3). The 88 infants without BA were diagnosed by using intraoperative cholangiography (n = 29), liver biopsy (n = 3), percutaneous ultrasound‐guided cholecystocholangiography (n = 4), or clinical follow‐up (n = 52). The jaundice conditions in infants without BA were completely resolved during a follow‐up period of 2 weeks to 12 months.…”

“…Triangular cord (TC) thickness and gallbladder abnormalities are the 2 most important ultrasonographic features for the diagnosis of BA . However, the identification of the TC thickness is considered to be operator dependent; for example, the identification accuracies have varied (from 29% to 100%) in different studies . In clinical practice, it is difficult for inexperienced individuals to quickly learn how to identify a positive sign of TC.…”