Diagnostic Imaging Pathways - Cholestatic Jaundice

Pathway

Images

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1a		Pancreatic Cancer Image 1a, 1b, and 1c (Computed Tomography): Dilated common bile duct, pancreatic duct and gallbladder. There is a mass located in the head of pancreas with involvement of the mesenteric vessels.
1b
1c
2		Pancreatic Cancer Image 2 (ERCP): "Double-duct" sign - strictures are seen in the common bile duct (yellow arrow) and pancreatic duct (grey arrow) with dilatation of the pancreatic duct.
3a		Pancreatic Cancer Image 3a (H&E, x2.5) and 3b (H&E, x10): Histological sections of a pancreatic adenocarcinoma showing the typical appearance of irregular malignant glands set in abundant desmoplastic stroma. Note, the residual normal pancreatic parenchyma (blue arrow). Image 3b shows the predisposition of this cancer for perineural invasion.
3b
4		Sclerosing Cholangitis Image 4 (CT Cholangiogram): Beading of intrahepatic and extrahepatic bile ducts consistent with sclerosing cholangitis.

Teaching Points

Teaching Points

• Ultrasound is the first imaging modality used in the algorithm for the investigation of cholestatic jaundice
• Further imaging depends on whether the bile ducts are dilated
  • If the bile ducts are dilated and an ultrasound fails to demonstrate a cause, further imaging depends on a provisional clinical diagnosis. Investigations may include CT scan of the abdomen, CT cholangiogram, magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound (EUS)
  • If the bile ducts are not dilated, hepatocellular causes of jaundice should be excluded prior to further imaging
• endoscopic retrograde cholangiopancreatography (ERCP) is reserved for therapeutic indications or if there remains ongoing clinical doubt with non-diagnostic imaging studies

References

References

Date of literature search: April 2015

The search methodology is available on request. Email

References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document

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Further Reading

1. T Hyodo, S Kumano, F Kushihata, M Okada, M Hirata, T Tsuda, et al. CT and MR cholangiography: advantages and pitfalls in perioperative evaluation of biliary tree. Br J Radiol. 2012;85(1015):887–96. (Review article). View the reference

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