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Diagnosing Bile Duct Stones

Comparison of Unenhanced Helical CT, Oral Contrast-Enhanced CT Cholangiography, and MR Cholangiography

Jorge A. Soto1, Oscar Alvarez2, Felipe Múnera1, Sol M. Velez1, Joaquín Valencia3 and Nelson Ramírez3

1 Department of Radiology, Universidad de Antioquia, Hospital Universitario San Vicente de Paúl, Calle 64 x Kra. 51D, Medellín, Colombia.
2 Department of Gastroenterology, Universidad de Antioquia, Hospital Universitario San Vicente de Paúl, Medellín, Colombia.
3 Department of Surgery, Universidad de Antioquia, Hospital Universitario San Vicente de Paúl, Medellín, Colombia.



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  		Fig. 1A. —42-year-old woman with single common bile duct stone 6 mm in diameter. Unenhanced axial helical CT scan shows stone with hypoattenuating center and hyperattenuating rim (arrow).

 


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  		Fig. 1B. —42-year-old woman with single common bile duct stone 6 mm in diameter. CT cholangiogram (coronal reformation) shows stone appears as intraductal filling defect, surrounded by contrast-enhanced bile (arrow).

 


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  		Fig. 1C. —42-year-old woman with single common bile duct stone 6 mm in diameter. Source image of MR cholangiography, acquired using multislice half-Fourier rapid acquisition with relaxation enhancement technique, reveals stone as filling defect (arrow) surrounded by high-signal-intensity bile.

 


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  		Fig. 2A. —56-year-old woman with 4-mm common bile duct stone. Unenhanced helical CT scan (sagittal reformation) clearly shows densely calcified bile duct stone (arrow).

 


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  		Fig. 2B. —56-year-old woman with 4-mm common bile duct stone. CT cholangiogram (sagittal reformation at similar plane and with same window settings as A) shows stone is almost completely obscured by contrast-enhanced bile.

 


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  		Fig. 2C. —56-year-old woman with 4-mm common bile duct stone. Frontal maximum-intensity-pixel-projection reconstruction of CT cholangiogram clearly shows hyperattenuating stone (arrow). Obscuration of densely calcified stones by contrast-enhanced bile is one of potential pitfalls of CT cholangiography.

 


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  		Fig. 2D. —56-year-old woman with 4-mm common bile duct stone. MR cholangiogram acquired with single-slice half-Fourier rapid acquisition with relaxation enhancement sequence shows stone is seen as subtle intraductal focus of low signal intensity (arrow).

 


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  		Fig. 3A. —60-year-old man with single common bile duct stone. Unenhanced helical CT scan (sagittal reformation) depicts stone as intraluminal soft-tissue density in bile duct (arrow).

 


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  		Fig. 3B. —60-year-old man with single common bile duct stone. CT cholangiogram (sagittal reformation at same level as A) shows stone as filling defect (arrow). Stone was also seen on MR cholangiography (not shown).

 


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  		Fig. 4A. —45-year-old man with single large stone in common bile duct. Unenhanced axial helical CT scan.

 


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  		Fig. 4B. —45-year-old man with single large stone in common bile duct. Axial CT cholangiogram obtained at same anatomic level as A. Faceted common bile duct stone is clearly seen (arrow).

 


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  		Fig. 4C. —45-year-old man with single large stone in common bile duct. Frontal maximum-intensity-pixel-projection reformation of CT cholangiogram. Faceted common bile duct stone is clearly seen (curved arrow) as filling defect but was not diagnosed by radiologists on unenhanced study (A). This is false-negative interpretation of unenhanced helical CT examination. Note metallic clips (straight arrows).

 


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  		Fig. 4D. —45-year-old man with single large stone in common bile duct. MR cholangiogram acquired using three-dimensional fast spin-echo sequence (frontal maximum-intensity-pixel-projection reformation) also shows faceted stone (arrow). Metallic clips are not seen.

 


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  		Fig. 5A. —57-year-old woman with epigastric pain. Unenhanced axial helical CT scan shows apparent intraductal density (arrow), which was interpreted as representing stone.

 


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  		Fig. 5B. —57-year-old woman with epigastric pain. CT cholangiogram (sagittal reformation) shows only common bile duct dilatation (arrow) without stones.

 


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  		Fig. 5C. —57-year-old woman with epigastric pain. Source image of MR cholangiography, acquired with three-dimensional fast spin-echo technique, shows duct dilatation (arrow) but no stones. Endoscopic retrograde cholangiography (not shown) confirmed absence of stones. This case is example of false-positive interpretation of unenhanced helical CT study.

 


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  		Fig. 6A. —34-year-old woman with fever and pain in right upper quadrant. Axial CT cholangiogram shows hypodense area with irregular borders in left hepatic lobe (arrow). Study was considered negative for presence of biliary stones. Note contrast in normal-caliber right hepatic ductal branch (arrowhead).

 


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  		Fig. 6B. —34-year-old woman with fever and pain in right upper quadrant. Maximum-intensity-pixel-projection reformation of MR cholangiogram obtained using multislice half-Fourier rapid acquisition with relaxation enhancement sequence shows large filling defects (arrows) in markedly dilated left hepatic bile duct system.

 


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  		Fig. 6C. —34-year-old woman with fever and pain in right upper quadrant. Endoscopic retrograde cholangiogram confirms presence of multiple stones (arrows) and severe dilatation of left intrahepatic ductal branches. This case depicts false-negative interpretation of CT cholangiograms.

 

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