DOI: 10.1148/rg.266055730
Normal and Pathologic Features of the Postoperative Biliary Tract at 3D MR Cholangiopancreatography and MR Imaging1
Christine Hoeffel, MD,
Louisa Azizi, MD,
Maité Lewin, MD, PhD,
Valérie Laurent, MD,
Christophe Aubé, MD,
Lionel Arrivé, MD and
Jean-Michel Tubiana, MD
1 From the Department of Radiology, Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75571 Paris Cedex 12, France (C.H., L.A., M.L., L.A., J.M.T.), and Université Paris–Descartes, Faculté de médecine Cochin–Port-Royal, Paris, France (C.H.); Department of Radiology, CHU Nancy-Brabois, Vandoeuvre-lès-Nancy, France (V.L.); and Department of Radiology, CHU Angers, Angers, France (C.A.). Presented as an education exhibit at the 2005 RSNA Annual Meeting. Received October 28, 2005; revision requested February 24, 2006; revision received and accepted April 17. All authors have no financial relationships to disclose.
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Figure 1. Normal biliary ductal anatomy in a 45-year-old man after cholecystectomy. Coronal MIP image from a 3D respiratory-triggered T2-weighted fast SE restore MR imaging data set shows a high insertion of the cystic duct (arrow).
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Figure 2. Normal postoperative appearance after liver transplantation with a duct-to-duct anastomosis. Coronal MIP image from a 3D respiratory-triggered T2-weighted fast SE restore data set shows two cystic duct remnants (straight arrows) and the anastomosis (curved arrow), through which a T tube has been placed.
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Figure 3. Size disjuncture between donor and recipient common bile ducts in a 60-year-old man with a liver transplant. Coronal MIP image from a 3D respiratory-triggered T2-weighted fast SE restore data set shows that the recipient common bile duct (curved arrow) has a larger diameter than that of the donor (arrowhead). The liver function is normal, and the intrahepatic ducts are not dilated. Note the two cystic duct remnants (straight arrows).
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Figure 4. Normal duct-to-duct anastomosis in a 56-year-old man 5 years after orthotopic liver transplantation. Coronal MIP image from a 3D respiratory-triggered T2-weighted fast SE restore data set shows a tortuous course of both the donor duct and the recipient duct, with kinking at the site of the anastomosis (arrow). Note the long parallel cystic duct remnant (arrowhead).
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Figure 5. Normal Roux-en-Y anastomosis in a 70-year-old man after a Whipple procedure for pancreatic carcinoma. Coronal reformatted image from a 3D respiratory-triggered T2-weighted fast SE restore data set shows a short segment of the common hepatic duct anastomosed to the jejunal loop (arrows), with no cystic duct remnant. Note the trifurcation of the biliary duct.
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Figure 6. Biliary-enteric anastomosis in a 30-year-old man who underwent resection of a choledochal cyst in childhood. Coronal MIP image from a 3D respiratory-triggered T2-weighted fast SE restore data set depicts a normal three-way anastomosis between a jejunal loop (straight arrow) and the left hepatic duct (arrowhead) and right posterior and anterior ducts (curved arrows).
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Figure 7a. Residual calculus in a 71-year-old woman after cholecystectomy. (a) Coronal MIP image from a 3D respiratory-triggered T2-weighted fast SE restore data set shows slight dilatation of the intrahepatic bile ducts but does not clearly depict the distal part of the common bile duct (arrows). The round or oval high-signal-intensity structures are cysts in the liver. (b) Thin-section source image obtained with the 3D fast SE restore sequence shows, much more clearly than in a, a filling defect with hypointense signal suggestive of a stone in the distal part of the common bile duct (arrow). (c) Axial free-breathing T2-weighted HASTE image shows a round low-signal-intensity structure (arrow) surrounded by high-signal-intensity fluid in the distal part of the common bile duct.
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Figure 7b. Residual calculus in a 71-year-old woman after cholecystectomy. (a) Coronal MIP image from a 3D respiratory-triggered T2-weighted fast SE restore data set shows slight dilatation of the intrahepatic bile ducts but does not clearly depict the distal part of the common bile duct (arrows). The round or oval high-signal-intensity structures are cysts in the liver. (b) Thin-section source image obtained with the 3D fast SE restore sequence shows, much more clearly than in a, a filling defect with hypointense signal suggestive of a stone in the distal part of the common bile duct (arrow). (c) Axial free-breathing T2-weighted HASTE image shows a round low-signal-intensity structure (arrow) surrounded by high-signal-intensity fluid in the distal part of the common bile duct.
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Figure 7c. Residual calculus in a 71-year-old woman after cholecystectomy. (a) Coronal MIP image from a 3D respiratory-triggered T2-weighted fast SE restore data set shows slight dilatation of the intrahepatic bile ducts but does not clearly depict the distal part of the common bile duct (arrows). The round or oval high-signal-intensity structures are cysts in the liver. (b) Thin-section source image obtained with the 3D fast SE restore sequence shows, much more clearly than in a, a filling defect with hypointense signal suggestive of a stone in the distal part of the common bile duct (arrow). (c) Axial free-breathing T2-weighted HASTE image shows a round low-signal-intensity structure (arrow) surrounded by high-signal-intensity fluid in the distal part of the common bile duct.
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Figure 8. Hematoma in the gallbladder fossa in a 55-year-old man after cholecystectomy. Axial T1-weighted fat-suppressed volumetric interpolated breath-hold image shows a hypointense fluid collection with an internal peripheral rim of high signal intensity in the gallbladder bed, features suggestive of a hematoma (arrows). The biliary tree is intact.
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Figure 9a. Hemobilia after a percutaneous liver biopsy in a 26-year-old man with a liver transplant. (a) Coronal MIP image from a 3D respiratory-triggered T2-weighted fast SE restore data set, obtained 3 days after the biopsy, demonstrates irregular filling defects in the dilated bile ducts (arrowheads) with an intact duct-to-duct anastomosis (arrow) and an intact recipient duct. (b) Axial T1-weighted gradient-recalled-echo MR image shows a curvilinear area of high signal intensity (arrow) along the dilated bile ducts, a finding suggestive of hemobilia. (c) Coronal MIP image from a 3D respiratory-triggered T2-weighted fast SE restore data set, obtained 5 months after the diagnosis of hemobilia, depicts multiple intrahepatic ducts with focal areas of mild dilatation (straight arrows) as well as small biliary lakes (arrowheads), findings suggestive of diffuse cholangitis and bile duct necrosis, which were confirmed at surgery. The recipient duct (curved arrow) appears normal.
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Figure 9b. Hemobilia after a percutaneous liver biopsy in a 26-year-old man with a liver transplant. (a) Coronal MIP image from a 3D respiratory-triggered T2-weighted fast SE restore data set, obtained 3 days after the biopsy, demonstrates irregular filling defects in the dilated bile ducts (arrowheads) with an intact duct-to-duct anastomosis (arrow) and an intact recipient duct. (b) Axial T1-weighted gradient-recalled-echo MR image shows a curvilinear area of high signal intensity (arrow) along the dilated bile ducts, a finding suggestive of hemobilia. (c) Coronal MIP image from a 3D respiratory-triggered T2-weighted fast SE restore data set, obtained 5 months after the diagnosis of hemobilia, depicts multiple intrahepatic ducts with focal areas of mild dilatation (straight arrows) as well as small biliary lakes (arrowheads), findings suggestive of diffuse cholangitis and bile duct necrosis, which were confirmed at surgery. The recipient duct (curved arrow) appears normal.
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Figure 9c. Hemobilia after a percutaneous liver biopsy in a 26-year-old man with a liver transplant. (a) Coronal MIP image from a 3D respiratory-triggered T2-weighted fast SE restore data set, obtained 3 days after the biopsy, demonstrates irregular filling defects in the dilated bile ducts (arrowheads) with an intact duct-to-duct anastomosis (arrow) and an intact recipient duct. (b) Axial T1-weighted gradient-recalled-echo MR image shows a curvilinear area of high signal intensity (arrow) along the dilated bile ducts, a finding suggestive of hemobilia. (c) Coronal MIP image from a 3D respiratory-triggered T2-weighted fast SE restore data set, obtained 5 months after the diagnosis of hemobilia, depicts multiple intrahepatic ducts with focal areas of mild dilatation (straight arrows) as well as small biliary lakes (arrowheads), findings suggestive of diffuse cholangitis and bile duct necrosis, which were confirmed at surgery. The recipient duct (curved arrow) appears normal.
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Figure 10a. Excision injury of a right anterior bile duct in a 24-year-old woman with abdominal pain and fever 6 days after a laparoscopic cholecystectomy. (a) Coronal MIP image from a 3D respiratory-triggered T2-weighted fast SE restore data set shows a mildly dilated and discontinuous right anterior duct (straight arrow) with a bile leak (arrowhead) that was treated with surgical drainage. Note that the right posterior duct is connected with the left hepatic duct (curved arrow). (b) Coronal MIP image from a 3D respiratory-triggered T2-weighted fast SE restore data set obtained 1 month later shows dilatation of the discontinuous right anterior bile duct (arrow), a finding compatible with stricture due to scarring.
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Figure 10b. Excision injury of a right anterior bile duct in a 24-year-old woman with abdominal pain and fever 6 days after a laparoscopic cholecystectomy. (a) Coronal MIP image from a 3D respiratory-triggered T2-weighted fast SE restore data set shows a mildly dilated and discontinuous right anterior duct (straight arrow) with a bile leak (arrowhead) that was treated with surgical drainage. Note that the right posterior duct is connected with the left hepatic duct (curved arrow). (b) Coronal MIP image from a 3D respiratory-triggered T2-weighted fast SE restore data set obtained 1 month later shows dilatation of the discontinuous right anterior bile duct (arrow), a finding compatible with stricture due to scarring.
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Figure 11. Bile leak due to displacement of a T tube in a 57-year-old man after an orthotopic liver transplantation. Coronal MIP image from a 3D respiratory-triggered T2-weighted fast SE restore data set shows a bile leak (arrows) along the T tube.
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Figure 12. Biliary leak through a drain placed in the subhepatic area 3 days after a complex duodenal surgery in a 50-year-old man. Coronal MIP image from a 3D respiratory-triggered T2-weighted fast SE restore data set demonstrates a leak from a branch of the right anterior bile duct (arrow) and a biloma (arrowhead).
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Figure 13. Partial tear of the common hepatic duct in a 30-year-old woman with abdominal pain and fever 7 days after a laparoscopic cholecystectomy. Coronal MIP image obtained with a volumetric interpolated breath-hold fat-saturated T1-weighted sequence 1 hour after the intravenous administration of mangafodipir trisodium shows an intact biliary tract with discrete narrowing of the common hepatic duct (straight arrow) and a subhepatic fluid collection (curved arrow) that consists of bile.
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Figure 14a. Biloma in a 30-year-old woman after a laparoscopic cholecystectomy. (a) Axial T2-weighted single-shot fast SE MR image shows a small fluid collection with high signal intensity (arrows). (b) Axial T2-weighted single-shot fast SE MR image, acquired 30 minutes after an injection of mangafodipir trisodium, shows extravasated contrast material as a localized pocket of low signal intensity (arrow) within the high-signal-intensity fluid collection, which represents bile.
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Figure 14b. Biloma in a 30-year-old woman after a laparoscopic cholecystectomy. (a) Axial T2-weighted single-shot fast SE MR image shows a small fluid collection with high signal intensity (arrows). (b) Axial T2-weighted single-shot fast SE MR image, acquired 30 minutes after an injection of mangafodipir trisodium, shows extravasated contrast material as a localized pocket of low signal intensity (arrow) within the high-signal-intensity fluid collection, which represents bile.
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Figure 15. Aberrant right hepatic duct in a 40-year-old woman. Coronal MIP image from a 3D respiratory-triggered T2-weighted fast SE restore data set demonstrates an aberrant right posterior duct (arrows) with a low insertion in the common hepatic duct.
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Figure 16. Variant biliary anatomy in a 45-year-old man. Coronal MIP image from a 3D respiratory-triggered T2-weighted fast SE restore data set shows a long cystic duct that parallels and has a rather low insertion in the common hepatic duct (arrows).
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Figure 17a. Surgically proved Bismuth type III excision injury with ligation in a 50-year-old woman with right upper quadrant pain and jaundice 3 days after a laparoscopic cholecystectomy. (a) Coronal breath-hold RARE image (20-mm-thick section) shows moderate intrahepatic ductal dilatation, a ductal cutoff due to ligation by a thread just below the biliary confluence, and a bile leak (arrowheads). A 1.5-cm-long segment of the extrahepatic duct is not visible (arrows), a finding suggestive of excision injury. (b) ERCP image shows an abrupt cutoff (arrowhead) of the distal part of the bile duct and contrast material extravasation indicative of bile leakage along a surgically placed drainage tube (arrows).
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Figure 17b. Surgically proved Bismuth type III excision injury with ligation in a 50-year-old woman with right upper quadrant pain and jaundice 3 days after a laparoscopic cholecystectomy. (a) Coronal breath-hold RARE image (20-mm-thick section) shows moderate intrahepatic ductal dilatation, a ductal cutoff due to ligation by a thread just below the biliary confluence, and a bile leak (arrowheads). A 1.5-cm-long segment of the extrahepatic duct is not visible (arrows), a finding suggestive of excision injury. (b) ERCP image shows an abrupt cutoff (arrowhead) of the distal part of the bile duct and contrast material extravasation indicative of bile leakage along a surgically placed drainage tube (arrows).
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Figure 18. Surgically proved Bismuth type II excision injury with ligation after a laparoscopic cholecystectomy. Coronal MIP image from a 3D respiratory-triggered T2-weighted fast SE restore data set, obtained 1 month after cholecystectomy, shows marked intrahepatic biliary dilatation and a cutoff due to a ligation injury 1 cm distal to the biliary confluence. A 1-cm-long extrahepatic duct segment is not depicted (arrowheads). Note the low insertion site of the right anterior duct in the confluence, at the uppermost point of the hepatic duct (arrow).
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Figure 19. Surgically confirmed Bismuth type III excision injury in a 53-year-old woman after a laparoscopic cholecystectomy. Coronal MIP image from a 3D respiratory-triggered T2-weighted fast SE restore data set shows moderate dilatation of the intrahepatic ducts, a cutoff of the common hepatic duct 1 cm below the biliary confluence (thin straight arrow), and a biloma (arrowheads). The distal common bile duct (thick straight arrow) is visible. Drainage of the bile duct is under way through a T tube inserted through the ductal section (curved arrow). Note the low insertion of the right anterior duct. The oval high-signal-intensity structures are cysts in the liver.
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Figure 20. Stenosis of the papilla after resection of a villous tumor of the papilla and papillotomy in a 55-year-old woman. Coronal MIP image from a 3D respiratory-triggered T2-weighted fast SE restore data set demonstrates dilatation of the main pancreatic duct (straight arrows), subtle irregular narrowing of the distal portion of the common bile duct (curved arrow), and mild dilatation of the common bile duct because of scar formation. The oval high-signal-intensity structures are cysts in the liver.
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Figure 21a. Surgically confirmed high-grade stricture of a biliary-enteric anastomosis created for treatment of biliary tract trauma in an 18-year-old man. (a) Coronal oblique RARE MR cholangiographic image (20-mm-thick section) clearly depicts a high-grade stricture of the anastomosis (arrow) with very slight dilatation of the common hepatic duct (8 mm) and normal intrahepatic ducts. (b) Corresponding percutaneous transhepatic cholangiogram helps confirm the high-grade stricture (arrow).
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Figure 21b. Surgically confirmed high-grade stricture of a biliary-enteric anastomosis created for treatment of biliary tract trauma in an 18-year-old man. (a) Coronal oblique RARE MR cholangiographic image (20-mm-thick section) clearly depicts a high-grade stricture of the anastomosis (arrow) with very slight dilatation of the common hepatic duct (8 mm) and normal intrahepatic ducts. (b) Corresponding percutaneous transhepatic cholangiogram helps confirm the high-grade stricture (arrow).
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Figure 22. Surgically confirmed stenosis of a duct-to-duct anastomosis in a 39-year-old man 3 months after an orthotopic liver transplantation for hepatocellular carcinoma. Sagittal oblique RARE MR cholangiographic image (20-mm-thick section) shows dilatation of the donor bile duct (straight arrow) and does not clearly depict the anastomosis. A fistula is visible at the site of the anastomosis, and there is a small fluid collection that represents a biloma (arrowheads) anterior to the anastomosis. The distal native common bile duct (curved arrow) also is visible.
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Figure 23. Surgically confirmed nonanastomotic ischemic stricture in a 50-year-old woman with jaundice and abnormal liver function 2 years after a right hepatic lobe transplantation and choledochocholedochostomy and 1 year after stent placement for anastomotic stenosis and hepatic artery thrombosis. Coronal MIP image from a 3D respiratory-triggered T2-weighted fast SE restore data set shows a hilar stricture (straight arrow) with mild dilatation of the intrahepatic ducts and a moderate stricture of the duct-to-duct anastomosis (curved arrow). Note the slight distention of the left hepatic duct remnant (arrowhead). Surgical treatment involved the creation of a biliary-enteric anastomosis between two bile ducts and a jejunal loop.
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Figure 24a. Nonanastomotic ischemic stenosis complicated by cholangitis, abscesses, and stones in a 66-year-old man 2 years after an orthotopic liver transplantation. (a) Three-dimensional volumetric MR cholangiographic image shows stones and ductal dilatation (arrowhead) above a high-grade stricture in the left hepatic duct (straight arrow). Abscesses (curved arrows) caused by cholangitis also are visible. (b) Percutaneous transhepatic cholangiogram helps confirm the presence of a high-grade stricture of the left main duct (arrow) and a stone (arrowhead) above the stricture.
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Figure 24b. Nonanastomotic ischemic stenosis complicated by cholangitis, abscesses, and stones in a 66-year-old man 2 years after an orthotopic liver transplantation. (a) Three-dimensional volumetric MR cholangiographic image shows stones and ductal dilatation (arrowhead) above a high-grade stricture in the left hepatic duct (straight arrow). Abscesses (curved arrows) caused by cholangitis also are visible. (b) Percutaneous transhepatic cholangiogram helps confirm the presence of a high-grade stricture of the left main duct (arrow) and a stone (arrowhead) above the stricture.
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Figure 25. Surgically confirmed high-grade stricture of a choledochoduodenal anastomosis in a 70-year-old woman 8 years after treatment for choledocholithiasis. Thin-section source image obtained with the 3D fast SE restore sequence demonstrates a hypointense filling defect (straight arrow) suggestive of a stone above the tightly constricted hepaticoduodenal anastomosis (curved arrow).
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Figure 26. Ischemic stricture due to a pseudoaneurysm with ligation of the hepatic artery during a Whipple procedure for pancreatic carcinoma in a 54-year-old patient. Coronal MIP image from a 3D respiratory-triggered T2-weighted fast SE restore data set demonstrates a long regular stricture in the common hepatic duct and at the origin of the left and right bile ducts (arrow) and moderate dilatation of the intrahepatic ducts. The arrowhead indicates a jejunal loop. A hepaticojejunal anastomosis is not visible.
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Figure 27a. Tumor recurrence in a 70-year-old man 1 year after a Whipple procedure for a pancreatic adenocarcinoma. (a) Coronal MIP image from a 3D respiratory-triggered T2-weighted fast SE restore data set shows dilatation of jejunal loops (straight arrows) and intrahepatic bile ducts and narrowing of the bile duct at the confluence (curved arrow). The anastomosis is not visible. (b) Axial T2-weighted fat-suppressed HASTE MR image shows an ill-defined high-signal-intensity hilar metastasis (arrows) from pancreatic adenocarcinoma, which extrinsically compresses the biliary confluence.
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Figure 27b. Tumor recurrence in a 70-year-old man 1 year after a Whipple procedure for a pancreatic adenocarcinoma. (a) Coronal MIP image from a 3D respiratory-triggered T2-weighted fast SE restore data set shows dilatation of jejunal loops (straight arrows) and intrahepatic bile ducts and narrowing of the bile duct at the confluence (curved arrow). The anastomosis is not visible. (b) Axial T2-weighted fat-suppressed HASTE MR image shows an ill-defined high-signal-intensity hilar metastasis (arrows) from pancreatic adenocarcinoma, which extrinsically compresses the biliary confluence.
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Figure 28. Stone formation near a biliary-enteric anastomosis in a 65-year-old woman after surgical treatment for choledocholithiasis. Coronal breath-hold RARE MR image (20-mm-thick section) shows a patent hepaticojejunal anastomosis (straight arrows) with filling defects in the common hepatic duct and right hepatic duct and at the origin of the left hepatic duct (curved arrows) and residual calculi in the common bile duct (arrowhead). The patency of the hepaticojejunal anastomosis and the presence of multiple stones were confirmed at surgery.
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Figure 29a. Pneumobilia after sphincterotomy. (a) Axial T2-weighted HASTE MR image shows linear areas of low signal intensity anterior to the segmental portal veins to hepatic segments II and III (arrows). (b) Coronal MIP image from a 3D respiratory-triggered T2-weighted fast SE restore data set shows the apparent absence of the bile duct to hepatic segment III (arrows). The duct was not visible at MR cholangiopancreatography because it was filled with air.
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Figure 29b. Pneumobilia after sphincterotomy. (a) Axial T2-weighted HASTE MR image shows linear areas of low signal intensity anterior to the segmental portal veins to hepatic segments II and III (arrows). (b) Coronal MIP image from a 3D respiratory-triggered T2-weighted fast SE restore data set shows the apparent absence of the bile duct to hepatic segment III (arrows). The duct was not visible at MR cholangiopancreatography because it was filled with air.
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Figure 30a. Cholangitis and secondary infection in a 41-year-old woman after common bile duct injury during a laparoscopic cholecystectomy. (a) Coronal MIP image from a 3D respiratory-triggered T2-weighted fast SE restore data set shows multiple intrahepatic bile duct strictures with irregular mild dilatation of the right intrahepatic ducts and discontinuity of the right bile ducts (straight arrows). An anastomosis (curved arrow) between the left bile duct and a jejunal loop is clearly depicted. (b) Axial T2-weighted HASTE MR image shows atrophy of the right hepatic lobe, scars from previous hepatic abscesses (straight arrow), ill-defined high-signal-intensity areas, and mild dilatation of the distal bile ducts (curved arrows), findings suggestive of infection secondary to cholangitis. The discontinuity of the right bile ducts and the patency of the hepaticojejunal anastomosis were confirmed at surgery.
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Figure 30b. Cholangitis and secondary infection in a 41-year-old woman after common bile duct injury during a laparoscopic cholecystectomy. (a) Coronal MIP image from a 3D respiratory-triggered T2-weighted fast SE restore data set shows multiple intrahepatic bile duct strictures with irregular mild dilatation of the right intrahepatic ducts and discontinuity of the right bile ducts (straight arrows). An anastomosis (curved arrow) between the left bile duct and a jejunal loop is clearly depicted. (b) Axial T2-weighted HASTE MR image shows atrophy of the right hepatic lobe, scars from previous hepatic abscesses (straight arrow), ill-defined high-signal-intensity areas, and mild dilatation of the distal bile ducts (curved arrows), findings suggestive of infection secondary to cholangitis. The discontinuity of the right bile ducts and the patency of the hepaticojejunal anastomosis were confirmed at surgery.
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Figure 31. Surgically confirmed obstructive mucocele of the cystic duct remnant in a 60-year-old woman after cholecystectomy. Coronal MIP image from a 3D respiratory-triggered T2-weighted fast SE restore data set shows a large, distended, irregularly shaped cystic duct remnant (arrows) compressing the common bile duct and causing dilatation of the intra- and extrahepatic ducts.
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Copyright © 2006 by the Radiological Society of North America.
