MR cholangiopancreatography in patients with primary sclerosing cholangitis: interobserver variability and comparison with endoscopic retrograde cholangiopancreatography

OBJECTIVE: The purpose of our study was to determine the degree of interobserver variability and correlation between MR cholangiopancreatography and endoscopic retrograde cholangiopancreatography (ERCP) for the presence of bile duct strictures in patients with primary sclerosing cholangitis. MATERIALS AND METHODS: For this retrospective study involving 26 patients with primary sclerosing cholangitis, 31 MR cholangiopancreatograms were compared with 30 endoscopic retrograde cholangiopancreatograms. The MR cholangiopancreatograms were independently interpreted by two abdominal radiologists in a blinded, randomized manner for overall image quality, extent of ductal visualization, and the presence and location of bile duct strictures. Unweighted multirater kappa coefficient values were estimated for each comparison. RESULTS: Visualization of more than 50% of the expected ductal length was possible in the extrahepatic, central intrahepatic, and peripheral intrahepatic bile ducts in 99%, 88%, and 69% of the MR cholangiopancreatograms and 100%, 86%, and 52% of the endoscopic retrograde cholangiopancreatograms, respectively. Strictures were detected in the extrahepatic, central, and peripheral ducts in 53%, 68%, and 87% of the MR cholangiopancreatograms and 73%, 67%, and 63% of the endoscopic retrograde cholangiopancreatograms, respectively. The interobserver agreement for stricture detection was 61% for MR cholangiopancreatography and 76% for ERCP. MR cholangiopancreatographic findings were consistent with ERCP findings for the presence of strictures in 69% of the cases. CONCLUSION: In patients with primary sclerosing cholangitis, MR cholangiopancreatography better shows the bile ducts and can depict more strictures, especially of the peripheral intrahepatic ducts, than ERCP. MR cholangiopancreatography can be used to noninvasively diagnose and follow up patients with primary sclerosing cholangitis.     

Role of MR cholangiopancreatography in patients with failed or inadequate ERCP

OBJECTIVE: The purpose of this study was to evaluate the spectrum of MR imaging features of primary sclerosing cholangitis. MATERIALS AND METHODS: A retrospective review was performed of MR imaging findings including MR cholangiography and multiphasic contrast-enhanced dynamic sequences in 22 patients with primary sclerosing cholangitis. MR imaging analysis included abnormalities of intra- and extrahepatic bile ducts, abnormalities of liver parenchyma, changes in liver morphology, and lymphadenopathy. RESULTS: Abnormal findings of bile ducts were seen in all 22 patients; the most common finding was intrahepatic bile duct dilatation (77%), followed by intrahepatic bile duct stenosis (64%), extrahepatic bile duct wall enhancement (67%), extrahepatic bile duct wall thickening (50%), extrahepatic bile duct stenosis (50%), and intrahepatic bile duct beading (36%). Increased enhancement of the liver parenchyma on dynamic arterial-phase images, predominantly in the peripheral areas of the liver, was identified in 56% of patients. Other findings included periportal lymphadenopathy (77%), periportal high signal intensity on T2-weighted images (68%), hypertrophy of the caudate lobe (68%), and abnormal hyperintensity of the liver parenchyma on T1-weighted images (23%). CONCLUSION: On MR imaging, primary sclerosing cholangitis showed several characteristic features, including bile duct abnormalities and increased enhancement of the liver parenchyma. MR cholangiography and contrast-enhanced dynamic MR techniques are useful for revealing intra- and extrahepatic signs of primary sclerosing cholangitis.     

Using contrast-enhanced MR cholangiography with IV mangafodipir trisodium (Teslascan) to evaluate bile duct leaks after cholecystectomy: a prospective study of 11 patients

OBJECTIVE: The purpose of our study was to determine whether contrast-enhanced MR cholangiography using IV mangafodipir trisodium can accurately detect the presence and location of bile duct leaks in patients who have undergone cholecystectomy. SUBJECTS AND METHODS: Our study group included 11 patients with suspected bile duct leaks after cholecystectomy. Axial single-shot fast spin-echo and gradient-echo images were acquired in all patients before and 1-2 hr after IV administration of mangafodipir trisodium. The contrast-enhanced MR cholangiograms were evaluated for image quality, degree of ductal or small bowel opacification, and the presence and location of bile duct leaks, strictures, and stones. MR cholangiograms were correlated with conventional contrast-enhanced cholangiograms obtained in all patients, including endoscopic retrograde cholangiography (n = 10) and percutaneous transhepatic cholangiography (n = 1). RESULTS: Excretion of mangafodipir trisodium was noted in the intrahepatic and extrahepatic bile ducts in all patients from 1 to 2 hr after IV administration. Bile ducts and fluid collections that contained excreted mangafodipir trisodium showed increased signal intensity on gradient-echo sequences and decreased signal intensity on single-shot fast spin-echo sequences. Conventional contrast-enhanced cholangiography showed the presence of bile duct leaks in six patients and the absence of bile duct leaks in five patients, with false-negative findings in one patient and false-positive findings in one patient for bile duct leak (sensitivity, 86%; specificity, 83%). CONCLUSION: Contrast-enhanced MR cholangiography with IV mangafodipir trisodium can successfully detect the presence and location of bile duct leaks in patients suspected of having such leaks after undergoing cholecystectomy. More research is necessary before acceptance of this examination as routine in the workup of these patients.     

Primary sclerosing cholangitis: evaluation with MR cholangiography-a case-control study

PURPOSE: To determine the accuracy of magnetic resonance (MR) cholangiography for detection of primary sclerosing cholangitis (PSC) and localization of PSC in the biliary tract. MATERIALS AND METHODS: In a prospective case-control study involving 102 patients, the MR cholangiograms obtained in 34 patients with PSC established with endoscopic retrograde cholangiopancreatography (ERCP) were compared with the MR cholangiograms obtained in 68 age-matched control patients with hepatobiliary diseases other than PSC. Two abdominal radiologists conducted an independent, blinded random review of the MR cholangiograms to assess for the presence or absence of PSC and determine the location of PSC in the biliary tract, and then compared the findings with those at ERCP. RESULTS: MR cholangiography was found to be accurate in detecting PSC and in defining the extent of disease. In the detection of PSC, the sensitivities were 88% and 85%; specificities, 97% and 92%; positive predictive values, 94% and 85%; and negative predictive values, 94% and 93% for readers 1 and 2, respectively. Interobserver agreement was excellent (kappa = 0.79). In the localization of extrahepatic PSC, the sensitivities were 83% and 89%; and specificities, 83% and 83% for readers 1 and 2, respectively. Interobserver agreement was good (kappa = 0.62). In the localization of intrahepatic PSC, the sensitivity was 87% for both readers; interobserver agreement was good (kappa = 0.71). CONCLUSION: MR cholangiography enables accurate detection and localization of PSC.     

Primary sclerosing cholangitis: value of cholangiography in determining the prognosis

We studied cholangiograms in 129 patients with primary sclerosing cholangitis (PSC) to determine if there was a correlation between any of the findings and the prognosis of the disease. The grade, length, and extent of strictures, the degree of bile duct dilatation, and the distribution of lesions were evaluated. Survival curves were generated to test the association of these radiologic signs with subsequent survival. High-grade intrahepatic duct strictures (greater than 75% narrowing) were associated with a 19% decrease in 3-year survival (p = .05) compared with lower-grade strictures. Diffuse intrahepatic strictures (involving greater than 25% of the ducts) were associated with a 16% decrease in 3-year survival (p = .012) compared with localized strictures. Statistically insignificant (p greater than .05) but measurable decreases in survival were observed with high-grade extrahepatic duct strictures, diffuse involvement of the extrahepatic ducts, long confluent strictures anywhere in the biliary tree, and marked dilatation of the intrahepatic ducts. In general, intrahepatic duct disease was found to have greater prognostic significance than extrahepatic duct disease. High-grade strictures and diffuse strictures of the intrahepatic ducts were found to be indicators of a poor prognosis in PSC and were more predictive of a poor prognosis than was extrahepatic duct disease.     

Recurrent pyogenic cholangitis: comparison between MR cholangiography and direct cholangiography

PURPOSE: To compare the accuracy of magnetic resonance (MR) cholangiography with that of direct cholangiography for the evaluation of recurrent pyogenic cholangitis. MATERIALS AND METHODS: Twenty-four patients with recurrent pyogenic cholangitis underwent MR cholangiography before surgery, and 18 of these 24 also underwent direct cholangiography. Two reviewers evaluated MR cholangiograms and direct cholangiograms and focused on identifying intrahepatic ductal dilatation, stricture, and calculi, as well as coexistent parenchymal abnormalities, on the basis of the classification of the internal lobes and segments of the liver. These observations were compared with surgical findings. RESULTS: According to examination results in the surgical specimens, 24 patients had 46 segmental abnormalities. MR cholangiography depicted all 46 (100%) segments with ductal dilatation, 22 (96%) of 23 segments with focal ductal stricture, and 43 (98%) of 44 segments with ductal calculi. Eighteen patients who underwent direct cholangiography had 32 segmental abnormalities according to examination results in the surgical specimens. Direct cholangiography depicted 15 (47%) of 32 segments with ductal dilatation, eight (44%) of 18 segments with focal ductal stricture, and 14 (45%) of 31 segments with ductal calculi. CONCLUSION: MR cholangiography is superior to direct cholangiography for accurate topographic evaluation of recurrent pyogenic cholangitis because it is able to depict all of the biliary tree, despite obstruction or stenosis.     

Chemotherapy-induced sclerosing cholangitis

AIM: To review the computed tomography (CT), magnetic resonance imaging (MRI) and cholangiographic findings of chemotherapy-induced sclerosing cholangitis (CISC). METHODS: Between January 1995 and December 2004, 11 patients in the endoscopic retrograde cholangiography database were identified with CISC. Twelve CT, four MRI, 69 endoscopic and nine antegrade cholangiographic studies in these patients were reviewed. Serial change in appearance and response to endoscopic treatment were recorded. RESULTS: CISC showed segmental irregular biliary dilatation with strictures of proximal extrahepatic bile ducts. The distal 5cm of common bile duct was not affected in any patient. CT and MRI findings included altered vascular perfusion of one or more liver segments, liver metastases or peritoneal carcinomatosis. Biliary strictures needed repeated stenting in 10 patients (mean: every 4.7 months). Cirrhosis (n=1) or confluent fibrosis (n=0) were uncommon findings. CONCLUSION: CISC shares similar cholangiographic appearances to primary sclerosing cholangitis (PSC). Unlike PSC, biliary disease primarily involved ducts at the hepatic porta rather than intrahepatic ducts. Multiphasic contrast-enhanced CT or MRI may show evidence of perfusion abnormalities, cavitary liver lesions, or metastatic disease.     

Bone marrow edema and associated pain in early stage osteonecrosis of the femoral head: prospective study with serial MR images

PURPOSE: To determine the accuracy of magnetic resonance (MR) cholangiography for demonstration of the biliary tract and detection of biliary complications in patients who have undergone orthotopic liver transplantation. MATERIALS AND METHODS: Breath-hold half-Fourier rapid acquisition with relaxation enhancement MR cholangiography was performed in 25 patients who had undergone orthotopic liver transplantation. MR cholangiograms were prospectively and independently interpreted by two radiologists for depiction of the biliary tract and ductal anastomosis and for complications (eg, biliary dilatation, stricture, stones). MR cholangiographic findings were correlated with findings from direct cholangiography (n = 24) and surgery (n = 1). RESULTS: MR cholangiography completely demonstrated first-order intrahepatic bile ducts in 23 (92%) patients, the donor extrahepatic bile duct in 25 (100%), the recipient extrahepatic bile duct in 17 of 18 (94%), and the anastomosis in 24 (96%). The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of MR cholangiography for detection of biliary dilatation and stricture were each 100%. Complete interobserver agreement occurred in the detection of biliary dilatation and stricture. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of MR cholangiography for detection of stones were 100% for one radiologist and 86%, 100%, 96%, 100%, and 95%, respectively, for the other. Both radiologists agreed on the diagnosis of bile duct stones in six of seven cases (kappa = 0.90). CONCLUSION: MR cholangiography enables accurate depiction of the biliary tract and detection of biliary complications in patients with an orthotopic liver transplant.     

Endoscopic retrograde intrahepatic cholangiogram: radiographic findings in intrahepatic disease.

Endoscopic retrograde intrahepatic cholangiograms were evaluated in 107 patients and correlated with intrahepatic diagnoses determined by liver biopsy. Included were normal livers (six), cirrhosis (38) portal fibrosis (14), cholangitis (22), metastases (11), and miscellaneous diagnoses (16). Results suggest that differentiation of the normal from the abnormal intrahepatic biliary system using the endoscopic retrograde intrahepatic cholangiogram is possible, and that certain patterns of abnormality prevail within given disease categories. The cholangiogram in cirrhosis is marked by ductular stenosis, diminished arborization, tortuosity, and approximation of the intrahepatic ducts. Sclerosing cholangitis demonstrates focal stenoses with concomitant ectasias and frequent similar involvement of the extrahepatic system. Chronic cholangitis and portal fibrosis are frequently associated with extrahepatic obstructing lesions and increased intrahepatic ductal caliber, but demonstrate no distinguishing intrahepatic characteristics. Intrahepatic metastases, polycystic liver disease, and primary hepatic neoplasm produce mass effects consisting of ductal displacement, narrowing, and obstruction. The potential of endoscopic retrograde intrahepatic cholangiography in evaluating the intraheptic biliary tree is significant; specifically in separating normal from abnormal, in distinguishing between intrahepatic processes, and as an adjunct to liver biopsy in determining the extent and location of intrahepatic abnormalities.     

AIDS-related cholangitis: radiographic findings in nine patients

Acalculous inflammation of the biliary tract is a recently reported complication of the acquired immunodeficiency syndrome (AIDS). In a 33-month period, nine men with AIDS were evaluated because of right upper quadrant and/or epigastric pain, jaundice, or abnormal liver function test results. Each patient underwent ultrasonography and endoscopic retrograde cholangiopancreatography; seven also underwent computed tomography. In eight of nine patients the imaging studies disclosed intrahepatic and extrahepatic bile duct changes identical to those seen in sclerosing cholangitis (strictures, focal dilatation, thickened duct walls). Isolated papillary stenosis and ductal dilatation were present in one patient, while eight patients had some stricturing of the distal common duct. The combination of papillary stenosis and intrahepatic ductal strictures appears unique to AIDS-related cholangitis. Endoscopic papillotomy provided variable relief to symptoms and biochemical abnormalities. Cholangitis caused by cytomegalovirus and/or Cryptosporidium infection is the proposed pathophysiologic mechanism.     

Percutaneous cholecystography in children

Percutaneous cholecystography was performed on 13 children who had biliary system abnormalities: two had biliary hypoplasia, five had sclerosing cholangitis, three had cirrhosis, two had distal choledochal obstruction, and one had an obstructed portoenterostomy. In 12 patients transcholecystic cholangiography showed, without significant complications, the intra-and extrahepatic bile ducts. In one patient with primary sclerosing cholangitis, the intrahepatic bile ducts were not opacified satisfactorily; dilatation of the gallbladder required surgical drainage. The transcholecystic technique is indicated when the intrahepatic bile ducts are either mildly dilated or not dilated.     

Oriental cholangiohepatitis: diagnostic imaging and interventional management

Diagnostic and therapeutic radiologic experience with six patients who had oriental cholangiohepatitis is described. These patients combined had 10 prior operations. Postoperatively each had recurrent cholangitis, numerous stones, concretions, and/or bile duct strictures. Diagnostically, sonography was valuable in the detection of intra- and extrahepatic stones and extrahepatic dilatation of ducts. An important pitfall in sonography was poor visualization of intrahepatic ductal dilatation (due to echogenic sludge filling the ducts) in most patients. CT was helpful diagnostically in all respects. Interventional procedures used postoperatively included percutaneous transhepatic intrahepatic stones, and flushing techniques. Most patients were treated during multiple sessions as outpatients. Cholangitis was the only complication from the procedures. Sectional imaging and interventional radiology perform valuable diagnostic and therapeutic roles in the pre- and postoperative management of patients with oriental cholangiohepatitis.     

Hepatobiliary and pancreatic MRI and MRCP findings in patients with HIV infection

OBJECTIVE: The purpose of this article is to describe the spectrum of MRI and MR cholangiopancreatography (MRCP) findings of hepatic, pancreatic, and biliary manifestations in patients with HIV infection. CONCLUSION: The spectrum of MRI and MRCP findings in HIV-infected patients includes acute or chronic hepatitis (or both), pancreatitis, cholangitis, acalculous cholecystitis, and biliary strictures that may resemble primary sclerosing cholangitis. The presence of segmental extrahepatic biliary strictures is characteristic of AIDS cholangiopathy.     

HIV-related/AIDS cholangiopathy: pictorial review with emphasis on MRCP findings and differential diagnosis

Magnetic resonance cholangiopancreatography provides accurate, noninvasive diagnosis of HIV/AIDS cholangiopathy through the identification of characteristic ductal abnormalities including multiple intrahepatic strictures, papillary stenosis, and long segmental extrahepatic strictures. Endoscopic retrograde cholangiopancreatography should be reserved for cytological or bioptic investigation in doubtful cases and for operative treatment when appropriate. Furthermore, cross-sectional imaging allows differentiation from other causes of biliary dilatation in HIV-positive patients, including infectious (bacterial) cholangitis, portal biliopathy, pancreatic or duodenal lymphoma, and mycobacterial lymphadenopathies.     

Visualization of the biliary tract using gadobenate dimeglumine: preliminary findings

OBJECTIVE: To compare contrast-enhanced magnetic resonance (MR) cholangiography (CE-MRC) performed with gadobenate dimeglumine with T2-weighted MRC (T2-MRC) for visualization of the bile ducts in nondilated biliary systems. MATERIALS AND METHODS: Twenty consecutive patients who underwent MR imaging (MRI) of the liver and pancreas with nondilated intrahepatic ducts were included in this retrospective study. T2-weighted MRC was performed using a multislice, high-resolution fat-suppressed half-Fourier acquisition turbo spin-echo sequence. Contrast-enhanced MR cholangiography was performed using a fat-suppressed 3-dimensional fast low-angle shot sequence acquired 1 to 1.5 hour after intravenous administration of gadobenate dimeglumine. For image interpretation, the biliary system was divided into 8 segments. Two readers graded visualization of each segment on T2-MRC and CE-MRC using a 5-point scale (0, nonvisualization; 4, excellent visualization). Final opinion for each sequence was rendered by consensus. Superiority of visualization was assessed using the McNemar test and comparing adequately (visualization scores 3 and 4) and inadequately (visualization scores 0, 1, and 2) visualized segments of the ducts on both sequences. Interobserver variability was assessed with kappa statistics. RESULTS: Overall and segment-based evaluation revealed superior visualization of biliary segments with CE-MRC compared with T2-MRC. We also found a statistically significant difference between the 2 sequences for overall and for right hepatic duct and cystic channel visualization (P < 0.05). A high concordance between readers 1 and 2 both for T2-MRC and CE-MRC was achieved (85.8% and 89.4%, respectively). CONCLUSIONS: Gadobenate dimeglumine can be used as an alternative intrabiliary contrast agent for contrast-enhanced MR cholangiography in nondilated biliary systems in patients with normal excretory liver function tests.     

Imaging of the intrahepatic biliary tree with thick slice MR cholangiography]

PURPOSE: To assess the value of single shot fast spin echo MR sequence (SS-FSE) in the evaluation of the normal and pathologic intrahepatic biliary tree. MATERIAL AND METHODS: 418 consecutive patients (457 examinations) referred for clinical and/or biological suspicion of biliary obstruction underwent MR cholangiopancreatography (MRCP). All patients were imaged with a Signa 1.5 T GE MR unit, with High Gradient Field Strength and Torso Phased Array Coil. Biliary ducts were imaged with SS-FSE sequence, coronal and oblique coronal 20 mm thick slices on a 256 x 256 matrix. Total acquisition time was 1 second. Source images were reviewed by two radiologists blinded to clinical information. In case of disagreement, a third radiologist's opinion was requested. In all cases, MRCP results were compared with direct biliary tract evaluation, other imaging studies and clinical and biological follow-up. RESULTS: In all cases, MRCP produced high quality images. Numerous branch of division were observed although the peripheral intrahepatic ducts were well seen in more than 90% in an area 2 cm below the capsule. The number of division was statistically higher when mechanical obstruction was present. Intrahepatic calculi or peripheral cholangiocarcinoma were well detect by MRCP. For the detection of cholangitis, MRCP sensitivity was 87.5% but the positive predictive value was only 57.7% because of a high number of false positive. The diagnosis of primary sclerosing cholangitis must be made only on strict criteria and slightly dilated peripheral bile ducts unconnected to the central ducts in several hepatic segments were a characteristic MR sign of primary sclerosing cholangitis. CONCLUSION: MRCP can be proposed as a first intention imaging technique for the evaluation of intrahepatic ducts.     

MRCP findings in recurrent pyogenic cholangitis

OBJECTIVE: In this essay, we present the spectrum of intrahepatic and extrahepatic bile duct abnormalities seen on MRCP in patients with recurrent pyogenic cholangitis. CONCLUSION: MRCP is a promising, noninvasive alternative to more invasive direct cholangiography for evaluating the intrahepatic and extrahepatic bile ducts in patients with recurrent pyogenic cholangitis.     

Idiopathic chronic pancreatitis in children: MR cholangiopancreatography after secretin administration

PURPOSE: To assess the accuracy of dynamic magnetic resonance (MR) cholangiopancreatography after secretin administration in detecting pancreatic duct abnormalities typical of early-onset idiopathic chronic pancreatitis in children with recurrent episodes of idiopathic acute pancreatitis. MATERIALS AND METHODS: Fifteen children (mean age, 11.3 years; range, 6-17 years) with at least three recurrent episodes of idiopathic acute pancreatitis prospectively underwent MR cholangiopancreatography before and after secretin administration. Image analysis included visualization of side branches, ductal narrowing, endoluminal filling defects, irregular ductal contour, cavities, and pancreas divisum. All patients underwent endoscopic retrograde cholangiopancreatography (ERCP). RESULTS: Dilated side branches were detected in three (20%) of 15 patients on MR cholangiopancreatograms obtained before secretin administration and in seven (47%) of 15 patients on images obtained after secretin administration. Ductal narrowing was detected in one (7%) of 15 patients on images obtained before secretin administration and in two (13%) of 15 patients on images obtained after secretin administration. Endoluminal filling defects in one (7%) of 15 patients were observed on MR cholangiopancreatograms obtained both before and after secretin administration. Irregular contour of the main pancreatic duct was present in four (27%) of 15 patients on MR cholangiopancreatograms obtained before secretin administration and in five (33%) of 15 patients on images obtained after secretin administration. Cavities and pancreas divisum were detected in one (7%) of 15 patients and in two (13%) of 15 patients, respectively, only on MR cholangiopancreatograms obtained after secretin administration. CONCLUSION: Secretin improves the sensitivity of MR cholangiopancreatography in diagnosing early-onset idiopathic chronic pancreatitis.     

Cholangiocarcinoma complicating primary sclerosing cholangitis: cholangiographic appearances

Cholangiograms from 104 patients (and serial cholangiograms in 66 patients) with primary sclerosing cholangitis (PSC) were reviewed. In 13 patients the additional diagnosis of cholangiocarcinoma was made at biopsy or autopsy. Cholangiograms from patients with both PSC and carcinoma were compared with cholangiograms from patients with PSC alone. Marked dilatation of ducts or ductal segments (100% vs. 24%) and the appearance of a polypoid mass (46% vs. 7%) were common findings in the group of patients whose disease was complicated by malignancy. In the malignant group, polypoid masses were larger, measuring 1 cm or greater in diameter. On serial cholangiograms, four of 15 patients with progressive stricture formation and four of five with progressive ductal dilatation proved to have carcinomas. The frequent occurrence of bile duct carcinoma as a complication of PSC in this group of patients indicates that PSC has a strong tendency to undergo malignant degeneration. Cholangiographic findings which suggest malignant degeneration include markedly dilated ducts or ductal segments, presence of a polypoid mass 1 cm or greater in diameter, and progressive stricture formation or ductal dilatation.     

Diagnostic and interventional procedures for the biliary tract

Various diagnostic imaging studies have been employed in the past year to evaluate the normal and abnormal biliary ductal system. Variations in the normal ductal drainage of the left lobe of the liver, in which the right lateral hepatic duct drained into the left hepatic duct, were studied because of the implications for the surgical resection of the left lobe. Choledochal cysts have been studied in adults using endoscopic retrograde cholangiopancreatography to evaluate the abnormal junction between the common bile duct and pancreatic duct and the long dilated common channel. An ultrasound study indicated that children with choledochal cysts also may have intrahepatic duct dilatation. An increased incidence of malignancy has been noted in adults with choledochal cysts, and their appearance on ultrasound, CT, and cholangiography were described. Cystic fibrosis produces abnormalities of the biliary tree, extrahepatic strictures, and more interestingly, intrahepatic ductal dilatation and abnormal contour without strictures. The usefulness of the preoperative ultrasonographic evaluation of the biliary tract in Oriental cholangiohepatitis was stressed. Bile duct abnormalities in fascioliasis were also noted on CT scans. Patterns of abnormality in the CT appearance of the thickened, contrast-enhanced, extrahepatic bile ducts were elucidated. Focal concentric, focal excentric, diffuse concentric, and diffuse excentric ducts were seen with various forms of pancreatic disease, choledocholithiasis, and various forms of cholangitis. An enhanced, thick-walled duct indicates disease, but is a nonspecific finding. Chronic cholecystitis was found to produce false-positive cholescintigram results in patients with suspected acute cholecystitis, but only in those with severe degrees of chronic cholecystitis. The results of multicenter trials using extracorporeal biliary lithotripsy in the United States have been published. They are somewhat disappointing and do not confirm the original excellent results reported in Germany for treatment of gallbladder stones. Much interest has been focused on the use of expandable metallic stents for the treatment of benign and malignant biliary obstruction. Preliminary data suggest good patency rates for benign lesions. Patency rates for malignant lesions are similar to those of previously available plastic stents.