Should surgeons operate on the evidence of ultrasound alone in jaundiced patients?

The biliary ultrasound scans of 132 patients having a laparotomy for jaundice have been reviewed to assess the role of ultrasound in the selection of patients for surgery. When scans were technically satisfactory the finding of a dilated extrahepatic duct (EHD) indicated obstructive jaundice in all cases, but the obstructing lesion in 5 per cent of such cases was too proximal for jaundice to be relieved by direct surgical decompression. Scans were further classified on the basis of abnormalities detected in the gallbladder. When EHD dilation was associated with gall bladder findings 'typical' of distal common bile duct (CBD) obstruction due to gall stones (small gallbladder with multiple gallstones) or tumour (dilated gallbladder without gallstones), surgically remediable obstruction was always present. Although ultrasound identified the obstructing lesion itself in a minority of cases, the cause of obstruction could be correctly inferred in 95 per cent of 'typical' scans. These results suggest that it is safe to proceed directly to surgery only when an experienced ultrasonographer demonstrates findings 'typical' of distal CBD obstruction due to gallstones or tumour.