Differential diagnosis Luminal Ex: cholelithiasis, choledocholithiasis Diagnostics: Abdominal xray (Black pigment or mixed gallstones may contain sufficient calcium to appear radiopaque on plain x-ray films) – less reliable HBT UTZ (Gallstones appear as echogenic foci in the gallbladder. They move freely with positional changes and cast an acoustic shadow) Endoscopic retrograde cholangiopancreatography (ERCP) permits x-ray imaging of the bile ducts. ERCP is usually performed in conjunction with endoscopic retrograde sphincterotomy and gallstone extraction. Rising levels of bilirubin and transaminases with progression of leukocytosis in the face of antibiotic therapy may indicate ascending cholangitis with need for urgent intervention.
Differential diagnosis Strictures Ex: cholangiocarcinoma (perihilar or Klatskintumor) Epidemiology: 1 case per 100,000 persons per year, male-to-female ratio for cholangiocarcinoma is 1:2.5 in patients in their 60s and 70s and 1:15 in patients younger than 40 years Diagnostics: Ultrasound may demonstrate biliary duct dilatation and larger hilar lesions. CT resembles ultrasound in that it may demonstrate ductal dilatation and large mass lesions. ERCP demonstrates the site of obstruction by direct retrograde dye injection and excludes ampullary pathology by endoscopic evaluation. Tumor marker carbohydrate antigen 19-9 (CA 19-9) can be evaluated in pancreatic and bile duct malignancies, as well as in benign cholestasis.
Differential diagnosis Extraluminal Ex: pancreatic head cancer Epidemiology: 8-12 cases per 100,000 persons per year. Unusual in persons younger than 45 years. After age 50 years, the frequency of pancreatic cancer increases linearly. In the United States, slightly more women than men are diagnosed each year with pancreatic cancer; slightly more men than women die of the disease. Diagnostics: Abdominal CT scanning continues to be the mainstay of initial diagnostic modalities used for assessing patients suspected to have pancreatic carcinoma. ERCP is highly sensitive at detecting pancreatic and/or biliaryductal abnormalities in pancreatic carcinoma. Tumor marker for pancreatic carcinoma is carbohydrate antigen 19-9 (CA 19-9).