DOI:10.2214/AJR.08.1104
AJR 2009; 192:W28-W35
© American Roentgen Ray Society
Recurrent Pyogenic Cholangitis: From Imaging to Intervention
Eric J. Heffernan1,
Tony Geoghegan1,
Peter L. Munk1,
Stephen G. Ho1 and
Alison C. Harris1
1 Department of Radiology, Vancouver General Hospital, 899 W 12th Ave.,
Vancouver, BC V5Z 1M9, Canada.
Received April 22, 2008;
accepted after revision July 12, 2008.
Address correspondence to E. J. Heffernan
(ejheffernan{at}eircom.net).
WEB This is a Web exclusive article.
Abstract
OBJECTIVE. The objective of this article is to familiarize the
reader with the sonographic, CT, MR cholangiopancreatography, and ERCP
appearances of recurrent pyogenic cholangitis and to briefly review the role
of interventional radiology in the management of this disease.
CONCLUSION. Recurrent pyogenic cholangitis is a complex disease, the
incidence of which is increasing in Western countries. Radiologists should be
aware of the role of imaging in the diagnosis of this disease and the use of
imaging as a guideline for subsequent intervention.
Introduction
Also known as oriental cholangiohepatitis, recurrent pyogenic
cholangitis is a complex disease that is characterized by intrahepatic
pigmented stones and recurrent attacks of cholangitis
[1]. Although its exact cause
is not known, there are strong associations between recurrent pyogenic
cholangitis and parasites such as Ascaris lumbricoides and
Clonorchis sinensis; other reported associations include
Escherichia coli cholangitis, nutritional deficiency, and low
socioeconomic status
[1-3].
It has been postulated that chronic infestation of the biliary tree by
parasitic organisms induces inflammatory and fibrotic changes in the bile duct
walls, leading to stricture formation, bile stasis, and intrahepatic stones
[1]. Men and women are affected
with equal incidence, most frequently in the third and fourth decades of life
[1,
3].
The intrahepatic calculi lead to progressive biliary obstruction and
recurrent infection, which in turn can result in multiple cholangitic hepatic
abscesses; further biliary strictures; and, in severe cases, progressive
hepatic parenchymal destruction, cirrhosis, and portal hypertension
[4].
Previously a condition prevalent only in Asian countries, recent decades
have seen a steady decline in the incidence of recurrent pyogenic cholangitis
in Asia, attributed to improved standards of living and Westernization of the
diet, whereas, at the same time, there has been a significant increase in the
prevalence of recurrent pyogenic cholangitis in North America because of
migration from endemic regions
[5]. As a result, radiologists
should be aware of its varied imaging features so that they can consider the
diagnosis in the correct clinical setting, especially when dealing with an
ethnically diverse patient population.
Recurrent pyogenic cholangitis should be considered whenever a patient with
the appropriate demographic background presents with pain, fever, and
jaundice. Common laboratory findings include leukocytosis and mildly elevated
bilirubin. Often, patients will report having had previous bouts of similar
abdominal pain or fever or both that either went undiagnosed or were not
severe enough to cause the patient to present to the hospital
[6]. None of the imaging
features of recurrent pyogenic cholangitis is pathognomonic of the condition;
however, when they are seen in combination with the typical clinical features
and recognized by the radiologist, the correct diagnosis is usually readily
made. The management of recurrent pyogenic cholangitis involves a
multidisciplinary approach, of which interventional radiology is a key
component.
Imaging of Recurrent Pyogenic Cholangitis
In addition to its role in diagnosing recurrent pyogenic cholangitis, multi
technique diagnostic imaging allows accurate anatomic evaluation of the
location, extent, and severity of the disease, important information that is
required for the planning of appropriate medical or surgical treatment.
Sonography
Often the first-line investigation in the workup for patients with
recurrent pyogenic cholangitis, sonography typically shows dilatation of the
biliary tree. Characteristically, there is disproportionate dilatation of the
extrahepatic and central intrahepatic ducts, with little if any dilatation of
the more peripheral biliary ducts
[1]
(Fig. 1). The distribution of
the duct dilatation tends to be diffuse and unrelated to the location of
calculi. This is likely due to widespread loss of elasticity of the duct
walls. Prominent periportal echogenicity is a frequent finding
[7].
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Fig. 1 —48-year-old man with recurrent pyogenic cholangitis who presented
with acute right upper quadrant pain. Sonogram shows disproportionately severe
dilatation of common hepatic duct (between calipers) and common bile
duct (arrow), with no dilated intrahepatic ducts identified.
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Although intrahepatic calculi may be identified in up to 90% of patients
(Figs. 2A, and
2B), they can be obscured by
pneumobilia, which is also a common finding in recurrent pyogenic cholangitis
[2,
3]. The calculi can be single
or multiple, intra- or extrahepatic or both, and may or may not be calcified,
resulting in variable echogenicity and acoustic shadowing.
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Fig. 2A —36-year-old man with recurrent pyogenic cholangitis who presented
with pain and fever. Sonograms show central (A) and peripheral
(B) intrahepatic calculi in left hepatic duct and lateral segment of
left lobe (arrows).
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Fig. 2B —36-year-old man with recurrent pyogenic cholangitis who presented
with pain and fever. Sonograms show central (A) and peripheral
(B) intrahepatic calculi in left hepatic duct and lateral segment of
left lobe (arrows).
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Sonography also plays a role in the diagnosis of complications of recurrent
pyogenic cholangitis and is routinely used in the follow-up of patients with
the condition. The development of focal liver lesions raises the possibility
of biloma or abscess formation when hypoechoic or anechoic. The sonographic
features of malignancy are variable; cholangiocarcinoma may be hypo-, iso-,
or, less commonly, hyperechoic relative to the liver
[8].
Percutaneous aspiration or drainage can be performed under sonographic
guidance and can allow differentiation between biloma and abscess when
uncertainty exists [9].
Percutaneous fine-needle aspiration or core biopsy of suspected neoplasms can
also be performed under sonographic guidance.
CT
Similar to sonography, CT usually shows dilatation of the first- and
second-order ducts, with nondilated or nonvisualized peripheral ducts
[9]. Hepatolithiasis is easier
to detect on unenhanced CT because 90% of the stones are hyperdense to normal
unenhanced liver parenchyma [1,
3]. Although calculi may be
obscured, contrast-enhanced CT allows better visualization of subtle
intrahepatic duct dilatation
[9] (Figs.
2A, and
2B). The number of calculi is
often underestimated by both sonography and CT.
Pneumobilia is a frequent finding and does not necessarily indicate
previous intervention, although in the majority of patients there will be a
history of endoscopic intervention or surgery
[2,
9]. In patients who have not
undergone previous intervention, pneumobilia is usually secondary to passage
of calculi through the ampulla, with reflux of enteric gas into the biliary
tree, although it can occasionally develop due to cholangitis caused by
gas-forming organisms, such as Klebsiella pneumoniae or
Clostridium perfringens.
Hepatic parenchymal atrophy is a common feature of recurrent pyogenic
cholangitis. It occurs most frequently in the left lateral segments, with the
right posterior segments next most commonly involved
[10] (Figs.
3A,
3B, and
4). This may be due to anatomic
differences: drainage of bile from the other hepatic segments is favored in
both the supine and erect positions
[9].
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Fig. 3A —41-year-old woman with recurrent episodes of sepsis due to recurrent
pyogenic cholangitis. On unenhanced CT image (A), large calcified
calculi are easily identified (arrows, A), whereas
contrast-enhanced portal venous phase (B) image better delineates
dilated bile ducts (arrows, B). Note marked atrophy of left
lateral segments of liver.
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Fig. 3B —41-year-old woman with recurrent episodes of sepsis due to recurrent
pyogenic cholangitis. On unenhanced CT image (A), large calcified
calculi are easily identified (arrows, A), whereas
contrast-enhanced portal venous phase (B) image better delineates
dilated bile ducts (arrows, B). Note marked atrophy of left
lateral segments of liver.
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Fig. 4 —46-year-old man with recurrent admissions for abdominal pain due to
recurrent pyogenic cholangitis. Contrast-enhanced CT image shows marked
atrophy of segments VI and VII, with posterior retraction of right hepatic
vein (black arrowhead) and displacement of the gallbladder (white
arrowhead) into unusual position, mimicking congenital absence of right
lobe. Note multiple small calculi in atrophied segment (arrows).
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Alterations in parenchymal attenuation are often seen. Fatty infiltration
may involve either atrophic or nonatrophic segments
(Fig. 5). Heterogeneous
enhancement may also be encountered and is more frequently seen during acute
exacerbations [9]. Enhancement
of bile duct walls may also be identified on contrast-enhanced CT and is
generally indicative of acute cholangitis
[9]
(Fig. 6).
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Fig. 5 —60-year-old woman with recurrent pyogenic cholangitis who was
admitted with abdominal pain and fever. Contrast-enhanced CT image shows that
right lobe and medial left lobe are hypodense relative to spleen due to fatty
infiltration. Left lateral segments are spared from fatty infiltration but are
markedly atrophied and contain mixture of noncalcified (white
arrowhead) and calcified (black arrowhead) calculi.
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Fig. 6 —43-year-old man who presented with acute sepsis due to recurrent
pyogenic cholangitis. Contrast-enhanced CT image shows enhancement of common
hepatic duct wall (black arrowhead), consistent with cholangitis.
Adjacent to this is partially thrombosed right portal vein (white
arrowhead). Note peripheral duct dilatation in segment III (black
arrow) and focal fat in segment IVb (white arrow).
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ERCP
Previously the reference standard for depicting the abnormalities of
recurrent pyogenic cholangitis
[4], direct cholangiography
characteristically shows disproportionate extrahepatic duct dilatation,
calculi, multiple intrahepatic strictures, and abrupt tapering of peripheral
ducts with decreased arborization of the biliary tree
[1]
(Fig. 7). Segmental or lobar
intrahepatic duct dilatation may be present rather than diffuse dilatation and
is generally due to a tight stricture or impacted stone
[10]. Extrahepatic strictures
are uncommon but are also well seen using ERCP
[10]. Although invasive, ERCP
retains some advantages over MR cholangiopancreatography (MRCP) in that it has
better spatial resolution (permitting better evaluation of peripheral ducts)
and allows therapeutic intervention at the same sitting
[10]. It should be noted that
septic shock can easily be precipitated in patients with recurrent pyogenic
cholangitis undergoing ERCP or percutaneous trans hepatic cholangiography
(PTC), even when IV antibiotics have been administered, and care should be
taken not to overdistend the biliary tree when introducing contrast medium
during these procedures.
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Fig. 7 —61-year-old man with recurrent pyogenic cholangitis who presented
with jaundice. Note predominant central and extrahepatic duct dilatation with
abrupt tapering of more peripheral ducts. ERCP image shows abrupt cutoff in
one of right ducts ("absent duct sign") (arrow)
indicating complete obstruction by stone or tight stricture.
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MRCP
Current MRCP protocols use rapid techniques that achieve image acquisition
in a single breath-hold [10].
The general advantages of MRCP over ERCP have been well-documented; advantages
specific to recurrent pyogenic cholangitis imaging include its ability to show
ducts proximal to an obstruction or tight stenosis and the ability to depict
extraductal disease without the risk of aggravating biliary sepsis. Recently,
techniques for improving the spatial resolution of MRCP have been developed,
including respiratory-triggered 3D fast spin-echo sequences. The data
acquisition times of these previously time-consuming sequences have been
reduced by using parallel imaging techniques, such as the array spatial
sensitivity technique (ASSET, GE Healthcare)
[11].
Although noncalcified calculi may be difficult to see on CT, on MRCP they
are usually clearly visualized as filling defects
[2] (Figs.
8A,
8B,
9A, and
9B). Distinguishing calculi
from pneumobilia can be difficult; however, calculi are usually located in the
dependent aspects of the bile ducts, whereas gas bubbles tend to rise to a
nondependent location.
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Fig. 8A —41-year-old woman with repeated episodes of cholangitis due to
recurrent pyogenic cholangitis who was under consideration for operative
management. Axial thin-slice MR cholangiopancreatography image shows multiple
low-signal filling defects (arrows) within dilated, crowded ducts in
atrophied left lateral segment.
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Fig. 8B —41-year-old woman with repeated episodes of cholangitis due to
recurrent pyogenic cholangitis who was under consideration for operative
management. Thick-slab reconstruction image confirms that dilatation is
confined to left lobe and clearly shows hepatolithiasis (arrow).
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Fig. 9A —52-year-old woman with recurrent pyogenic cholangitis. Thin-slice
axial T2-weighted image from MR cholangiopancreatography performed to evaluate
nonvisualized ducts after ERCP shows large calculus impacted in left lobe
(arrow).
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Fig. 9B —52-year-old woman with recurrent pyogenic cholangitis. Thick-slab
reconstruction image shows dilatation of extrahepatic biliary tree and central
intrahepatic ducts, with abrupt tapering to normal-caliber ducts in right
lobe. Again note obstructing calculus in left lobe (arrow): MR
cholangiopancreatography allows visualization of dilated ducts peripheral to
this obstructing calculus, major advantage over ERCP.
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As on other imaging techniques, central and extrahepatic duct dilatation is
typically seen. There is frequently decreased arborization and abrupt tapering
of peripheral ducts [2]. Duct
strictures in recurrent pyogenic cholangitis are usually short (less than 1
cm) and not readily identified on CT; however, they are easily seen on MRCP
[9]. MRCP has been reported to
show 100% of surgically proven dilated duct segments, 96% of focal strictures,
and 98% of calculi [4].
Atrophic hepatic segments may be hypo-, iso-, or hyperintense to normal liver
on T1-weighted images and iso- or hyperintense on T2-weighted images and are
usually seen in association with crowded, dilated ducts
[2].
Imaging of Complications of Recurrent Pyogenic Cholangitis
Hepatic Abscess
Abscess formation is encountered in up to 20% of recurrent pyogenic
cholangitis patients who undergo cross-sectional imaging
[2] (Figs.
10A, and
10B). The abscesses may be
multiple, are commonly multiseptate, and occur most frequently in the right
lobe [9]. The presence of rim
enhancement on CT is suggestive of abscess rather than biloma. When the
diagnosis is unclear, sonographically guided aspiration is a useful
adjunct.
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Fig. 10A —45-year-old man with history of recurrent pyogenic cholangitis who
presented with acute sepsis. Contrast-enhanced CT image shows multiple rounded
low-density lesions (arrowheads) in right lobe of liver, some of
which show rim enhancement. Fine-needle aspiration of one of lesions was
performed, in part to exclude metastatic cholangiocarcinoma, and yielded small
amount of pus. Stent is present in common duct (arrow).
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Fig. 10B —45-year-old man with history of recurrent pyogenic cholangitis who
presented with acute sepsis. Percutaneous biliary drainage (black
arrow) via right anterior duct was performed, but posterior right
segments were not drained. Additional needle puncture (black
arrowhead) was performed and contrast material introduced, which outlined
extremely irregular ducts with multifocal strictures and pooling of contrast
material in some of abscesses (white arrows). Note Cotton-Leung
common duct stent (Cook Medical) (white arrowhead).
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Biloma
Intrahepatic bile lakes are frequently seen and may or may not communicate
with the biliary tree on direct cholangiography
[4] (Figs.
11A,
11B, and
11C). Bilomas typically appear
anechoic on sonography and uniformly hypodense on CT. They may contain
calculi. Extrahepatic biloma is an occasional complication and is caused by
leakage of intrahepatic bile from a severely dilated obstructed duct
[2].
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Fig. 11A —68-year-old man with recurrent pyogenic cholangitis who presented
with right upper quadrant pain. Coronal (A) and sagittal (B)
reconstruction images from contrast-enhanced CT show large fluid-density
collection (arrows) in right lobe of liver, containing multiple
calculi and clearly separate from gallbladder (GB). Mild ascites is also
present.
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Fig. 11B —68-year-old man with recurrent pyogenic cholangitis who presented
with right upper quadrant pain. Coronal (A) and sagittal (B)
reconstruction images from contrast-enhanced CT show large fluid-density
collection (arrows) in right lobe of liver, containing multiple
calculi and clearly separate from gallbladder (GB). Mild ascites is also
present.
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Fig. 11C —68-year-old man with recurrent pyogenic cholangitis who presented
with right upper quadrant pain. Subsequent ERCP image shows no communication
between this biloma and biliary tree. Note massively dilated common duct and
decreased arborization of intrahepatic ducts.
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Portal Vein Thrombosis
Although thrombosis of the portal vein may rarely occur as a complication
of cirrhosis in recurrent pyogenic cholangitis, it can also be the result of
intimal fibrosis secondary to inflammatory changes in the adjacent periportal
spaces [1]
(Fig. 6).
Malignancy
Recurrent pyogenic cholangitis is a well-known risk factor for
cholangiocarcinoma, which complicates cases in up to 5% of patients
[1]. It may be secondary to
chronic bacterial infection, stasis of bile, or mechanical irritation by
calculi [12]. In the setting
of recurrent pyogenic cholangitis, cholangiocarcinoma occurs more commonly in
atrophied segments or segments with a heavy stone burden
[5] and has a relatively poor
prognosis, at least in part because early diagnosis is made difficult by the
additional recurrent pyogenic cholangitis changes on imaging
[12]. The typical appearance
of hilar or extrahepatic cholangiocarcinoma is of focal narrowing or
obliteration of the involved duct, with an enhancing area of focal thickening,
whereas the usual CT appearance of peripheral cholangiocarcinoma is that of a
low-density mass that may have a thin rim of contrast enhancement
[12] (Figs.
12A, and
12B). Because the lesion may
mimic a hepatic abscess, fine-needle aspiration may be required to
differentiate benign pathology from cholangiocarcinoma in these patients
[13]. Although
diffusion-weighted MRI has been shown to improve the detection of liver
lesions and may have some role in the imaging of recurrent pyogenic
cholangitis patients, it does not appear to confer any advantage in the
differentiation of benign from malignant pathologic processes
[14].
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Fig. 12A Portal venous phase CT image shows large, irregular, low-density mass in
right lobe of liver adjacent to area of atrophy with duct crowding
(arrow). Surgical resection confirmed cholangiocarcinoma; however,
resection margin was positive.
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The incidence of hepatocellular carcinoma (HCC) has also been reported to
be elevated in recurrent pyogenic cholangitis patients
[15], likely related to the
development of cirrhosis in severe cases. There is limited data on HCC in the
setting of recurrent pyogenic cholangitis; however, in our experience it has
similar imaging characteristics to HCC occurring in patients with other causes
of cirrhosis.
Management of Recurrent Pyogenic Cholangitis
Therapeutic options for patients with recurrent pyogenic cholangitis
include antibiotic therapy for acute attacks, stricture dilatation, biliary
drainage, stone removal, biliary bypass, liver resection, and trans plantation
[1]. A multidisciplinary
approach involving gastroenterologists, interventional radiologists, and
surgeons is recommended because all three specialties play pivotal roles in
the management of patients with this complex disease. The goal of therapy is
to completely clear the biliary tree of calculi and to eliminate bile stasis
to prevent acute attacks of cholangitis and further stone formation
[4]. Where possible, patients
are treated relatively conservatively using ERCP or PTC to achieve these
goals, with surgical management reserved for those patients in whom endoscopic
and percutaneous techniques have been unsuccessful.
Endoscopic Intervention
In patients with extractable stones—that is, confined to the
extrahepatic biliary tree or central intrahepatic ducts—removal at ERCP
or by percutaneous techniques should be considered. Endoscopic options include
stone extraction using a balloon, basket, or forceps. In recurrent pyogenic
cholangitis patients with predominantly extrahepatic lithiasis, ERCP has been
reported to achieve complete stone clearance in more than 90%
[5]. However, in a significant
proportion, the stones are confined to the left lateral segment of the liver,
which makes endoscopic therapy extremely difficult
[16]
(Fig. 13).
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Fig. 13 —68-year-old man with recurrent bouts of pain and sepsis due to
recurrent pyogenic cholangitis. ERCP image shows dilated, stone-filled left
hepatic duct (arrow). Attempted stone removal, using basket, was
unsuccessful because basket could not be advanced beyond calculi.
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Stricture dilatation can also be performed using balloon angioplasty
catheters, and stents may be inserted endoscopically to maintain duct patency.
Although metal stents have a good short-term patency rate, their long-term
patency is very low and as a result their use is not recommended in recurrent
pyogenic cholangitis patients, most of whom are relatively young
[15].
Surgical Intervention
A variety of procedures may be used by surgeons in the management of
recurrent pyogenic cholangitis, including biliary bypass procedures; segmental
hepatic resection; and, occasionally, orthotopic liver transplantation
[17].
Biliary Bypass Procedures
Surgical exploration of the common hepatic or common bile duct, with stone
clearance, may be performed as an isolated procedure but is best combined with
a bypass operation [16]. The
aim of a biliary bypass procedure is to eliminate bile stasis and prevent
recurrent stone formation. Technical options include choledochojejunostomy and
choledo choduodenostomy; the latter retains endoscopic access to the biliary
tree, which is of obvious benefit in recurrent pyogenic cholangitis patients.
An alternative is the Hutson loop, which is a form of Roux-en-Y choledo
chojejunostomy that is fixed to the abdominal wall, facilitating subsequent
retrograde extraction of residual or recurrent calculi
[5].
Segmental Hepatic Resection
This surgical option may be considered when there are calculi within
segmental ducts, particularly when segmental atrophy has already occurred.
Resection of an atrophic segment has very little effect on hepatic function
and can be performed laparoscopically
[16]. In addition to helping
prevent acute attacks of cholangitis and abscess formation, resection
eliminates the risk of malignancy in an atrophic segment
[16]. There is, however, a
high morbidity rate associated with this procedure, reported to be up to 33%
[5].
Orthotopic Liver Transplantation
Repeated episodes of hepatobiliary obstruction and infection may lead to
progressive hepatic parenchymal injury in patients with recurrent pyogenic
cholangitis, and hepatic failure is a recognized potential long-term
complication of the disease, particularly in patients in whom diagnosis has
been delayed [6]. Liver
transplantation for end-stage liver disease due to recurrent pyogenic
cholangitis has been reported
[6,
17]; however, there is limited
data on this aspect of recurrent pyogenic cholangitis management in the
literature, and, to the best of our knowledge, there are no published reports
regarding the potential risk of recurrence of recurrent pyogenic cholangitis
after transplantation.
The Role of Interventional Radiology
Many patients with recurrent pyogenic cholangitis have undergone previous
surgery for the disease, making ERCP impossible in some cases. Thus,
percutaneous biliary drainage is frequently necessary in the setting of acute
sepsis. Percutaneous catheters may be used as a temporizing measure in
cholangitis or may be used for long-term drainage of obstructed segments. In
addition, intracorporeal shock wave lithotripsy, stone removal, stricture
dilatation, and stent insertion may be performed through percutaneous access
(Figs. 14A,
14B,
15A,
15B, and
15C). Percutaneous stone
clearance rates of up to 94% have been reported
[5].
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Fig. 14A —32-year-old woman with previous biliary-enteric anastomosis for
recurrent pyogenic cholangitis. Cholangiogram obtained through percutaneous
biliary drain shows multiple small calculi (arrow) in left hepatic
duct.
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Fig. 14B —32-year-old woman with previous biliary-enteric anastomosis for
recurrent pyogenic cholangitis. Choledochoscope has been inserted through a
20-French sheath (arrowhead), intracorporeal shock wave lithotripsy
performed, and stone fragments pushed through choledochojejunostomy. This
postprocedure cholangiogram shows that left hepatic duct is now stone
free.
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Fig. 15A —75-year-old man who presented with septic shock due to recurrent
pyogenic cholangitis. Sonography showed common bile duct packed with small
calculi, and open duct exploration was performed. Surgeon was unable to remove
all of common duct stones and left T-tube in place. T-tube
(arrowhead) cholangiogram 7 weeks later shows innumerable tiny
calculi throughout common duct.
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Fig. 15B —75-year-old man who presented with septic shock due to recurrent
pyogenic cholangitis. Sonography showed common bile duct packed with small
calculi, and open duct exploration was performed. Surgeon was unable to remove
all of common duct stones and left T-tube in place. Choledochoscope
(straight arrow) has been inserted alongside safety wire (curved
arrow) and intracorporeal shock wave lithotripsy performed. Stone
fragments were extracted using a Dormier basket and Fogarty balloon.
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Fig. 15C —75-year-old man who presented with septic shock due to recurrent
pyogenic cholangitis. Sonography showed common bile duct packed with small
calculi, and open duct exploration was performed. Surgeon was unable to remove
all of common duct stones and left T-tube in place. Postprocedure
cholangiogram shows marked reduction in stone burden. To facilitate passage of
remaining small calculi, balloon angioplasty of ampulla was performed.
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As with ERCP, there is a risk of aggravating biliary sepsis with
interventional radiology procedures. This risk can be minimized by using IV
antibiotic cover, performing low-pressure contrast injections, and keeping the
duration of interventional sessions to a minimum
[18].
Conclusion
Recurrent pyogenic cholangitis is a complex disease often requiring
repeated medical, surgical, and radiologic treatment. Its incidence in Western
countries is increasing, and it is important that radiologists be aware of its
cross-sectional imaging features so that the diagnosis is considered when a
patient from an endemic area presents with the typical clinical features of
abdominal pain, fever, and jaundice. Sonography, CT, and MRCP not only allow
the correct diagnosis to be made but also serve as a vital road map for
subsequent intervention by illustrating the location and extent of disease.
Radiologists should also appreciate the potential role of interventional
radiology in disease management.
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Abstract
Introduction
