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 approximately 98% of cases, but in only 15% in the common bile duct, whereas computerized tomography scan reveals them in greater than or equal to 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.