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Using Contrast-Enhanced MR Cholangiography with IV Mangafodipir Trisodium (Teslascan) to Evaluate Bile Duct Leaks After Cholecystectomy: A Prospective Study of 11 Patients

Kenneth M. Vitellas1, Adam El-Dieb1, Kuldeep K. Vaswani1, William F. Bennett1, John Fromkes2, Christopher Ellison3 and James G. Bova1

1 Department of Radiology, The Ohio State University Medical Center, S-211 Rhodes Hall, 450 W. 10th Ave., Columbus, OH 43210.
2 Department of Digestive Diseases, The Ohio State University Medical Center, Columbus, OH 43210.
3 Department of General Surgery, The Ohio State University Medical Center, Columbus, OH 43210.



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  		Fig. 1A. —66-year-old woman with abdominal pain and elevated bilirubin level after laparoscopic cholecystectomy. Axial gradient-echo MR cholangiogram obtained 1 hr 30 min after IV administration of mangafodipir trisodium shows extravasation of mangafodipir trisodium (arrows) into gallbladder fossa, compatible with leak. Mangafodipir trisodium produces increased signal intensity on gradient-echo image.

 


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  		Fig. 1B. —66-year-old woman with abdominal pain and elevated bilirubin level after laparoscopic cholecystectomy. Axial single-shot fast spin-echo MR image obtained at same time as A shows extravasated mangafodipir trisodium (arrows) as decreased signal intensity. Because mangafodipir trisodium is less dense than bile, it extravasates to nondependent portion of fluid collection.

 


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  		Fig. 1C. —66-year-old woman with abdominal pain and elevated bilirubin level after laparoscopic cholecystectomy. Axial gradient-echo MR image shows that common bile duct (arrow) does not opacify, which is compatible with transection of extrahepatic bile duct. These findings were confirmed on endoscopic retrograde cholangiography.

 


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  		Fig. 2A. —69-year-old woman with abdominal pain, nausea, and vomiting after undergoing laparoscopic cholecystectomy. (Reprinted with permission from [18]) Axial gradient-echo MR cholangiogram obtained 1 hr after IV administration of mangafodipir trisodium shows extravasation of contrast material (arrows) into perihepatic space.

 


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  		Fig. 2B. —69-year-old woman with abdominal pain, nausea, and vomiting after undergoing laparoscopic cholecystectomy. (Reprinted with permission from [18]) Axial gradient-echo MR image obtained at same time as A shows extravasation of contrast material (straight arrows) and site of leak at base of right hepatic duct (curved arrow). Opacified common bile duct (arrowhead) indicates continuity with liver. These findings were confirmed on endoscopic retrograde cholangiography.

 


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  		Fig. 3A. —44-year-old woman with jaundice, fever, abdominal pain, elevated bilirubin level, and bile exiting peritoneal drain after laparoscopic cholecystectomy. Axial gradient-echo MR cholangiogram shows contrast agent extravasating into perihepatic space (arrows).

 


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  		Fig. 3B. —44-year-old woman with jaundice, fever, abdominal pain, elevated bilirubin level, and bile exiting peritoneal drain after laparoscopic cholecystectomy. Axial gradient-echo MR image obtained at same time as A shows contrast agent extravasating from cystic duct (arrow). These findings were confirmed on endoscopic retrograde cholangiography.

 


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  		Fig. 4A. —28-year-old woman with abdominal pain, elevated bilirubin level, and bile exiting peritoneal drain after laparoscopic cholecystectomy. Axial gradient-echo MR cholangiogram obtained 2 hr after IV administration of mangafodipir trisodium reveals calculus (arrow) in proximal main left hepatic duct.

 


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  		Fig. 4B. —28-year-old woman with abdominal pain, elevated bilirubin level, and bile exiting peritoneal drain after laparoscopic cholecystectomy. Axial gradient-echo MR image obtained at same time as A shows opacification of the common hepatic duct (arrow).

 


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  		Fig. 4C. —28-year-old woman with abdominal pain, elevated bilirubin level, and bile exiting peritoneal drain after laparoscopic cholecystectomy. Axial gradient-echo MR image obtained at same time as A shows no contrast agent in common bile duct (arrow). No free extravasation was identified. In absence of bile duct dilatation, these findings are compatible with fistula to drain, which was illustrated during contrast-enhanced MR cholangiography and confirmed with percutaneous transhepatic cholangiography (not shown).

 


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  		Fig. 5A. —54-year-old woman with abdominal pain and bile exiting peritoneal drain after laparoscopic cholecystectomy. Axial gradient-echo MR cholangiogram obtained 1 hr after IV administration of mangafodipir trisodium shows peritoneal drain (arrow) near gallbladder fossa. Contrast material can be seen in common bile duct (arrowhead). Signal void anterior to contrast material in common bile duct is related to stent.

 


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  		Fig. 5B. —54-year-old woman with abdominal pain and bile exiting peritoneal drain after laparoscopic cholecystectomy. Axial gradient-echo MR image obtained 2 hr after IV administration of mangafodipir trisodium shows contrast material opacification of catheter (arrow). No free extravasation was identified. These findings are compatible with fistula from cystic duct (not shown) to drain, which was confirmed on endoscopic retrograde cholangiography.

 


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  		Fig. 6A. —23-year-old woman with abdominal pain, fever, and bile exiting peritoneal drain after laparoscopic cholecystectomy. Endoscopic retrograde cholangiogram reveals no evidence of leak or fistula.

 


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  		Fig. 6B. —23-year-old woman with abdominal pain, fever, and bile exiting peritoneal drain after laparoscopic cholecystectomy. Axial gradient-echo MR cholangiogram obtained 1 hr 30 min after IV administration of mangafodipir trisodium shows contrast material opacification of peritoneal drain (arrow), which is compatible with fistula to drain. No free extravasation of contrast agent was seen.

 


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  		Fig. 7. —50-year-old man with abdominal pain after laparoscopic cholecystectomy. Axial gradient-echo MR cholangiogram obtained 2 hr after IV administration of mangafodipir trisodium shows large subhepatic fluid collection (straight arrows) that does not accumulate contrast agent. Contrast agent can be seen in common bile duct (curved arrow). Endoscopic retrograde cholangiography (not shown) revealed no leak. Biloma or hematoma was presumptive diagnosis of this fluid collection.

 

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