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Imaging of Biliary Tract Inflammation: An Update

¹ Department of Radiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave., Madison, WI 53792-3252.
² Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI.

View larger version (116K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —35-year-old man with recurrent pyogenic cholangitis. T1-weighted gradient-recalled echo MR image in early arterial phase after gadolinium injection shows high-signal-intensity pigmented stone (arrow) surrounded by low-signal-intensity bile in dilated segment II branch.

View larger version (128K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —35-year-old man with recurrent pyogenic cholangitis. Endoscopic retrograde cholangiogram shows large stone in segment II branch and smaller stones in segment III limb (arrows).

View larger version (140K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —36-year-old man with primary sclerosing cholangitis. T2-preparation 4- to 6-minute respiration-gated MR cholangiopancreatogram shows excellent detail of both intrahepatic and extrahepatic stricture disease.

View larger version (131K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —36-year-old man with primary sclerosing cholangitis. Conventional 5-cm thick-slab MR cholangiopancreatogram corresponding to A.

View larger version (143K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —42-year-old woman with primary sclerosing cholangitis. Images show potential advantage of MR cholangiopancreatography. Endoscopic retrograde cholangiogram shows that even with balloon occlusion injection, only central ducts are depicted.

View larger version (114K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —42-year-old woman with primary sclerosing cholangitis. Images show potential advantage of MR cholangiopancreatography. T2-preparation respiratory-gated MR cholangiopancreatogram shows dilated peripheral branches.

View larger version (107K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —28-year-old man with hepatic parenchymal changes of primary sclerosing cholangitis. Late arterial phase gadolinium-enhanced T1-weighted gradient-echo MR image shows inhomogeneous hyperenhancement of left lateral segment associated with ductal dilatation.

View larger version (113K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —28-year-old man with hepatic parenchymal changes of primary sclerosing cholangitis. Six-minute delayed phase MR image shows increased periportal uptake.

View larger version (112K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5 —37-year-old woman with hepatic parenchymal changes of primary sclerosing cholangitis. T2-weighted MR image shows prominent high signal intensity around portal triad.

View larger version (112K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A —57-year-old man with primary sclerosing cholangitis and cholangiocarcinoma. T1-weighted gradient-echo MR image in late arterial phase shows typical rim enhancement of cholangiocarcinoma (arrow).

View larger version (122K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B —57-year-old man with primary sclerosing cholangitis and cholangiocarcinoma. T1-weighted gradient-echo 7-minute delayed phase MR image shows diffuse tumor uptake of contrast material (arrow).

View larger version (113K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7A —66-year-old woman with primary biliary cirrhosis. T1-weighted gradient-echo 6-minute delayed phase gadolinium-enhanced MR image shows numerous areas of low-signal-intensity rim surrounding high-signal-intensity portal venous triad resulting in periportal halo sign (arrowheads). Large hepatocellular carcinoma (arrows) associated with primary biliary cirrhosis also is evident.

View larger version (106K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7B —66-year-old woman with primary biliary cirrhosis. In this particular case, T2-weighted MR image displays halo effect better than does A.

View larger version (115K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8 —13-year-boy undergoing transplantation evaluation because of biopsy-proven autoimmune hepatitis symptomatic for 6 months. T1-weighted gradient-echo gadolinium-enhanced 6-minute delayed phase MR image shows extensive late-enhancing fibrotic change.

View larger version (131K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9 —27-year-old woman with ulcerative colitis and overlap syndrome of primary sclerosing cholangitis (PSC) and autoimmune hepatitis. Endoscopic retrograde cholangiogram shows intrahepatic ductal disease suggestive of PSC but no extrahepatic disease. Positive anti–smooth-muscle antibody titer led to addition of steroids to treatment regimen.

View larger version (142K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10A —70-year-old man with autoimmune pancreatitis responsive to steroids. ERCP shows both distal common duct (arrow) and main pancreatic duct (arrowheads) are irregularly narrowed.

View larger version (127K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10B —70-year-old man with autoimmune pancreatitis responsive to steroids. ERCP from same examination as A shows right intraductal strictures are worse than those on left.

View larger version (123K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10C —70-year-old man with autoimmune pancreatitis responsive to steroids. ERCP after steroid treatment shows stricture disease of distal common duct (arrow) and main pancreatic duct (arrowhead) has reversed. Intrahepatic ductal disease has not substantially changed.

View larger version (115K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11A —65-year-old man with autoimmune pancreatitis. Endoscopic retrograde cholangiogram shows malignant-appearing stricture (arrow) assumed to be related to pancreatic carcinoma. Main pancreatic duct was not injected.

View larger version (160K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11B —65-year-old man with autoimmune pancreatitis. CT scan obtained at approximately same time as A shows diffusely enlarged body and tail (sausage pancreas), especially for age of patient.

View larger version (170K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11C —65-year-old man with autoimmune pancreatitis. CT scan obtained after steroid treatment shows pancreas has reverted toward normal size. Marbled fat has developed, and enhancement has improved.

View larger version (122K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11D —65-year-old man with autoimmune pancreatitis. ERCP after steroid treatment shows irregular narrowing of main pancreatic duct at head and neck even though patient is asymptomatic.

View larger version (105K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11E —65-year-old man with autoimmune pancreatitis. ERCP obtained at same time as D shows distal common duct stricture has disappeared.

View larger version (122K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12A —30-year-old woman with eosinophilic cholangitis and hypereosinophilia syndrome. Endoscopic retrograde cholangiogram before treatment shows severe central stricture disease.

View larger version (119K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12B —30-year-old woman with eosinophilic cholangitis and hypereosinophilia syndrome. Endoscopic retrograde cholangiogram after steroid treatment shows reversal of strictures.

View larger version (140K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 13A —16-year-old boy with biliary inflammatory pseudotumor and elevated results of liver function tests. T2-preparation respiration-gated MR cholangiopancreatogram shows normal common bile duct (arrow) coursing to hilar stricture (arrowhead) with peripheral duct dilatation.

View larger version (165K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 13B —16-year-old boy with biliary inflammatory pseudotumor and elevated results of liver function tests. T2-weighted axial MR image shows central mass (arrow) of low signal intensity.

View larger version (162K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 13C —16-year-old boy with biliary inflammatory pseudotumor and elevated results of liver function tests. Portal venous phase gadolinium-enhanced MR image shows central mass with no portal venous flow to left lobe. Patient later underwent successful transplantation, and benign fibrotic hilar mass was found at pathologic examination.

View larger version (135K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 14 —78-year-old man with biliary inflammatory pseudotumor. MR cholangiopancreatogram shows focal mass (arrow) of low signal intensity encasing common bile duct. Benign fibrotic mass was found at surgery.

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