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US Approach to Jaundice in Infants and Children¹

¹ From the Department of Radiology, Albert Einstein Medical Center, 5501 Old York Rd, Philadelphia, PA 19141-3098. Presented as a scientific exhibit at the 1998 RSNA scientific assembly. Received April 27, 1999; revisions requested June 22 and received August 17; accepted September 22. Address reprint requests to J.A.G.

View larger version (151K): [in a new window]   Figure 1.   Normal liver. Transverse sonogram of the normal liver clearly shows the peripheral portal venous vasculature (arrows).

View larger version (159K): [in a new window]   Figure 2.   Hepatitis in a 2-week-old boy with jaundice and an enlarged abdomen. Transverse sonogram demonstrates an enlarged liver with a diffusely coarse echotexture and a tiny gallbladder (GB). The peripheral portal venous vasculature is not visualized.

View larger version (163K): [in a new window]   Figure 3.   Cytomegalovirus hepatitis in a young male infant with jaundice, hepatosplenomegaly, thrombocytopenia, and elevated levels of liver enzymes. Sagittal sonogram of the liver shows coarse echotexture with multiple, bright, often shadowing, echogenic foci (arrow) scattered throughout the liver. Plain radiography of the abdomen may show calcification.

View larger version (137K): [in a new window]   Figure 4a.   Biliary atresia in a 2-week-old boy with jaundice and hepatosplenomegaly. (a) Sagittal sonogram of the liver shows diffusely coarse echotexture, lack of visualization of the peripheral portal venous vasculature, and reduced beam penetration. There was hepatosplenomegaly, and the gallbladder measured only 8.2 mm in length. (b) Hepatobiliary scan obtained after a 35-minute delay demonstrates absence of activity in the central common bile duct and small intestine. Initial images (not shown) demonstrated poor uptake of the radionuclide by the liver.

View larger version (108K): [in a new window]   Figure 4b.   Biliary atresia in a 2-week-old boy with jaundice and hepatosplenomegaly. (a) Sagittal sonogram of the liver shows diffusely coarse echotexture, lack of visualization of the peripheral portal venous vasculature, and reduced beam penetration. There was hepatosplenomegaly, and the gallbladder measured only 8.2 mm in length. (b) Hepatobiliary scan obtained after a 35-minute delay demonstrates absence of activity in the central common bile duct and small intestine. Initial images (not shown) demonstrated poor uptake of the radionuclide by the liver.

View larger version (135K): [in a new window]   Figure 5.   Pathologic changes in neonatal hepatitis. Low-power photomicrograph (hematoxylin-eosin stain) demonstrates lobular disarray, giant cell transformation, and mononuclear lobular infiltrate.

View larger version (174K): [in a new window]   Figure 6.   Pathologic changes in biliary atresia. Low-power photomicrograph (hematoxylin-eosin stain) demonstrates a marked degree of fibrosis, bile duct proliferation, and portal inflammation.

View larger version (0K): [in a new window]   Figure 7.   Permission to reprint this figure was denied by the publisher. See print version.

View larger version (101K): [in a new window]   Figure 8a.   Choledochal cyst (type IA) in a 6-year-old girl with jaundice and clinical evidence of pancreatitis. (a) Transverse sonogram shows a minimally enlarged pancreas (P) and a 4-cm anechoic cyst (C) in the region of the pancreatic head. (b) Transverse sonogram of the liver demonstrates dilated intrahepatic ducts (arrows) and coarse liver echotexture thought to be due to cholestasis. (c) Color Doppler image helps confirm the absence of flow in the dilated common hepatic duct, which communicates with the choledochal cyst. This finding was confirmed with duplex Doppler US.

View larger version (111K): [in a new window]   Figure 8b.   Choledochal cyst (type IA) in a 6-year-old girl with jaundice and clinical evidence of pancreatitis. (a) Transverse sonogram shows a minimally enlarged pancreas (P) and a 4-cm anechoic cyst (C) in the region of the pancreatic head. (b) Transverse sonogram of the liver demonstrates dilated intrahepatic ducts (arrows) and coarse liver echotexture thought to be due to cholestasis. (c) Color Doppler image helps confirm the absence of flow in the dilated common hepatic duct, which communicates with the choledochal cyst. This finding was confirmed with duplex Doppler US.

View larger version (141K): [in a new window]   Figure 8c.   Choledochal cyst (type IA) in a 6-year-old girl with jaundice and clinical evidence of pancreatitis. (a) Transverse sonogram shows a minimally enlarged pancreas (P) and a 4-cm anechoic cyst (C) in the region of the pancreatic head. (b) Transverse sonogram of the liver demonstrates dilated intrahepatic ducts (arrows) and coarse liver echotexture thought to be due to cholestasis. (c) Color Doppler image helps confirm the absence of flow in the dilated common hepatic duct, which communicates with the choledochal cyst. This finding was confirmed with duplex Doppler US.

View larger version (150K): [in a new window]   Figure 9a.   Choledochal cyst (type IC) with biliary atresia in a female neonate with jaundice. (a) Sagittal sonogram shows a fusiform choledochal cyst (arrow) involving the common bile duct. The surrounding hepatic echotexture is coarse. The gallbladder (not shown) was tiny. (b) Intraoperative cholangiogram demonstrates a small gallbladder (GB) and choledochal cyst (CC). (c) Intraoperative cholangiogram obtained after a stronger injection of contrast material reveals atretic intrahepatic biliary ducts consistent with biliary atresia. A hepatobiliary scan (not shown) showed no excretion of the radiopharmaceutical.

View larger version (132K): [in a new window]   Figure 9b.   Choledochal cyst (type IC) with biliary atresia in a female neonate with jaundice. (a) Sagittal sonogram shows a fusiform choledochal cyst (arrow) involving the common bile duct. The surrounding hepatic echotexture is coarse. The gallbladder (not shown) was tiny. (b) Intraoperative cholangiogram demonstrates a small gallbladder (GB) and choledochal cyst (CC). (c) Intraoperative cholangiogram obtained after a stronger injection of contrast material reveals atretic intrahepatic biliary ducts consistent with biliary atresia. A hepatobiliary scan (not shown) showed no excretion of the radiopharmaceutical.

View larger version (131K): [in a new window]   Figure 9c.   Choledochal cyst (type IC) with biliary atresia in a female neonate with jaundice. (a) Sagittal sonogram shows a fusiform choledochal cyst (arrow) involving the common bile duct. The surrounding hepatic echotexture is coarse. The gallbladder (not shown) was tiny. (b) Intraoperative cholangiogram demonstrates a small gallbladder (GB) and choledochal cyst (CC). (c) Intraoperative cholangiogram obtained after a stronger injection of contrast material reveals atretic intrahepatic biliary ducts consistent with biliary atresia. A hepatobiliary scan (not shown) showed no excretion of the radiopharmaceutical.

View larger version (99K): [in a new window]   Figure 10a.   Choledochal cyst with biliary atresia in a newborn who presented with increasing jaundice and in whom a cystic abdominal mass had been noted at prenatal US. (a) Sagittal sonogram of the right upper quadrant shows a large cystic mass in the porta hepatis. The mass, a choledochal cyst (CC), tapers cranially. The liver echotexture is coarse, and none of the intrahepatic bile ducts or a normal common bile duct are visualized. A = aorta, HV = hepatic vein, pv = portal vein. (b) Color Doppler image shows biliary vessels surrounding the avascular choledochal cyst (CC). (c) Intraoperative cholangiogram shows aqueous contrast material filling the gallbladder (GB) and choledochal cyst (CC) with no filling of the intrahepatic bile ducts.

View larger version (140K): [in a new window]   Figure 10b.   Choledochal cyst with biliary atresia in a newborn who presented with increasing jaundice and in whom a cystic abdominal mass had been noted at prenatal US. (a) Sagittal sonogram of the right upper quadrant shows a large cystic mass in the porta hepatis. The mass, a choledochal cyst (CC), tapers cranially. The liver echotexture is coarse, and none of the intrahepatic bile ducts or a normal common bile duct are visualized. A = aorta, HV = hepatic vein, pv = portal vein. (b) Color Doppler image shows biliary vessels surrounding the avascular choledochal cyst (CC). (c) Intraoperative cholangiogram shows aqueous contrast material filling the gallbladder (GB) and choledochal cyst (CC) with no filling of the intrahepatic bile ducts.

View larger version (140K): [in a new window]   Figure 10c.   Choledochal cyst with biliary atresia in a newborn who presented with increasing jaundice and in whom a cystic abdominal mass had been noted at prenatal US. (a) Sagittal sonogram of the right upper quadrant shows a large cystic mass in the porta hepatis. The mass, a choledochal cyst (CC), tapers cranially. The liver echotexture is coarse, and none of the intrahepatic bile ducts or a normal common bile duct are visualized. A = aorta, HV = hepatic vein, pv = portal vein. (b) Color Doppler image shows biliary vessels surrounding the avascular choledochal cyst (CC). (c) Intraoperative cholangiogram shows aqueous contrast material filling the gallbladder (GB) and choledochal cyst (CC) with no filling of the intrahepatic bile ducts.

View larger version (139K): [in a new window]   Figure 11a.   Caroli disease in a 7-year-old girl with jaundice and intermittent right upper quadrant pain. (a) Transverse sonogram demonstrates coarse liver texture with dilatation of the intrahepatic bile ducts with a cystlike projection from the left intrahepatic duct (arrow). (b) Sagittal sonogram of the porta hepatis shows a dilated common bile duct (calipers) and cystlike projection (arrow) arising from the common hepatic duct (arrowheads). (c) Intraoperative cholangiogram shows dilated common hepatic and common bile ducts with a cyst (arrow) arising from the common hepatic duct (arrowheads).

View larger version (150K): [in a new window]   Figure 11b.   Caroli disease in a 7-year-old girl with jaundice and intermittent right upper quadrant pain. (a) Transverse sonogram demonstrates coarse liver texture with dilatation of the intrahepatic bile ducts with a cystlike projection from the left intrahepatic duct (arrow). (b) Sagittal sonogram of the porta hepatis shows a dilated common bile duct (calipers) and cystlike projection (arrow) arising from the common hepatic duct (arrowheads). (c) Intraoperative cholangiogram shows dilated common hepatic and common bile ducts with a cyst (arrow) arising from the common hepatic duct (arrowheads).

View larger version (162K): [in a new window]   Figure 11c.   Caroli disease in a 7-year-old girl with jaundice and intermittent right upper quadrant pain. (a) Transverse sonogram demonstrates coarse liver texture with dilatation of the intrahepatic bile ducts with a cystlike projection from the left intrahepatic duct (arrow). (b) Sagittal sonogram of the porta hepatis shows a dilated common bile duct (calipers) and cystlike projection (arrow) arising from the common hepatic duct (arrowheads). (c) Intraoperative cholangiogram shows dilated common hepatic and common bile ducts with a cyst (arrow) arising from the common hepatic duct (arrowheads).

View larger version (129K): [in a new window]   Figure 12.   Caroli disease with intrahepatic cysts in a young girl. Transverse sonogram shows multiple intrahepatic cysts, some of which contain portal radicles (arrowheads).

View larger version (14K): [in a new window]   Figure 13.   Algorithm for the differentiation of hepatitis, biliary atresia, and choledochal cyst in the neonate. OR = surgery.

View larger version (149K): [in a new window]   Figure 14a.   Inspissated bile syndrome in a 2-month-old infant with jaundice and dehydration. (a) Oblique sonogram of the porta hepatis shows a dilated tubular structure (diameter, 7.2 mm) containing a fluid-debris level (arrow) and surrounded by coarse, hyperechoic liver texture due to cholestasis. (b) Color Doppler image helps confirm that the tubular structure anterior to the portal vein (PV) is a markedly dilated common bile duct (CBD). Note sludge within the gallbladder (GB). (c) On another color Doppler image, intrahepatic ductal dilatation (arrows) is evident.

View larger version (149K): [in a new window]   Figure 14b.   Inspissated bile syndrome in a 2-month-old infant with jaundice and dehydration. (a) Oblique sonogram of the porta hepatis shows a dilated tubular structure (diameter, 7.2 mm) containing a fluid-debris level (arrow) and surrounded by coarse, hyperechoic liver texture due to cholestasis. (b) Color Doppler image helps confirm that the tubular structure anterior to the portal vein (PV) is a markedly dilated common bile duct (CBD). Note sludge within the gallbladder (GB). (c) On another color Doppler image, intrahepatic ductal dilatation (arrows) is evident.

View larger version (151K): [in a new window]   Figure 14c.   Inspissated bile syndrome in a 2-month-old infant with jaundice and dehydration. (a) Oblique sonogram of the porta hepatis shows a dilated tubular structure (diameter, 7.2 mm) containing a fluid-debris level (arrow) and surrounded by coarse, hyperechoic liver texture due to cholestasis. (b) Color Doppler image helps confirm that the tubular structure anterior to the portal vein (PV) is a markedly dilated common bile duct (CBD). Note sludge within the gallbladder (GB). (c) On another color Doppler image, intrahepatic ductal dilatation (arrows) is evident.

View larger version (163K): [in a new window]   Figure 15.   Acute hepatitis. Sagittal sonogram of the liver shows brightly echoic peripheral portal venous vasculature and moderate hepatomegaly. GB = gallbladder.

View larger version (145K): [in a new window]   Figure 16.   Chronic hepatitis in a 9-year-old boy. Transverse sonogram of the liver shows massive hepatomegaly with a diffusely coarse echotexture.

View larger version (152K): [in a new window]   Figure 17.   Hepatoblastoma in a 7-month-old boy with an abdominal mass. Transverse sonogram demonstrates a heterogeneous solid mass in the right hepatic lobe (arrows) that contains shadowing calcifications (arrowhead).

View larger version (158K): [in a new window]   Figure 18.   Hepatocellular carcinoma in a 16-year-old boy with jaundice and recurrent malignancy. Sagittal sonogram shows a heterogeneous solid mass (arrows) in the porta hepatis.

View larger version (148K): [in a new window]   Figure 19a.   Rhabdomyosarcoma of the common bile duct in a 7-year-old boy with jaundice, hepatomegaly, and itching. (a) Transverse scan of the pancreas (P) shows a round, solid heterogeneous mass (arrows) in the region of the pancreatic head. (b) Oblique sonogram of the porta hepatis shows the solid mass (arrows) in the markedly dilated common bile duct (CBD). GB = gallbladder, PV = portal vein. (c) Transverse sonogram of the liver demonstrates dilated intrahepatic ducts (arrow), coarse liver texture thought to be due to cholestasis, and a normal gallbladder (GB). (d) Intraoperative cholangiogram helps confirm the presence of the large mass with irregular borders filling the distal common bile duct (arrows).

View larger version (155K): [in a new window]   Figure 19b.   Rhabdomyosarcoma of the common bile duct in a 7-year-old boy with jaundice, hepatomegaly, and itching. (a) Transverse scan of the pancreas (P) shows a round, solid heterogeneous mass (arrows) in the region of the pancreatic head. (b) Oblique sonogram of the porta hepatis shows the solid mass (arrows) in the markedly dilated common bile duct (CBD). GB = gallbladder, PV = portal vein. (c) Transverse sonogram of the liver demonstrates dilated intrahepatic ducts (arrow), coarse liver texture thought to be due to cholestasis, and a normal gallbladder (GB). (d) Intraoperative cholangiogram helps confirm the presence of the large mass with irregular borders filling the distal common bile duct (arrows).

View larger version (119K): [in a new window]   Figure 19c.   Rhabdomyosarcoma of the common bile duct in a 7-year-old boy with jaundice, hepatomegaly, and itching. (a) Transverse scan of the pancreas (P) shows a round, solid heterogeneous mass (arrows) in the region of the pancreatic head. (b) Oblique sonogram of the porta hepatis shows the solid mass (arrows) in the markedly dilated common bile duct (CBD). GB = gallbladder, PV = portal vein. (c) Transverse sonogram of the liver demonstrates dilated intrahepatic ducts (arrow), coarse liver texture thought to be due to cholestasis, and a normal gallbladder (GB). (d) Intraoperative cholangiogram helps confirm the presence of the large mass with irregular borders filling the distal common bile duct (arrows).

View larger version (103K): [in a new window]   Figure 19d.   Rhabdomyosarcoma of the common bile duct in a 7-year-old boy with jaundice, hepatomegaly, and itching. (a) Transverse scan of the pancreas (P) shows a round, solid heterogeneous mass (arrows) in the region of the pancreatic head. (b) Oblique sonogram of the porta hepatis shows the solid mass (arrows) in the markedly dilated common bile duct (CBD). GB = gallbladder, PV = portal vein. (c) Transverse sonogram of the liver demonstrates dilated intrahepatic ducts (arrow), coarse liver texture thought to be due to cholestasis, and a normal gallbladder (GB). (d) Intraoperative cholangiogram helps confirm the presence of the large mass with irregular borders filling the distal common bile duct (arrows).

View larger version (128K): [in a new window]   Figure 20a.   Hemangioendothelioma in a 9-month-old boy with hepatomegaly. (a) Transverse image obtained with Elegra SieScape technology (Siemens Medical Systems, Iselin, NJ) demonstrates a large complex mass occupying most of the anterior portion of the right lobe of the liver (arrows). Note small calcifications (arrowhead). (b) Power color Doppler image demonstrates multiple venous channels within the mass.

View larger version (144K): [in a new window]   Figure 20b.   Hemangioendothelioma in a 9-month-old boy with hepatomegaly. (a) Transverse image obtained with Elegra SieScape technology (Siemens Medical Systems, Iselin, NJ) demonstrates a large complex mass occupying most of the anterior portion of the right lobe of the liver (arrows). Note small calcifications (arrowhead). (b) Power color Doppler image demonstrates multiple venous channels within the mass.

View larger version (154K): [in a new window]   Figure 21.   Glycogen storage disease with hepatocellular adenoma in an older teenage boy with jaundice and hepatomegaly. Transverse hepatic sonogram demonstrates coarse liver texture and a slightly hypoechoic, rounded mass posteromedially in the right lobe (calipers). The mass proved to be an adenoma.

View larger version (154K): [in a new window]   Figure 22.   Neuroblastoma in a newborn girl with jaundice and a prenatal diagnosis of abdominal tumor. Sagittal sonogram of the right upper quadrant demonstrates a brightly echoic, enlarged adrenal gland (arrows) as well as multiple ill-defined, brightly echoic nodular areas throughout the liver (arrowheads). RK = right kidney.

View larger version (126K): [in a new window]   Figure 23.   Cholelithiasis. Sagittal sonogram of the gallbladder demonstrates brightly echoic, mobile, shadowing foci consistent with gallstones (arrows).

View larger version (122K): [in a new window]   Figure 24.   Tumefactive sludge. Sagittal sonogram of the gallbladder shows multiple conglomerations of tumefactive sludge (sludge balls) (arrows).

View larger version (100K): [in a new window]   Figure 25a.   Choledocholithiasis in a 7-year-old boy with right upper quadrant pain and jaundice. (a) Oblique sonogram of the porta hepatis shows dilatation of the common hepatic (CHD) and common bile ducts (CBD). There was also mild dilatation of the intrahepatic bile ducts. (b)Transverse sonogram of the pancreas (P) and gallbladder (GB) demonstrates an obstructing stone (arrow) in the distal most part of the common bile duct.

View larger version (120K): [in a new window]   Figure 25b.   Choledocholithiasis in a 7-year-old boy with right upper quadrant pain and jaundice. (a) Oblique sonogram of the porta hepatis shows dilatation of the common hepatic (CHD) and common bile ducts (CBD). There was also mild dilatation of the intrahepatic bile ducts. (b)Transverse sonogram of the pancreas (P) and gallbladder (GB) demonstrates an obstructing stone (arrow) in the distal most part of the common bile duct.

View larger version (168K): [in a new window]   Figure 26.   Acalculous cholecystitis in a young child with jaundice, right upper quadrant pain, vomiting, and fever. Sagittal sonogram shows marked thickening of the gallbladder wall (calipers).

View larger version (142K): [in a new window]   Figure 27.   Cirrhosis in a young child. Sagittal sonogram of the liver demonstrates typical findings of a small coarse liver with irregular borders (arrows) surrounded by ascites (A).

View larger version (130K): [in a new window]   Figure 28a.   Hepatic fibrosis with recessive polycystic kidney disease in a 2-year-old girl with jaundice and renal failure. (a) Transverse hepatic sonogram shows coarse liver texture. (b) Sagittal sonogram of the kidney reveals its echogenic parenchyma without corticomedullary differentiation. Brighter, small, hyperechoic areas within the medullary pyramids represent innumerable fluid-tubular interfaces (arrows).

View larger version (135K): [in a new window]   Figure 28b.   Hepatic fibrosis with recessive polycystic kidney disease in a 2-year-old girl with jaundice and renal failure. (a) Transverse hepatic sonogram shows coarse liver texture. (b) Sagittal sonogram of the kidney reveals its echogenic parenchyma without corticomedullary differentiation. Brighter, small, hyperechoic areas within the medullary pyramids represent innumerable fluid-tubular interfaces (arrows).

View larger version (120K): [in a new window]   Figure 29a.   Hepatofugal flow in a premature male infant with jaundice and cirrhosis following prolonged total parenteral nutrition. Duplex color Doppler (a) and color Doppler (b) US images demonstrate hepatofugal flow in the portal vein (PV). HA = hepatic artery.

View larger version (147K): [in a new window]   Figure 29b.   Hepatofugal flow in a premature male infant with jaundice and cirrhosis following prolonged total parenteral nutrition. Duplex color Doppler (a) and color Doppler (b) US images demonstrate hepatofugal flow in the portal vein (PV). HA = hepatic artery.

View larger version (79K): [in a new window]   Figure 30.   Drawing illustrates the typical collateral channels in cirrhosis and portal hypertension. CV = cardinal vein, GEV = gastroesophageal varices, GSV = gastrosplenic varices, HV = hepatic vein, IMV = inferior mesenteric vein, IVC = inferior vena cava, LRV = left renal vein, PDV = pancreaticoduodenal vein, PUV = paraumbilical vein, PV = portal vein, PVV = paravertebral veins, SMV = superior mesenteric vein, SRV = splenorenal varices, SV = splenic vein, U = umbilicus.

View larger version (139K): [in a new window]   Figure 31a.   (a) Gastroesophageal varices in a 15-year-old girl with cirrhosis, massive splenomegaly (not shown), known gastroesophageal varices, and gastrointestinal bleeding. Sagittal sonogram shows a coarse liver texture and dilated anechoic tubular structures (arrows) that widen the lesser sac, a finding that, before the era of duplex color Doppler US, was presumed to represent varices. The diameter of the lesser sac should not measure more than 1.7 times the depth of the aorta at the level where the trunk of the celiac arises. A = aorta. (b) Color Doppler image of another patient shows gastroesophageal varices (V). A = aorta.

View larger version (178K): [in a new window]   Figure 31b.   (a) Gastroesophageal varices in a 15-year-old girl with cirrhosis, massive splenomegaly (not shown), known gastroesophageal varices, and gastrointestinal bleeding. Sagittal sonogram shows a coarse liver texture and dilated anechoic tubular structures (arrows) that widen the lesser sac, a finding that, before the era of duplex color Doppler US, was presumed to represent varices. The diameter of the lesser sac should not measure more than 1.7 times the depth of the aorta at the level where the trunk of the celiac arises. A = aorta. (b) Color Doppler image of another patient shows gastroesophageal varices (V). A = aorta.

View larger version (50K): [in a new window]   Figure 32a.   Recanalized ductus venosus in a 7-year-old girl with end-stage liver disease. (a) Duplex Doppler US image demonstrates hepatopedal flow in the portal vein (arrowhead) with recanalization of the ductus venosus (arrow). (b) Duplex Doppler US image shows the hepatofugal flow via the recanalized ductus venosus (arrow) into the inferior vena cava (IVC).

View larger version (43K): [in a new window]   Figure 32b.   Recanalized ductus venosus in a 7-year-old girl with end-stage liver disease. (a) Duplex Doppler US image demonstrates hepatopedal flow in the portal vein (arrowhead) with recanalization of the ductus venosus (arrow). (b) Duplex Doppler US image shows the hepatofugal flow via the recanalized ductus venosus (arrow) into the inferior vena cava (IVC).