HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text Full Text (PDF) CME Test (opens in a new window) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Vitellas, K. M. Articles by Nelson, R. C. Search for Related Content PubMed PubMed Citation Articles by Vitellas, K. M. Articles by Nelson, R. C. Related Collections Magnetic Resonance Imaging Gastrointestinal Radiology Related Article

Radiologic Manifestations of Sclerosing Cholangitis with Emphasis on MR Cholangiopancreatography¹

¹ From the Department of Radiology, Ohio State University Medical Center, S-209 Rhodes Hall, 450 W 10th Ave, Columbus, OH 43210 (K.M.V.); the Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (M.T.K.); the Departments of Radiology (K.S.F., C.E.S., R.C.N.) and Gastroenterology (J.M.B.), Duke University Medical Center, Durham, NC; and the Department of Gastroenterology, Saint Paul Medical Center, Vancouver, British Columbia, Canada (R.A.E.). Recipient of a Certificate of Merit award for a scientific exhibit at the 1998 RSNA scientific assembly. Received April 21, 1999; revision requested June 14 and received December 17; accepted December 20. Address correspondence to K.M.V.

View larger version (130K): [in a new window]   Figure 1a.   Normal cholangiographic findings. (a) Coronal thick-section MRCP image shows the anteriorly located common hepatic duct and left bile ducts most clearly. Arrowhead = cystic duct. (b, c) Oblique coronal MRCP images obtained at a shallow angle (b) and a steep angle (c) show the more posteriorly located right bile ducts and distal common bile duct most clearly. Arrowhead = cystic duct, arrows = pancreatic duct.

View larger version (132K): [in a new window]   Figure 1b.   Normal cholangiographic findings. (a) Coronal thick-section MRCP image shows the anteriorly located common hepatic duct and left bile ducts most clearly. Arrowhead = cystic duct. (b, c) Oblique coronal MRCP images obtained at a shallow angle (b) and a steep angle (c) show the more posteriorly located right bile ducts and distal common bile duct most clearly. Arrowhead = cystic duct, arrows = pancreatic duct.

View larger version (136K): [in a new window]   Figure 1c.   Normal cholangiographic findings. (a) Coronal thick-section MRCP image shows the anteriorly located common hepatic duct and left bile ducts most clearly. Arrowhead = cystic duct. (b, c) Oblique coronal MRCP images obtained at a shallow angle (b) and a steep angle (c) show the more posteriorly located right bile ducts and distal common bile duct most clearly. Arrowhead = cystic duct, arrows = pancreatic duct.

View larger version (148K): [in a new window]   Figure 2a.   PSC. (2a) ERCP image shows multifocal strictures and irregularity of the right intrahepatic bile ducts. (2b) Coronal thick-section MRCP image shows multiple strictures of the right posterior branches (arrows); however, the strictures of the peripheral ducts are not demonstrated.

View larger version (143K): [in a new window]   Figure 2b.   PSC. (2a) ERCP image shows multifocal strictures and irregularity of the right intrahepatic bile ducts. (2b) Coronal thick-section MRCP image shows multiple strictures of the right posterior branches (arrows); however, the strictures of the peripheral ducts are not demonstrated.

View larger version (128K): [in a new window]   Figure 3a.   (3a) ERCP image shows multifocal strictures of the extrahepatic bile duct and central ducts, which produce a beaded appearance (arrows). The peripheral ducts could not be opacified. (3b) Coronal thick-section MRCP image does not show the strictures of the extrahepatic bile duct as clearly (arrows). However, the peripheral ducts are demonstrated and are seen to also have strictures.

View larger version (126K): [in a new window]   Figure 3b.   (3a) ERCP image shows multifocal strictures of the extrahepatic bile duct and central ducts, which produce a beaded appearance (arrows). The peripheral ducts could not be opacified. (3b) Coronal thick-section MRCP image does not show the strictures of the extrahepatic bile duct as clearly (arrows). However, the peripheral ducts are demonstrated and are seen to also have strictures.

View larger version (138K): [in a new window]   Figure 4.   PSC. (4) ERCP image shows several strictures of the anterior right hepatic duct alternating with areas of dilatation, thus producing a beaded appearance (arrows). More subtle intrahepatic ductal strictures are noted.

View larger version (119K): [in a new window]   Figure 5.   Coronal thick-section MRCP image shows a high-grade hilar stricture (straight arrow) with proximal dilatation, multifocal intrahepatic strictures and dilatation, and a beaded appearance of the anterior right hepatic duct (curved arrow). In a patient with PSC who develops a focal, high-grade stricture, cholangiocarcinoma should be considered. Bile duct brushings obtained during ERCP showed no tumor in this patient.

View larger version (132K): [in a new window]   Figure 6a.   Early PSC in a 45-year-old man with ulcerative colitis and elevated results of liver function tests. (a) Coronal MRCP image shows a stricture at the distal common bile duct (arrowhead), extrahepatic and left intrahepatic ductal dilatation and irregularity, and a subtle stricture at the bifurcation of the posterior right hepatic duct (arrow). The peripheral ducts intersect with the more central ducts at acute angles. (b) Percutaneous cholangiogram shows similar findings. The stricture at the bifurcation of the posterior right hepatic duct is seen more clearly (arrow).

View larger version (132K): [in a new window]   Figure 6b.   Early PSC in a 45-year-old man with ulcerative colitis and elevated results of liver function tests. (a) Coronal MRCP image shows a stricture at the distal common bile duct (arrowhead), extrahepatic and left intrahepatic ductal dilatation and irregularity, and a subtle stricture at the bifurcation of the posterior right hepatic duct (arrow). The peripheral ducts intersect with the more central ducts at acute angles. (b) Percutaneous cholangiogram shows similar findings. The stricture at the bifurcation of the posterior right hepatic duct is seen more clearly (arrow).

View larger version (122K): [in a new window]   Figure 7a.   PSC in a 24-year-old man with fever. (a) Coronal MRCP image shows multifocal strictures and irregularity of the intrahepatic bile ducts. The left peripheral ducts intersect the central ducts almost at right angles. Note the low and medial insertion of the cystic duct (arrows). (b) ERCP image shows similar findings.

View larger version (127K): [in a new window]   Figure 7b.   PSC in a 24-year-old man with fever. (a) Coronal MRCP image shows multifocal strictures and irregularity of the intrahepatic bile ducts. The left peripheral ducts intersect the central ducts almost at right angles. Note the low and medial insertion of the cystic duct (arrows). (b) ERCP image shows similar findings.

View larger version (125K): [in a new window]   Figure 8a.   PSC in a 67-year-old man with ulcerative colitis and jaundice. (a) Coronal MRCP image does not show the intersegmental bile ducts, an appearance suggestive of strictures. There are random strictures and moderate dilatation of the left intrahepatic bile ducts. Note the choledochojejunostomy (arrow). (b) Percutaneous cholangiogram clearly shows the extent of the PSC because of the ductal distention produced by the contrast material injection.

View larger version (142K): [in a new window]   Figure 8b.   PSC in a 67-year-old man with ulcerative colitis and jaundice. (a) Coronal MRCP image does not show the intersegmental bile ducts, an appearance suggestive of strictures. There are random strictures and moderate dilatation of the left intrahepatic bile ducts. Note the choledochojejunostomy (arrow). (b) Percutaneous cholangiogram clearly shows the extent of the PSC because of the ductal distention produced by the contrast material injection.

View larger version (102K): [in a new window]   Figure 9a.   Advanced PSC. (9a) Coronal MRCP image shows strictures and dilatation of the left main hepatic duct; the left peripheral ducts are not seen. Multifocal strictures of the right central hepatic ducts are noted. (9b) Percutaneous transhepatic cholangiogram shows similar findings. Strictures of the central ducts prevent opacification of the peripheral ducts.

View larger version (200K): [in a new window]   Figure 9b.   Advanced PSC. (9a) Coronal MRCP image shows strictures and dilatation of the left main hepatic duct; the left peripheral ducts are not seen. Multifocal strictures of the right central hepatic ducts are noted. (9b) Percutaneous transhepatic cholangiogram shows similar findings. Strictures of the central ducts prevent opacification of the peripheral ducts.

View larger version (111K): [in a new window]   Figure 10.   Coronal MRCP image shows central ductal strictures and dilatation. At ERCP, the peripheral ducts could not be opacified.

View larger version (132K): [in a new window]   Figure 11.   Webs in a patient with PSC. ERCP image shows multiple webs of the common bile duct (arrowheads).

View larger version (125K): [in a new window]   Figure 12.   Web in a patient with PSC. Coronal MRCP image shows a web of the common hepatic duct (arrowhead).

View larger version (103K): [in a new window]   Figure 13.   Diverticulum. Coronal MRCP image shows a diverticulum of the common bile duct (arrow).

View larger version (146K): [in a new window]   Figure 14.   Diverticula in a patient with PSC. Percutaneous transhepatic cholangiogram shows multiple tiny outpouchings emanating from the mural surface of the extrahepatic and right and left hepatic ducts.

View larger version (112K): [in a new window]   Figure 15a.   Diverticulum in a patient with PSC. (a) Coronal MRCP image shows a diverticulum arising from the anterior right hepatic duct (arrow). The diverticulum contains a filling defect, which is compatible with a calculus. (b) Longitudinal ultrasonographic (US) scan shows the calculus surrounded by bile in the diverticulum. The diverticulum could not be filled at ERCP because of a high-grade stricture at the neck of the diverticulum (not shown).

View larger version (128K): [in a new window]   Figure 15b.   Diverticulum in a patient with PSC. (a) Coronal MRCP image shows a diverticulum arising from the anterior right hepatic duct (arrow). The diverticulum contains a filling defect, which is compatible with a calculus. (b) Longitudinal ultrasonographic (US) scan shows the calculus surrounded by bile in the diverticulum. The diverticulum could not be filled at ERCP because of a high-grade stricture at the neck of the diverticulum (not shown).

View larger version (124K): [in a new window]   Figure 16.   Stones in a patient with PSC. Coronal MRCP image shows intrahepatic and extrahepatic ductal dilatation due to a stricture at a choledochojejunostomy (bottom arrow). Note the stones in the left hepatic duct (top arrows).

View larger version (119K): [in a new window]   Figure 17a.   Cholangiocarcinoma. (a) Coronal single-shot fast spin-echo MR image (echo time, 90 msec) shows ill-defined high signal intensity at the porta hepatis and in the right periductal region (arrowheads). The common bile duct could not be identified. (b) Coronal MRCP image (echo time, 890 msec) shows an obstructing hilar stricture (arrow) with proximal ductal dilatation. (c) Axial fast spoiled gradient-echo MR image obtained 10 minutes after administration of gadolinium contrast material shows periductal enhancement (arrows). Brush cytologic biopsy during ERCP revealed cholangiocarcinoma.

View larger version (162K): [in a new window]   Figure 17b.   Cholangiocarcinoma. (a) Coronal single-shot fast spin-echo MR image (echo time, 90 msec) shows ill-defined high signal intensity at the porta hepatis and in the right periductal region (arrowheads). The common bile duct could not be identified. (b) Coronal MRCP image (echo time, 890 msec) shows an obstructing hilar stricture (arrow) with proximal ductal dilatation. (c) Axial fast spoiled gradient-echo MR image obtained 10 minutes after administration of gadolinium contrast material shows periductal enhancement (arrows). Brush cytologic biopsy during ERCP revealed cholangiocarcinoma.

View larger version (142K): [in a new window]   Figure 17c.   Cholangiocarcinoma. (a) Coronal single-shot fast spin-echo MR image (echo time, 90 msec) shows ill-defined high signal intensity at the porta hepatis and in the right periductal region (arrowheads). The common bile duct could not be identified. (b) Coronal MRCP image (echo time, 890 msec) shows an obstructing hilar stricture (arrow) with proximal ductal dilatation. (c) Axial fast spoiled gradient-echo MR image obtained 10 minutes after administration of gadolinium contrast material shows periductal enhancement (arrows). Brush cytologic biopsy during ERCP revealed cholangiocarcinoma.

View larger version (134K): [in a new window]   Figure 18a.   Cholangiocarcinoma. (a, b) Coronal (a) and axial (b) single-shot fast spin-echo MR images (echo time, 90 msec) show ill-defined high signal intensity in the extrahepatic and proximal intrahepatic periductal areas (arrows). (c-e) Axial fast spoiled gradient-echo MR images obtained 1 minute (c), 3 minutes (d), and 10 minutes (e) after administration of gadolinium contrast material show progressive abnormal enhancement of the porta hepatis (arrows). (f) Percutaneous transhepatic cholangiogram shows an irregular high-grade stenosis with shouldered margins in the common hepatic duct (arrows). Note the multifocal intrahepatic strictures and dilatations, which are compatible with PSC. Brush cytologic biopsy revealed cholangiocarcinoma.

View larger version (142K): [in a new window]   Figure 18b.   Cholangiocarcinoma. (a, b) Coronal (a) and axial (b) single-shot fast spin-echo MR images (echo time, 90 msec) show ill-defined high signal intensity in the extrahepatic and proximal intrahepatic periductal areas (arrows). (c-e) Axial fast spoiled gradient-echo MR images obtained 1 minute (c), 3 minutes (d), and 10 minutes (e) after administration of gadolinium contrast material show progressive abnormal enhancement of the porta hepatis (arrows). (f) Percutaneous transhepatic cholangiogram shows an irregular high-grade stenosis with shouldered margins in the common hepatic duct (arrows). Note the multifocal intrahepatic strictures and dilatations, which are compatible with PSC. Brush cytologic biopsy revealed cholangiocarcinoma.

View larger version (146K): [in a new window]   Figure 18c.   Cholangiocarcinoma. (a, b) Coronal (a) and axial (b) single-shot fast spin-echo MR images (echo time, 90 msec) show ill-defined high signal intensity in the extrahepatic and proximal intrahepatic periductal areas (arrows). (c-e) Axial fast spoiled gradient-echo MR images obtained 1 minute (c), 3 minutes (d), and 10 minutes (e) after administration of gadolinium contrast material show progressive abnormal enhancement of the porta hepatis (arrows). (f) Percutaneous transhepatic cholangiogram shows an irregular high-grade stenosis with shouldered margins in the common hepatic duct (arrows). Note the multifocal intrahepatic strictures and dilatations, which are compatible with PSC. Brush cytologic biopsy revealed cholangiocarcinoma.

View larger version (139K): [in a new window]   Figure 18d.   Cholangiocarcinoma. (a, b) Coronal (a) and axial (b) single-shot fast spin-echo MR images (echo time, 90 msec) show ill-defined high signal intensity in the extrahepatic and proximal intrahepatic periductal areas (arrows). (c-e) Axial fast spoiled gradient-echo MR images obtained 1 minute (c), 3 minutes (d), and 10 minutes (e) after administration of gadolinium contrast material show progressive abnormal enhancement of the porta hepatis (arrows). (f) Percutaneous transhepatic cholangiogram shows an irregular high-grade stenosis with shouldered margins in the common hepatic duct (arrows). Note the multifocal intrahepatic strictures and dilatations, which are compatible with PSC. Brush cytologic biopsy revealed cholangiocarcinoma.

View larger version (138K): [in a new window]   Figure 18e.   Cholangiocarcinoma. (a, b) Coronal (a) and axial (b) single-shot fast spin-echo MR images (echo time, 90 msec) show ill-defined high signal intensity in the extrahepatic and proximal intrahepatic periductal areas (arrows). (c-e) Axial fast spoiled gradient-echo MR images obtained 1 minute (c), 3 minutes (d), and 10 minutes (e) after administration of gadolinium contrast material show progressive abnormal enhancement of the porta hepatis (arrows). (f) Percutaneous transhepatic cholangiogram shows an irregular high-grade stenosis with shouldered margins in the common hepatic duct (arrows). Note the multifocal intrahepatic strictures and dilatations, which are compatible with PSC. Brush cytologic biopsy revealed cholangiocarcinoma.

View larger version (122K): [in a new window]   Figure 18f.   Cholangiocarcinoma. (a, b) Coronal (a) and axial (b) single-shot fast spin-echo MR images (echo time, 90 msec) show ill-defined high signal intensity in the extrahepatic and proximal intrahepatic periductal areas (arrows). (c-e) Axial fast spoiled gradient-echo MR images obtained 1 minute (c), 3 minutes (d), and 10 minutes (e) after administration of gadolinium contrast material show progressive abnormal enhancement of the porta hepatis (arrows). (f) Percutaneous transhepatic cholangiogram shows an irregular high-grade stenosis with shouldered margins in the common hepatic duct (arrows). Note the multifocal intrahepatic strictures and dilatations, which are compatible with PSC. Brush cytologic biopsy revealed cholangiocarcinoma.

View larger version (122K): [in a new window]   Figure 19a.   Cholangiocarcinoma. (a) Coronal MRCP image shows a stricture at the hepatic hilum with mild intrahepatic ductal dilatation, nonvisualization of the right hepatic duct, and nodularity of the left hepatic duct. The increased signal intensity in the periductal areas (arrows) suggests cholangiocarcinoma or periportal edema. (b) Gadolinium-enhanced axial fat-saturated T1-weighted spin-echo MR image shows enhancement of the periductal areas (arrows), a finding compatible with a tumor.

View larger version (152K): [in a new window]   Figure 19b.   Cholangiocarcinoma. (a) Coronal MRCP image shows a stricture at the hepatic hilum with mild intrahepatic ductal dilatation, nonvisualization of the right hepatic duct, and nodularity of the left hepatic duct. The increased signal intensity in the periductal areas (arrows) suggests cholangiocarcinoma or periportal edema. (b) Gadolinium-enhanced axial fat-saturated T1-weighted spin-echo MR image shows enhancement of the periductal areas (arrows), a finding compatible with a tumor.

View larger version (118K): [in a new window]   Figure 20.   Ascending cholangitis in a 50-year-old man with fever and jaundice 6 months after cholecystectomy. ERCP image shows a common bile duct stricture (arrow), a result of iatrogenic injury at surgery, and multifocal intrahepatic bile duct strictures and dilatation.

View larger version (147K): [in a new window]   Figure 21a.   Oriental cholangiohepatitis. (a, b) Coronal thick-section (a) and maximum-intensity projection (b) MRCP images show a stricture of the extrahepatic bile duct (arrow) and multiple strictures of the central intrahepatic bile ducts, with fusiform dilatation of the peripheral ducts forming bile lakes (cholangiectasis). (c) Percutaneous transhepatic cholangiogram partially shows the peripheral ductal abnormalities. Arrow = extrahepatic bile duct stricture. Analysis of the bile showed C sinensis, and brush cytologic biopsy of the extrahepatic bile duct stricture revealed cholangiocarcinoma.

View larger version (135K): [in a new window]   Figure 21b.   Oriental cholangiohepatitis. (a, b) Coronal thick-section (a) and maximum-intensity projection (b) MRCP images show a stricture of the extrahepatic bile duct (arrow) and multiple strictures of the central intrahepatic bile ducts, with fusiform dilatation of the peripheral ducts forming bile lakes (cholangiectasis). (c) Percutaneous transhepatic cholangiogram partially shows the peripheral ductal abnormalities. Arrow = extrahepatic bile duct stricture. Analysis of the bile showed C sinensis, and brush cytologic biopsy of the extrahepatic bile duct stricture revealed cholangiocarcinoma.

View larger version (130K): [in a new window]   Figure 21c.   Oriental cholangiohepatitis. (a, b) Coronal thick-section (a) and maximum-intensity projection (b) MRCP images show a stricture of the extrahepatic bile duct (arrow) and multiple strictures of the central intrahepatic bile ducts, with fusiform dilatation of the peripheral ducts forming bile lakes (cholangiectasis). (c) Percutaneous transhepatic cholangiogram partially shows the peripheral ductal abnormalities. Arrow = extrahepatic bile duct stricture. Analysis of the bile showed C sinensis, and brush cytologic biopsy of the extrahepatic bile duct stricture revealed cholangiocarcinoma.

View larger version (144K): [in a new window]   Figure 22.   AIDS-related cholangitis in a 25-year-old man with human immunodeficiency virus infection and obstructive jaundice. Coronal MRCP image shows an obstructing stricture of the distal common bile duct (arrow) with proximal ductal dilatation. Cryptosporidium was isolated from the bile ducts.

View larger version (153K): [in a new window]   Figure 23.   AIDS-related cholangitis in a patient with human immunodeficiency virus infection. ERCP image shows strictures and irregularity of the intrahepatic bile ducts. Both cytomegalovirus and Cryptosporidium were found in the bile.

View larger version (115K): [in a new window]   Figure 24.   Floxuridine-induced cholangitis in a 64-year-old woman with jaundice who was treated with intraarterial floxuridine for metastatic colon cancer. Coronal MRCP image shows common hepatic duct and hilar strictures with proximal ductal dilatation. CT showed no evidence of hepatic metastases or hilar lymphadenopathy.

View larger version (105K): [in a new window]   Figure 25a.   Ischemic cholangitis in a 38-year-old man who developed jaundice 5 days after liver transplantation for PSC. (a) Coronal MRCP image shows random strictures throughout the biliary tree with minimal multifocal intrahepatic ductal dilatation. (b) T-tube cholangiogram shows similar findings. Doppler US showed a tardus-parvus waveform suggestive of a proximal arterial stenosis (not shown), and a hepatic arteriogram showed a high-grade stenosis of the hepatic artery (not shown).

View larger version (145K): [in a new window]   Figure 25b.   Ischemic cholangitis in a 38-year-old man who developed jaundice 5 days after liver transplantation for PSC. (a) Coronal MRCP image shows random strictures throughout the biliary tree with minimal multifocal intrahepatic ductal dilatation. (b) T-tube cholangiogram shows similar findings. Doppler US showed a tardus-parvus waveform suggestive of a proximal arterial stenosis (not shown), and a hepatic arteriogram showed a high-grade stenosis of the hepatic artery (not shown).

View larger version (116K): [in a new window]   Figure 26.   Eosinophilic cholangitis in a 42-year-old woman with jaundice and eosinophilia. Coronal MRCP image shows subtle intrahepatic ductal irregularity. Note the peripheral ducts intersecting at right angles, which suggest an inflammatory process. The symptoms rapidly resolved after corticosteroid therapy.

View larger version (176K): [in a new window]   Figure 27a.   Hepatic metastases in a 65-year-old man with gastric cancer who presented with jaundice. (a) ERCP image shows multiple intrahepatic and extrahepatic ductal strictures, an appearance that mimics PSC. (b) CT scan shows multiple hepatic metastases and lymphadenopathy of the porta hepatis and portacaval region.

View larger version (146K): [in a new window]   Figure 27b.   Hepatic metastases in a 65-year-old man with gastric cancer who presented with jaundice. (a) ERCP image shows multiple intrahepatic and extrahepatic ductal strictures, an appearance that mimics PSC. (b) CT scan shows multiple hepatic metastases and lymphadenopathy of the porta hepatis and portacaval region.