Diagnostic Ultrasound - Abdomen and Pelvis

AIDS-Related Cholangiopathy
TERMINOLOGY
Abbreviations
• AIDS cholangitis, AIDS-related sclerosing cholangitis, AIDS
cholangiopathy, HIV cholangiopathy
Definitions
• Secondary sclerosing cholangitis usually resulting from
opportunistic infection of biliary tract in AIDS patients with
CD4 count < 100/mm³
IMAGING
General Features
• Best diagnostic clue
○ AIDS patient with papillary stenosis, intrahepatic
strictures, thickened bile ducts and gallbladder (GB)
Ultrasonographic Findings
• Grayscale ultrasound
○ Focal biliary duct strictures and associated dilatation
○ Bile duct wall thickening
○ Dilatation and wall thickening of common bile duct
(CBD) with papillary stenosis
○ Diffuse GB wall thickening without gallstones
Radiographic Findings
• ERCP
○ Sclerosing cholangitis and papillary stenosis
– Unique to AIDS cholangiopathy
○ Long extrahepatic bile duct strictures, ±intrahepatic
sclerosing cholangitis
MR Findings
• MRCP
○ Multiple intra- and extrahepatic biliary strictures, with
associated dilation
○ Papillary stenosis with CBD dilation
○ Isolated intermediate to long segment CBD stricture
○ GB wall and bile duct thickening
Imaging Recommendations
• Best imaging tool
○ US: Initial imaging test
– Normal US essentially rules out diagnosis
○ MRCP
○ ERCP: Diagnostic and therapeutic
DIFFERENTIAL DIAGNOSIS
Primary Sclerosing Cholangitis
• Multifocal irregular ductal strictures with alternating ductal
ectasia
• Affects intrahepatic and extrahepatic ducts
Autoimmune Cholangitis
• Bile duct wall thickening and strictures
• Most commonly affects distal CBD, can affect intrahepatic
ducts
• Seen in setting of autoimmune pancreatitis
Ascending Cholangitis (Acute Bacterial Cholangitis)
• Ductal stricture and biliary wall thickening
• Usually secondary to choledocholithiasis
Cholangiocarcinoma
• Infiltrative mass along ductal epithelium
• Invades hepatic parenchyma and regional lymph node
metastases
PATHOLOGY
General Features
• Chronic inflammation of biliary tract from opportunistic
pathogens
• Most common pathogens: Cryptosporidium, CMV
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Epigastric/RUQ pain, diarrhea
○ Fever and jaundice, less common
• Clinical profile
○ ↑ ↑ cholestatic enzymes (Alk Phos and GGT)
○ Mild ↑ AST/ALT, bilirubin normal or↑
Demographics
• Epidemiology
○ Late-stage AIDS patients (CD4 < 100/mm³)
○ ↓ ↓ incidence 2° highly active retroviral therapy (HAART)
Natural History & Prognosis
• Survival not affected by cholangiopathy
• Mortality rate determined by natural history of AIDS
Treatment
• Papillary stenosis with symptoms: Sphincterotomy for pain
relief, does not alter intrahepatic disease
• Dominant CBD stricture: Stenting
• Intra- or extrahepatic sclerosing cholangitis: Options
limited, mainstay is restoration of immune system with
HAART
DIAGNOSTIC CHECKLIST
Image Interpretation Pearls
• AIDS patient with papillary stenosis, intrahepatic strictures,
or acalculous cholecystitis
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. Datta J et al: Extrahepatic cholangiocarcinoma developing in the setting of
AIDS cholangiopathy. Am Surg. 79(3):321-2, 2013
3. Imam MH et al: Secondary sclerosing cholangitis: pathogenesis, diagnosis,
and management. Clin Liver Dis. 17(2):269-77, 2013
4. Tonolini M et al: HIV-related/AIDS cholangiopathy: pictorial review with
emphasis on MRCP findings and differential diagnosis. Clin Imaging.
37(2):219-26, 2013
5. Shanbhogue AK et al: Benign biliary strictures: a current comprehensive
clinical and imaging review. AJR Am J Roentgenol. 197(2):W295-306, 2011
6. Catalano OA et al: Biliary infections: spectrum of imaging findings and
management. Radiographics. 29(7):2059-80, 2009
7. Daly CA et al: Sonographic prediction of a normal or abnormal ERCP in
suspected AIDS related sclerosing cholangitis. Clin Radiol. 51(9):618-21, 1996
8. Lack, E. E. Pathology of the Pancreas, Gallbladder, Extrahepatic Biliary Tract,
and Ampullary Region. Oxford University Press. 2003
Diagnoses: Biliary System
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