Crohn''s disease and sclerosing cholangitis: CT and PTC diagnosis, with MR findings

Computed tomography (CT), percutaneous transhepatic cholangiography (PTC) and magnetic resonance imaging (MRI) findings in a case of sclerosing cholangitis associated with Crohn's disease of the colon and terminal ileum are described. CT gives additional information on dilatation of peripheral bile ducts and confirms findings of PTC, i.e. a decreased arborization of the biliary tree, a nodular appearance of the common bile duct and multifocal bile duct strictures. CT findings could be recognized on MRI which provided no additional information.     

Role of computerized tomography in the evaluation of extraductal extension of hilar cholangiocarcinoma

This study was aimed at assessing the role of CT in the investigation of extraductal spread of hilar cholangiocarcinoma. October 1990 to November 1993, twenty-one patients with hilar cholangiocarcinoma were examined. The diagnosis was made on the basis of the following CT findings: intrahepatic bile ducts dilatation, nonunion of the right and the left bile ducts, normal size of extrahepatic bile ducts and the tumor depicted "per se". As for extraductal spread, we considered parenchymal invasion, involvement of vascular structures and parenchymal, lymph node and peritoneal metastases. In all cases CT demonstrated intrahepatic bile duct dilatation and nonunion at the confluence. CT demonstrated a hypodense mass in 10/21 cases and an isodense mass in 11/21 cases. Portal vein involvement was detected in 7/10 cases and hepatic artery involvement was correctly suspected in 1/8 cases; CT demonstrated parenchymal and lymph node metastases in 1/6 and 2/7 cases. In conclusion, CT proved to be a valuable technique, like PTC and US, to assess tumor resectability.     

Development of virtual CT cholangiopancreatoscopy

Endoluminal virtual computed tomographic (CT) cholangiopancreatoscopic views of the pancreatic and common bile ducts were generated in 16 patients by using helical CT data sets and endoscopic three-dimensional reconstruction images. In all patients with ductal dilatation, virtual images were obtained and findings correlated with those at helical CT and endoscopic retrograde cholangiopancreatography. Virtual CT cholangiopancreatoscopy is a feasible technique, and initial experience shows promising results.     

Detection of choledocholithiasis: comparison of unenhanced helical CT and endoscopic retrograde cholangiopancreatography

PURPOSE: To compare unenhanced helical computed tomography (CT) and endoscopic retrograde cholangiopancreatography (ERCP) in the detection of common bile duct calculi. MATERIALS AND METHODS: Within 13 months, 51 patients (aged 18-94 years) with clinically suspected choledocholithiasis underwent unenhanced helical CT immediately before undergoing ERCP. CT scans were evaluated for the presence of bile duct stones, ampullary stones, the gallbladder and gallbladder stones, intrahepatic biliary dilatation, and the size of the bile duct at the porta hepatis and in the pancreatic head. ERCP images were evaluated for the presence of bile duct or ampullary stones, as well as for biliary dilatation. RESULTS: Unenhanced helical CT depicted common bile duct stones in 15 of 17 patients found to have stones at ERCP. Three patients had stones impacted at the ampulla, all of which were detected with CT. In addition, there was one false-positive finding at CT. CT had a sensitivity of 88%, a specificity of 97%, and an accuracy of 94% in the diagnosis of common bile duct stones. CONCLUSION: Unenhanced helical CT is useful for evaluating suspected choledocholithiasis.     

Familial occurrence of congenital bile duct cysts

Congenital bile duct cysts are now a well-documented anomaly of the biliary tree, and have become more common in Japan. Familial occurrence of congenital bile duct cysts, however, is extremely rare, with only six reported cases in the literature. We report a familial pattern of congenital bile duct cysts in a mother and her daughter. A 33-year-old female was admitted for evaluation of right upper quadrant abdominal pain and fever 6 days after an uneventful delivery of her second child. A computed tomography (CT) and ultrasound scan (US) revealed an obstructed biliary tract. Percutaneous transhepatic biliary drainage was then performed, and a cholangiogram revealed a Scholtz type B choledochocele without an anomalous connection of the pancreaticobiliary ducts. Endoscopic US demonstrated that the choledochocele was associated with a stone in the cyst. A pylorus-preserving pancreatoduodenal resection was performed, and a histological study revealed that the choledochocele was lined by biliary mucosa without evidence of malignancy. The newborn infant had an abdominal tumour. An US and CT revealed a congenital bile duct cyst. An operation was performed and the intraoperative cholangiogram showed an Alonso-Lej type I congenital bile duct cyst with an anomalous connection of the pancreaticobiliary ducts. Whether congenital bile duct cysts are hereditary remains to be elucidated.     

A microcholangiographic study of liver disease models in rats

RATIONALE AND OBJECTIVES: Rats develop hepatobiliary injury due to small bowel bacterial overgrowth (SBBO) that, at specimen, resembles cholangiography sclerosing cholangitis. To better visualize the smaller bile ducts, we used microcholangiography to determine the spectrum of biliary lesions in this and five other models of liver disease. METHODS: The models studied were as follows: (1) Surgically created jejunal, self-filling blind loops induce SBBO. (2) Intraperitoneal injection of a bacterial cell wall polymer, peptidoglycan-polysaccharide (PG-PS), causes granulomatous hepatitis. (3) Intraperitoneal injection of endotoxin (lipopolysaccharide) causes sinusoidal congestion and shock. (4) Bile duct ligation induces bile duct proliferation. (5) Alpha-naphthyl-isothiocyanate (ANIT) induces bile duct proliferation. (6) Carbon tetrachloride (CCl4) causes fibrosis and cirrhosis. Warmed barium sulfate, gelatin, and saline were injected in the extrahepatic bile duct. Liver slices (2 mm) underwent microradiographic techniques, and images were correlated with histology. RESULTS: Rats with SBBO had irregular and dilated extrahepatic bile ducts with thickened walls. Rats treated with endotoxin and CCl4 had normal microcholangiograms. Bile duct proliferation was identified following ANIT and bile duct ligation. Rats given PG-PS demonstrated irregular intrahepatic bile ducts. Microcholangiograms following SBBO and PG-PS showed similarities including focal ductal dilatation, narrowing, proliferation, and destruction. CONCLUSION: Various models of liver injury induce characteristic cholangiographic appearances. Microcholangiography is useful in examining biliary tract lesions and complements histology.     

Liver metastases from colon cancer with intra-bile duct tumor growth: radiologic features

PURPOSE: Our goal was to characterize the radiologic features of liver metastases from colon cancer with intrahepatic bile duct (IHBD) dilatation. METHOD: Radiologic findings of liver metastases from colon cancer with IHBD dilatation of four patients were compared with pathologic findings. RESULTS: The cause of bile duct dilatation in all cases was due to papillary tumor growth in the bile duct. In two patients, intra-bile duct tumor growth (IBDTG) was observed on imaging. In the other two patients, IBDTG was not observed, but a nontapered abrupt obstruction of a dilated bile duct was seen, corresponding to the microscopically proven papillary tumor growth in the ductal lumen. In three patients who underwent an extensive hepatic resection, there has been no recurrence. In one patient who had a nonanatomic limited resection, a recurrence was seen 1 year after surgery. CONCLUSION: When liver tumor with IBDTG is suspected on imaging, liver metastases should be considered in the differential diagnosis besides hepatocellular carcinoma or cholangiocellular carcinoma. Careful preoperative assessment for IBDTG by imaging is essential to determine the extent of surgical resection.     

Hepatic peribiliary cysts: multiple tiny cysts within the larger portal tract, hepatic hilum, or both

PURPOSE: To describe characteristic imaging features of hepatic peribiliary cysts. MATERIALS AND METHODS: Four patients with hepatic cysts in which the radiologic (n = 3) or histologic (n = 1) findings were consistent with peribiliary cysts of the liver (multiple small cysts seen exclusively in the larger portal tract, hepatic hilum, or both at gross examination and dilatations of extramural peribiliary gland at histologic examination) underwent computed tomography (CT) and ultrasound (US). In three patients, CT was performed after drip infusion of cholangiographic contrast material. RESULTS: Contrast material-enhanced CT clearly depicted many tiny cysts along the larger portal veins up to the third- or fourth-order branch (n = 3). US depicted multiple cysts in the echogenic portal tract definitely (n = 2) or equivocally (n = 2). On cholangiographic contrast-enhanced CT scans, cystic areas were located adjacent to or surrounding the bile ducts, and the possibility of biliary dilatation, communication, or both was disproved. CONCLUSION: Hepatic peribiliary cysts can be diagnosed with US and enhanced CT, especially with CT performed after administration of cholangiographic contrast material.     

Apropos of a case of acute pancreatitis revealing cystic dilatation of the common bile duct

Dilatation of the common bile duct is rarely caused by cystic formations. Though the pathogenesis is uncertain, congenital disorders have been suggested. Most cases are observed in small children (80% female predominance) with only 20% of the cases reported in adults. Clinical signs vary. Recurrent acute pancreatitis has been reported but is rare. New imaging techniques using CT-scan cholangiography and sometimes MR cholangiography have greatly improved the diagnostic approach. MR of the bile ducts is a recent noninvasive technique enabling an analysis of the biliopancreatic ducts without contrast injection into the bile. To our knowledge, cystic dilatation of the common bile duct has not been previously reported in the literature. We report an interesting case in a 25-year-old woman who developed an episode of acute pancreatitis during the post partum period. We describe the clinical aspects and the different imaging findings, including magnetic resonance cholangiography results.     

Acute cholecystitis and persistent liver necrosis in mice provoked by isothiocyanate

Two known cholangiotoxic agents, alpha-naphthylisothiocyanate (ANIT) and p-phenylenediisothiocyanate (PDT), were administered in single doses to mice to study their effects on the gallbladder. Both compounds caused maximal bile duct necrosis and periportal hepatocytic necrosis at 24 hours. In contrast, the gallbladders were edematous but not necrotic at 24 hours after treatment. At 48 hours, and in some animals up to four days, severe cholecystitis was present, while bile ducts revealed progressive regeneration. The delay in the onset of gallbladder lesions was assumed to be the result of the toxic agent concentration in gallbladder bile after hepatic bile secretion was suppressed for 24 hours. The lesions provoked by PDT were similar to those induced by ANIT, except for a hemorrhagic component.     

Laparoscopic intracorporeal ultrasound. An alternative to cholangiography?

The purpose of this study was to compare laparoscopic intracorporeal ultrasound (LICU) examination of the biliary duct system with cholangiography for delineation of duct anatomy and determination of presence or absence of ductal calculi. Thirty-one patients had LICU examination of the extrahepatic bile ducts after exposure of the gallbladder but prior to dissection of the cystic duct. After LICU examination, cystic duct dissection and cholangiography were done. Evaluation of duct anatomy and decision for duct exploration were based on findings of both tests. All patients had successful LICU examination and 30 had successful cholangiography. Duct size as determined by LICU corresponded precisely with cholangiography. LICU provided useful anatomical information in two patients with aberrant anatomy and detected cholangiogram. LICU aids in delineation of biliary duct anatomy and accurately determines presence or absence of duct calculi.     

Magnetic resonance cholangiopancreatography: a novel approach to the evaluation of suspected pancreaticobiliary neoplasms

BACKGROUND: Magnetic resonance cholangiopancreatography (MRCP) is a new noninvasive diagnostic method for pancreaticobiliary (PB) imaging without endoscopy, sedation, or iodinated contrast. The purpose of this study was to evaluate the ability of MRCP to depict pancreatic and biliary ductal anatomy compared to that of endoscopic retrograde cholangiopancreatography (ERCP) and to evaluate the ability of MRCP to accurately diagnose PB neoplasms. METHODS: Twenty patients had MRCP, and 17 also had ERCP. All studies were read prospectively by experienced reviewers blinded to other imaging data. Pathologic diagnosis was made in all patients. RESULTS: Bile duct dilatation seen by ERCP in 14 of 17 patients was correctly identified by MRCP in all 14 patients, and normal ducts were correctly identified by MRCP in the other 3 patients. The pancreatic duct was visible on MRCP in the pancreatic head in 17 of 20 patients, the body in 17 of 20 patients, and the tail in 15 of 20 patients. At ERCP, pancreatic duct dilatation was present in 11 cases and was identified by MRCP in 10 of them. Eighteen of 20 patients had malignant PB neoplasms. MRCP indicated PB neoplasm in 19 patients. Seventeen of these 19 patients had histologically confirmed malignant neoplasms pathologically, whereas 2 had benign pathology (both chronic pancreatitis). Among the 17 patients who also had ERCP, MRCP and ERCP correctly agreed on a final diagnosis of malignant neoplasm in 14 cases. In the three cases in which MRCP and ERCP disagreed on a final diagnosis, MRCP was correct in one and incorrect in two. CONCLUSIONS: MRCP can accurately and noninvasively delineate PB ductal anatomy and diagnose PB neoplasms comparably to ERCP. MRCP is an interesting new noninvasive method for evaluating patients with suspected PB neoplasms.     

Rating the legislative environment

PURPOSE: To evaluate MR-cholangiography after instillation of contrast media via indwelling biliary tubes. METHODS: In 8 patients with stenoses of the central bile ducts, physiological saline solution and diluted contrast media (Gd-DTPA, 5 mmol/l) were consecutively administered via an indwelling biliary tube. MR cholangiograms were obtained before and after saline injection using a HASTE-sequence and after administration of Gd-DTPA using a T1-weighted gradient echo sequence. RESULTS: Peripheral bile ducts were better visualised in the water-sensitive approach than after Gd-DTPA enhancement. In patients with short-time drainage bile duct definition was poor due to periportal oedema. Visualisation of peripheral bile ducts could be improved by injection of saline solution in these patients. After administration of Gd-DTPA via the biliary tube contrast enhancement of the central bile ducts was achieved in all patients except for one patient on long-term drainage with an indwelling Yamakawa tube. CONCLUSION: T1-weighted visualisation of the central bile ducts can be achieved by means of injection of Gd-DTPA via indwelling biliary tubes.     

Mast cell cholangiopathy: another cause of sclerosing cholangitis

A 75-year-old woman with known systemic mastocytosis presented with abdominal pain, ascites, and bile duct thickening on computed tomography and ultrasonography. A liver biopsy specimen showed infiltration with mast cells. Endoscopic retrograde cholangiography showed ductal changes compatible with those found in primary sclerosing cholangitis. Brush cytology of the intrahepatic bile ducts confirmed mast cell infiltration. Systemic mastocytosis can infiltrate the biliary system, producing a cholangiopathy radiographically similar to primary sclerosing cholangitis.     

Effect of pancreatic ductal and parenchymal changes on exocrine function in chronic pancreatitis

The effect of pancreatic ductal and parenchymal changes on exocrine pancreatic function was analyzed prospectively in 75 patients with chronic pancreatitis (CP). Endoscopic retrograde pancreatography (ERP), computed tomography (CT), and serum pancreolauryl test (PLT) were performed to evaluate the degree of ductal, parenchymal, and functional changes, respectively. Results were evaluated by stepwise multivariate logistic regression and are expressed as the odds ratio (OR). A strong association was found between the degree of ductal changes in ERP and the degree of exocrine functional impairment (OR = 5.8). However, the association between the degree of parenchymal changes in CT and the degree of pancreatic dysfunction was weaker and was clearly confounded by the degree of ductal changes. On the basis of these findings, we suggest that the development of exocrine pancreatic functional impairment in patients with CP depends primarily on the degree of ductal changes, while parenchymal abnormalities play a less important role.     

MR cholangiography of congenital biliary malformations in infancy

We presented MR cholangiography (MRC) of congenital biliary malformations in infancy. MRC was obtained during induced sleeping. In two cases of congenital dilation of bile duct, MRC revealed cystic or spindle dilatation of intra- and extra hepatic bile ducts. In one biliary atresia, MRC revealed the serpentine gall bladder and cystic dilatation of the extrahepatic bile duct without connection to the dilated hilar bile duct. MR cholangiography, which can be obtained noninvasively, is useful for the diagnosis and the preoperative assessment of congenital biliary malformations in infancy.     

An unusual hyperplastic hepatocellular nodule in a patient with hepatitis C virus-related liver cirrhosis

Recent advances in diagnostic imaging techniques have increased the likelihood of detecting novel nodular lesions of the liver. We report here a case of unusual hyperplastic hepatocellular tumor found in a 70-yr-old woman with hepatitis C virus-related cirrhosis. A mass was incidentally detected in the right lobe by abdominal ultrasonography and confirmed by computed axial tomography (CT). Magnetic resonance imaging demonstrated that the tumor had hyperintense signal with a small hypointense region in the center and a thin, hypointense rim on T1-weighted image and a hypointense signal on T2-weighted image. CT during hepatic arteriography showed that the tumor was hypodense with a central hyperdense region, whereas CT during arterial portography revealed that the tumor was isodense and surrounded by a thin circular hypodense band with a central hypodense region. These radiographic findings suggested a diagnosis of dysplastic nodule with malignant foci of hepatocellular carcinoma. The patient underwent tumor resection. Macroscopically, the tumor, 45 x 45 x 30 mm in size, was encapsulated and had a central stellate-like scar with radiating septa. Histological examination showed a hyperplastic hepatocellular tumor without cellular, nuclear or structural atypia. The central fibrous scar contained abundant small, artery-like and vein-like vessels, whereas there were no normal portal triads but rather several portal tract-like structures lacking bile ducts in the parenchyma of the tumor. Some of the portal tract-like structures were composed of artery-like and vein-like vessels, and the others possessed vein-like vessels only. There were no bile ducts in the tumor. The nontumorous liver tissue had evidence of macronodular cirrhosis. Finally, this tumor was regarded as an unusual type of hyperplastic hepatocellular nodule encountered in cirrhotic liver, characterized by the presence of central stellate-like fibrosis and the lack of bile ducts. Although the pathogenesis of the hyperplastic lesion is unclear, it may represent a focal regenerative hepatocellular response to localized circulatory disorder.     

Laparoscopic cholecystectomy. Do preoperative factors predict the need to convert to open?

We reviewed our experience with the last 587 laparoscopic cholecystectomies performed between May 1990 and January 1993 to correlate preoperative findings that may predict the conversion of a laparoscopic cholecystectomy to that of an open procedure. The prediction of a need to convert to an open cholecystectomy would allow the surgeon to discuss the higher risk of conversion with the patient and also allow for an earlier intraoperative decision to convert if difficulty was encountered. In addition to routine demographic data, ultrasound reports were available for 526 patients and the following information was recorded: presence of stones, thickened gallbladder wall, common bile duct dilatation, gallbladder sludge, and cystic duct impaction. Overall, a two times higher rate of conversion was found for male patients and patients with a body mass index > 27.2 kg/m2. Additionally, a thickened gallbladder wall on preoperative ultrasound was correlated with a six times higher conversion rate to open cholecystectomy. As expected, the positive intraoperative cholangiogram was associated with a higher incidence of conversion. Additionally, finding a dilated common bile duct on ultrasound was found to be associated with a nearly seven times higher rate of positive intraoperative cholangiogram. No statistical significance was found between conversion and age, previous abdominal operations, the presence of stones, common bile duct dilatation, gallbladder sludge, cystic duct impaction, or a distended gallbladder. Thus, these predictive findings allow the surgeon to preoperatively discuss the higher risk of conversion and allow for an earlier judgment decision to convert if intraoperative difficulty is encountered.     

Hepatocellular carcinoma presenting as a tumour of the hilar and extrahepatic bile ducts

A case of hepatocellular carcinoma extending within the large extra- and intrahepatic bile ducts is reported. No primary tumour was found in the liver parenchyma by abdominal ultrasound, spiral computed tomography or magnetic resonance, but transduodenal cholangioscopy showed tumour in the common hepatic ducts and the two main branches. Endoscopic biopsy showed highly differentiated hepatocellular carcinoma. The patient was treated with endoscopic biliary drainage and died at home 7 months after admittance.     

Non-Hodgkin lymphoma as a cause of intrahepatic periportal low attenuation on CT

Two cases of non-Hodgkin lymphoma (NHL), one AIDS related, with hepatic involvement manifesting as infiltrating mass-like periportal intrahepatic low attenuation on CT are described. One case demonstrated mass effect with compression of adjacent bile ducts causing jaundice. NHL should be included in the differential diagnosis of mass-like periportal intrahepatic low attenuation lesions.