EURORAD ESR

Case 13001

Mycotic acute cholangitis: MRI findings

Author(s)
Tonolini Massimo, M.D.

"Luigi Sacco" University Hospital
Radiology Department
Via G.B. Grassi 74
20157 Milan, Italy
Email:mtonolini@sirm.org
 
Patient
male, 42 year(s)
 
 
  • Figure 1
    MR cholangiopancreatography (MRCP) and Endoscopic Retrograde Cholangiopancreatography (ERCP) in 2011
     

    In 2011, initial axial T2-weighted (a) and MRCP (b) images showed marked dilatation of intrahepatic biliary system and common hepatic duct.

     
    Area of Interest: Biliary Tract / Gallbladder; Imaging Technique: MR; Procedure: Cholangiography; Special Focus: Infection;

    In 2011, MRCP showed marked dilatation of intrahepatic biliary system and common hepatic duct, due to a 1-cm filling defect (arrow) consistent with common bile duct stone.

     
    Area of Interest: Biliary Tract / Gallbladder; Imaging Technique: MR; Procedure: Cholangiography; Special Focus: Infection;

    ERCP confirmed marked intrahepatic biliary dilatation and intraluminal filling defect (arrow) consistent with stone in the midportion of the choledochus. Sphincterotomy was performed. Note guidewire.

     
    Area of Interest: Biliary Tract / Gallbladder; Imaging Technique: Fluoroscopy; Procedure: Endoscopy; Special Focus: Infection;

    A week later, repeated MRI (d) witn MRCP (e) showed persistent common bile duct stone (arrow in e) with reduced upstream biliary dilatation.

     
    Area of Interest: Biliary Tract / Gallbladder; Imaging Technique: MR; Procedure: Cholangiography; Special Focus: Infection;

    A week later, repeated MRI (d) witn MRCP (e) showed persistent common bile duct stone (arrow in e) with reduced upstream biliary dilatation.

     
    Area of Interest: Biliary Tract / Gallbladder; Imaging Technique: MR; Procedure: Cholangiography; Special Focus: Infection;

    Repeated MRCP confirmed persistent common bile duct stone (arrow) which was removed endoscopically using balloon catheter and Dormia basket.

     
    Area of Interest: Biliary Tract / Gallbladder; Imaging Technique: Fluoroscopy; Procedure: Endoscopy; Special Focus: Infection;

    At discharge, repeated MRCP showed cleared common bile duct.

     
    Area of Interest: Biliary Tract / Gallbladder; Imaging Technique: MR; Procedure: Cholangiography; Special Focus: Infection;
     
     
  • Figure 2
    Urgent unenhanced and post-contrast multidetector CT (current)
     

    Three years later, emergency CT including unenhanced (a) and post-contrast (b...f) showed lung base atelectasis (*) without pleural effusion.

     
    Area of Interest: Biliary Tract / Gallbladder; Imaging Technique: CT; Procedure: Cholangiography; Special Focus: Infection;

    Post-contrast CT showed homogeneous enhancement of the liver parenchyma in the portal venous phase, reappearance of central (b) and peripheral (arrows in c...f) intrahepatic biliary dilatation.

     
    Area of Interest: Biliary Tract / Gallbladder; Imaging Technique: CT; Procedure: Cholangiography; Special Focus: Infection;

    Post-contrast CT showed homogeneous enhancement of the liver parenchyma in the portal venous phase, reappearance of central (b) and peripheral (arrows in c...f) intrahepatic biliary dilatation.

     
    Area of Interest: Biliary Tract / Gallbladder; Imaging Technique: CT; Procedure: Cholangiography; Special Focus: Infection;

    Multiplanar reconstructions from portal phase CT showed homogeneous enhancement of the liver parenchyma, reappearance of central and peripheral (arrows) intrahepatic biliary dilatation in both lobes.

     
    Area of Interest: Biliary Tract / Gallbladder; Imaging Technique: CT; Procedure: Cholangiography; Special Focus: Infection;

    Multiplanar reconstructions from portal phase CT showed homogeneous enhancement of the liver parenchyma, reappearance of central and peripheral (arrows) intrahepatic biliary dilatation in both lobes.

     
    Area of Interest: Biliary Tract / Gallbladder; Imaging Technique: CT; Procedure: Cholangiography; Special Focus: Infection;

    Multiplanar reconstructions from portal phase CT showed reappearance of intrahepatic biliary dilatation (arrow) with non-dilated common bile duct (short arrow). Note metallic clips from previous cholecystectomy (thin...

     
    Area of Interest: Biliary Tract / Gallbladder; Imaging Technique: CT; Procedure: Cholangiography; Special Focus: Infection;
     
     
  • Figure 3
    Initial MRI with MRCP (current)
     

    Three days later MRCP showed appearance of moderate left hemisystem dilatation (arrow), moderately dilated common bile duct with filling defects (short arrow) consistent with recurrent choledocholithiasis.

     
    Area of Interest: Biliary Tract / Gallbladder; Imaging Technique: MR; Procedure: Cholangiography; Special Focus: Infection;

    Axial T2-weighted images with and without fat suppression revealed "geographic" hyperintense parenchymal regions (+) in several liver segments, without mass effect.

     
    Area of Interest: Biliary Tract / Gallbladder; Imaging Technique: MR; Procedure: Cholangiography; Special Focus: Infection;

    Axial T2-weighted images with and without fat suppression revealed "geographic" hyperintense parenchymal regions (+) in several liver segments, without mass effect.

     
    Area of Interest: Biliary Tract / Gallbladder; Imaging Technique: MR; Procedure: Cholangiography; Special Focus: Infection;

    Additionally, strongly hyperintense "periportal tracking" (thin arrows) was noted.

     
    Area of Interest: Biliary Tract / Gallbladder; Imaging Technique: MR; Procedure: Cholangiography; Special Focus: Infection;

    Additionally, strongly hyperintense "periportal tracking" (thin arrows) was noted. In the ventral left lobe one of the parenchymal abnormalities showed 2-cm central strong hyperintensity (*) suggesting initial...

     
    Area of Interest: Biliary Tract / Gallbladder; Imaging Technique: MR; Procedure: Cholangiography; Special Focus: Infection;

    Additionally, strongly hyperintense "periportal tracking" (thin arrows) was noted. In the ventral left lobe one of the parenchymal abnormalities showed 2-cm central strong hyperintensity (*) suggesting initial...

     
    Area of Interest: Biliary Tract / Gallbladder; Imaging Technique: MR; Procedure: Cholangiography; Special Focus: Infection;

    In the unenhanced T1-weighted acquisitions most of the oedematous parenchymal regions were not discernible, apart from the exception of the one located in the ventral left lobe (*) with inhomogeneously hypointense...

     
    Area of Interest: Biliary Tract / Gallbladder; Imaging Technique: MR; Procedure: Cholangiography; Special Focus: Infection;

    After intravenous gadolinium contrast, the ventral left liver lobe showed a 2-cm hypoenhancing lesion (*) corresponded to the colliquation-abscess area previously noted in T2-weighted sequences.

     
    Area of Interest: Biliary Tract / Gallbladder; Imaging Technique: MR-Angiography; Procedure: Cholangiography; Special Focus: Infection;

    Additionally, thin periductal hyperenhancement (thin arrows) was noted in both lobes.

     
    Area of Interest: Biliary Tract / Gallbladder; Imaging Technique: MR; Procedure: Cholangiography; Special Focus: Infection;

    Additionally, thin periductal hyperenhancement (thin arrows) was noted in both lobes.

     
    Area of Interest: Biliary Tract / Gallbladder; Imaging Technique: MR; Procedure: Cholangiography; Special Focus: Infection;
     
     
  • Figure 4
    Endoscopic cholangiography and biliary drainage
     

    ERCP showed inhomogeneous opacification of the choledochus (arrow) filled by sludge and small stones. Note metallic clips from previous cholecystectomy (thin arrow).

     
    Area of Interest: Biliary Tract / Gallbladder; Imaging Technique: Fluoroscopy; Procedure: Cholangiography; Special Focus: Infection;

    Recurrent choledocholithiasis was treated using Dormia basket (short arrow), allowing pus to drain from the choledochus. Note metallic clips from previous cholecystectomy (thin arrow).

     
    Area of Interest: Biliary Tract / Gallbladder; Imaging Technique: Fluoroscopy; Procedure: Cholangiography; Special Focus: Infection;

    Nasobiliary drainage (arrowhead) was positioned with apex in the left biliary intrahepatic ducts.

     
    Area of Interest: Biliary Tract / Gallbladder; Imaging Technique: Fluoroscopy; Procedure: Cholangiography; Special Focus: Infection;

    Detail cholangiographic image showed diffuse calibre irregularities (arrowheads) of several intrahepatic ducts, consistent with cholangitis.

     
    Area of Interest: Biliary Tract / Gallbladder; Imaging Technique: Fluoroscopy; Procedure: Cholangiography; Special Focus: Infection;
     
     
  • Figure 5
    Follow-up MRI in improved clinical conditions and cooperation
     

    Repeated MRI including T2-weighted acquisitions showed partial decrease of the oedematous "geographic" parenchymal regions (+). Note persistent lung base hypoventilation and minimal pleural effusion (arrowhead).

     
    Area of Interest: Biliary Tract / Gallbladder; Imaging Technique: MR; Procedure: Cholangiography; Special Focus: Infection;

    Repeated MRI including T2-weighted acquisitions showed partial decrease of the oedematous "geographic" parenchymal regions (+). Note persistent lung base hypoventilation and minimal pleural effusion (arrowhead).

     
    Area of Interest: Biliary Tract / Gallbladder; Imaging Technique: MR; Procedure: Cholangiography; Special Focus: Infection;

    The dominant residual region with abnormal parenchymal signal intensity in the ventral left liver lobe (*) appeared more homogeneous, without showing appreciable signs of colliquation anymore.

     
    Area of Interest: Biliary Tract / Gallbladder; Imaging Technique: MR; Procedure: Cholangiography; Special Focus: Infection;

    The strongly hyperintense "periportal tracking" (thin arrows) partially persisted in the central liver.

     
    Area of Interest: Biliary Tract / Gallbladder; Imaging Technique: MR; Procedure: Cholangiography; Special Focus: Infection;

    After intravenous gadolinium contrast, the dominant abnormal signal region in the ventral left lobe (*) showed homogeneous enhancement without signs suggesting colliquation/abscess anymore.

     
    Area of Interest: Biliary Tract / Gallbladder; Imaging Technique: MR; Procedure: Cholangiography; Special Focus: Infection;

    The periductal hyperenhancement (thin arrows) partially persisted, particularly in the left main duct.

     
    Area of Interest: Biliary Tract / Gallbladder; Imaging Technique: MR; Procedure: Cholangiography; Special Focus: Infection;

    After endoscopic treatment, repeated MRCP showed resolved biliary dilatation and cleared choledocholithiasis.

     
    Area of Interest: Biliary Tract / Gallbladder; Imaging Technique: MR; Procedure: Cholangiography; Special Focus: Infection;
     
     
In 2011, initial axial T2-weighted (a) and MRCP (b) images showed marked dilatation of intrahepatic biliary system and common hepatic duct.
 
In 2011, MRCP showed marked dilatation of intrahepatic biliary system and common hepatic duct, due to a 1-cm filling defect (arrow) consistent with common bile duct stone.
 
ERCP confirmed marked intrahepatic biliary dilatation and intraluminal filling defect (arrow) consistent with stone in the midportion of the choledochus. Sphincterotomy was performed. Note guidewire.
 
A week later, repeated MRI (d) witn MRCP (e) showed persistent common bile duct stone (arrow in e) with reduced upstream biliary dilatation.
 
A week later, repeated MRI (d) witn MRCP (e) showed persistent common bile duct stone (arrow in e) with reduced upstream biliary dilatation.
 
Repeated MRCP confirmed persistent common bile duct stone (arrow) which was removed endoscopically using balloon catheter and Dormia basket.
 
At discharge, repeated MRCP showed cleared common bile duct.
 
Three years later, emergency CT including unenhanced (a) and post-contrast (b...f) showed lung base atelectasis (*) without pleural effusion.
 
Post-contrast CT showed homogeneous enhancement of the liver parenchyma in the portal venous phase, reappearance of central (b) and peripheral (arrows in c...f) intrahepatic biliary dilatation.
 
Post-contrast CT showed homogeneous enhancement of the liver parenchyma in the portal venous phase, reappearance of central (b) and peripheral (arrows in c...f) intrahepatic biliary dilatation.
 
Multiplanar reconstructions from portal phase CT showed homogeneous enhancement of the liver parenchyma, reappearance of central and peripheral (arrows) intrahepatic biliary dilatation in both lobes.
 
Multiplanar reconstructions from portal phase CT showed homogeneous enhancement of the liver parenchyma, reappearance of central and peripheral (arrows) intrahepatic biliary dilatation in both lobes.
 
Multiplanar reconstructions from portal phase CT showed reappearance of intrahepatic biliary dilatation (arrow) with non-dilated common bile duct (short arrow). Note metallic clips from previous cholecystectomy (thin arrow).
 
Three days later MRCP showed appearance of moderate left hemisystem dilatation (arrow), moderately dilated common bile duct with filling defects (short arrow) consistent with recurrent choledocholithiasis.
 
Axial T2-weighted images with and without fat suppression revealed "geographic" hyperintense parenchymal regions (+) in several liver segments, without mass effect.
 
Axial T2-weighted images with and without fat suppression revealed "geographic" hyperintense parenchymal regions (+) in several liver segments, without mass effect.
 
Additionally, strongly hyperintense "periportal tracking" (thin arrows) was noted.
 
Additionally, strongly hyperintense "periportal tracking" (thin arrows) was noted. In the ventral left lobe one of the parenchymal abnormalities showed 2-cm central strong hyperintensity (*) suggesting initial colliquation.
 
Additionally, strongly hyperintense "periportal tracking" (thin arrows) was noted. In the ventral left lobe one of the parenchymal abnormalities showed 2-cm central strong hyperintensity (*) suggesting initial colliquation.
 
In the unenhanced T1-weighted acquisitions most of the oedematous parenchymal regions were not discernible, apart from the exception of the one located in the ventral left lobe (*) with inhomogeneously hypointense signal.
 
After intravenous gadolinium contrast, the ventral left liver lobe showed a 2-cm hypoenhancing lesion (*) corresponded to the colliquation-abscess area previously noted in T2-weighted sequences.
 
Additionally, thin periductal hyperenhancement (thin arrows) was noted in both lobes.
 
Additionally, thin periductal hyperenhancement (thin arrows) was noted in both lobes.
 
ERCP showed inhomogeneous opacification of the choledochus (arrow) filled by sludge and small stones. Note metallic clips from previous cholecystectomy (thin arrow).
 
Recurrent choledocholithiasis was treated using Dormia basket (short arrow), allowing pus to drain from the choledochus. Note metallic clips from previous cholecystectomy (thin arrow).
 
Nasobiliary drainage (arrowhead) was positioned with apex in the left biliary intrahepatic ducts.
 
Detail cholangiographic image showed diffuse calibre irregularities (arrowheads) of several intrahepatic ducts, consistent with cholangitis.
 
Repeated MRI including T2-weighted acquisitions showed partial decrease of the oedematous "geographic" parenchymal regions (+). Note persistent lung base hypoventilation and minimal pleural effusion (arrowhead).
 
Repeated MRI including T2-weighted acquisitions showed partial decrease of the oedematous "geographic" parenchymal regions (+). Note persistent lung base hypoventilation and minimal pleural effusion (arrowhead).
 
The dominant residual region with abnormal parenchymal signal intensity in the ventral left liver lobe (*) appeared more homogeneous, without showing appreciable signs of colliquation anymore.
 
The strongly hyperintense "periportal tracking" (thin arrows) partially persisted in the central liver.
 
After intravenous gadolinium contrast, the dominant abnormal signal region in the ventral left lobe (*) showed homogeneous enhancement without signs suggesting colliquation/abscess anymore.
 
The periductal hyperenhancement (thin arrows) partially persisted, particularly in the left main duct.
 
After endoscopic treatment, repeated MRCP showed resolved biliary dilatation and cleared choledocholithiasis.
 
 
 
Home Search Sections Teaching Cases History FAQ Case Archives Contact Login Disclaimer Imprint Switch to MOBILE version
View desktop version