Patients with obstructive jaundice require a stepwise approach to investigation and management. Ultrasound (US) is the initial screening modality of choice and has been shown to be accurate in demonstrating the presence of dilated bile ducts, as well as the level and cause of obstruction. For adequate radiological communication to the clinician, degree of bile duct dilatation, level of obstruction, appearance of the transition zone and cause of obstruction must be reported. However, without a structured reporting method, much of this information may be omitted.
The aim of the study was to investigate the adequacy of US findings in patients with obstructive jaundice, as documented, without standardised reporting.
A retrospective chart review of 130 US reports of adult patients presenting at Grey’s Hospital US Department with a clinical assessment of obstructive jaundice was conducted. Data for the period January to December 2013, were analysed. US reports of patients with dilated bile ducts were assessed for report adequacy by looking at four important clinical factors, that is, the degree of bile duct dilatation, the level of obstruction, the appearance of the transition zone and the cause of the obstruction.
A report adequacy score was assessed in 79 patients with dilated bile ducts; however, two reports were excluded because of obscuration by gas. There was a high level of report inadequacy (38%) without the use of a structured reporting template. The level of obstruction was the most common component missing from the reports (25%), followed by the appearance of the transition zone (18%) and cause of obstruction (12%).
We propose the use of an US report template for obstructive jaundice patients in order to ensure comprehensive reporting. Structured radiological reporting will improve the method of communication between clinicians and radiologists, thus improving the quality of patient care.
Jaundice is a commonly encountered condition in clinical practice.
Radiology reports are an important method of communication between the radiologist and the referring clinician.
Several studies have been performed to demonstrate the accuracy of US in the assessment of bile duct dilatation and level and cause of obstruction.
The objectives of the study were:
to determine the diagnostic adequacy of US reports by application of a novel scoring system and
to compare US report adequacy among practitioners of varying levels of experience (sonographers, junior doctors, senior doctors and consultants).
Our study is a retrospective chart review of US reports of adult (≥ 18 years) patients who presented at Grey’s Hospital US Department with a clinical assessment of obstructive jaundice specified on the request form. This included documentation of the presence of clinical jaundice with other additional symptoms such as dark urine, pale stool, right upper quadrant pain and pruritus or documentation of biochemical markers suggestive of obstructive jaundice on liver function tests (LFTs), that is, elevated alkaline phosphatase, gamma-glutamyl transpeptidase and bilirubin.
Request forms of patients who fulfilled our inclusion criteria were obtained from the US Department filing system. US reports of the selected patients were retrieved from the Radiology Information System and PACS. The US examinations were performed on the Toshiba Aplio XG and Philips HD7 XE machines, using a wide-range, low-frequency curved-probe of 3–5 MHz and the C5-2 probe, respectively. The biliary tree was assessed trans-abdominally, using longitudinal and transverse views with the patient in the supine or right anterior oblique position. The bile ducts were considered dilated if the internal diameter of the common bile duct (CBD) was > 7 mm or if the intrahepatic bile ducts were > 2 mm in diameter. All US examinations were performed during working hours. In order to maintain confidentiality, each patient was allocated a study number. Data for a period of 12 months (January to December 2013) were collected. A total number of 130 US reports were analysed. Ethical clearance was obtained from the University of KwaZulu-Natal Biomedical Research Ethics Committee.
Data were collected from the US request forms and US reports using designed data collection sheets, with key parameters pertaining to the aim of the study. Reports of patients with the presence of dilated bile ducts on US were scored by their level of completeness. A report was considered adequate if it mentioned all four of the following:
the degree of bile duct dilatation;
the level of obstruction;
the appearance of the transition zone; and
the cause of obstruction.
A report missing any of the above items was considered inadequate. Data were analysed using Stata v13 software.
US examinations were performed by radiology consultants, registrars, medical officers (MOs) and sonographers. Report adequacy scores among the different ranks (sonographers, junior doctors [both MOs and registrars with less than 2 years of experience working in a radiology department], senior doctors [both MOs and registrars with more than 2 years of experience working in a radiology department] and consultants) were compared. US reports were also assessed for recommendation of further imaging by the personnel performing the US.
We reviewed 130 US reports of adult patients (age range of 20–89 years; mean 51.3). Ninety were female and 40 were male patients. Of these patients, 51 (39.2%) did not have dilated bile ducts on US, and 79 (60.8%) had dilated bile ducts. Of the 79 reports, 2 (2.5%) were excluded from the report adequacy score assessment because they mentioned the limitation of US examination because of obscuration by gas resulting in difficulty to assess the site of obstruction. Sixty-two percent (48/77) of reports were found to be adequate and 38% (29/77) were inadequate (
Score of adequacy of diagnostic ultrasound reports.
Score | % | 95% confidence interval | ||
---|---|---|---|---|
Adequate | 48 | 62 | 51.5% – 73.2% | < 0.001 |
Inadequate | 29 | 38 | 26.9% – 49.4% | - |
- | - |
Report adequacy score components.
Score components | % | |
---|---|---|
Degree of bile duct dilatation | ||
Present | 74 | 96 |
Absent | 3 | 4 |
Cause of obstruction | ||
Present | 68 | 88 |
Absent | 9 | 12 |
Transition zone | ||
Present | 63 | 82 |
Absent | 14 | 18 |
Level of obstruction | ||
Present | 58 | 75 |
Absent | 19 | 25 |
US findings were completely normal in 37% (19/51) of the patients without dilated bile ducts. Cholelithiasis was found in 59% (30/51) of these patients. Of the 79 patients with dilated ducts, 33% (26/79) of the reports suggested a benign cause of obstruction and 53.2% (42/79) reports suggested a malignant cause. Of the 42 patients with a malignant cause of obstruction, 57.1% (24/42) were female patients and 42.9% (18/42) were male patients (age range was 32–89; mean of 60.3). Of the 26 patients with a benign cause of obstruction, 92.3% (24/26) were female patients and 7.7% (2/26) were male patients (age range, 20–79; mean of 43.4). The spectrum of findings is displayed on
The spectrum of suggested causes of biliary obstruction in both benign and malignant groups: (a) cause of obstruction; (b) benign and (c) malignant.
In the total 130 patients who we assessed, 26.9% (35/130) cases were reported by sonographers, 29.2% (38/130) cases were reported by junior doctors, 36.2% (47/130) cases were reported by senior doctors and 7.7% (10/130) cases were reported by consultants (
Adequacy of diagnostic reports by different ranks.
Person who performed ultrasound | Diagnostic report adequacy |
Total | |||
---|---|---|---|---|---|
Adequate | Inadequate | ||||
% | % | ||||
Consultants | 7 | 100 | 0 | 0 | 7 |
Senior doctors | 20 | 71 | 8 | 29 | 28 |
Sonographers | 12 | 55 | 10 | 45 | 22 |
Junior doctors | 9 | 45 | 11 | 55 | 20 |
Recommendation for further investigation by the person performing the US examination was uncommon among all the ranks. Junior doctors recommended additional investigation most often (25%) and senior doctors least often (11%). Sonographers and consultants both recommended additional investigations in 14% of reports. None of these group differences were statistically significant.
The aim of radiological investigation in patients with obstructive jaundice is to confirm the presence of dilated bile ducts, demonstrate the level and cause of obstruction and assist in assessing tumour resectability in malignant cases.
Several studies have demonstrated the accuracy of US in the assessment of bile ducts dilatation and level and cause of obstruction.
Radiology reports are the main means of communication between the radiologist and the referring clinician, and they should be clear and precise and address the question raised by the referring clinician.
US has been shown to have low sensitivity in determining the cause of biliary obstruction especially in the distal CBD, mainly because US is dependent on several factors such as operator experience, technical factors and patient body habitus.
The level of obstruction was the most common component missing from the reports at 25%; followed by transition zone at 18% and cause of obstruction at 12% (
Examples illustrating the differences in the appearance of the transition zone in some study patients: (a) Smooth tapering of a benign stricture in the distal common bile duct (white arrow) in a patient with chronic pancreatitis; (b) coarse calcifications in the head of pancreas (yellow arrow) in the same patient; (c) and (d) abrupt cut-off of the common bile duct (white arrow) in two different patients with pancreatic head masses.
There were a higher number of inadequate reports among junior doctors and sonographers at 55% and 45%, respectively (
Malignancy was the most common suggested cause of obstruction in our patients, at 53.2% (42/79), which is compatible with other studies
Example of a malignant cause of biliary obstruction: (a) Gallbladder mass (white arrow) which has invaded segments 4A and B of the liver (yellow arrow in image a and b) and the porta hepatis (red arrow in image c), causing obstruction of the common bile duct.
The most common benign cause of obstruction was an obstructing calculus (61.5%), with a female predominance of 92.3% (24/26). There was no US diagnosis in 27% (7/26) of patients with benign cause of obstruction (
Example of a benign cause for biliary obstruction: (a) Obstructing calculus (white arrow) in the distal common bile duct as a rounded echogenic structure with posterior acoustic shadowing, causing proximal dilatation of the common bile duct; (b) multiple gallbladder calculi (white arrow) in the same patient.
Effective investigation and management of patients with biliary obstruction usually requires multimodality imaging with a stepwise approach of several imaging and therapeutic techniques.
Referral approach for patients with obstructive jaundice.
This study was performed in a single tertiary institution with limited radiology staff. This could result in bias; therefore, our results cannot be generalised. Inherent limitations include potential biases resulting from exclusion of request forms that were illegible, patients with mixed picture on LFT results and patients who had inadequate information provided on the request forms.
Our study demonstrates that at our institution there is a low rate of US report adequacy for patients with obstructive jaundice and a very low rate of recommendation of appropriate further imaging. In an attempt to improve this, we encourage the use of a standard template for US reporting for patients with biliary obstruction as well as a protocol directing further investigation. The impact of this standardised reporting guide on US report adequacy in our institution will be a topic for further research in our department.
The authors thank Catherine Connoly for her assistance with data analysis.
The authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article.
N.D. was the primary investigator and prepared the manuscript, M.G. was the supervisor for the project, made conceptual contribution and was involved with manuscript editing.