DOI:10.2214/AJR.07.3033
AJR 2008; 190:984-992
© American Roentgen Ray Society
Imaging of Biliary Tract Inflammation: An Update
Joshua Q. Knowlton1,
Andrew J. Taylor1,
Mark Reichelderfer2 and
Jason Stang2
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.
Received August 16, 2007;
accepted after revision November 1, 2007.
Address correspondence to A. J. Taylor
(ataylor{at}uwhealth.org).
Abstract
OBJECTIVE. The concepts of biliary tract inflammation are changing.
Some previously common entities are now rare. New autoimmune conditions are
being recognized, and imaging has continued to advance, resulting in better
and in many areas less-invasive techniques for examination of the biliary
tract.
CONCLUSION. Radiologists should be aware of the etiologic factors of
biliary tract inflammation being proposed. They should also understand new
approaches to imaging of the biliary tract.
Keywords: autoimmune • biliary tract • inflammation • MRI
Many important changes in the imaging of biliary tract inflammation have
occurred since the mid 1990s. Because of both better treatment and better
diagnostic methods, some entities common in the past have become rare.
Advances in imaging have increased the number of noninvasive methods of
diagnosis. New concepts about the cause of inflammatory processes in the
biliary tract have come to light and led to new diagnoses that radiologists
need to understand. We detail these facets of biliary tract inflammation.
Disappearing Diagnosis
AIDS cholangiopathy has become an uncommon clinical entity
[1]. The decrease in incidence
reflects the efficacy and availability of antiretroviral agents in the United
States. Also decreasing to the point of rarity is secondary sclerosing
cholangitis from chronic biliary tract stone disease. Diffuse intrahepatic or
extrahepatic stricture disease is more likely to be caused by secondary
factors such as postsurgical complications, intraarterial chemotherapy,
radiation exposure, and autoimmune processes.
Advances in Imaging
Since the mid 1990s, great advances have been made in imaging of the
biliary tract. This progress reflects improvements in techniques that were
already available, such as transabdominal and endoscopic sonography, CT, and
especially MRI. The wider availability of 1.5-T scanners and faster gradients
has increased spatial resolution and speed of imaging. MRI is now the best
noninvasive technique for imaging of biliary tract inflammation because of the
ability to define intraductal stone disease, display both intrahepatic and
extrahepatic biliary stricture disease, and help in screening for the
malignant conditions that accompany some inflammatory processes.
An early study [2] of MRI in
the evaluation of the biliary tract for stone disease showed a sensitivity of
90% and a specificity of 96% for stone detection. Although results of another
early study [3] suggested
difficulty in diagnosis of stones smaller than 3 mm in diameter, a more recent
study [4] showed MR
cholangiopancreatography (MRCP) (sensitivity, 90.5%; specificity, 87.5%) was
equal to endoscopic sonography (sensitivity, 93.8%; specificity, 96.6%) in the
depiction of choledocholithiasis, even with stones smaller than 5 mm.
Stone disease can take the form of pigmented mud stones in recurrent
pyogenic cholangitis. ERCP is crucial in treatment, and the findings at ERCP
establish the diagnosis. CT also shows some stones and the associated
complications of hepatitis and bile duct dilatation. MRCP, however, has been
shown more sensitive than CT in displaying the extent of intrahepatic stone
load [5]. Thus MRCP can be
helpful in both making the diagnosis and providing a road map for anticipated
invasive intervention. Unlike the T2-weighted sequences used for other bile
duct imaging, T1-weighted images are most helpful in depiction of intrahepatic
stones [5]. The relatively high
signal intensity of the pigmented stones as visualized by T1-weghted sequences
in recurrent pyogenic cholangitis allows use of thinner sections (Figs.
1A and
1B).
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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.
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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.
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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.
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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.
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Patients with primary sclerosing cholangitis (PSC) have benefited from
advances in MRI. Imaging findings provide critical information for both
establishing the diagnosis and monitoring the progression of PSC. MRCP is
steadily replacing endoscopic retrograde cholangiography (ERC) for these
purposes
[6–9].
The present use of MRI for evaluation of PSC has three components. First, MRCP
displays the intrahepatic and extrahepatic portions of the biliary tree.
Second, the morphologic features of the hepatic parenchyma can help support
the diagnosis of PSC. Third, MRI can be used to help diagnose
cholangiocarcinoma, which is associated with PSC. Studies
[6,
7,
9] have been conducted to
compare ERC with MR cholangiography (MRC) in the imaging diagnosis of PSC. The
results have shown that MRC and ERC are comparable in detection of PSC. The
sensitivity of MRC ranges from 80% to 88% and the specificity from 87% to
99%.
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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.
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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).
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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).
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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.
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Display of the biliary tract in PSC greatly helps solidify the diagnosis
and serves as a road map if endoscopic interventional procedures are
anticipated. A typical approach to MRI is to perform a thick-section
(3–8 cm) T2-weighted sequence in the coronal or coronal oblique plane.
This technique reproduces an appearance similar to that on ERC. However, 2D
thin-section (4–6 mm) T2-weighted images in the coronal or axial plane
also are necessary because small ductal filling defects and other subtle
anatomic changes of PSC can be missed if only thick sections are used.
An MRI sequence has been proposed
[10] in which parallel imaging
is used to obtain 3D T2-weighted turbo spin-echo images with near-isotropic
voxels of approximately 1 mm. This technique, however, requires either a
relatively long breath-hold of 28–30 seconds, which results in lower
contrast resolution, or respiratory gating, which causes additional blurring
due to respiratory motion. At our institution, an MRCP technique has become
available that better suppresses the background and leads to greater
conspicuity of the fluid-containing structures of the biliary tract. A
T2-preparation pulse sequence, which suppresses the background, is combined
with 3D driven-equilibrium RARE sequence with respiratory gating
[11] (Figs.
2A and
2B).
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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.
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MRCP display of the ductal changes of PSC has both inherent advantages and
disadvantages compared with ERC. The filling pressure during ERC maximally
distends any communicating ductal system, the contrast agent making subtle
stricture disease, particularly at the periphery, easier to visualize. For
ductal display alone, use of MRC is likely to lead to underdiagnosis of
minimal-change PSC. At the same time, if more central strictures obstruct the
flow of contrast material, MRC provides upstream ductal detail (Figs.
3A and
3B).
The ability of MRI to display the hepatic parenchyma and perihepatic lymph
nodes can be helpful in the diagnosis of PSC. In the later stages of PSC, the
liver tends to have a markedly prominent caudate lobulation, the unusual
finding of left lobe atrophy, with the more usual posterior segment atrophy,
prominent central regenerative nodules, and enlarged perihepatic lymph nodes
[12–14].
Late arterial imaging with IV gadolinium enhancement can show peripheral areas
of hyperenhancement. This pattern is thought to be secondary to a transient
hepatic attenuation difference effect whereby increased arterial flow
compensates for decreased portal venous flow in areas where bile duct
obstruction occurs [8,
12,
14]
(Fig. 4A). The periportal area
also is abnormal on MRI. A rind of high signal intensity on T2-weighted images
can be found surrounding segments of the portal tracts
(Fig. 5). This finding is
thought to reflect a combination of compressed fibrosis, lymphatics, and
inflammatory infiltrate [15].
Later contrast-enhanced images also can show increased uptake in this area
(Fig. 4B).
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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.
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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.
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MRI is useful in examining for cholangiocarcinoma, which is associated with
PSC in 10–15% of cases
[8]. ERC is very poor for
cholangiocarcinoma detection. MRI with gadolinium enhancement in the arterial
phase is useful for detection of this tumor, because the images show
peripheral enhancement; delayed phase scans show diffuse tumor uptake (Figs.
6A and
6B).
New Concepts
Most of the new concepts in biliary tract inflammation come in the area of
autoimmune disease. Primary biliary cirrhosis (PBC) is a well-known entity,
but others have been added, including autoimmune hepatitis, autoimmune
pancreatitis, overlap syndromes, eosinophilic cholangitis, and biliary
inflammatory pseudotumor.
Primary Biliary Cirrhosis
PBC is caused by inflammation of the small to medium bile ducts, both acute
and chronic inflammatory components leading to cholestatic clinical features.
PBC typically affects women (more than 90% of cases) 30 to 65 years old.
Abnormal serologic results of elevated levels of antimitochondrial antibodies
and the less-specific antinuclear antibodies are typical. There is frequently
an association with other autoimmune processes, such as Sjögren's
syndrome, CREST syndrome, Raynaud's phenomenon, and inflammatory bowel
disease.
In most cases of PBC, imaging is not needed. Any biliary tract
abnormalities reflect only the secondary changes of developing cirrhosis. When
the clinical features are unclear, however, imaging can provide valuable
information. In particular, MRI can show a fairly specific appearance of the
periportal halo sign, seen in 43% of PBC patients in one study
[16]. This unusual appearance
is best seen on gadolinium-enhanced T1-weighted gradient-echo portal venous or
equilibrium phase images. It can be appreciated to a lesser extent on
T2-weighted images. A high-signal-intensity center surrounded by a rim of low
signal intensity is seen in this 5- to 10-mm lesion
[16] (Figs.
7A and
7B). Histologically this
configuration is thought to represent the portal triad surrounded by an area
of hepatic parenchymal loss rimmed by regenerative nodules
[16]. Management of PBC with
the use of ursodeoxycholic acid is aimed at the cholestatic characteristics of
the disease. Hepatocellular carcinoma develops in approximately 5% of patients
with PBC (Figs. 7A and
7B).
Autoimmune Hepatitis and Overlap Syndromes
The clinical course of PBC can be complicated by simultaneous involvement
with autoimmune hepatitis, resulting in an overlap syndrome. The combination
of PSC and autoimmune hepatitis is another overlap syndrome. Autoimmune
hepatitis produces a more inflammatory component than do PBC and PSC, which
are more cholestatic in nature. Autoimmune hepatitis causes chronic
inflammatory infiltration beginning in the peri portal region and frequently
broaching the periportal plate to affect the adjacent hepatic parenchyma.
When it appears alone, autoimmune hepatitis affects women more than men in
a ratio of 3–4 to 1 and occurs in a younger population, 15–40
years old [17,
18]. If the patient is not
treated, autoimmune hepatitis can lead to death within 6 months
[19]. The condition of
patients who survive frequently continues to cirrhosis; 5.9% of liver
transplantations in the United States are necessitated by this disease
[20]. A diagnosis is made both
after other causes of hepatitis are ruled out and abnormal serologic results
are obtained for anti–smooth muscle antibodies, antinuclear antibodies,
or antibody to liver/kidney microsome 1
[17]. Liver biopsy is needed
to help secure the diagnosis and to assess the degree of inflammation. If
imaging is performed, MRI is the method of choice to show areas of increased
parenchymal enhancement in an untreated patient or various degrees of hepatic
fibrosis, global volume loss, and lymphadenopathy later
[18]
(Fig. 8). As many as 18% of
patients with biliary autoimmune disorders present with two simultaneous
disorders [21]
(Fig. 9). The greater
inflammatory component of autoimmune hepatitis translates into the need for
immunosuppressive therapy for the overlap syndrome
[21].
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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.
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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.
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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.
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Autoimmune Pancreatitis
Imaging findings can be critical, although nonspecific, information in the
diagnosis of autoimmune pancreatitis. Autoimmune pancreatitis is a chronic
fibroinflammatory process affecting the pancreatic ductal system through
lymphoplasmacytic infiltration of the parenchyma. This process can similarly
affect the intrahepatic biliary tree. Plasma cell infiltrates can also involve
the gallbladder, lung, breast, and kidney
[22,
23].
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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.
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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.
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Autoimmune pancreatitis typically affects 50- to 60-year-old patients in a
2 to 1 ratio of men to women. The presenting signs and symptoms are related to
jaundice, weight loss, and mild abdominal pain. Associated illnesses include
inflammatory bowel disease, Sjögren's syndrome, and rheumatoid arthritis.
Serologic results are positive, levels of antinuclear antibodies,
antimitochondrial antibodies, and anti–smooth muscle antibodies all
possibly being elevated. The unique serologic finding in autoimmune
pancreatitis is elevation of the IgG4 level
[22].
On endoscopic retrograde pancreatography or MR pancreatography, the
pancreatic duct is diffusely or focally irregularly narrowed
(Fig. 10A). The intrahepatic
duct can simulate a PSC type of stricture
(Fig. 10B), and
malignant-appearing ductal narrowing of the intrapancreatic portion of the
extrahepatic biliary tree may be present
(Fig. 11A). On CT or MRI the
pancreas can be diffusely enlarged with loss of normal fatty marbling,
so-called sausage pancreas (Fig.
11B). The pancreas also can be focally enlarged, however,
simulating pancreatic carcinoma and necessitating 21–34% of Whipple
procedures for benign disorders
[22,
24,
25]. A capsule can be present
around the pancreas and have low attenuation on CT scans and low signal
intensity on T2-weighted MR images but occasionally becoming enhanced with IV
contrast material
[26–28].
Peripancreatic fat infiltration is minimal, if present at all; pseudocyst
formation [29] and pancreatic
calcification [30] are rarely
reported. Enlarged peripancreatic lymph nodes also can be seen
[28].
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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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It is important to make the correct diagnosis to institute appropriate
medical treatment and avoid unnecessary surgery for presumed pancreatic
carcinoma. Administration of steroids tends to reverse many imaging
abnormalities: The pancreas can decrease in size and become better enhanced
(Fig. 11C); the pancreatic
duct changes can reverse (Fig.
10C), although complete reversal may not occur
(Fig. 11D); the intrahepatic
biliary tree changes can reverse but to a lesser degree than pancreatic duct
changes (Fig. 10C); and the
intrapancreatic common bile duct change can subside with pancreatic
parenchymal changes (Fig. 11E)
[28,
31]. However, biliary
strictures can progress even with steroid treatment
[28].
Miscellaneous Conditions
Two rare entities related to biliary tract inflammation are eosinophilic
cholangitis and biliary inflammatory pseudotumor. Intrahepatic duct strictures
can be seen in association with the hypereosinophilia syndrome. Eosinophils
also can infiltrate the heart, skin, CNS, bowel, gallbladder, and liver
[32]. Intrahepatic biliary
tree strictures can simulate PSC and other autoimmune entities (Figs.
12A and
12B). With treatment with
steroids or other immunosuppressive agents, the biliary tract and other
clinical abnormalities can reverse.
Biliary inflammatory pseudotumor is a chronic inflammatory process of the
hilar area that is radiographically indistinguishable from hilar
cholangiocarcinoma. The causes of this hilar obstruction are varied and
include lymphoplasmacytic infiltration, PSC, a granulomatous process, stone
disease, and even recurrent pyogenic cholangitis
[33,
34]. Biliary inflammatory
pseudotumor cannot be differentiated from Klatskin's tumor preoperatively or
consistently intraoperatively
[33]. Its appearance has
earned it the name "malignant masquerade"
[35]. Although an unusual
entity, biliary inflammatory pseudotumor has been reported to be the cause of
hilar obstruction in 5–10% of patients in some surgical series
[33].
With the diversity of etiologic factors, it is not surprising that the
imaging appearance of biliary inflammatory pseudotumor is varied. Central
stricture is present at ERC and MRC. The obstructive mass can be focal or
diffuse [33,
34] (Figs.
13A,
13B,
13C, and
14). Portal venous compromise
can be present. Attempts at preoperative cell retrieval to prove benignity are
never successful; thus, all patients need treatment based on the assumption
that the lesion is malignant
[33].
Conclusion
The clinical area of biliary inflammation has changed. It is important to
understand the changing concepts of the various pathophysiologic mechanisms
and the use of imaging for these various diagnoses.
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