Jaundice: Clinical Pearls and Perils Revisited

I recount some clinical “pearls and perils” to help reassess the contributions of abdominal ultrasound, cholangiography, needle biopsy of the liver, and laparoscopy. Abdominal ultrasound demonstrates stones in the gallbladder in ∼98% of cases, but in only 15% in the common bile duct, whereas computerized tomography scan reveals them in ≥50%. On cholangiography a blood clot (in hemobilia) may closely resemble a common duct stone, as may spasm or tumor of the distal duct. Iatrogenic stricture at the junction of the left and right hepatic ducts may be indistinguishable from a Klatskin tumor. Differentiation of extrahepatic from intrahepatic cholestasis is frequently impossible in needle specimens of the liver. Needle biopsy provides the best means of establishing a diagnosis of alcoholic hepatitis. Laparoscopy is particularly valuable in the diagnosis of cirrhosis missed in blind biopsy specimens.