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Diagnosing Biliary Complications of Orthotopic Liver Transplantation with Mangafodipir Trisodium–Enhanced MR Cholangiography: Comparison with Conventional MR Cholangiography

¹ Department of Radiology, Mayo Clinic Jacksonville, 4500 San Pablo Rd., Jacksonville, FL 32224.
² Department of Transplantation, Division of Transplant Medicine, Mayo Clinic Jacksonville, Joe Adams 1100 Transplant Center, Jacksonville, FL 32216.

View larger version (110K): [in a new window]   Fig. 1A. —60-year-old man 2 months after orthotopic liver transplantation for hepatitis C–related cirrhosis and hepatocellular carcinoma who presented with serum alkaline phosphatase level of 1,025 U/L and bilirubin of 3.9 mg/dL. MRI diagnosis was minimal narrowing of choledochocholedochal anastomosis with no stricture. Clinical improvement occurred after medication was adjusted. Coronal T2-weighted HASTE image (TR/TE, 2,800/1,100; slice thickness, 40 mm) depicts recipient and donor ducts, as well as pancreatic duct, but suggests a long anastomotic stricture (arrow). Note neighboring fluid collections and edema.

View larger version (115K): [in a new window]   Fig. 1B. —60-year-old man 2 months after orthotopic liver transplantation for hepatitis C–related cirrhosis and hepatocellular carcinoma who presented with serum alkaline phosphatase level of 1,025 U/L and bilirubin of 3.9 mg/dL. MRI diagnosis was minimal narrowing of choledochocholedochal anastomosis with no stricture. Clinical improvement occurred after medication was adjusted. Thin-slice coronal HASTE image (1,000/89; slice thickness, 3 mm) through liver hilum partially shows low-signal-intensity common duct walls (arrows), but adjacent fluid compromises conspicuity. Arrowhead indicates signal void of portal vein.

View larger version (145K): [in a new window]   Fig. 1C. —60-year-old man 2 months after orthotopic liver transplantation for hepatitis C–related cirrhosis and hepatocellular carcinoma who presented with serum alkaline phosphatase level of 1,025 U/L and bilirubin of 3.9 mg/dL. MRI diagnosis was minimal narrowing of choledochocholedochal anastomosis with no stricture. Clinical improvement occurred after medication was adjusted. Axial HASTE image (1,000/89; slice thickness, 4 mm) shows common duct (arrow) in cross section surrounded by edematous hilar tissue.

View larger version (101K): [in a new window]   Fig. 1D. —60-year-old man 2 months after orthotopic liver transplantation for hepatitis C–related cirrhosis and hepatocellular carcinoma who presented with serum alkaline phosphatase level of 1,025 U/L and bilirubin of 3.9 mg/dL. MRI diagnosis was minimal narrowing of choledochocholedochal anastomosis with no stricture. Clinical improvement occurred after medication was adjusted. Maximum-intensity-projection image from coronal mangafodipir-enhanced T1-weighted MR cholangiogram shows minimally narrowed and irregular anastomosis (long arrow) and duodenal excretion of contrast-enhanced bile (short arrows) within 5 min.

View larger version (124K): [in a new window]   Fig. 2A. —70-year-old man 6 weeks after retransplantation and biliary–enteric reconstruction who presented with serum alkaline phosphatase level of 3,560 U/L and bilirubin of 3.2 mg/dL. MRI diagnosis was distal common duct and anastomotic narrowing with no physiologically significant stricture. Subsequent liver biopsy found acute cellular rejection. Coronal HASTE MR cholangiogram shows central intrahepatic biliary radicles and small segment of common hepatic duct (arrow). Neither biliary–enteric anastomosis nor inferior common duct is clearly seen. Note high-signal-intensity postoperative collections, edema, and bowel contents.

View larger version (144K): [in a new window]   Fig. 2B. —70-year-old man 6 weeks after retransplantation and biliary–enteric reconstruction who presented with serum alkaline phosphatase level of 3,560 U/L and bilirubin of 3.2 mg/dL. MRI diagnosis was distal common duct and anastomotic narrowing with no physiologically significant stricture. Subsequent liver biopsy found acute cellular rejection. Single 3-mm-thick coronal MR cholangiogram better delineates structures at liver hilum, including low-signal-intensity duct wall (arrow), but distal common duct and anastomosis are not visualized. Note perihilar edema.

View larger version (121K): [in a new window]   Fig. 2C. —70-year-old man 6 weeks after retransplantation and biliary–enteric reconstruction who presented with serum alkaline phosphatase level of 3,560 U/L and bilirubin of 3.2 mg/dL. MRI diagnosis was distal common duct and anastomotic narrowing with no physiologically significant stricture. Subsequent liver biopsy found acute cellular rejection. Coronal maximum-intensity-projection image from mangafodipir trisodium–enhanced MR cholangiogram shows attenuated distal duct (arrowheads). Excretion into Roux-en-Y limb (solid arrow) is well documented by 5 min. Note high-signal-intensity material that represents evolving postoperative hematoma (open arrows).

View larger version (132K): [in a new window]   Fig. 3A. —54-year-old woman 6 days after orthotopic liver transplantation for cryptogenic cirrhosis who presented with abdominal pain, elevated WBC, serum alkaline phosphatase of 515 U/L, and bilirubin of 7.8 mg/dL. MRI diagnosis was biliary anastomotic leak, confirmed by next-day endoscopic retrograde cholangiography. At surgical conversion to biliary–enteric anastomosis 2 days later, small focus of anastomotic necrosis and peritonitis was noted. Axial thin-slice MR cholangiogram depicts nonspecific perihepatic fluid and hilar edema. Note common duct (arrow) in cross section.

View larger version (102K): [in a new window]   Fig. 3B. —54-year-old woman 6 days after orthotopic liver transplantation for cryptogenic cirrhosis who presented with abdominal pain, elevated WBC, serum alkaline phosphatase of 515 U/L, and bilirubin of 7.8 mg/dL. MRI diagnosis was biliary anastomotic leak, confirmed by next-day endoscopic retrograde cholangiography. At surgical conversion to biliary–enteric anastomosis 2 days later, small focus of anastomotic necrosis and peritonitis was noted. Coronal MR cholangiogram shows fluid-signal bands at anastomosis (arrow) that, in retrospect, probably represent site of leak.

View larger version (133K): [in a new window]   Fig. 3C. —54-year-old woman 6 days after orthotopic liver transplantation for cryptogenic cirrhosis who presented with abdominal pain, elevated WBC, serum alkaline phosphatase of 515 U/L, and bilirubin of 7.8 mg/dL. MRI diagnosis was biliary anastomotic leak, confirmed by next-day endoscopic retrograde cholangiography. At surgical conversion to biliary–enteric anastomosis 2 days later, small focus of anastomotic necrosis and peritonitis was noted. Axial maximum-intensity-projection image from enhanced MR cholangiogram shows copious contrast material flowing from anastomosis (long arrow) and accumulating over liver surface (short arrows).

View larger version (99K): [in a new window]   Fig. 4A. —58-year-old man 2.5 months after orthotopic liver transplantation for cryptogenic cirrhosis who presented with alkaline phosphatase level of 1,150 U/L and bilirubin of 0.4 mg/dL. MRI diagnosis was moderately severe high-grade anastomotic stricture. Diagnosis was confirmed by subsequent endoscopic retrograde cholangiography, during which stricture was dilated and stented. Coronal MR cholangiogram shows nondilated intrahepatic ducts (open arrows), donor's common duct (thin arrow), recipient's common duct (large arrowhead), and pancreatic duct (small arrowhead). Long discontinuity is suggested at anastomosis (thick arrow).

View larger version (94K): [in a new window]   Fig. 4B. —58-year-old man 2.5 months after orthotopic liver transplantation for cryptogenic cirrhosis who presented with alkaline phosphatase level of 1,150 U/L and bilirubin of 0.4 mg/dL. MRI diagnosis was moderately severe high-grade anastomotic stricture. Diagnosis was confirmed by subsequent endoscopic retrograde cholangiography, during which stricture was dilated and stented. Coronal subvolume maximum-intensity-projection image from mangafodipir trisodium–enhanced MR cholangiogram more clearly shows anastomotic stricture (thick arrow), its significance confirmed by 45-min delay in contrast excretion into recipient's duct. Arrowhead indicates recipient's cystic duct remnant; thin arrow indicates duodenal contrast material.

View larger version (83K): [in a new window]   Fig. 5A. —71-year-old man 8 months after orthotopic liver transplantation for hepatitis C–related cirrhosis who presented with alkaline phosphatase level of 1,899 U/L and bilirubin of 0.6 mg/dL. MRI diagnosis was high-grade anastomotic strictures. Diagnosis was confirmed, and stricture was dilated and stented next day on endoscopic retrograde cholangiography (ERC). Stricture eventually necessitated conversion to biliary–enteric reconstruction. Coronal HASTE MR cholangiogram shows mild intrahepatic ductal dilatation (short arrows) and marked dilatation of donor's common duct. Tight anastomotic stricture (long arrow) is suggested. Note remnant (arrowhead) of donor's cystic duct.

View larger version (130K): [in a new window]   Fig. 5B. —71-year-old man 8 months after orthotopic liver transplantation for hepatitis C–related cirrhosis who presented with alkaline phosphatase level of 1,899 U/L and bilirubin of 0.6 mg/dL. MRI diagnosis was high-grade anastomotic strictures. Diagnosis was confirmed, and stricture was dilated and stented next day on endoscopic retrograde cholangiography (ERC). Stricture eventually necessitated conversion to biliary–enteric reconstruction. Coronal subvolume maximum-intensity-projection image from mangafodipir trisodium–enhanced MR cholangiogram shows similar findings. Contrast material was finally documented in recipient's common duct 1 hr after injection. Note poor depiction of more peripheral intrahepatic ducts.

View larger version (145K): [in a new window]   Fig. 5C. —71-year-old man 8 months after orthotopic liver transplantation for hepatitis C–related cirrhosis who presented with alkaline phosphatase level of 1,899 U/L and bilirubin of 0.6 mg/dL. MRI diagnosis was high-grade anastomotic strictures. Diagnosis was confirmed, and stricture was dilated and stented next day on endoscopic retrograde cholangiography (ERC). Stricture eventually necessitated conversion to biliary–enteric reconstruction. ERC image obtained next day confirms MRI findings.

View larger version (98K): [in a new window]   Fig. 6A. —48-year-old man 2 months after orthotopic liver transplantation with biliary–enteric reconstruction as result of hepatitis B–related cirrhosis and recurrent hepatocellular carcinoma who presented with serum alkaline phosphatase level of 1,057 U/L and bilirubin of 4.9 mg/dL. At explantation, bile ducts were necrotic. Coronal HASTE MR cholangiogram depicts intra- and extrahepatic biliary tree containing casts of necrotic debris (arrowhead).

View larger version (139K): [in a new window]   Fig. 6B. —48-year-old man 2 months after orthotopic liver transplantation with biliary–enteric reconstruction as result of hepatitis B–related cirrhosis and recurrent hepatocellular carcinoma who presented with serum alkaline phosphatase level of 1,057 U/L and bilirubin of 4.9 mg/dL. At explantation, bile ducts were necrotic. Coronal subvolume maximum-intensity-projection image from mangafodipir trisodium–enhanced MR cholangiogram clearly depicts debris as low-signal-intensity filling defects (arrow) in contrast-filled central ducts.

View larger version (109K): [in a new window]   Fig. 6C. —48-year-old man 2 months after orthotopic liver transplantation with biliary–enteric reconstruction as result of hepatitis B–related cirrhosis and recurrent hepatocellular carcinoma who presented with serum alkaline phosphatase level of 1,057 U/L and bilirubin of 4.9 mg/dL. At explantation, bile ducts were necrotic. Axial source image from contrast-enhanced MR cholangiogram shows debris in cross-sectioned ducts (arrows) and patchy enhancement of transplanted liver.

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