EURORAD ESR

Case 15035

Acute viral hepatitis: don't miss subtle and potentially misleading MRI signs

Author(s)
Tonolini Massimo, MD.

"Luigi Sacco" University Hospital, Radiology Department; Via G.B. Grassi 74 20157 Milan, Italy; Email:mtonolini@sirm.org
 
Patient
female, 39 year(s)
 
 
  • Figure 1
    Initial ultrasound (in emergency department)
     

    Urgent ultrasound (left lobe in a, right lobe in b) showed minimally enlarged liver with normal, homogeneous echotexture, without abnormal focal lesions; non-dilated intrahepatic and common bile ducts.

     
    Area of Interest: Liver; Imaging Technique: Ultrasound; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    Urgent ultrasound (left lobe in a, right lobe in b) showed minimally enlarged liver with normal, homogeneous echotexture, without abnormal focal lesions; non-dilated intrahepatic and common bile ducts.

     
    Area of Interest: Liver; Imaging Technique: Ultrasound; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    The medium-sized gallbladder had multiple intraluminal stones (arrowheads) consistent with known cholelithiasis, and marked circumferential, stratified mural thickening (*) measuring nearly 1 cm.

     
    Area of Interest: Liver; Imaging Technique: Ultrasound; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    The medium-sized gallbladder had multiple intraluminal stones (arrowheads) consistent with known cholelithiasis, and marked circumferential, stratified mural thickening (*) measuring nearly 1 cm.

     
    Area of Interest: Liver; Imaging Technique: Ultrasound; Procedure: Diagnostic procedure; Special Focus: Inflammation;
     
     
  • Figure 2
    Unenhanced MRI with MR-cholangiopancreatography (24 hours after Fig.1)
     

    T1-weighted images (a, fat-suppressed b) showed mild perihepatic effusion (+), and confirmed marked (1 cm) , low-signal intensity circumferential thickening of gallbladder wall (*). Note cholelithiasis (arrowheads).

     
    Area of Interest: Liver; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    T1-weighted images (a, fat-suppressed b) showed mild perihepatic effusion (+), and confirmed marked (1 cm) , low-signal intensity circumferential thickening of gallbladder wall (*). Note cholelithiasis (arrowheads).

     
    Area of Interest: Liver; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    T2-weighted images (c...f) showed mild perihepatic and right parietocolic peritoneal effusion (+), confirmed circumferential gallbladder mural thickening (*) with strongly hyperintense, fluid-like signal. Note...

     
    Area of Interest: Liver; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    T2-weighted images (c...f) showed mild perihepatic and right parietocolic peritoneal effusion (+), confirmed circumferential gallbladder mural thickening (*) with strongly hyperintense, fluid-like signal. Note...

     
    Area of Interest: Liver; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    The minimally enlarged liver showed normal, homogeneous parenchymal signal intensity. Thin fluid-like "tram-track" hyperintensities (arrows) consistent with periportal oedema were noted in both lobes. Note ascites (+).

     
    Area of Interest: Liver; Imaging Technique: MR; Procedure: Image compression; Special Focus: Inflammation;

    The minimally enlarged liver showed normal, homogeneous parenchymal signal intensity. Thin fluid-like "tram-track" hyperintensities (arrows) consistent with periportal oedema were noted in both lobes. Note ascites (+).

     
    Area of Interest: Liver; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    MR-cholangiopancreatography confirmed perihepatic effusion (+) and periportal oedema (arrows). Note non-dilated intrahepatic biliary tract, normal choledochus (thick arrow), pancreas divisum (thin arrows) as...

     
    Area of Interest: Liver; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    High (800) b-value diffusion-weighted images (h..j) did not reveal visually abnormal signal regions in the liver parenchyma.

     
    Area of Interest: Liver; Imaging Technique: MR-Diffusion/Perfusion; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    High (800) b-value diffusion-weighted images (h..j) did not reveal visually abnormal signal regions in the liver parenchyma.

     
    Area of Interest: Liver; Imaging Technique: MR-Diffusion/Perfusion; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    The thickened gallbladder wall (*) showed visually low signal in diffusion-weighted images with corresponding hyperintensity on apparent diffusion coefficient (ADC) map (k) indicating unrestricted diffusion.

     
    Area of Interest: Liver; Imaging Technique: MR-Diffusion/Perfusion; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    The thickened gallbladder wall (*) showed visually low signal in diffusion-weighted images with corresponding hyperintensity on apparent diffusion coefficient (ADC) map (k) indicating unrestricted diffusion.

     
    Area of Interest: Liver; Imaging Technique: MR-Diffusion/Perfusion; Procedure: Diagnostic procedure; Special Focus: Inflammation;
     
     
  • Figure 3
    Follow-up ultrasound at discharge
     

    The gallbladder (calipers), occupied by cholelithiasis (arrowhead), showed thin walls consistent with regression of mural oedema.

     
    Area of Interest: Liver; Imaging Technique: Ultrasound; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    The liver (left lobe in a, right lobe in b) showed normal, homogeneous echotexture without focal lesions. No ascites and biliary dilatation.

     
    Area of Interest: Liver; Imaging Technique: Ultrasound; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    The liver (left lobe in a, right lobe in b) showed normal, homogeneous echotexture without focal lesions. No ascites and biliary dilatation.

     
    Area of Interest: Liver; Imaging Technique: Ultrasound; Procedure: Diagnostic procedure; Special Focus: Inflammation;
     
     
Urgent ultrasound (left lobe in a, right lobe in b) showed minimally enlarged liver with normal, homogeneous echotexture, without abnormal focal lesions; non-dilated intrahepatic and common bile ducts.
 
Urgent ultrasound (left lobe in a, right lobe in b) showed minimally enlarged liver with normal, homogeneous echotexture, without abnormal focal lesions; non-dilated intrahepatic and common bile ducts.
 
The medium-sized gallbladder had multiple intraluminal stones (arrowheads) consistent with known cholelithiasis, and marked circumferential, stratified mural thickening (*) measuring nearly 1 cm.
 
The medium-sized gallbladder had multiple intraluminal stones (arrowheads) consistent with known cholelithiasis, and marked circumferential, stratified mural thickening (*) measuring nearly 1 cm.
 
T1-weighted images (a, fat-suppressed b) showed mild perihepatic effusion (+), and confirmed marked (1 cm) , low-signal intensity circumferential thickening of gallbladder wall (*). Note cholelithiasis (arrowheads).
 
T1-weighted images (a, fat-suppressed b) showed mild perihepatic effusion (+), and confirmed marked (1 cm) , low-signal intensity circumferential thickening of gallbladder wall (*). Note cholelithiasis (arrowheads).
 
T2-weighted images (c...f) showed mild perihepatic and right parietocolic peritoneal effusion (+), confirmed circumferential gallbladder mural thickening (*) with strongly hyperintense, fluid-like signal. Note cholelithiasis (arrowheads).
 
T2-weighted images (c...f) showed mild perihepatic and right parietocolic peritoneal effusion (+), confirmed circumferential gallbladder mural thickening (*) with strongly hyperintense, fluid-like signal. Note cholelithiasis (arrowheads).
 
The minimally enlarged liver showed normal, homogeneous parenchymal signal intensity. Thin fluid-like "tram-track" hyperintensities (arrows) consistent with periportal oedema were noted in both lobes. Note ascites (+).
 
The minimally enlarged liver showed normal, homogeneous parenchymal signal intensity. Thin fluid-like "tram-track" hyperintensities (arrows) consistent with periportal oedema were noted in both lobes. Note ascites (+).
 
MR-cholangiopancreatography confirmed perihepatic effusion (+) and periportal oedema (arrows). Note non-dilated intrahepatic biliary tract, normal choledochus (thick arrow), pancreas divisum (thin arrows) as incidental finding.
 
High (800) b-value diffusion-weighted images (h..j) did not reveal visually abnormal signal regions in the liver parenchyma.
 
High (800) b-value diffusion-weighted images (h..j) did not reveal visually abnormal signal regions in the liver parenchyma.
 
The thickened gallbladder wall (*) showed visually low signal in diffusion-weighted images with corresponding hyperintensity on apparent diffusion coefficient (ADC) map (k) indicating unrestricted diffusion.
 
The thickened gallbladder wall (*) showed visually low signal in diffusion-weighted images with corresponding hyperintensity on apparent diffusion coefficient (ADC) map (k) indicating unrestricted diffusion.
 
The gallbladder (calipers), occupied by cholelithiasis (arrowhead), showed thin walls consistent with regression of mural oedema.
 
The liver (left lobe in a, right lobe in b) showed normal, homogeneous echotexture without focal lesions. No ascites and biliary dilatation.
 
The liver (left lobe in a, right lobe in b) showed normal, homogeneous echotexture without focal lesions. No ascites and biliary dilatation.
 
 
 
Home Search Sections Teaching Cases History FAQ Case Archives Contact Login Disclaimer Imprint Switch to MOBILE version
View desktop version