Evaluation of intrahepatic cholestasis with radionuclide hepatobiliary imaging

Since hepatobiliary imaging with^99mTc=labeled iminodiacetic acid derivatives (HIDA) allows relatively separate, sequential measurement of hepatocyte clearance, parenchymal transit, and biliary excretion, these agents should be useful in differentiating intrahepatic cholestasis (IC) from other hepatobiliary disorders. We studied 18 patients with clinical evidence of IC in whom the parenchymal transit time was increased disproportionately to any decrease in hepatocyte clearance. In a second group of 14 patients with hepatocyte disease but without clinical evidence of IC, the average parenchymal transit time was increased less in relation to the average decrease in hepatocyte clearance than in the IC group. In 15 patients with extrahepatic biliary obstruction, the average hepatocyte clearance was disproportionately increased, as in IC, but large-duct obstruction was identified by scintigrams, ultrasound, or computed tomography. These preliminary results suggest that IC can be diagnosed with hepatobiliary imaging.     

Complications of orthotopic liver transplantation: imaging findings

Orthotopic liver transplantation has become the major treatment for end-stage chronic liver disease and for severe acute liver failure. Despite the improvement in survival due to advances in organ preservation, improved immunosuppressive therapy agents, and refinement of surgical techniques, there are significant complications after liver transplantation. These complications mainly include biliary strictures, stones, and leakage; arterial and venous stenoses and thromboses; lymphoproliferative disorders; recurrent tumors; hepatitis virus C infection; liver abscesses; right adrenal gland hemorrhage; fluid collections; and hematomas. The diagnosis of acute rejection, one of the most serious complications after liver transplantation, is established with graft biopsy and histologic study. The role of imaging methods consists of excluding the other complications, which can have clinical signs and symptoms similar to those of acute rejection. This pictorial essay describes imaging findings of the various complications after liver transplantation and focuses on their radiologic diagnosis. Knowledge and early recognition of these complications with the most suitable imaging modality are crucial for graft and patient survival.     

Carcinoma of the ampulla of Vater: Sonographic and CT diagnosis

Twenty patients with carcinoma of the ampulla of Vater were studied with sonography (N = 9) or both sonography and CT (N = 11). The tumor was shown by sonography in 16 patients (80%) as a small, round or oval, fairly well delineated mass in between the dilated distal common bile duct and duodenum which was delineated owing to luminal fluid or gas (N = 13); or as a polypoid mass within the dilated distal common bile duct resulting in abrupt obstruction (N = 3). In the remaining four patients, the mass was not delineated. Bile ducts were dilated down to the level of mass or ampullary region in all cases (100%), while the pancreatic duct was dilated in five cases (45%). We believe that sonography is the technique of initial choice in the diagnosis of carcinoma of the ampulla of Vater by identifying the mass at the distal end of the dilated common bile duct and/or pancreatic duct.     

Choledochal cyst in adults

Choledochal cysts are being recognized with an increasing frequency among the adult population. In this series a correct preoperative diagnosis was established in eight of the ten patients. The clinical triad of obstructive jaundice, right upper abdominal pain, and a palpable flactuant mass was noted in only two cases but at least one of these symptoms was present in all patients. Acute pancreatitis, cholecystitis, and biliary calculi were the commonly associated findings. New etiologic and clinical concepts of choledochal cysts are reviewed and the spectrum of radiographic features in adults is presented.Presented at 77th Annual Meeting of the American Roentgen Ray Society, Washington, D.C., September 1976     

Ultrasound of hemobilia: a clinical and experimental study

Clinical observations on patients with hemobilia secondary to percutaneous biliary procedures and laboratory studies on animals with experimentally induced hemobilia indicate that the presence of fresh blood or clot within the biliary tree may yield an erroneous impression of duct size in ultrasound examinations. Recognition of this potential source of error becomes increasingly important as the use of percutaneous procedures for the relief of biliary obstruction increases.     

MR versus multislice CT cholangiography in evaluating patients with obstruction of the biliary tract

Background We compared magnetic resonance cholangiography (MRC) with multislice computed tomographic (MSCT) cholangiography in the assessment of patients with bile duct obstruction. Methods Thirty-six patients with clinical or biochemical signs of biliary obstruction were prospectively studied. MRC was performed with fast spin-echo and single-shot fast spin-echo sequences. Source images, maximum intensity projection, and multiplanar reconstruction were evaluated. MSCT cholangiography was performed without biliary contrast agent, with intravenous injection of 150 mL of iodinated contrast material at 4 mL/s, 2.5-mm slice thickness, 7.5-mm/s table speed, and 1.25-mm reconstruction interval. Axial, multiplanar, and minimum intensity projection reformatted images were evaluated. MRC and MSCT findings were compared with endoscopic retrograde cholangiopancreatography (ERCP; 20 patients), percutaneous cholangiography (eight patients), intraoperative cholangiography (two patients), surgery (11 patients), and cytology (11 patients) with respect to cause and site of obstruction. Results With regard to presence and site of obstruction, agreement was observed across MRC, MSCT cholangiography, and reference investigations in all cases. Concerning cause, the correct diagnosis was made by MSCT cholangiography in 34 of 36 patients. Two cases of common bile duct lithiasis, diagnosed on MRC and ERCP, were missed by MSCT cholangiography. Conciusion MSCT cholangiography can be considered a possible noninvasive alternative to MRC.     

MR versus multislice CT cholangiography in evaluating patients with obstruction of the biliary tract

BACKGROUND: We compared magnetic resonance cholangiography (MRC) with multislice computed tomographic (MSCT) cholangiography in the assessment of patients with bile duct obstruction. METHODS: Thirty-six patients with clinical or biochemical signs of biliary obstruction were prospectively studied. MRC was performed with fast spin-echo and single-shot fast spin-echo sequences. Source images, maximum intensity projection, and multiplanar reconstruction were evaluated. MSCT cholangiography was performed without biliary contrast agent, with intravenous injection of 150 mL of iodinated contrast material at 4 mL/s, 2.5-mm slice thickness, 7.5-mm/s table speed, and 1.25-mm reconstruction interval. Axial, multiplanar, and minimum intensity projection reformatted images were evaluated. MRC and MSCT findings were compared with endoscopic retrograde cholangiopancreatography (ERCP; 20 patients), percutaneous cholangiography (eight patients), intraoperative cholangiography (two patients), surgery (11 patients), and cytology (11 patients) with respect to cause and site of obstruction. RESULTS: With regard to presence and site of obstruction, agreement was observed across MRC, MSCT cholangiography, and reference investigations in all cases. Concerning cause, the correct diagnosis was made by MSCT cholangiography in 34 of 36 patients. Two cases of common bile duct lithiasis, diagnosed on MRC and ERCP, were missed by MSCT cholangiography. CONCLUSION: MSCT cholangiography can be considered a possible noninvasive alternative to MRC.     

Patterns of calcifications and cholangiographic findings in hepatobiliary tuberculosis

The radiologic findings on conventional examinations (plain films and cholangiograms) in a large group of patients with proven hepatobiliary tuberculosis are reviewed. The plain film findings of large chalky and confluent hepatic calcifications or nodal-type calcifications along the course of the common bile duct are suggestive of hepatobiliary tuberculosis. Small, discrete, scattered calcifications may be mimicked by histoplasmosis but can be differentiated from hepatobiliary tuberculosis. Obstructing defects seen on cholangiography are indicative of tuberculosis when adjacent calcifications are present. The patterns of liver calcifications could provide a clue to the diagnosis of hepatobiliary tuberculosis and its differentiation from liver calcifications of various other etiologies.     

Choledochal cyst complicating pregnancy: Antepartum diagnosis with MRI

Choledochal cyst presenting during pregnancy is a rare condition, associated with potentially life-threatening complications for both the mother and developing fetus. Clinical symptoms are nonspecific, and radiographic evaluation is complicated by the presence of the gravid uterus. The authors describe a 34-year-old pregnant female presenting in the third trimester with obstructive jaundice and a right upper quadrant mass. Multiplanar and multisequence imaging with MR established the antepartum diagnosis of choledochal cyst, avoiding the use of ionizing radiation during pregnancy.     

Differential features of some unusual biliary tumors

The clinical and radiographic features of several unusual tumors involving the biliary tract are reviewed. The differential diagnostic findings of granular cell myoblastoma, villous tumors, sarcoma botryoides, and carcinoid of the bile ducts on direct cholangiography are illustrated. Selected examples of secondary invasion of the biliary tract by hepatoma and metastatic lesions are also included.     

Bile duct involvement in hepatocellular carcinoma: MR demonstration

Background: To determine the magnetic resonance (MR) features of hepatocellular carcinoma (HCC) with associated bile duct involvement. Methods: MR examinations of six patients (mean age, 62 years) demonstrating bile duct involvement due to HCC were retrospectively reviewed and compared to surgical and pathologic findings. Results: Three of the tumors were solitary, and three were multifocal. In two patients, MR showed direct biliary duct invasion by tumor. On T1-weighted MR images, four tumors were hypointense compared to the liver and two were isointense. On T2-weighted MR images, four tumors were hyperintense, and two were isointense. The two tumors studied with dynamic T1-weighted MR images obtained after intravenous administration of a gadolinium chelate, displayed enhancement similar to that of the liver. There was no evidence of a tumor capsule on either unenhanced or enhanced MR images. Intrahepatic bile duct dilatation was seen in five patients. The extrahepatic bile duct was normal in all cases. Conclusion: Although rare, HCC should be included when considering the etiology of intrahepatic bile duct obstruction. Imaging features suggestive of the diagnosis by MR include intrabiliary tumor or bile duct obstruction with an associated hepatic mass.     

Choledochal cyst: Report of a case with specific ultrasonographic findings

A case of choledochal cyst in a 17 month old child is described. The ultrasonographic findings were felt to be specific in this case since the dilated common bile duct was noted to enter directly into a large right upper quadrant cyst. The clinical history, ultrasonographic findings, and differential diagnostic features are discussed.     

Biliary ascariasis associated with cholangiocarcinoma

A 52-year-old man presented with obstructive jaundice. Sonography of the liver disclosed dilatation of intrahepatic ducts in which multiple elongated intraluminal lesions were contained due to biliary ascariasis. A localized mass projecting into the common bile duct and causing its obstruction proved to be a coexistent Cholangiocarcinoma.     

Choledochal cyst due to anomalous pancreatobiliary junction in the adult: sonographic findings

Background: Adult cases of choledochal cyst due to anomalous pancreaticobiliary duct junction have been rarely reported. At present, sonography (US) is the first tool for diagnosing biliary disorders. The aim of this study was to reevaluate the US findings of choledochal cysts due to anomalous pancreaticobiliary duct junction in adults. Methods: We reviewed the clinical manifestations and US findings of 12 such adult cases confirmed by endoscopic retrograde cholangiopancreatic ductography (ERCP). Patients were assigned to three groups: (a) associated with biliary carcinoma (two cases), (b) associated with choledocholithiasis (one case), and (c) not associated with other abdominal diseases (nine cases). Results: Patients in group c were asymptomatic, and the lesions were detected incidentally detected by US. In contrast, patients in group a sought medical care because of symptoms such as jaundice and those in group b sought medical attention because of abdominal pain. The diameter of a dilated bile duct on US was considerably less than that of ERCP (ERCP: 26–58 mm, mean = 37.6 mm; US: 13–32 mm, mean = 21.8 mm). Its diameter changed significantly under probe compression when the dilated bile duct took a purely cystic form but changed very little when it took a tubular form. Conclusion: Unlike cases in children, adult cases of choledochal cyst are generally asymptomatic. Careful US observation of the bile duct is thus expected to detect asymptomatic adult choledochal cysts cases. Cyst diameter can change significantly under probe compression, so it is important not to compress the bile duct during routine US examination. Received: 13 September 2000/Accepted: 18 October 2000     

Bile duct disease: Prospective comparison of ERCP,CT, and fat suppression MRI

The authors compared computed tomography (CT) and endoscopic retrograde cholangiopancreatography (ERCP), techniques commonly used to study the biliary tree, with pre- and post-Gd-DTPA breath-hold fast low angle shot (FLASH) and fat suppressed spin-echo in 28 consecutive patients with bile duct abnormalities detected on ERCP, including 11 patients with malignant disease and 17 patients with benign disease. ERCP, CT, and magnetic resonance (MR) images were prospectively interpreted in a blinded fashion and reviewed by consensus. ERCP characterized all cases of malignant disease by the presence of a narrowed bile duct lumen with irregular margins. CT and MRI detected all cases of malignant disease and characterized nine of 11 as malignant. In seven of these cases, CT and MRI showed thickening of extrahepatic bile duct walls >5 mm. MRI images showed intrahepatic-enhancing periportal tissue in four cases, which was not seen on CT images, and which was biopsyproven tumor extension. Benign disease was characterized on ERCP images by the demonstration of smooth tapered narrowings in 16 cases, whereas on CT and MR images it was characterized by mild to moderate dilatation of the intrahepatic bile ducts and wall thickness < 5 mm in 13 cases. Overall ERCP correctly characterized 27 cases as benign or malignant and CT and MRI both characterized 25. The results of this study show a trend that ERCP is superior to CT and MRI for characterizing bile duct disease.     

Choledochal cysts in children: evaluation with three-dimensional sonography

In this report, we describe the application of 3-dimensional (3D) sonography for diagnosing choledochal cysts in 3 girls who were 18 months, 2 years, and 11 years old. The 3D images that were obtained during the sonographic examination revealed that all 3 patients had a type I choledochal cyst and also demonstrated dilatation of the biliary tracts. The 3 patients then underwent surgical excision of their cysts, cholecystectomy, and hepaticojejunostomy. Besides its other clinical applications, 3D sonography promises to be a valuable adjunct to conventional 2-dimensional imaging for the evaluation of choledochal cysts in pediatric patients.     

Ultrasound detection of choledocholithiasis: Prospective comparison with ERCP in the postcholecystectomy patient

The role of ultrasound as a screening test for choledocholithiasis was prospectively assessed by comparing the results of upper abdominal ultrasound with direct cholangiography in 59 unselected symptomatic postcholecystectomy patients. Ultrasound detected duct stones in 13 of 29 patients (sensitivity, 45%) and their absence in 29 of 30 (specificity, 97%). A positive ultrasound diagnosis of choledocholithiasis was correct 13 times out of 14 (predictive value, 93%) whereas a negative diagnosis was correct on only 29 of 45 occasions (predictive value, 64%). No significant learning effect was seen. Intestinal gas obscuring the distal common duct was the most important factor limiting the ability of ultrasound to detect duct stones. Duct stones were present in 25 of 35 patients shown to have a dilated common duct on ultrasound, and in 4 of 24 with nondilated ducts; the predictive value of duct dilatation at ultrasound for duct stones was therefore 71% and that of nondilatation in excluding stones was 83%. Dilated intrahepatic bile ducts were demonstrated at ultrasound in only 17% of patients with choledocholithiasis. We conclude that ultrasound cannot reliably diagnose or exclude bile duct stones and is an inadequate screening test for the symptomatic postcholecystectomy patient.     

Comparative analysis of three common imaging modalities for nasolabial cysts

ObjectiveTo compare the clinical diagnostic value of ultrasonography (USG), computed tomography (CT), and magnetic resonance imaging (MRI) for nasolabial cysts.MethodsThe clinical and imaging data of 20 patients with 21 nasolabial cysts confirmed surgically and histopathologically were retrospectively analyzed.ResultsThe largest cyst was 3.4 × 2.7 × 2.3 cm, and the smallest cyst was 1.1 × 0.7 × 0.5 cm. All cysts were located in the soft tissue between the nasolabial fold and maxillary bone. USG showed sensitivity of 95%, accuracy of 95%, and a missed diagnosis rate of 5%; CT showed sensitivity of 80%, accuracy of 80%, and a missed diagnosis rate of 20%; and MRI showed sensitivity of 85%, accuracy of 85%, and a missed diagnosis rate of 15%.ConclusionsUSG showed higher sensitivity and accuracy and a lower missed diagnosis rate than CT and MRI. Therefore, USG is worth popularizing on a large scale for the diagnosis of nasolabial cysts.     

Lymphoma in the wall of the bile ducts: Radiologic imaging

Extranodal lymphoma is not uncommon; however, lymphomatous involvement of the wall of the bile duct is rare, with only a few case reports available. Three cases were imaged with computed tomography (CT) and direct cholangiography at our institution. In one, Hodgkin disease recurred in the duct wall, producing a radiographic pattern indistinguishable from sclerosing cholangitis. In another, central sclerosis on cholangiography was associated with a separate liver mass identified by CT. This presentation of non-Hodgkin lymphoma mimicked cholangiocarcinoma. The third patient had multifocal, diffuse histiocytic lymphoma arising in the gallbladder and cystic duct, as well as in the kidneys and pancreas. Although the condition is unusual, the diagnosis of lymphoma in the bile duct wall should be considered, particularly when the cholangiographic picture of diffuse central sclerosis is associated with little or no observable mass on CT.     

Periportal tuberculous adenitis: A rare cause of obstructive jaundice

A patient with a clinical history of pulmonary tuberculosis presented with obstructive jaundice. Compression of the extrahepatic bile ducts was caused by calcified lymph nodes secondary to tuberculous adenitis of the porta hepatis. The role of radiologic methods in the diagnosis and management of this unusual complication is discussed.