CHOLANGIOCARCINOMA

SHELBY RHODA
DMS 495
SPRING 2016
CASE HISTORY
39 yo African American male, 148 lbs
Liver US ordered to evaluate biliary stent and possible hepatic
lesions seen on previous CT Abdomen and Pelvis without
contrast
Previous CT Abdomen and Pelvis
multiple hepatic lesions, possible occluded MPV, biliary ductal
dilatation, moderate abdominal ascites
Labs: elevated bilirubin, AST, ALP, and WBC, positive for
Hepatitis B and C
CASE HISTORY CONTD
Current symptoms: cirrhosis, sepsis, jaundice, abdominal
distention with ascites, and abdominal pain
Ascending cholangitis
Symptoms ongoing since diagnosis of cholangiocarcinoma
Cholangiocarcinoma diagnosis: October of 2015
Biliary stent was placed via ERCP in February, tumors were
seen in intrahepatic ducts and stent was replaced immediately
due to dysfunction, tumors seen at Ampulla of Vater in the distal
common bile duct
 MAIN PORTAL VEIN

Figure 1: Transverse on Figure 2: Sagittal on the main portal vein

main portal vein at the at the porta hepatis showing a lumen
head of the pancreas containing internal echoes
showing a hypoechoic
 MAIN PORTAL VEIN

Figure 3: Sagittal on the Figure 4: Sagittal of the

main portal vein showing main portal vein showing
absence of patency using minimal velocity of flow
color Doppler imaging with spectral Doppler
 HEPATIC ARTERY

Figure 5: Hepatic artery

velocity of 293.9 cm/s
shown with spectral
 GALLBLADDER

Figure 6: Sagittal on the Figure 7: Transverse on

gallbladder with patient in the gallbladder with
supine position showing an patient in supine position
anechoic lumen with a showing a thickened wall
 COMMON BILE DUCT

Figure 8: lengthened out Figure 9: Common bile duct

common bile duct stent with stent evaluated with color
echogenic walls and an Doppler showing no internal
anechoic lumen at the porta vascularity
 LIVER

Figure 10: Sagittal Figure 11: Transverse

image showing image showing
heterogeneous liver heterogeneous liver
 CT - LIVER

Figure 12: CT of Abdomen and

Pelvis showing hypoechoic areas
the mid portion of the liver
representing liver masses
Figure 13: Ct of Abdomen and Pelvis showin
in
hypoechoic areas in the inferior portion of
liver representing liver masses
 LEFT PORTAL VEIN

Figure13: Transverse
Figure 14: Minimal velocity
image of the liver
shown within the left portal
showing the left portal
vein using spectral Doppler
vein with no internal
 LIVER

Figure 15: Transverse

image of the inferior Figure 16: Transverse
portion of the liver image of the liver
showing anechoic free showing anechoic free
DIAGNOSIS: CHOLANGIOCARCINOMA

Rare neoplasm arising from the biliary tree

incidence from 1-2 per 100,000 population in the United States
Second most common primary malignancy of the liver
Classified as intrahepatic, hilar, or distal
Most common risk factors: recurrent biliary infections, stone
disease, and Hepatitis B
Common clinical symptoms: jaundice, RUQ pain, distended
abdomen with ascites
DIAGNOSIS: SONOGRAPHIC FINDINGS

Hypoechoic lesion in gallbladder or biliary tree

Thickened gallbladder wall
Portal vein thrombosis
Liver metastases
portosystemic collaterals
Similar: presents will all of the above except lesions visualized
within the gallbladder
Different: increased hepatic artery velocity
FOLLOW-UP

Surgery: biliary stent placement via endoscopic retrograde

cholangiopancreatography (ERCP)
Treatment: palliative care, hospice care at home
Prognosis: poor
average survival rate of 5 years
PITFALL AND DIFFERENTIAL

Pitfall: not evaluating hepatic artery when MPV is occluded

Differential: Hepatocellular carcinoma
Differentiated by biopsy and lab results
Cholangiocarcinoma has a much higher incidence of ductal obstruction
than with HCC
CONCLUSION

39 yo male was ordered a Liver US to evaluate biliary stent

placement
Multiple liver lesions, occluded MPV, and thickened GB wall
were documented by the sonographer to the radiologist
Patient sent home on hospice care
Teachable moment: always check previous prior to the
ultrasound
Liver lesions seen better on CT
REFERENCES

Carol Rumack, Stephanie Wilson, J. Charboneau, Deborah

Levine. Diagnostic Ultrasound. Fourth edition. Philadelphia,
PA: Mosby, Inc.; 2011.
Curry, Reva. Tempkin, Betty. Sonography: Introduction to
Normal Structure and Function. Third edition. St. Louis,
MO: Saunders; 2011.
Kupinski, Ann M. Diagnostic Medical Sonography: The
Vascular System. First edition. Baltimore, MD: Lippincott
Williams & Wilkins; 2013.
REFERENCES

Li-Da Chen, Hui-Xiong Xu. Intrahepatic Cholangiocarcinoma

and Hepatocellular Carcinoma: differential diagnosis with
contrast- enhanced ultrasound. 20th edition. Guangzhou,
China: European Socioety of Radiology; 2009.
Whitlock, Patty J.Cholangiocarcinoma. Retrieved from
http://jdm.sagepub.com/content/25/5/259.abstract