60s-year-old male, smoker, presented to the ED with complaints of abdominal distention worsening for the last few years. No abdominal pain, but did have a bout of fever and cold symptoms a day prior. No problems with his diet or bowel movements. No history of weight loss, nausea, vomiting, or urinary complaints. Abdominal exam was soft, non-distended with no tenderness. Initial labs included a GGT of 1110, WBC 11, alkaline phosphatase of 602, AST/ALT 129/118 Total/Direct bilirubin ratio of 1:0.4 , Lipase 32, Creatinine 1.2.
The liver function test derangement prompted a POCUS biliary which showed a dilated CBD measuring 0.98cm and a limited view of gallbladder fundus. A differential diagnosis included a distal CBD vs ampullary mass. The patient underwent a CT pancreatic protocol that showed intra and extra hepatic biliary duct dilatation with a soft tissue density mass within the distal CBD. He was admitted for further work up to medicine and GI teams.
—Mumin Hakim MD
SONO Pearls: Most learners who ask for help finding the CBD have already found it. It’s more a challenge of identifying and interpreting the image. Tip to always remember is that the CBD lies just anterior to the portal vein.
