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Bile Ducts

Runs in portal triad anterior to portal veins. Hepatic artery arises from celiac axis, travels in the hepatoduodenal ligament anterior to the portal vein and medial to the common duct → Mickey Mouse on transverse view (head = PV, ear to the patient’s left = hepatic artery, ear to the right = bile duct). Replaced R hepatic artery arises from SMA


Hyperechoic, sometimes shadowing, intraductal stones mostly located near the ampulla of Vater.

Intrahepatic ducts stones

Pigment stones from bacterial deconjugation of bilirubin - Recurrent pyogenic cholangitis, biliary flukes (Clonorchis sinensis, Ascaris lumbricoides)


Intrabiliary gas: brighter reflections and dirtier shadows than stones, ring-down artifact


Most common is Klatskin tumor (dilated intrahepatic ducts w/o communication)

DDx: GB cancer, HCC, Pancreatic ca, Ampullary ca.

Intraductal cholangiocarcinoma

Stricture, polypoid or diffuse sclerosing pattern; most are unresectable; US: dilated duct w/ abrupt termination

Bile duct wall thickening

Hypoechoic layer adjacent to echogenic wall.

Sclerosing cholangitis

Young men, assoc. w/ IBD especially UC, Bile duct wall thickening > 5 mm, multifocal strictures, beading in the intrahepatic ducts. Predisposition for cholangiocarcinoma, prominent nodes in the porta hepatis.

Other causes of BD wall thickening: Choledocholithiasis, AIDS (CMV or Cryptosporidium), Pancreatitis, Recurrent Pyogenic Cholangitis

Choledochal Cysts

  1. Type 1: Fusiform dilatation of the extrahepatic duct

  2. Type 2: Diverticular outpouching of the extrahepatic duct

  3. Type 3: Choledochocele

  4. Type 4: Multifocal dilatations

  5. Type 5: Caroli’s disease: multifocal saccular dilatation of the intrahepatic bile ducts with sparing of the extrahepatic ducts. Leads to hepatic fibrosis and portal HTN and variceal bleeding. Assoc. w/ medullary sponge kidneys (tubular ectasia).

Sono: cystic intrahepatic lesions w/ communication w/ bile ducts, comet tail artifacts, Central Dot Sign - dilated duct surrounds hepatic artery and PV.

DDx: Von Mayerman biliary hamartomas

Mirizzi’s Sy

Common bile duct obstruction caused by gallstone in the cystic duct or the GB neck; low inserting cystic duct; cholangiography is the gold standard