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Biliary Obstruction: Findings at MR Cholangiography and Cross-sectional MR Imaging¹

¹ From the Department of Radiology (J.A.S., J.E.L., F.M.) and the Department of Medicine, Division of Gastroenterology (O.A., J.C.R., G.C.), Universidad de Antioquia, Hospital Universitario San Vicente de Paúl, Calle 64 x Carrera 51D, Medellín, Colombia. Presented as a scientific exhibit at the 1998 RSNA scientific assembly. Received March 1, 1999; revision requested April 21 and received May 12; accepted May 14. Address reprint requests to J.A.S. (e-mail: jorgeasoto@aol.com).

View larger version (101K): [in a new window]   Figure 1a.   Hilar cholangiocarcinoma (Klatskin tumor) in a 48-year-old man with painless jaundice. (a) Coronal MR cholangiogram obtained with a single-section half-Fourier RARE sequence shows intrahepatic duct dilatation and obstruction at the porta hepatis (arrow). (b) Axial fat-suppressed T2-weighted fast spin-echo MR image shows the tumor (arrow) as slightly hyperintense relative to liver parenchyma. (c) Axial T1-weighted gradient-echo MR image obtained 3 minutes after injection of gadolinium contrast material demonstrates enhancement of the tumor (arrow).

View larger version (139K): [in a new window]   Figure 1b.   Hilar cholangiocarcinoma (Klatskin tumor) in a 48-year-old man with painless jaundice. (a) Coronal MR cholangiogram obtained with a single-section half-Fourier RARE sequence shows intrahepatic duct dilatation and obstruction at the porta hepatis (arrow). (b) Axial fat-suppressed T2-weighted fast spin-echo MR image shows the tumor (arrow) as slightly hyperintense relative to liver parenchyma. (c) Axial T1-weighted gradient-echo MR image obtained 3 minutes after injection of gadolinium contrast material demonstrates enhancement of the tumor (arrow).

View larger version (173K): [in a new window]   Figure 1c.   Hilar cholangiocarcinoma (Klatskin tumor) in a 48-year-old man with painless jaundice. (a) Coronal MR cholangiogram obtained with a single-section half-Fourier RARE sequence shows intrahepatic duct dilatation and obstruction at the porta hepatis (arrow). (b) Axial fat-suppressed T2-weighted fast spin-echo MR image shows the tumor (arrow) as slightly hyperintense relative to liver parenchyma. (c) Axial T1-weighted gradient-echo MR image obtained 3 minutes after injection of gadolinium contrast material demonstrates enhancement of the tumor (arrow).

View larger version (82K): [in a new window]   Figure 2a.   Peripheral cholangiocarcinoma in a 45-year-old woman who presented with right upper quadrant pain and weight loss. (a) Oblique coronal MR cholangiogram obtained with a single-section half-Fourier RARE sequence shows dilatation of intrahepatic bile duct radicles, primarily in the right hepatic lobe (straight arrows). The normal common bile duct (arrowhead) and a collapsed gallbladder (curved arrow) are also seen. (b) Axial T1-weighted spin-echo MR image shows the tumor as heterogeneous and hypointense. The dilated bile duct branches (arrows) are seen converging toward the tumor. (c) On an axial fat-suppressed T2-weighted fast spin-echo MR image, the tumor appears predominantly hyperintense. As in b, the dilated bile duct branches (arrows) are seen converging toward the tumor.

View larger version (134K): [in a new window]   Figure 2b.   Peripheral cholangiocarcinoma in a 45-year-old woman who presented with right upper quadrant pain and weight loss. (a) Oblique coronal MR cholangiogram obtained with a single-section half-Fourier RARE sequence shows dilatation of intrahepatic bile duct radicles, primarily in the right hepatic lobe (straight arrows). The normal common bile duct (arrowhead) and a collapsed gallbladder (curved arrow) are also seen. (b) Axial T1-weighted spin-echo MR image shows the tumor as heterogeneous and hypointense. The dilated bile duct branches (arrows) are seen converging toward the tumor. (c) On an axial fat-suppressed T2-weighted fast spin-echo MR image, the tumor appears predominantly hyperintense. As in b, the dilated bile duct branches (arrows) are seen converging toward the tumor.

View larger version (143K): [in a new window]   Figure 2c.   Peripheral cholangiocarcinoma in a 45-year-old woman who presented with right upper quadrant pain and weight loss. (a) Oblique coronal MR cholangiogram obtained with a single-section half-Fourier RARE sequence shows dilatation of intrahepatic bile duct radicles, primarily in the right hepatic lobe (straight arrows). The normal common bile duct (arrowhead) and a collapsed gallbladder (curved arrow) are also seen. (b) Axial T1-weighted spin-echo MR image shows the tumor as heterogeneous and hypointense. The dilated bile duct branches (arrows) are seen converging toward the tumor. (c) On an axial fat-suppressed T2-weighted fast spin-echo MR image, the tumor appears predominantly hyperintense. As in b, the dilated bile duct branches (arrows) are seen converging toward the tumor.

View larger version (132K): [in a new window]   Figure 3a.   Cholangiocarcinoma arising in a choledochal cyst in a 29-year-old man who presented with jaundice and weight loss. (a, b) Maximum-intensity-projection image (a) and source image (b) from MR cholangiography performed with a 3D fast spin-echo sequence in the coronal plane show a cystic lesion with thick, irregular walls (arrows) as well as intrahepatic bile duct dilatation. Intraductal tumor growth is also noted (arrowhead in b). (c, d) Axial fat-suppressed T2-weighted fast spin-echo MR images (c obtained at a higher level than d) also demonstrate a cystic lesion with thick, irregular walls (open arrows) along with intrahepatic bile duct dilatation. In addition, there is evidence of tumor extension to the liver parenchyma (solid arrows in c) and the peritoneum (solid arrows in d) as well as tumor growth within intrahepatic ductal branches (arrowheads in c). The diagnosis was confirmed with laparoscopy and biopsy; however, the poor condition of the patient precluded therapeutic intervention.

View larger version (112K): [in a new window]   Figure 3b.   Cholangiocarcinoma arising in a choledochal cyst in a 29-year-old man who presented with jaundice and weight loss. (a, b) Maximum-intensity-projection image (a) and source image (b) from MR cholangiography performed with a 3D fast spin-echo sequence in the coronal plane show a cystic lesion with thick, irregular walls (arrows) as well as intrahepatic bile duct dilatation. Intraductal tumor growth is also noted (arrowhead in b). (c, d) Axial fat-suppressed T2-weighted fast spin-echo MR images (c obtained at a higher level than d) also demonstrate a cystic lesion with thick, irregular walls (open arrows) along with intrahepatic bile duct dilatation. In addition, there is evidence of tumor extension to the liver parenchyma (solid arrows in c) and the peritoneum (solid arrows in d) as well as tumor growth within intrahepatic ductal branches (arrowheads in c). The diagnosis was confirmed with laparoscopy and biopsy; however, the poor condition of the patient precluded therapeutic intervention.

View larger version (130K): [in a new window]   Figure 3c.   Cholangiocarcinoma arising in a choledochal cyst in a 29-year-old man who presented with jaundice and weight loss. (a, b) Maximum-intensity-projection image (a) and source image (b) from MR cholangiography performed with a 3D fast spin-echo sequence in the coronal plane show a cystic lesion with thick, irregular walls (arrows) as well as intrahepatic bile duct dilatation. Intraductal tumor growth is also noted (arrowhead in b). (c, d) Axial fat-suppressed T2-weighted fast spin-echo MR images (c obtained at a higher level than d) also demonstrate a cystic lesion with thick, irregular walls (open arrows) along with intrahepatic bile duct dilatation. In addition, there is evidence of tumor extension to the liver parenchyma (solid arrows in c) and the peritoneum (solid arrows in d) as well as tumor growth within intrahepatic ductal branches (arrowheads in c). The diagnosis was confirmed with laparoscopy and biopsy; however, the poor condition of the patient precluded therapeutic intervention.

View larger version (142K): [in a new window]   Figure 3d.   Cholangiocarcinoma arising in a choledochal cyst in a 29-year-old man who presented with jaundice and weight loss. (a, b) Maximum-intensity-projection image (a) and source image (b) from MR cholangiography performed with a 3D fast spin-echo sequence in the coronal plane show a cystic lesion with thick, irregular walls (arrows) as well as intrahepatic bile duct dilatation. Intraductal tumor growth is also noted (arrowhead in b). (c, d) Axial fat-suppressed T2-weighted fast spin-echo MR images (c obtained at a higher level than d) also demonstrate a cystic lesion with thick, irregular walls (open arrows) along with intrahepatic bile duct dilatation. In addition, there is evidence of tumor extension to the liver parenchyma (solid arrows in c) and the peritoneum (solid arrows in d) as well as tumor growth within intrahepatic ductal branches (arrowheads in c). The diagnosis was confirmed with laparoscopy and biopsy; however, the poor condition of the patient precluded therapeutic intervention.

View larger version (104K): [in a new window]   Figure 4a.   Unresectable pancreatic carcinoma in a 71-year-old man. (a) Source image from MR cholangiography performed with a multisection half-Fourier RARE sequence shows marked dilatation of the common bile duct (solid arrow) and pancreatic duct (open arrow) and obstruction in the head of the gland. (b) On an axial T2-weighted fast spin-echo MR image, the tumor is slightly hyperintense (arrow). (c) Axial fat-suppressed T1-weighted spin-echo MR image shows the tumor as hypointense (arrow). Flattening of the lateral margin of the superior mesenteric vein is also noted (arrowhead). Invasion of the vessel was discovered at laparotomy, and the tumor could not be resected.

View larger version (152K): [in a new window]   Figure 4b.   Unresectable pancreatic carcinoma in a 71-year-old man. (a) Source image from MR cholangiography performed with a multisection half-Fourier RARE sequence shows marked dilatation of the common bile duct (solid arrow) and pancreatic duct (open arrow) and obstruction in the head of the gland. (b) On an axial T2-weighted fast spin-echo MR image, the tumor is slightly hyperintense (arrow). (c) Axial fat-suppressed T1-weighted spin-echo MR image shows the tumor as hypointense (arrow). Flattening of the lateral margin of the superior mesenteric vein is also noted (arrowhead). Invasion of the vessel was discovered at laparotomy, and the tumor could not be resected.

View larger version (152K): [in a new window]   Figure 4c.   Unresectable pancreatic carcinoma in a 71-year-old man. (a) Source image from MR cholangiography performed with a multisection half-Fourier RARE sequence shows marked dilatation of the common bile duct (solid arrow) and pancreatic duct (open arrow) and obstruction in the head of the gland. (b) On an axial T2-weighted fast spin-echo MR image, the tumor is slightly hyperintense (arrow). (c) Axial fat-suppressed T1-weighted spin-echo MR image shows the tumor as hypointense (arrow). Flattening of the lateral margin of the superior mesenteric vein is also noted (arrowhead). Invasion of the vessel was discovered at laparotomy, and the tumor could not be resected.

View larger version (82K): [in a new window]   Figure 5a.   Carcinoma of the head of the pancreas in a 74-year-old man. (a) Oblique coronal MR cholangiogram obtained with a single-section half-Fourier RARE sequence shows neoplastic obstruction of the intrapancreatic segment of the common bile duct. The slightly dilated pancreatic duct is not included in the imaging plane with this single-section technique. (b) On a T1-weighted spin-echo MR image, the tumor (arrow) is hypointense relative to normal glandular tissue. (c) Retrograde cholangiogram shows a stent that was placed endoscopically as palliative therapy for jaundice because severe cardiopulmonary disease precluded surgery.

View larger version (142K): [in a new window]   Figure 5b.   Carcinoma of the head of the pancreas in a 74-year-old man. (a) Oblique coronal MR cholangiogram obtained with a single-section half-Fourier RARE sequence shows neoplastic obstruction of the intrapancreatic segment of the common bile duct. The slightly dilated pancreatic duct is not included in the imaging plane with this single-section technique. (b) On a T1-weighted spin-echo MR image, the tumor (arrow) is hypointense relative to normal glandular tissue. (c) Retrograde cholangiogram shows a stent that was placed endoscopically as palliative therapy for jaundice because severe cardiopulmonary disease precluded surgery.

View larger version (150K): [in a new window]   Figure 5c.   Carcinoma of the head of the pancreas in a 74-year-old man. (a) Oblique coronal MR cholangiogram obtained with a single-section half-Fourier RARE sequence shows neoplastic obstruction of the intrapancreatic segment of the common bile duct. The slightly dilated pancreatic duct is not included in the imaging plane with this single-section technique. (b) On a T1-weighted spin-echo MR image, the tumor (arrow) is hypointense relative to normal glandular tissue. (c) Retrograde cholangiogram shows a stent that was placed endoscopically as palliative therapy for jaundice because severe cardiopulmonary disease precluded surgery.

View larger version (164K): [in a new window]   Figure 6.   Pancreatic carcinoma with vascular involvement in a 64-year-old man. Axial fat-suppressed T1-weighted MR image demonstrates tumor tissue extending to the celiac axis and its branches (arrowheads). This finding indicates that the tumor is unresectable.

View larger version (85K): [in a new window]   Figure 7.   Ampullary carcinoma in a 55-year-old woman. Coronal MR cholangiogram obtained with a single-section half-Fourier RARE sequence shows severe dilatation of the biliary tree and obstruction at the level of the ampulla. The obstructing lesion has an irregular surface and shouldered margins (white arrow). Multiple biliary stones are also noted (black arrows). A fungating ampullary mass was discovered at endoscopy, and the patient underwent surgical resection because there was no evidence of either local or distant spread.

View larger version (95K): [in a new window]   Figure 8a.   Gallbladder carcinoma with periportal adenopathy in an 80-year-old woman. (a) Coronal MR cholangiogram obtained with a single-section half-Fourier RARE sequence demonstrates biliary obstruction in the midportion of the common bile duct (solid arrow) as well as the normal distal portion (open arrow). A tumor in the gallbladder fundus appears as an irregular filling defect (arrowheads). (b, c) Axial fat-suppressed T1-weighted spin-echo (b) and T2-weighted fast spin-echo (c) MR images show extensive periportal and peripancreatic lymphadenopathy (curved arrow); these enlarged lymph nodes are the cause of biliary obstruction. The tumor in the gallbladder fundus is seen as nodular wall thickening (arrowhead in c). Multiple gallstones and a large left renal cyst (straight arrow) are also noted. The patient was treated with retrograde stent placement.

View larger version (150K): [in a new window]   Figure 8b.   Gallbladder carcinoma with periportal adenopathy in an 80-year-old woman. (a) Coronal MR cholangiogram obtained with a single-section half-Fourier RARE sequence demonstrates biliary obstruction in the midportion of the common bile duct (solid arrow) as well as the normal distal portion (open arrow). A tumor in the gallbladder fundus appears as an irregular filling defect (arrowheads). (b, c) Axial fat-suppressed T1-weighted spin-echo (b) and T2-weighted fast spin-echo (c) MR images show extensive periportal and peripancreatic lymphadenopathy (curved arrow); these enlarged lymph nodes are the cause of biliary obstruction. The tumor in the gallbladder fundus is seen as nodular wall thickening (arrowhead in c). Multiple gallstones and a large left renal cyst (straight arrow) are also noted. The patient was treated with retrograde stent placement.

View larger version (143K): [in a new window]   Figure 8c.   Gallbladder carcinoma with periportal adenopathy in an 80-year-old woman. (a) Coronal MR cholangiogram obtained with a single-section half-Fourier RARE sequence demonstrates biliary obstruction in the midportion of the common bile duct (solid arrow) as well as the normal distal portion (open arrow). A tumor in the gallbladder fundus appears as an irregular filling defect (arrowheads). (b, c) Axial fat-suppressed T1-weighted spin-echo (b) and T2-weighted fast spin-echo (c) MR images show extensive periportal and peripancreatic lymphadenopathy (curved arrow); these enlarged lymph nodes are the cause of biliary obstruction. The tumor in the gallbladder fundus is seen as nodular wall thickening (arrowhead in c). Multiple gallstones and a large left renal cyst (straight arrow) are also noted. The patient was treated with retrograde stent placement.

View larger version (121K): [in a new window]   Figure 9.   Carcinoma arising in a porcelaneous gallbladder in a 76-year-old woman. Axial fat-suppressed T2-weighted MR image shows hyperintense tumor invading the right lobe of the liver (straight solid arrows) and causing dilatation of the intrahepatic bile ducts (curved arrows). The gallbladder wall (open arrows) is markedly hypointense due to the presence of circumferential calcification. The final diagnosis was confirmed with percutaneous biopsy; however, the patient refused further therapy.

View larger version (120K): [in a new window]   Figure 10a.   Metastatic stomach cancer in a 62-year-old woman who presented with painless jaundice. The patient had a history of partial gastric resection for adenocarcinoma. (a) Maximum-intensity-projection image from MR cholangiography performed with a 3D fast spin-echo sequence shows duct dilatation and obstruction at the level of the proximal common bile duct. Retrograde therapy was unsuccessful, and the patient underwent percutaneous drainage and stent placement. (b) Percutaneous cholangiogram demonstrates duct decompression resulting from successful treatment. Cross-sectional MR images (not shown) demonstrated enlarged periportal lymph nodes, which were considered to be secondary to recurrent stomach cancer.

View larger version (105K): [in a new window]   Figure 10b.   Metastatic stomach cancer in a 62-year-old woman who presented with painless jaundice. The patient had a history of partial gastric resection for adenocarcinoma. (a) Maximum-intensity-projection image from MR cholangiography performed with a 3D fast spin-echo sequence shows duct dilatation and obstruction at the level of the proximal common bile duct. Retrograde therapy was unsuccessful, and the patient underwent percutaneous drainage and stent placement. (b) Percutaneous cholangiogram demonstrates duct decompression resulting from successful treatment. Cross-sectional MR images (not shown) demonstrated enlarged periportal lymph nodes, which were considered to be secondary to recurrent stomach cancer.

View larger version (130K): [in a new window]   Figure 11a.   Bile duct dilatation with hepatolithiasis in a 57-year-old woman with a history of hepaticojejunostomy who presented with severe cholangitis and sepsis. Axial fat-suppressed T2-weighted fast spin-echo MR image (a), maximum-intensity-projection image from 3D fast spin-echo MR imaging (b), and 3D fast spin-echo MR image (c) demonstrate massive dilatation of the intrahepatic bile ducts with multiple biliary stones (straight arrows) and stenosis of the anastomosis (curved arrow in b and c). The patient underwent emergency percutaneous drainage.

View larger version (149K): [in a new window]   Figure 11b.   Bile duct dilatation with hepatolithiasis in a 57-year-old woman with a history of hepaticojejunostomy who presented with severe cholangitis and sepsis. Axial fat-suppressed T2-weighted fast spin-echo MR image (a), maximum-intensity-projection image from 3D fast spin-echo MR imaging (b), and 3D fast spin-echo MR image (c) demonstrate massive dilatation of the intrahepatic bile ducts with multiple biliary stones (straight arrows) and stenosis of the anastomosis (curved arrow in b and c). The patient underwent emergency percutaneous drainage.

View larger version (126K): [in a new window]   Figure 11c.   Bile duct dilatation with hepatolithiasis in a 57-year-old woman with a history of hepaticojejunostomy who presented with severe cholangitis and sepsis. Axial fat-suppressed T2-weighted fast spin-echo MR image (a), maximum-intensity-projection image from 3D fast spin-echo MR imaging (b), and 3D fast spin-echo MR image (c) demonstrate massive dilatation of the intrahepatic bile ducts with multiple biliary stones (straight arrows) and stenosis of the anastomosis (curved arrow in b and c). The patient underwent emergency percutaneous drainage.

View larger version (105K): [in a new window]   Figure 12a.   Bile duct dilatation with hepatolithiasis in a 63-year-old woman with a history of choledochoduodenostomy who developed mild jaundice and pain. Three-dimensional fast spin-echo MR cholangiogram (a) and maximum-intensity-projection image (b) demonstrate dilatation in the left hepatic bile ducts with hepatolithiasis (straight solid arrows). The normal pancreatic duct is also clearly depicted (open arrows in b). Note the hypointense band at the site of the anastomosis (curved arrow in b); this was thought to be secondary to poor duct distensibility and fibrosis at the anastomotic site. Surgical revision of the anastomosis and biliary stone extraction were recommended.

View larger version (125K): [in a new window]   Figure 12b.   Bile duct dilatation with hepatolithiasis in a 63-year-old woman with a history of choledochoduodenostomy who developed mild jaundice and pain. Three-dimensional fast spin-echo MR cholangiogram (a) and maximum-intensity-projection image (b) demonstrate dilatation in the left hepatic bile ducts with hepatolithiasis (straight solid arrows). The normal pancreatic duct is also clearly depicted (open arrows in b). Note the hypointense band at the site of the anastomosis (curved arrow in b); this was thought to be secondary to poor duct distensibility and fibrosis at the anastomotic site. Surgical revision of the anastomosis and biliary stone extraction were recommended.