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.     

Extrahepatic cholangiocarcinoma associated with clonorchiasis: CT evaluation

BACKGROUND: I evaluated the computed tomographic (CT) features of nine pathologically proven cases of cholangiocarcinoma in the extrahepatic bile duct associated with clonorchiasis. METHODS: CT scans of nine pathologically proven cholangiocarcinoma associated with clonorchiasis were reviewed retrospectively. CT scans were analyzed for the following parameters: tumor (detection, location, gross morphologic type, contrast enhancement), intrahepatic bile duct (dilatation, pattern of dilatation), common bile duct (dilatation, Clonorchis sinensis worms), gallbladder (inflammation, C. sinensis worms), invasion of the contiguous viscera (pancreas, duodenum, liver), lobar atrophy, and lymphadenopathy and metastasis. RESULTS: CT depicted the level and cause of obstruction in all nine patients (100%). Contrast enhancement of the tumors relative to the liver parenchyma showed isoattenuation in five tumors (55%) and hyperattenuation in four tumors (44%). Severe, uniform dilatation of the intrahepatic bile duct was identified in six patients (67%) and central dilatation was seen in two patients (22%). No evidence of dilatation of the intrahepatic bile duct was seen in one patent (11%). Most tumors were located in the proximal third of the extrahepatic bile duct ( n = 7, 78%). Male preponderance was found ( n = 8, 89%). CONCLUSION: Cholangiocarcinoma associated with clonorchiasis was located predominantly in the proximal third of the extrahepatic bile duct and detected more readily than nonclonorchiasis-associated cholangiocarcinoma.     

肝外胆管癌的MSCT诊断

目的探讨肝外胆管癌的MSCT表现及其诊断价值。方法收集我院2008年-2011年经手术或穿刺病理证实肝外胆管癌23例,所有患者行16层螺旋CT平扫、动脉期、静脉期、延迟期扫描,并经MPR、CPR处理,回顾分析胆管癌各期CT表现及胆管癌显示率。结果肝外胆管癌上段9例,中段8例,下段6例;动脉期16例轻度强化,4例中度强化;静脉期3例轻度强化,13例中度以上强化,4例明显强化;2例动脉期、静脉期均呈明显强化;22例延迟期中度以上强化,1例各期无明显强化：CT直接征象为胆管不规则局限性增厚、环状不均匀增厚或表现为结节、肿块状,间接征象为肝内外胆管扩张：MPR、CPR能直接显示病变范围、狭窄程度及周围浸润情况。结论合理运用MPR、CPR技术,能准确显示肝外胆管癌直接征象、位置及浸润范围,结合各期CT表现,对确立诊断及指导临床治疗具有重要价值。     

Carcinoma of the gallbladder associated with clonorchiasis: clinicopathologic and CT evaluation

BACKGROUND: The computed tomographic (CT) features of three cases with pathologically proven adenocarcinoma of the gallbladder associated with clonorchiasis. METHODS: CT scans of three cases with pathologically proven adenocarcinoma of the gallbladder associated with clonorchiasis were retrospectively reviewed. Scans were analyzed for the following parameters: (a) gross morphologic pattern (intralumenal mass lesion, mass replacing the gallbladder, focal or diffuse wall thickening); (b) contrast enhancement of the tumors; (c) associated gallstones or Chlonorchis sinensis worms; (d) direct invasion into the liver; (e) metastasis to adjacent viscera (pancreas, duodenum); (f) the extrahepatic bile duct (dilatation, metastasis, stone, C. sinensis worms); (g) the intrahepatic bile duct (dilatation); and (h) lymphadenopathy and metastasis. RESULTS: The gross morphologic pattern of three cases with carcinoma of the gallbladder was an intralumenal mass lesion (the least common type), whereas the patterns of infiltration and a mass replacing the gallbladder were not identified. Mild contrast enhancement of the tumors relative to the liver was demonstrated in all patients. Gallstones and C. sinensis worms were not visualized in the gallbladder and the extrahepatic bile duct. An unusual metastasis to the distal common bile duct and the pancreas was found in this series. CONCLUSION: Three cases with adenocarcinoma of the gallbladder associated with clonorchiasis showed intralumenal mass lesions within the gallbladder lumen. The cause-and-effect relation between clonorchiasis and gallbladder carcinoma is discussed.     

原发性十二指肠神经内分泌肿瘤的CT表现

目的 探讨原发性十二指肠神经内分泌肿瘤的CT表现.方法 回顾性分析经病理证实的10例十二指肠神经内分泌肿瘤的多层螺旋CT表现.结果 病灶多位于十二指肠近段(十二指肠球部3例、降部6例、水平部1例);6例表现为腔内息肉状肿块,4例表现为壁内肿块;最大径1.6～6.5 am,平均2.3 cm.CT平扫呈等或稍低密度,平均CT值为41HU;密度均匀者7例,不均匀者3例;所有病灶均未见钙化.增强检查动脉期肿块明显强化,门脉期和平衡期强化程度逐渐降低,均匀强化者6例,不均匀强化者4例,三期增强扫描平均CT值分别为95 HU、83 HU、65 HU.肝内外胆管扩张2例;腹腔及腹膜后淋巴结肿大4例;胰腺受累1例;术后复发并侵犯血管1例.结论 十二指肠神经内分泌肿瘤三期动态增强CT表现有一定特征性,发现早期明显强化对诊断具有较高价值.     

MR imaging of intrahepatic cholangiocarcinoma

Background: The purpose of this study was to determine the magnetic resonance (MR) features of intrahepatic cholangiocarcinoma. Methods: MR imaging studies of seven cases of pathologically proven intrahepatic cholangiocarcinoma were retrospectively reviewed. Results: On MR images the tumors presented as a single mass (N = 5) or multiple nodules (N = 2), as welldelineated (N = 5) or ill-defined (N = 2), and as non-encapsulated (N = 7). Mean tumor diameter ranged from 6–14 cm (mean, 10 cm). On T1-weighted (TR/TE = 400–600/10–17 msec) images, the tumors were hypointense compared to the liver. The five tumors studied with dynamic MR imaging showed progressive centripetal filling-in after intravenous administration of a gadolinium chelate. On T2-weighted (TR/TE = 2000–2500/80–100 msec) images, all tumors were hyperintense compared to the liver; five were markedly hyperintense and two moderately hyperintense. Vascular encasement, bile duct dilatation within the tumor, and central scar were depicted on MR images in four, three, and two tumors respectively. Conclusion: The typical MR appearance of intrahepatic cholangiocarcinoma is a large well-delineated nonencapsulated tumor associated with intrahepatic venous encasement.     

Biliary parasitic diseases including clonorchiasis,opisthorchiasis and fascioliasis

Parasitic infection of the biliary tree is caused by liver flukes, namely Clonorchis sinensis and Opisthorchis viverrini. These flukes reside in the peripheral small bile ducts of the liver and produce chronic inflammation of the bile duct, bile duct dilatation, mechanical obstruction, and bile duct wall thickening. On imaging, peripheral small intrahepatic bile ducts are dilated, but the large bile ducts and extrahepatic bile ducts are not dilated or slightly dilated. There is no visible caused of obstruction. Sometimes, in heavy infection, adult flukes are demonstrated on sonography, CT or MR cholangiography as small intraluminal lesions. The flukes in the gallbladder may appear as floating, small objects on sonography. Chronic infection may result in cholangiocarcinoma of the liver parenchyma or along the bile ducts. Human infection of Fasciola hepatica, a cattle flukes, may occur inadvertently, and the flukes migrate in the liver (hepatic phase) and reside the bile ducts (biliary phase). Image findings in the hepatic phase present with multiple, small, clustered, necrotic cavities or abscesses in the peripheral parts of the liver, showing “tunnels and caves” sign, reflecting parasite migration in the liver parenchyma. In the biliary phase, the flukes are demonstrated in the intra- and extrahepatic bile ducts and the gallbladder as small intraluminal flat objects, sometimes moving spontaneously. Bile ducts are dilated.     

多层螺旋CT在恶性低位胆道梗阻疾病诊断中的应用研究

目的探讨多层螺旋CT成像鉴别不同组织来源的恶性低位胆道梗阻疾病的诊断价值。 方法回顾性分析新疆维吾尔自治区儿童医院2015年3月至2017年12月经手术或经内镜逆行性胰胆管造影术活检证实的恶性低位胆道梗阻患者30例的临床资料。总结术前多层螺旋CT诊断的胆管癌、胰头癌和壶腹癌的影像学表现，并与病理活检结果进行对照，采用Kappa检验判断术前诊断与术后病理诊断的一致性。 结果30例患者多层螺旋CT均可清晰显示胆道系统扩张及远端梗阻部位胆管壁增厚、管腔狭窄。胆管癌表现为肝内胆管中、重度扩张，远端胆管呈"截断征"，梗阻部位可见软组织密度肿块沿胆管侧壁向管腔内生长；壶腹癌患者胆总管、胰管均扩张，呈典型"双管征"；胰头癌患者肿块密度不均，边界不清，强化不明显，呈相对低密度，胰体尾部常萎缩。多层螺旋CT诊断胆管癌准确性、敏感度、特异度分别为88.9%、88.9%、83.3%；诊断胰头癌准确性、敏感度、特异度分别为75.0%、85.7%、91.3%；诊断壶腹癌准确性、敏感度、特异度分别为75.0%、60.0%、96.0%。多层螺旋CT诊断与病理检查诊断结果经Kappa一致性检验分析，κ=0.70，P<0.01。 结论多层螺旋CT对于引起恶性梗阻性黄疸的壶腹区肿瘤术前诊断与病理诊断有较好一致性，能清晰显示胆道梗阻部位、程度、肿块以及与周围血管的关系，可作为临床诊断的常规影像学手段。     

Biliary obstruction in metastatic disease: thin-section helical CT findings

BACKGROUND: We describe the thin-section helical computed tomographic (CT) findings of biliary obstruction caused by metastasis. METHODS: Thin-section helical CT (5 mm slice thickness, 1:1 pitch, portal phase) and direct cholangiography in 50 consecutive patients with biliary obstruction caused by metastases were reviewed retrospectively by three radiologists. The primary sites were the stomach ( n = 36), colon ( n = 12), jejunum ( n = 1), and uterus ( n = 1). The level of biliary obstruction was analyzed with the Bismuth classification, and the CT findings of biliary obstruction were classified into six types: small (<2 cm) periductal masses, large (>/=2 cm) periductal masses, extrinsic compression by a metastatic liver mass, high-attenuation intraductal mass, intrapancreatic mass, and no demonstrable lesion. RESULTS: The level of biliary obstruction was the hilum in 18 patients (36%), the proximal common duct in 20 (40%), the distal common duct in five (10%), and the periampullary area in seven (14%). Of 18 hilar obstructions, tumor involvement of the secondary confluence of intrahepatic bile ducts was seen in 10 (right in six, left in one, and bilateral in three). Periductal masses were seen in 68% (small in 18, large in 16). In one patient (2%), a large metastatic mass of the liver resulted in extrinsic compression and biliary obstruction. Lesions mimicking primary biliary or pancreatic tumor were seen in four, respectively. In seven, we found no obstructing lesion on CT. CONCLUSION: Biliary obstruction in patients with known primary malignancies can show atypical patterns mimicking primary pancreatobiliary malignancies on thin-section helical CT.     

Icteric-type hepatoma: magnetic resonance imaging and magnetic resonance cholangiographic features

Background: We evaluated the imaging features of magnetic resonance imaging (MRI) and magnetic resonance cholangiography (MRC) of icteric-type hepatoma and correlated these with the findings of endoscopic retrograde cholangiography (ERC), percutaneous cholangiography, and surgery. Methods: Thirteen patients with viral hepatitis complicated by cirrhosis of the liver and obstructive jaundice underwent MRC and dynamic MRI. Five patients received percutaneous transhepatic cholangiography and drainage; one of these patients also underwent resection of the left hepatic lobe. Another patient received MRC followed by thrombectomy and T-tube insertion. ERC and endoscopic nasobiliary drainage were performed in another patient for bile diversion. Results: Primary liver tumors and dilatation of biliary system were demonstrated in all patients. No capsule formation could be found in any primary liver tumors. MRI showed the simultaneous presence of an intraluminal tumor in the portal trunk and common hepatic duct in eight patients. Three different MRC features were found: (a) an oval defect in the hilar bile duct(s) with dilated intrahepatic ducts (n= 9), (b) dilated intrahepatic ducts with missing major bile ducts (n= 2), and (c) localized stricture of the hilar bile duct(s) (n= 2). Conclusion: The presence of one or more of the following features in multiplanar MRI and MRC help to identify this rare, specific type of hepatocellular carcinoma: (a) the presence of an intraluminal tumor in both the portal trunk and the common hepatic duct, (b) enhancement of the intraluminal tumor in the common hepatic duct on the arterial phase, (c) type I MRC feature, and (d) hemobilia, blood clot within the gallbladder, and/or type II MRC feature. Received: 12 January 2000/Revision accepted: 12 July 2000     

肝内胆管囊腺瘤的CT诊断

目的描述肝内胆管囊腺瘤的CT表现,探讨该肿瘤的CT征象。方法回顾性分析经手术病理证实的6例肝内胆管囊腺瘤的CT表现和诊断。结果 6例肿瘤最大径为5.4～26.4cm,平均11.2cm。3例位于肝右叶,2例位于肝左叶,1例同时累及肝左右叶。肿瘤均为多房性单发囊性肿块,内见多发分隔,边界清楚。2例囊内分隔局部增厚,其中1例见分隔处有局限性乳头状突起,1例见壁结节,1例分隔见多个点状及短线状钙化。增强后,囊壁、分隔、乳头状突起及壁结节轻至中度强化。2例因肿块压迫出现肝内胆管扩张。其中1例肿块的小囊与肝内扩张的胆管相通。结论中年女性,CT表现为肝内单发低密度囊性肿块,边界清楚,囊内有多个分隔,囊内可有乳头状突起或壁结节,此时应考虑肝内胆管囊腺瘤的诊断。     

MRCP结合常规MRI诊断恶性肿瘤性胆道梗阻的临床应用

目的研究MRCP结合MRI对胆道梗阻恶性肿瘤的诊断价值。方法46例胆道梗阻恶性肿瘤患者,常规T1WI、T2WI及脂肪抑制T2WI检查后,行MRCP检查。分析不同部位胆管梗阻恶性肿瘤的MRI、MRCP表现,与病理诊断对照。结果46例患者,4例MRCP仅肝内胆管扩张,肿块T2WI高信号,病理诊断肝内胆管细胞癌;10例MRCP肝门"空虚征"、肝内胆管枯树枝状扩张,肿块T2WI高信号7例,病理诊断胆管癌6例,胆囊癌4例;32例胆总管截断或狭窄,近段胆管、肝内胆管扩张,肿块T2WI稍高信号14例,病理诊断胆管癌12例、胆囊癌3例、胰头癌6例、壶腹癌5例、十二指肠腺癌及乳头腺癌6例。结论常规MRI和MRCP联合应用有利于恶性肿瘤性胆道梗阻的定位、定性诊断。     

Portal biliopathy: a multitechnique imaging approach

Portal biliopathy (PB) is a disorder characterized by biliary ductal and gallbladder wall abnormalities seen in patients with extrahepatic portal vein obstruction. These abnormalities consist mainly of bile duct compression and tethering, stenoses, fibrotic strictures and dilatation of both extrahepatic and intrahepatic bile ducts, as well as gallbladder varices. In this pictorial essay, we describe the imaging findings of PB, which allow differentiation of this entity from other diseases that may have similar imaging findings including cholangiocarcinoma, extrinsic compression of the bile duct caused by metastatic adenopathy or sclerosing cholangitis.     

肝内胆管乳头状瘤的CT及MR表现

目的：探讨肝内胆管乳头状瘤（Intrahepatic biliary papillomatosis,IHBP）的临床病理特征、影像学表现。方法 ：回顾性分析5例经手术病理证实的IHBP患者的临床病理特征及影像学表现,并结合文献进行分析和讨论。结果：5例IHBP患者中2例表现为间歇性黄疸、1例腹痛伴发热、1例左腰背部酸痛,1例体检时发现。影像学特点：5例均发现全胆管树系统扩张,胆总管下段无明确占位或结石,受累肝内胆管相对比另一肝叶胆管或胆总管不成比例的扩张,受累肝内胆管呈＂瘤样＂扩张,扩张的肝内胆管出现乳头状或长条状肿块影,MRCP示扩张胆管内多发乳头状及条状充盈缺损,3例位于右肝内胆管、2例位于左肝内胆管,肿块直径约0.3~2.5 cm,于CT平扫呈等或稍低密度,MR T1WI表现为等或稍低信号,T2WI上多呈等高信号,DWI上呈乳头状及条状高信号,增强扫描肿块呈轻度强化。结论：IHBP的影像学表现有一定的特征性,尤其MRCP、DWI及动态增强检查,熟悉该病的特征性影像学表现有助于对IHBP诊断及鉴别诊断。     

Primary sclerosing cholangitis: sonographic findings

Background: To determine the value of sonography of the upper abdomen in primary sclerosing cholangitis (PSC). Methods: In a prospective study of 23 patients with PSC we performed upper abdominal sonography. Sonographic findings of the bile ducts were correlated with endoscopic retrograde cholangiographic (ERC) findings. Signs of advanced disease and complications were also sought. Results: The major limitation of ultrasound was its inability to exclude intrahepatic duct disease. In six patients with multiple strictures and pruning but without dilatations on ERC, sonography showed no intrahepatic duct abnormalities. Extrahepatic duct disease was adequately demonstrated on ultrasound. Mural thickening of the common bile duct (CBD), the hallmark of PSC in the appropriate clinical setting, was demonstrated in 17 of 18 cases with a stenosis on ERC. Ultrasound confirmed advanced disease manifested by signs of portal hypertension in seven patients. Marked nonsegmental intrahepatic duct dilatation and the presence of a mass lesion occurred in two of three cases in which complicating cholangiocarcinoma was found. Conclusion: Despite its inability to exclude intrahepatic duct disease, sonography is useful in diagnosing and following PSC.An editorial commentary on this article follows on p. 113.     

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.     

低张MSCT增强扫描在胆总管壶腹部梗阻诊断中的价值

目的探讨低张MSCT增强扫描在胆总管壶腹部梗阻诊断中的应用价值。方法回顾性分析47例经低张CT增强扫描的胆总管壶腹部梗阻患者的CT表现。结果所有病例经手术或临床治疗得以证实。胆总管轻度扩张17例，其中3例为炎症性狭窄，14例为结石；中度扩张18例，15例为结石，3例为壶腹癌；重度扩张12例，均为壶腹癌。肝内胆管软藤状扩张15例，均为壶腹癌；残根状扩张19例，均为胆总管结石；不典型肝内胆管扩张13例，其中3例为炎症性，10例为结石。壶腹癌中9例可见“双管征”，5例可见“双环征”，3例可见“半月征”，8例可见乳头状软组织结节影。29例结石在梗阻部位可见点状略高密度影。3例炎症性狭窄显示梗阻端胆管逐渐变细。结论低张MSCT增强扫描在胆总管壶腹部梗阻的诊断和鉴别诊断中具有很高的价值。     

胆管囊肿的CT诊断

目的：探讨胆管囊肿的临床、病因、分型及ＣＴ诊断与鉴别诊断问题。材料与方法：对１３例患者的临床资料与ＣＴ资料进行了回顾性分析。结果：１０例胆总管呈圆形或椭圆形扩张，１例肝内胆管呈多发性局限性囊状扩张，２例同时累及肝内、外胆管，２例胆系造影ＣＴ扫描，造影剂进入囊肿内。结论：ＣＴ扫描对本病的诊断具有很大的价值。     

不同梗阻类型急性化脓性胆管炎的治疗对策

目的探讨对不同梗阻类型的急性化脓性胆管炎（Acute Suppurative Cholangitis,ASC）的分型和处理,进一步重视肝内梗阻的ASC的治疗.方法回顾分析37例ASC,按不同梗阻部位分为肝外型、肝内型和混合型.单纯采用胆道探查取石T管引流30例,胆道镜取石4例,左外叶切除2例,肝吸虫病例术后口服吡喹酮.结果手术36例中,除1例肝内外胆管结石合并右叶肝脓肿,术前肝、肾功能不全,术后发生多脏器功能衰竭（MOF）要求放弃治疗外,其余35例中,术后发生MOF 3例,死亡1例.术后出现胆瘘2例,胆道出血1例,34例均治愈出院.结论积极的抗休克,适当的手术时机,及时有效的胆道减压和解除梗阻是进一步提高手术治疗效果和降低死亡率的关键.     

Radiologic features of papillary adenoma and papillomatosis of the biliary tract

Background: The purpose of this study was to describe the imaging findings of papillary adenoma of the bile ducts. Methods: Imaging modalities including sonography, computed tomography, cholangiography, and endoscopic sonography obtained in five patients with papillary adenoma of the bile duct were retrospectively reviewed and correlated with pathologic findings. Results: In four cases, imaging findings were a dilatation of the bile ducts due to a protruding mass within the lumen of the common bile duct. In one case, the biliary tract obstruction was not due to the mass but to mucus secretion that was detected at sonography, endoscopic sonography, and cholangiography. Multiple lesions were observed in two cases at pathology and not detected preoperatively. All the lesions contained foci of in situ carcinoma or mild dysplasia. Conclusion: Imaging is useful in detecting bile duct tumors. Hypersecretion of mucus is rare but highly characteristic of bile duct adenoma. Received: 6 July 1995/Accepted: 18 August 1995