DIAGNOSTIC ANCILLARY PROCEDURES AND FINDINGS

RICCEL, VON AT EMAN

ULTRASOUND

– Ultrasound tests can show whether the liver or bile ducts are enlarged and whether tumors or cysts are blocking the flow of bile.• Initial test of choice

– Assess any abnormalities of the heptabiliary tract– It cannot be used to make a diagnosis of biliary atresia, but it

does help rule out other common causes of jaundice• Produces an image on a computer screen using sound

waves.

Hepatobiliary scintigraphy

• Demonstrates bile duct patency using radionucleotide (DISIDA)

• A new diagnostic approach to biliary atresia with emphasis on the ultrasonographic triangular cord sign

• Triangular cord sign – Sensitivity 100% and

Specificity 100%– Liver hilum appears

hyperechogenic

LIVER SCANS• HEPATOBILIARY IMINODIACETIC

ACID (HIDA) SCANNING– Traces the path of bile in the body

and can show whether bile flow is blocked

– Infants with biliary atresia usually have normal uptake of the isotope but absent excretion into the biliary system and small intestine

– Enhance isotope excretion with 5 days of pretreatment with phenobarbital

LIVER BIOPSY– It can help rule out

other liver problems, such as hepatitis• Recommended before

surgical procedure• Portal tract edema,

fibrosis, inflammation, intracellular and canalicular cholestasis, proliferation of bile ductules

OPERATIVE CHOANGIOGRAPHY• Gold standard for the diagnosis of BA • If intact extrahepatic biliary system is not visualized,then

extrahepatic biliary atresia is evident. • If an intact biliary tree is visible, then perform an

intraoperative cholangiogram – Cannulate the bile duct through transverse abdominal

incision and inject contrast to determine if the biliary ducts are patent

– At the porta hepatis there are microscopic bile ductules that have proliferated which communicate with the intrahepatic system

• Correctable lesion – 20%– fibrosis of the distal biliary tree, however proximal biliary

tree and intrahepatic bile ducts are patent • Excise fibrotic area and direct drainage to bowel

• Non – correctable – 80%– Fibrosis to the level of the porta hepatis– Kasai procedure

TREATMENT

• The current management of BA patients involves two steps: – Kasai operation (in

the neonatal period), which aims to restore bile flow.

Fig. 1: KASAI procedure

Fig. 2: Hepatoporto-cholecystostomy

• Liver transplantation in those where the Kasai operation has failed in its primary aim or complications of biliary cirrhosis have supervened

REFERENCES

• Sabiston Textbook of Surgery 17th Edition• Harrison’s Principles of Internal Medicine 17th

Edition• http://digestive.niddk.nih.gov/ddiseases/

pubs/atresia/BiliaryAtresia.pdf