Diagnostic Ultrasound - Abdomen and Pelvis

Recurrent Pyogenic Cholangitis
Diagnoses: Biliary System
Cholangiocarcinoma
• May have a periductal soft tissue density appearance
• Prominent enhanced ductal wall thickening
• Often associated with hepatic or lymph node metastases
• Portal vein of affected segment may be obliterated
Intrahepatic Stones Secondary to Biliary Stricture
• Stricture may be due to prior surgery, trauma or
chemotherapy
• Non-Asian patient
• Similar clinical presentation as RPC with RUQ pain, fever
and chills
Caroli Disease
• Congenital, multifocal, segmental, saccular dilatation of
intrahepatic bile ducts
• May have intraductal stones
PATHOLOGY
General Features
• Etiology
○ Associated with biliary parasitic infection with Clonorchis
sinensis &/or Ascaris lumbricoides
○ Associated with E. coli infection of bile ducts
– Bacterial production of beta-glucuronidase
– Leads to hydrolysis of bilirubin, development of
calcium bilirubinate stones within intra- and
extrahepatic bile ducts
○ Associated with poor general nutrition
• Genetics
○ No known genetic predisposition
Staging, Grading, & Classification
• Classification based on distribution of affected biliary
segment
○ May be isolated to left lobe, particularly lateral segment
○ May involve all biliary segments, as well as CBD
Gross Pathologic & Surgical Features
• Dilated bile ducts with brown, mud-like pigment stones,
pus
• May have parasitic infection in biliary ducts with Clonorchis
or Ascaris
Microscopic Features
• Periductal inflammatory changes with infiltration of
periportal spaces with inflammatory cells leading to
periductal fibrosis and ultimately biliary cirrhosis
• Localized segmental hepatic atrophy
• Fatty changes in liver
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Recurrent episodes of RUQ pain, fever and jaundice
○ Other signs/symptoms
– Hypotension, septic shock
– Related to gram-negative septicemia
• Clinical profile
○ Leukocytosis, elevated alkaline phosphatase and bilirubin
Demographics
• Age: Over 40
• No gender predilection
• Epidemiology:Primarily within southeast Asia and
immigrants from southeast Asia
Natural History & Prognosis
• Repeated episodes of acute bacterial cholangitis
• May be life-threatening due to uncontrolled fulminant
biliary sepsis
○ Treated with urgent surgical or percutaneous biliary
drainage
• Complications
○ Biliary strictures, cholangitic liver abscesses
○ Repeated episodes of cholangitis & stricture formation
lead to biliary cirrhosis
○ Cholangiocarcinoma (5-6%)
Treatment
• Options, risks, complications
○ Most mild cases respond to broad-spectrum intravenous
antibiotics
○ In severe biliary sepsis, prompt biliary drainage is
mandatory
○ Endoscopic sphincterotomy
○ Surgical drainage
– Biliary drainage with hepaticojejunostomy
– Left hepatic lobe resection if isolated left lobe disease
○ Interventional radiology
– Percutaneous biliary drainage of affected segments
– Basket removal of pigment stones
– Balloon dilation of biliary strictures
– Repeated percutaneous procedures to clear pigment
stones & mud-like biliary debris
○ Medical therapy
– Long-term suppressive antibiotic therapy
DIAGNOSTIC CHECKLIST
Consider
• Consider RPC in southeast Asian patient with recurrent
episodes of acute bacterial cholangitis
Image Interpretation Pearls
• Intra- and extrahepatic bile duct dilatation with pigmented
stones and ductal inflammation
SELECTED REFERENCES
1. Katabathina VS et al: Adult bile duct strictures: role of MR imaging and MR
cholangiopancreatography in characterization. Radiographics. 34(3):565-86,
2014
2. Park HS et al: CT Differentiation of cholangiocarcinoma from periductal
fibrosis in patients with hepatolithiasis. AJR Am J Roentgenol. 187(2):445-
53, 2006
3. Jeyarajah DR: Recurrent Pyogenic Cholangitis. Curr Treat Options
Gastroenterol. 7(2):91-98, 2004
4. Chan FL et al: Modern imaging in the evaluation of hepatolithiasis.
Hepatogastroenterology. 44(14):358-69, 1997
5. Lim JH: Oriental cholangiohepatitis: pathologic, clinical, and radiologic
features. AJR Am J Roentgenol. 157(1):1-8, 1991
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