Recommendations for the Management of Incidental Hepatobiliary Findings in Adults: Endorsement and Adaptation of the 2017 and 2013 ACR Incidental Findings Committee White Papers by the Canadian Association of Radiologists Incidental Findings Working Group
Restricted accessResearch articleFirst published online November, 2020
Recommendations for the Management of Incidental Hepatobiliary Findings in Adults: Endorsement and Adaptation of the 2017 and 2013 ACR Incidental Findings Committee White Papers by the Canadian Association of Radiologists Incidental Findings Working Group
The Canadian Association of Radiologists Incidental Findings Working Group consists of both academic subspecialty and general radiologists and is tasked with adapting and expanding upon the American College of Radiology incidental findings white papers to more closely apply to Canadian practice patterns, particularly more comprehensively dealing with the role of ultrasound and pursuing more cost-effective approaches to the workup of incidental findings without compromising patient care. Presented here are the 2020 Canadian guidelines for the management of hepatobiliary incidental findings. Topics covered include initial assessment of hepatic steatosis and cirrhosis, the workup of incidental liver masses identified on ultrasound and computed tomography (with algorithms presented), incidental gallbladder findings (wall thickening, calcification, and polyps), and management of incidental biliary dilatation.
BerlandLLSilvermanSGGoreRM, et al.Managing incidental findings on abdominal CT: white paper of the ACR incidental findings committee. J Am Coll Radiol. 2010;7(10):754–773.
2.
HertsBRSilvermanSGHindmanNM, et al.Management of the incidental renal mass on CT: a white paper of the ACR incidental findings committee. J Am Coll Radiol. 2018;15(2):264–273.
3.
KirkpatrickIDCBrahmGLMnatzakanianGNHurrellCHertsBRBirdJR. Recommendations for the management of the incidental renal mass in adults: endorsement and adaptation of the 2017 ACR incidental findings committee white paper by the Canadian association of radiologists incidental findings working group. Can Assoc Radiol J. 2019;70(2):125–133.
4.
GoreRMPickhardtPJMorteleKJ, et al.Management of incidental liver lesions on CT: a white paper of the ACR incidental findings committee. J Am Coll Radiol. 2017;14(11):1429–1437.
5.
WilesRThoeniRFBarbuST, et al.Management and follow-up of gallbladder polyps: joint guidelines between the European society of gastrointestinal and abdominal radiology (ESGAR), European association for endoscopic surgery and other interventional techniques (EAES), International society of digestive surgery – European federation (EFISDS) and European society of gastrointestinal endoscopy (ESGE). Eur Radiol. 2017;27(9):3856–3866.
6.
SchwenzerNFSpringerFSchramlCStefanNMachannJSchickF. Non-invasive assessment and quantification of liver steatosis by ultrasound, computed tomography and magnetic resonance. J Hepatol. 2009;51(3):433–445.
7.
StraussSGavishEGottliebPKatsnelsonL. Interobserver and intraobserver variability in the sonographic assessment of fatty liver. AJR Am J Roentgenol. 2007;189(6):W320–W323.
8.
DasarathySDasarathyJKhiyamiAJosephRLopezRMcCulloughAJ. Validity of real time ultrasound in the diagnosis of hepatic steatosis: a prospective study. J Hepatol. 2009;51(6):1061–1067.
9.
BohteAEvan WervenJRBipatSStokerJ.The diagnostic accuracy of US, CT, MRI and 1H-MRS for the evaluation of hepatic steatosis compared with liver biopsy: a meta-analysis. Eur Radiol. 2011;21(1):87–97.
10.
GoulartACOliveiraIRAlencarAP, et al.Diagnostic accuracy of a noninvasive hepatic ultrasound score for non-alcoholic fatty liver disease (NAFLD) in the Brazilian longitudinal study of adult health (ELSA-Brasil). Sao Paulo Med J. 2015;133(2):115–124.
11.
HamerOWAguirreDACasolaGLavineJEWoenckhausMSirlinCB. Fatty liver: imaging patterns and pitfalls. Radiographics. 2006;26(6):1637–1653.
12.
MarshallRHEissaMBluthEIGulottaPMDavisNK. Hepatorenal index as an accurate, simple, and effective tool in screening for steatosis. AJR Am J Roentgenol. 2012;199(5):997–1002.
13.
ShiralkarKJohnsonSBluthEIMarshallRHDornellesAGulottaPM. Improved method for calculating hepatic steatosis using the hepatorenal index. J Ultrasound Med. 2015;34(6):1051–1059.
14.
LawrenceDAOlivaIBIsraelGM. Detection of hepatic steatosis on contrast-enhanced CT images: diagnostic accuracy of identification of areas of presumed focal fatty sparing. AJR Am J Roentgenol. 2012;199(1):44–47.
15.
JacobsJEBirnbaumBAShapiroMA, et al.Diagnostic criteria for fatty infiltration of the liver on contrast-enhanced helical CT. AJR Am J Roentgenol. 1998;171(3):659–664.
16.
SangsterGPPreviglianoCHNaderMChwoschtschinskyEHeldmannMG. MDCT Imaging findings of liver cirrhosis: spectrum of hepatic and extrahepatic abdominal complications. HPB Surg. 2013;2013:129396.
17.
GuptaAAKimDCKrinskyGALeeVS. CT and MRI of cirrhosis and its mimics. AJR Am J Roentgenol. 2004;183(6):1595–1601.
18.
TanKC. Enlargement of the hilar periportal space. Radiology. 2008;248(2):699–700.
19.
ItoKMitchellDGGabataT. Enlargement of hilar periportal space: a sign of early cirrhosis at MR imaging. J Magn Reson Imaging. 2000;11(2):136–140.
20.
BrancatelliGFederleMPAmbrosiniR, et al.Cirrhosis: CT and MR imaging evaluation. Eur J Radiol. 2007;61(1):57–69.
21.
GoyalNJainNRachapalliVCochlinDLRobinsonM. Non-invasive evaluation of liver cirrhosis using ultrasound. Clin Radiol. 2009;64(11):1056–1066.
22.
ParkHSDesserTSJeffreyRBKamayaA. Doppler ultrasound in liver cirrhosis: correlation of hepatic artery and portal vein measurements with model for end-stage liver disease score. J Ultrasound Med. 2017;36(4):725–730.
23.
StammERMeierJMPokharelSS, et al.Normal main portal vein diameter measured on CT is larger than the widely referenced upper limit of 13 mm. Abdom Radiol (NY). 2016;41(10):1931–1936.
24.
TseJRJeffreyRBKamayaA. Performance of hepatic artery velocity in evaluation of causes of markedly elevated liver tests. Ultrasound Med Biol. 2018;44(11):2233–2240.
25.
JonesECChezmarJLNelsonRCBernardinoME. The frequency and significance of small (less than or equal to 15 mm) hepatic lesions detected by CT. AJR Am J Roentgenol. 1992;158(3):535–539.
26.
KoeaJB. Hepatic incidentaloma: the rule of tens. HPB (Oxford). 2013;15(5):379–383.
27.
ChoiSHKwonHJLeeSY, et al.Focal hepatic solid lesions incidentally detected on initial ultrasonography in 542 asymptomatic patients. Abdom Radiol (NY). 2016;41(2):265–272.
28.
KuszykBSBluemkeDAUrbanBA, et al.Portal-phase contrast-enhanced helical CT for the detection of malignant hepatic tumors: sensitivity based on comparison with intraoperative and pathologic findings. AJR Am J Roentgenol. 1996;166(1):91–95.
29.
SchwartzLHGandrasEJColangeloSMErcolaniMCPanicekDM. Prevalence and importance of small hepatic lesions found at CT in patients with cancer. Radiology. 1999;210(1):71–74.
30.
VolkMStrotzerMLenhartMTechertJSeitzJFeuerbachS. Frequency of benign hepatic lesions incidentally detected with contrast-enhanced thin-section portal venous phase spiral CT. Acta Radiol. 2001;42(2):172–175.
31.
MayoZKennedySGaoYMillerBJ. What is the clinical importance of incidental findings on staging CT scans in patients with sarcoma?Clin Orthop Relat Res. 2019;477(4):730–737.
32.
GoreRMThakrarKHWenzkeDRNewmarkGMMehtaUKBerlinJW. That liver lesion on MDCT in the oncology patient: is it important?Cancer Imaging. 2012;12(5):373–384.
33.
KrakoraGACoakleyFVWilliamsGYehBMBreimanRSQayyumA. Small hypoattenuating hepatic lesions at contrast-enhanced CT: prognostic importance in patients with breast cancer. Radiology. 2004;233(3):667–673.
34.
KnoxMSlanetzPPhillipsJ, et al.Incidental liver lesions seen on Breast MRI: When is additional imaging warranted?Eur J Radiol. 2017;95(3):319–324.
35.
JangHJLimHKLeeWJLeeSJYunJYChoiD. Small hypoattenuating lesions in the liver on single-phase helical CT in preoperative patients with gastric and colorectal cancer: prevalence, significance, and differentiating features. J Comput Assist Tomogr. 2002;26(5):718–724.
36.
SemaanABranchiVMarowskyAL, et al.Incidentally detected focal liver lesions – a common clinical management dilemma revisited. Anticancer Res. 2016;36(6):2923–2932.
37.
MohamedEAdiamahADunnWKHigashiYCameronICGomezD. Outcome of indeterminate liver lesions on computed tomography in patients with colorectal cancer. Ann R Coll Surg Engl. 2018;100(5):382–387.
38.
ElnahalSMShinagareABSzymonifkaJHongTSEnzingerPCMamonHJ. Prevalence and significance of subcentimeter hepatic lesions in patients with localized pancreatic adenocarcinoma. Pract Radiat Oncol. 2012;2(4):e89–e94.
39.
LeiferDMMiddletonWDTeefeySAMeniasCOLeahyJR. Follow-up of patients at low risk for hepatic malignancy with a characteristic hemangioma at US. Radiology. 2000;214(1):167–172.
40.
FateenWRyderSD. Screening for hepatocellular carcinoma: patient selection and perspectives. J Hepatocell Carcinoma. 2017;4:71–79.
41.
BaloghJVictorD3rdAshamEH, et al.Hepatocellular carcinoma: a review. J Hepatocell Carcinoma. 2016;3(2):41–53.
42.
TsungAGellerDA. Workup of the incidental liver lesion. Adv Surg. 2005;39(1):331–341.
43.
NewsomePNCrambRDavisonSM, et al.Guidelines on the management of abnormal liver blood tests. Gut. 2018;67(1):6–19.
44.
BuhlerHPirovinoMAkobiantzA, et al.Regression of liver cell adenoma. A follow-up study of three consecutive patients after discontinuation of oral contraceptive use. Gastroenterology. 1982;82(4):775–782.
45.
KatabathinaVSMeniasCOShanbhogueAKJagirdarJPaspulatiRMPrasadSR. Genetics and imaging of hepatocellular adenomas: 2011 update. Radiographics. 2011;31(6):1529–1543.
46.
RosPES. Benign tumors of the liver. In: GoreRMLevineMS, ed. Textbook of Gastrointestinal Radiology. 4th ed. Elsevier; 2015:1608–1628.
47.
ChicheLAdamJP. Diagnosis and management of benign liver tumors. Semin Liver Dis. 2013;33(3):236–247.
48.
CogleyJRMillerFH. MR imaging of benign focal liver lesions. Radiol Clin North Am. 2014;52(4):657–682.
49.
KamayaAMaturenKETyeGALiuYIPartiNNDesserTS. Hypervascular liver lesions. Semin Ultrasound CT MR. 2009;30(5):387–407.
50.
VilgrainVBoulosLVulliermeMPDenysATerrisBMenuY. Imaging of atypical hemangiomas of the liver with pathologic correlation. Radiographics. 2000;20(2):379–397.
51.
BurrelMLlovetJMAyusoC, et al.MRI angiography is superior to helical CT for detection of HCC prior to liver transplantation: an explant correlation. Hepatology. 2003;38(4):1034–1042.
52.
RodeABancelBDouekP, et al.Small nodule detection in cirrhotic livers: evaluation with US, spiral CT, and MRI and correlation with pathologic examination of explanted liver. J Comput Assist Tomogr. 2001;25(3):327–336.
53.
SaingSHaywoodPDuncanJKMaNCameronALGoodallS. Cost-effective imaging for resectability of liver lesions in colorectal cancer: an economic decision model. ANZ J Surg. 2018;88(6):e507–e511.
54.
ChoiJYLeeJMSirlinCB. CT and MR imaging diagnosis and staging of hepatocellular carcinoma: part II. Extracellular agents, hepatobiliary agents, and ancillary imaging features. Radiology. 2014;273(1):30–50.
55.
SemaanSVietti VioliNLewisS, et al.Hepatocellular carcinoma detection in liver cirrhosis: diagnostic performance of contrast-enhanced CT vs. MRI with extracellular contrast vs. gadoxetic acid. Eur Radiol. 2020;30(2):1020–1030.
56.
American College of Radiology. CT/MRI LI-RADS v; 2018.
57.
VallsCIannacconneRAlbaE, et al.Fat in the liver: diagnosis and characterization. Eur Radiol. 2006;16(10):2292–2308.
58.
KaltenbachTEEnglerPKratzerW, et al.Prevalence of benign focal liver lesions: ultrasound investigation of 45,319 hospital patients. Abdom Radiol (NY). 2016;41(1):25–32.
59.
MaviliaMGPakalaTMolinaMWuGY. Differentiating cystic liver lesions: a review of imaging modalities, diagnosis and management. J Clin Transl Hepatol. 2018;6(2):208–216.
60.
KimJYKimSHEunHW, et al.Differentiation between biliary cystic neoplasms and simple cysts of the liver: accuracy of CT. AJR Am J Roentgenol. 2010;195(5):1142–1148.
61.
BorhaniAAWiantAHellerMT. Cystic hepatic lesions: a review and an algorithmic approach. AJR Am J Roentgenol. 2014;203(6):1192–1204.
62.
SebastianSAraujoCNeitlichJDBerlandLL. Managing incidental findings on abdominal and pelvic CT and MRI, part 4: white paper of the ACR incidental findings committee II on gallbladder and biliary findings. J Am Coll Radiol. 2013;10(12):953–956.
63.
StephenAEBergerDL. Carcinoma in the porcelain gallbladder: a relationship revisited. Surgery. 2001;129(6):699–703.
64.
TowfighSMcFaddenDWCortinaGR, et al.Porcelain gallbladder is not associated with gallbladder carcinoma. Am Surg. 2001;67(1):7–10.
65.
SchnelldorferT. Porcelain gallbladder: a benign process or concern for malignancy?J Gastrointest Surg. 2013;17(6):1161–1168.
66.
DesJardinsHDuyLScheireyCSchnelldorferT. Porcelain gallbladder: is observation a safe option in select populations?J Am Coll Surg. 2018;226(6):1064–1069.
67.
CorwinMTSiewertBSheimanRGKaneRA. Incidentally detected gallbladder polyps: is follow-up necessary?—long-term clinical and US analysis of 346 patients. Radiology. 2011;258(1):277–282.
68.
CairnsVNealCPDennisonARGarceaG. Risk and cost-effectiveness of surveillance followed by cholecystectomy for gallbladder polyps. Arch Surg. 2012;147(12):1078–1083.
69.
BabuBIDennisonARGarceaG. Management and diagnosis of gallbladder polyps: a systematic review. Langenbecks Arch Surg. 2015;400(4):455–462.
70.
BhattNRGillisASmootheyCOAwanFNRidgwayPF. Evidence based management of polyps of the gall bladder: a systematic review of the risk factors of malignancy. Surgeon. 2016;14(5):278–286.
71.
ShinSRLeeJKLeeKH, et al.Can the growth rate of a gallbladder polyp predict a neoplastic polyp?J Clin Gastroenterol. 2009;43(9):865–868.
72.
WilesRVaradpandeMMulySWebbJ. Growth rate and malignant potential of small gallbladder polyps—systematic review of evidence. Surgeon. 2014;12(4):221–226.
73.
MatcukGRJrGrantEGRallsPW. Ultrasound measurements of the bile ducts and gallbladder: normal ranges and effects of age, sex, cholecystectomy, and pathologic states. Ultrasound Q. 2014;30(1):41–48.
LevyADMurakataLAAbbottRMRohrmannCAJrFrom the archives of the AFIP. Benign tumors and tumorlike lesions of the gallbladder and extrahepatic bile ducts: radiologic-pathologic correlation. Armed forces institute of pathology. Radiographics. 2002;22(2):387–413.
76.
OhSHHanHYKimHJ. Comet tail artifact on ultrasonography: is it a reliable finding of benign gallbladder diseases?Ultrasonography. 2019;38(3):221–230.
77.
JungSELeeJMLeeK, et al.Gallbladder wall thickening: MR imaging and pathologic correlation with emphasis on layered pattern. Eur Radiol. 2005;15(4):694–701.
78.
HammadAYMiuraJTTuragaKKJohnstonFMHohenwalterMDGamblinTC. A literature review of radiological findings to guide the diagnosis of gallbladder adenomyomatosis. HPB (Oxford). 2016;18(2):129–135.
79.
KimBSOhJYNamKJ, et al.Focal thickening at the fundus of the gallbladder: computed tomography differentiation of fundal type adenomyomatosis and localized chronic cholecystitis. Gut Liver. 2014;8(2):219–223.
80.
AtkinsonCJLisantiCJSchwopeRB, et al.Mild asymptomatic intrahepatic biliary dilation after cholecystectomy, a common incidental variant. Abdom Radiol (NY). 2017;42(5):1408–1414.
81.
BowieJD. What is the upper limit of normal for the common bile duct on ultrasound: how much do you want it to be?Am J Gastroenterol. 2000;95(4):897–900.
82.
McArthurTAPlanzVFinebergNSBerlandLLLockhartME. CT evaluation of common duct dilation after cholecystectomy and with advancing age. Abdom Imaging. 2015;40(6):1581–1586.
83.
ChalfantJSSkaggsAWLoehfelmTWFananapazirGCorwinMT. Incidentally detected biliary ductal dilatation on contrast-enhanced CT: what is the incidence of occult obstructing malignancy?Abdom Radiol (NY). 2019;44(12):4022–4027.
84.
RaptopoulosVFabianTMSilvaW, et al.The effect of time and cholecystectomy on experimental biliary tree dilatation. A multi-imaging evaluation. Invest Radiol. 1985;20(3):276–286.
85.
OddiR. Di una speciale disposizione a sfintere allo sbocco del coledoco. Arch Ital Biol. 1887:317–322.
86.
TakahashiYTakahashiTTakahashiWSatoT. Morphometrical evaluation of extrahepatic bile ducts in reference to their structural changes with aging. Tohoku J Exp Med. 1985;147(3):301–309.
87.
NakadaI. Changes in morphology of the distal common bile duct associated with aging. Gastroenterol JPN. 1981;16(1):54–63.
88.
BenjaminovFLeichtmanGNaftaliTHalfEEKonikoffFM. Effects of age and cholecystectomy on common bile duct diameter as measured by endoscopic ultrasonography. Surg Endosc. 2013;27(1):303–307.
89.
FarahmandHPourGholamiMFathollahMS. Chronic extrahepatic bile duct dilatation: sonographic screening in the patients with opioid addiction. Korean J Radiol. 2007;8(3):212–215.
90.
SmythDStaceN. Biliary dilatation induced by different opiate drugs: a case series of eight patients. N Z Med J. 2016;129(1446):111–113.
91.
YehBMLiuPSSotoJACorveraCAHussainHK. MR imaging and CT of the biliary tract. Radiographics. 2009;29(6):1669–1688.
92.
PatelBNRosenbergMVernuccioF, et al.Characterization of small incidental indeterminate hypoattenuating hepatic lesions: added value of single-phase contrast-enhanced dual-energy CT material attenuation analysis. AJR Am J Roentgenol. 2018;211(3):571–579.
93.
WortmanJRBunchPMFulwadhvaUPBonciGASodicksonAD. Dual-energy CT of incidental findings in the abdomen: can we reduce the need for follow-up imaging?AJR Am J Roentgenol. 2016;207(4):W58–W68.
94.
WangNJuYWuJ, et al.Differentiation of liver abscess from liver metastasis using dual-energy spectral CT quantitative parameters. Eur J Radiol. 2019;113(2):204–208.
95.
KaltenbachBWichmannJLPfeiferS, et al.Iodine quantification to distinguish hepatic neuroendocrine tumor metastasis from hepatocellular carcinoma at dual-source dual-energy liver CT. Eur J Radiol. 2018;105(1):20–24.
96.
ChioreanLCantisaniVJenssenCSidhuPSBaumUDietrichCF. Focal masses in a non-cirrhotic liver: the additional benefit of CEUS over baseline imaging. Eur J Radiol. 2015;84(9):1636–1643.
97.
American College of Radiology. CEUS LI-RADS v; 2017.
98.
ZhangHPBaiMGuJYHeYQQiaoXHDuLF. Value of contrast-enhanced ultrasound in the differential diagnosis of gallbladder lesion. World J Gastroenterol. 2018;24(6):744–751.
99.
SerraCFelicaniCMazzottaE, et al.CEUS in the differential diagnosis between biliary sludge, benign lesions and malignant lesions. J Ultrasound. 2018;21(2):119–126.
