Diagnostic Ultrasound - Abdomen and Pelvis

Recurrent Pyogenic Cholangitis
Diagnoses: Biliary System
TERMINOLOGY
• Recurrent episodes of acute pyogenic cholangitis with
intra- and extrahepatic biliary pigment stones
• Synonyms: Hepatolithiasis, oriental cholangiohepatitis
IMAGING
• Intra- and extrahepatic biliary ductal dilatations with stones
• Lateral segment of left lobe and posterior segment of right
lobe more commonly involved
• Biliary ductal thickening due to repeated inflammation
• Severe atrophy of affected lobe/segment, biliary cirrhosis
• Grayscale ultrasound
○ Presence of echogenic sludge/stones ±posterior
acoustic shadowing in intrahepatic and extrahepatic duct
○ Periportal hypo-/hyperechogenicity due to periductal
inflammation
○ Ductal rigidity and straightening, rapid tapering of
peripheral intrahepatic duct
• Cholangiography and MRCP
KEY FACTS
○ Intra- and extrahepatic duct dilatation with stones as
filling defects
TOP DIFFERENTIAL DIAGNOSES
• Ascending cholangitis
• Sclerosing cholangitis
• Cholangiocarcinoma
• Intrahepatic stones secondary to biliary stricture
• Caroli disease
CLINICAL ISSUES
• Common symptoms/signs: Recurrent episodes of RUQ
pain, fever and jaundice
• Risk of developing cholangiocarcinoma (5-6%)
DIAGNOSTIC CHECKLIST
• Consider RPC in southeast Asian patients with recurrent
episodes of acute bacterial cholangitis
(Left) Graphic shows recurrent
pyogenic cholangitis with
marked dilation of
intrahepatic ſt and
extrahepatic bile ducts
with multiple common bile
duct and intrahepatic duct
stones. The peripheral
intrahepatic duct shows rapid
tapering and decreased
arborization. (Right) Grayscale
ultrasound shows an ovoid
intrahepatic stone ſt with
posterior acoustic shadowing
in the right hepatic duct
causing upstream intrahepatic
bile duct dilatation st.
(Left) Grayscale ultrasound of
the liver shows multiple
echogenic regions ſt with
posterior acoustic shadowing
in the intrahepatic biliary
system, consistent with
intrahepatic stones in this
patient with recurrent
pyogenic cholangitis. (Right)
Transverse grayscale
ultrasound of the liver shows
echogenic stones ſt and
sludge filling moderately
dilated intrahepatic ducts.
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