Sonographic Evaluation of the Common Bile Duct in Cats

Renee Leveille, David S. Biller, and Jonathan T. Shiroma

Ultrasound is an excellent imaging tool in the evaluation of healthy cats and in 22 cats with nonsurgical jaundice was
the biliary tract in cats. Extrahepatic obstruction could be 1-4 mm. Six of 7 cats with a CBD >5 m m had extrahepatic
diagnosed by the presence of dilated common bile duct biliary obstruction.
(CBD), which was measured ventral to the portal vein in the J Vet Intern Med 1996;10:296-299. Copyright 0 1996 by the
porta hepatis. At this level, the diameter of the CBD in 6 American College of Veterinary Internal Medicine.

C holestatic hepatic disease is common in cats.' The spe-

cific cause and pathogenesis are difficult to determine
in most cases because the clinical signs are nonspecific and
nonfasted normal cats; and, to evaluate the usefulness of
ultrasonography for distinguishing obstructive from nonob-
structive biliary disease.
no single liver function test or biochemical test is adequate
for diagnosis of hepatobiliary disease. Furthermore, severe Materials and Methods
hepatic pathology in cats may be present with only mild to Six clinically healthy adult cats from a breeding colony were
moderate increases in the serum activity of liver enzymes. examined sonographically. Results of blood chemistry tests includ-
Differentiation between extrahepatic and intrahepatic biliary ing serum alkaline phosphatase and gamma glutamyl transferase
obstruction can be difficult based on history, clinical signs, activities, total bilirubin concentration, and total protein concentra-
and biochemical tests, but is important because surgical relief tion were normal in all 6 cats. All abdominal organs were within
of an extrahepatic obstruction may be necessary. Sludged normal limits ultrasonographically.
bile and bile pigment stones associated with cholangiohepa- Each cat was examined immediately and 3 hours after eating, and
after 0.5, I , I .S, 2, and 2.5 days of fasting. Water was available at
titis complex are the most common causes of partial or com-
all times. Cats were manually restrained in dorsal recumbency and
plete extrahepatic bile duct obstruction in cats.'
examined after routine preparation for ultrasonography. Sonographic
Intravenous cholecystography may be inconclusive if he- examinations were performed using a real-time mechanical sector
patocellular disease, or intrahepatic or extrahepatic biliary scanner with a 7.5-MHz transducer (axial resolution, 0.5 mm; lateral
obstruction prevents sufficient opacification of the biliary resolution, 0.9 mm). Studies were recorded on videotape and ultra-
tract.' In human patients, ultrasonography most often is used sound film with a multiformat camera. The sonographic appearance
as the primary imaging modality of the biliary tract because it and size of the CBD were evaluated ventral to the portal vein on (1)
has high sensitivity for the presence of gallstones, it enables right-sided intercostal longitudinal scan, (2) right-sided intercostal
accurate evaluation of the status of the intrahepatic and extra- transverse scan, (3) ventral longitudinal scan, (4)ventral transverse
hepatic bile ducts, and the examination can be performed scan, and ( 5 ) right cranioventral oblique scan. Real-time imaging
relatively rapidly and at low cost.' Ultrasonography has been was performed parallel to the plane of the long axis of the CBD. The
luminal diameter of the widest segment of the CBD was measured
used with increasing frequency in veterinary medicine and
perpendicular to its long axis by electronic calipers because the
may be useful in the diagnosis of intrahepatic and extrahe- outer margin of the wall of the CBD cannot be shown easily. The
patic obstruction in icteric cats. measurements of CBD diameter were compared for all time periods
The hepatic ducts are not visible ultrasonographically in using a Friedman test.
normal dogs and cats, and only a portion of the cystic duct Twenty-nine icteric cats presented at 3 institutions were studied
is visualized oc~asionally.~ Distention of the intrahepatic ultrasonographically (The Ohio State University, n = 14; The Uni-
ducts is suspected when hypoechoic tortuous tubular struc- versity of Montreal, n = 12; and The University of Florida, n = I).
tures are seen adjacent to the intrahepatic portal veins. The The radiologist performing the scans was not blinded to patient
ultrasonographic changes in surgically induced extrahepatic history, but the presence or absence of obstruction usually had not
biliary obstruction in dogs have been reported.' The normal been established at the time of the study because ultrasonography
generally was the initial imaging examination. A CBC, serum bio-
ultrasonographic appearance of the common bile duct (CBD)
chemical evaluations, and sonographic examination were performed
in cats has not been reported, nor has the use of ultrasonogra- at the time of admission and as follow-up examinations. In addition
phy to differentiate obstructive from nonobstructive biliary to CBD measurement, any abdominal abnormalities were recorded.
disease in this species. The final diagnosis was obtained from percutaneous ultrasound-
The purpose of this study was to describe the ultrasono- guided fine-needle aspiration or liver biopsy, surgical biopsy, nec-
graphic appearance and anatomic relationships among the ropsy, or based on response to clinical management.
neck of the gall bladder, the CBD, and the portal vein in The measurements of the CBD diameter of the nonobstructed and
normal cats; to evaluate the size of the CBD in fasted and obstructed biliary tract groups were compared using a Mann-Whit-
ney test with statistical significance at P 5 .01.

From the Dipartement de Sciences Cliniques, Fucultk de Me'de- Results

cine Ve'terinuire, Universite' de Montreal. The overall median diameter of the CBD, for all time
Accepted March 25, 1996.
periods in the 6 healthy cats, was 2.7 mm (range, 2 to 4
Reprint requests: Rene'e Le'veilli, DVM, Department of Clinical
Sciences, The Ohio Stute University, 601 Vernon L. Tharp, Colum- mm). The measurements of the CBD for each cat were tabu-
bus, OH 43210-1089. lated; no marked difference was noted before and during the
Copyright 0 I996 by the American College of Veterinary Internal fasting period. The CBD could be seen in every cat except
Medicine for 1 cat 3 hours after feeding because of an interfering
0891-6640/96/1005-0003$3.00/0 reverberation artifact secondary to intestinal gas. The right

296 Journal of Veterinary Internal Medicine, Vol 10, No 5 (September-October), 1996: pp 296-299
 19391676, 1996, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1939-1676.1996.tb02065.x by Cochrane Colombia, Wiley Online Library on [29/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
ULTRASONOGRAPHY OF CBD IN CATS 291

Table 1. Causes of Nonobstructive Biliary Disease

and Ultrasonographic Measurement of the Common
Bile Duct (CBD) in 2 Cats
CBD Diameter
Diagnosis (mm; median, range)
Lipidosis i n = 16) 2.0 (1.0-4.0)
Cholangiohepatitis (n = 2) 2.0-3.0
Lipidosis-lymphoma ( n = 1) 3.0
lntrahepatic cholestasis (n = 1) 3.4
Hepatic failure ( n = 1) 2.0
Pancreatic adenocarcinoma (n = 1) 3.0

pancreatic adenocarcinoma (n = I), and unknown cause of

hepatic failure (n = 1). The CBD had a tortuous appearance
and its median diameter was 2.4 mm (range, 1 to 4 mm).
These values did not differ significantly from the ones ob-
tained in the normal cats in our study.
Fig 1. Right cranioventral oblique scan of a normal CBD with tor- Seven cats had obstruction of the CBD associated with
tuous appearance. The CBD measures 3 m m in diameter. Abbrevia- pancreatitis (n = 4), obstruction of the duodenal papilla by
tions: PV, portal vein; CVC, caudal vena cava; AO, aorta; GB, gall a foreign body (n = I), calculi (n = I), and calculi associated
bladder.
with chronic fibrosing cholangitis (n = 1) (Table 2). The
median value for the diameter of the CBD in these obstructed
cats was 5 mm (range, 5 to 11 mm) (Figs 3 and 4). The
cranioventral oblique scan provided the best approach for diameter of the CBD was significantly greater in cats with
the identification and evaluation of the CBD. The CBD was obstruction compared with those with hepatic disease and
identified as a tubular, often tortuous structure ventral to the no obstruction ( P < .01). The precise level of the obstruction
portal vein in the porta hepatis (Figs 1 and 2). could not be determined in any of the cats, and the specific
Extrahepatic obstruction was not identified in 22 cats cause of obstruction was identified in 5 of 7 cats (all but
based on the clinical, ultrasonographic, surgical, and post- cats 3 and 5). In cat 3, the foreign body obstructing the
mortem findings (Table 1). The causes of icterus in these duodenal papilla was not recognized. In cat 5, the ultrasono-
cats were hepatic lipidosis (n = 17), cholangiohepatitis (n graphic examination showed a distended gall bladder, dilated
= 2), cholangiohepatitis with chronic pancreatitis (n = I), CBD, and multiple fluid-filled tubular or round structures
within the hepatic parenchyma. These ultrasonographic
findings were compatible with severe dilatation of intrahe-
patic and extrahepatic bile ducts.

Discussion
lcterus is a common clinical sign in cats. At the time of
presentation, most cats with biliary-related disease and ic-
term are severely ill, and vomiting, dehydratation, and an-

Table 2. Causes of Obstructive Biliary Disease

and Ultrasonographic Measurement of the Common
Bile Duct (CBD) in 7 Cats
Cat CBD Diameter
No. Causes Method (rnm)

1 Pancreatitis sx 5.0
2 Chronic pancreatitis sx 6.0
3 Duodenal papilla obstruction by Sx 5.0
a foreign body
4 Chronic pancreatitis sx 11.0
5 Chronic fibrosing cholangitis Sx, Bx 6.0
and cholelithiasis
6 Pancreatitis sx 5.0
7 Cholelithiasis PM 5.0
Fig 2. Ventral transverse scan of the right cranial quadrant show-
ing the anatomical relationship between the CBD, PV, CVC, and AO. Abbreviations: Bx, biopsy; Sx. surgery; PM, necropsy.
 19391676, 1996, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1939-1676.1996.tb02065.x by Cochrane Colombia, Wiley Online Library on [29/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
298 LEVEILLE, BILLER, AND SHIROMA

The entire length of the CBD should be examined if possi-

ble, even when the CBD diameter is normal, to diagnose
cholelithiasis or a tumor causing partial obstruction. The
lateral and axial resolutions of the transducer may explain
variations in measurements. Maximal CBD diameter in hu-
man patients measured with ultrasonography can increase
during deep inspiration.' ' Difficulties usually arise because
of bowel gas obscuring detail around the distal CBD. .

Although a dilated CBD usually implies obstruction, a

previously dilated duct may not return to normal caliber
despite relief of the obstruction. Severe or prolonged Jisten-
tion and inflammation in the wall may decrease the elastic-
ity.? In patients with underlying restrictive disease of the
liver (eg, tumor, cirrhosis), the intrahepatic ducts may be
Fig 3. Right cranioventral oblique scan of a dilated CBD caused resistant to dilatation." Dilatation of the CBD itself is a
by pancreatitis (cat 51. The CBD measures 5 mm in diameter. more sensitive indicator of the presence of obstruction. ' I
Intrahepatic bile duct dilatation follows extrahepatic bile
duct dilatation, and not the reverse.',13
orexia are common clinical signs. Extrahepatic biliary ob- In 1977, Neiman et al reported that the specific level of
struction may result from extraluminal compression, obstruction could be determined in approxiniatly 60% of
intraluminal obstruction, or mural thickening. Tumors of the human patients and the actual cause of obstruction deter-
pancreas and duodenum, and tumors and abscesses of the mined in approximately 40% of patients using ultrasonogra-
hilus of the liver and portal lymph nodes may cause compres- phy. l 4 Other investigators reported the sensitivities of ultra-
sion of the ducts.6 sonography in determining the level and cause of obstruction
In human patients with jaundice, ultrasonography has re- to be 92% to 95%'' and 71% to 88%, respectively". In our
placed IV cholangiography as a primary imaging technique study, the distal termination of the CBD was difficult to
in evaluating the biliary system. Absence of gall bladder visualize. This may have occured because the hilar region
dilatation does not necessarily exclude extrahepatic obstruc- of the porta hepatis often is obscured by gastric or intestinal
tion, because the gall bladder may be contracted because of gas. However, the precise cause was determined in 5 of 7
inflamrnati~n.~ In normal fasled dogs, previous studies have cats with extrahepatic biliary obstruction. Whereas it may
indicated that there is considerable variation in size of the be difficult to identify the site of extrahepatic obstruction
gall bladder.' Ultrasonography has been described in dogs ultrasonographically, an enlarged CBD can be accurately
as an imaging method to differentiate between hepatic and identified and, if ultrasonography shows cholelithiasis in the
'(I Subtle dilatation of the intrahepatic CBD of an icteric patient, this has predictive value. Serial
ducts and minimal enlargement of the CBD both were notice- ultrasonographic examinations also will make the diagnosis
able 4 hours after induced biliary obstruction in dogs.'" Ny- apparent.
land et a1 also found ultrasonographically evident enlarge- The results of our study indicate that ultrasonography is
ment of the CBD 24 to 48 hours after experimental bile duct useful in the diagnosis and treatment of icteric cats. Based
ligation in dogs.' on ultrasonographic findings, a confident diagnosis regarding
Ultrasonographic examination of the liver in cats is much the presence or absence of biliary obstruction can be made.
more difficult than in humans or dogs because the liver is Knowledge of CBD position with respect to the major ves-
located more cranially under the rib cage and is oriented
along a more dorsoventral axis. In this study, standard ultra-
sonographic scans from the ventral abdomen were insuffi-
cient to visualize the biliary tract consistently. The right
cranioventral oblique scan was most useful for imaging dila-
tation of the biliary tract. As the normal CBD has a tortuous
appearance, it should be distinguished from blood vessels
using spectral or color Doppler, and measured dorsal to the
portal vein to avoid confusion with the tapering gall bladder
neck. The ultrasonographic appearance of the obstructed
CBD in cats was similar to that reported in a study of experi-
mental ligation of the CBD in dogs.'
Based on the ultrasonographic and clinical findings in
normal and icteric cats in this study, we suggest that the
upper limit for the diameter of the CBD in normal cats is 4
mm. In cats with nonobstructive biliary disease, the diameter
of the CBD also is likely to be normal. A CBD diameter Fig 4. Dilatation of the CBD and presence of choledocholiths (cat
2.5 mm in cats is suggestive of posthepatic obstruction. 7). The CBD measures 5 m m in diameter.
 19391676, 1996, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1939-1676.1996.tb02065.x by Cochrane Colombia, Wiley Online Library on [29/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
ULTRASONOGRAPHY OF CBD IN CATS 299

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taken to differentiate the CBD from the gall bladder neck and in vivo of canine gall bladder volume, using four volumetric
or a portal vessel. The upper limit for the normal CBD in formulas and step-wise regression models. Am J Vet Res 1993;54:
832-835.
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9. Wrigley RH. Radiographic and ultrasonographic diagnosis of
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liver diseases in dogs and cats. Vet Clin North Am Small Anim
underlying cause. Practice 1985; 15:21-38.
10. Zeman RK, et al. Acute experimental biliary obstruction in
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