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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).

	Abstract

Top Abstract Introduction Clinical Experience Imaging Technique Malignant Obstruction Biliary-Enteric Anastomoses Conclusions References

 
Twenty-two patients with malignant biliary obstruction and 21 patients with suspected obstruction of biliary-enteric anastomoses were evaluated over a 12-month period with magnetic resonance (MR) cholangiography and cross-sectional MR imaging. In patients with malignant obstruction, MR cholangiography helped accurately determine the status of the biliary ductal system by identifying the exact location and extent of the obstruction and the severity of duct dilatation. In so doing, MR cholangiography helped determine whether percutaneous transhepatic cholangiography with antegrade stent placement or retrograde cholangiography with stent placement constituted the more suitable treatment. Cross-sectional MR imaging was necessary to identify the organ of tumor origin, define the tumor margins, and determine the stage of disease. This information helped evaluate the appropriateness of curative surgical therapy versus palliative drainage procedures. In patients with biliary-enteric anastomoses, MR cholangiography clearly depicted the site of the anastomosis and demonstrated the status of the intrahepatic ducts, thereby helping determine which patients would benefit from undergoing antegrade duct cannulation with a drainage procedure or perhaps balloon dilation. In some of these patients, MR cholangiography was sufficient to help plan therapeutic intervention. MR cholangiography also demonstrates the presence and size of biliary stones and associated findings such as intraductal tumor growth. In addition, MR cholangiography may obviate retrograde cholangiography, which can be technically difficult to perform.

Index Terms: Bile duct radiography, 76.122 • Bile ducts, calculi, 76.28 • Bile ducts, MR, 76.121411, 121412, 121415 • Bile ducts, stenosis or obstruction, 76.28 • Bile ducts, surgery, 76.453

	Introduction

Top Abstract Introduction Clinical Experience Imaging Technique Malignant Obstruction Biliary-Enteric Anastomoses Conclusions References

 
Magnetic resonance (MR) cholangiography has proved effective in demonstrating bile duct dilatation, strictures, and choledocholithiasis (1–14). In patients with malignant biliary obstruction or stenosis of biliary-enteric anastomoses, this noninvasive imaging technique demonstrates the site of the stenosis, the degree of proximal dilatation, the presence and size of biliary stones, and associated findings such as intraductal tumor growth. These MR cholangiographic findings can help determine the type of therapy to be administered. In patients with malignant obstruction, conventional (cross-sectional) MR imaging is performed along with MR cholangiography to determine the size and define the margins of the tumor. These factors must be considered when assessing the resectability of a malignant lesion. In this article, we discuss and illustrate the characteristic features of malignant biliary obstruction and stenosis of biliary-enteric anastomoses at MR cholangiography and cross-sectional MR imaging.

	Clinical Experience

Top Abstract Introduction Clinical Experience Imaging Technique Malignant Obstruction Biliary-Enteric Anastomoses Conclusions References

 
The patients in this series (20 male, 23 female; age range, 27–82 years [mean, 60.3 years]) were evaluated at our institution with MR cholangiography over a 12-month period (December 1997–November 1998). Twenty-two patients had malignant obstruction, and 21 patients had biliary-enteric anastomoses (created with hepaticojejunostomy in 11 and with choledochoduodenostomy in 10). Causes of malignant obstruction included pancreatic adenocarcinoma (n = 8), hilar cholangiocarcinoma (n = 4), ampullary carcinoma (n = 4), invasive gallbladder carcinoma (n = 2), periportal malignant lymphadenopathy (n = 2), intrahepatic cholangiocarcinoma (n = 1), and cholangiocarcinoma complicating a choledochal cyst (n = 1). The final diagnosis in these patients was established with percutaneous biopsy (n = 9); surgery (n = 7); endoscopic brushing and cytologic analysis (n = 2); or findings at MR imaging, computed tomography (CT), or conventional cholangiography (n = 4). Interventional procedures included retrograde drainage with stent placement (n = 7), antegrade drainage with stent placement (n = 3), antegrade drainage alone (n = 5), and surgical resection (n = 5). No interventional procedure was performed in two patients.

	Imaging Technique

Top Abstract Introduction Clinical Experience Imaging Technique Malignant Obstruction Biliary-Enteric Anastomoses Conclusions References

 
MR imaging was performed with a 1.5-T scanner (ACS-NT; Philips Medical Systems, Best, The Netherlands). MR cholangiography was performed with three different pulse sequences: multisection three-dimensional (3D) fast spin-echo, single-section half-Fourier rapid acquisition with relaxation enhancement (RARE), and multisection half-Fourier RARE. The imaging parameters used for these three sequences are shown in the Table. A chemically selective fat saturation prepulse was applied for the three sequences. No negative oral contrast agent or antiperistaltic agent was administered. For the 3D fast spin-echo sequence, we used respiratory triggering to reduce artifacts resulting from respiratory motion. The nominal scanning time for this non–breath-hold sequence was 6 minutes 10 seconds; however, the use of respiratory triggering increased the actual scanning time to approximately 9–12 minutes depending on the patient's breathing pattern and respiration rate. For the half-Fourier RARE sequences, we sampled 65% of the data used to fill k space; the inherent symmetry of k space along the phase axis allowed data filling of the remainder of the phase-encoding steps (12,13). The two half-Fourier RARE sequences were implemented during single breath-holds. Total scanning time was 10 seconds for the single-section half-Fourier RARE sequence (2.5 seconds per projection, four projections) and 16 seconds for the multisection half-Fourier RARE sequence (2 seconds per section, eight sections). The 3D fast spin-echo and multisection half-Fourier RARE MR images were obtained in a right anterior oblique-coronal plane. With the single-section half-Fourier sequence, each of the four projections was obtained in a different plane. In patients with malignant obstruction, we also acquired axial cross-sectional MR images. These included T1-weighted spin-echo images with and without fat suppression, T2-weighted fast spin-echo images with fat suppression, and contrast-enhanced dynamic gradient-echo images (Table).

	Malignant Obstruction

Top Abstract Introduction Clinical Experience Imaging Technique Malignant Obstruction Biliary-Enteric Anastomoses Conclusions References

 
MR cholangiography demonstrated bile duct dilatation and strictures in all patients with malignant obstruction (n = 22). Malignant strictures usually manifest as areas of narrowing with proximal bile duct dilatation. Because visualization of ducts at MR cholangiography depends on the presence of fluid (bile) within the lumen, tight strictures occasionally appear as short segments of signal dropout. Various studies have shown the sensitivity of MR cholangiography for the detection of focal strictures affecting the bile ducts to be approximately 95% (1–6,11). Malignant obstruction occurring at the porta hepatis is usually secondary to cholangiocarcinoma, metastatic disease to the liver or periportal lymph nodes, invasive hepatocellular carcinoma, or invasive gallbladder carcinoma (15). The extrahepatic suprapancreatic biliary tract may be obstructed by lesions such as lymphadenopathy or by direct extension of malignancies arising in adjacent organs (eg, gallbladder, pancreas, stomach, colon) (16). Neoplastic obstruction of the intrapancreatic portion of the common bile duct may be caused by carcinoma of the head of the pancreas, cholangiocarcinoma, or ampullary carcinoma (15).

To help differentiate between benign and malignant causes of biliary strictures and dilatation, principles that apply to conventional cholangiography may also be applied to MR cholangiography. Malignant lesions usually manifest as irregular strictures with shouldered margins, whereas benign stenoses tend to have smooth borders with tapered margins. However, differentiation may be difficult with MR cholangiography and often depends on discovering a mass or tumor associated with the stricture at cross-sectional T1- or T2-weighted MR imaging, a finding that indicates a malignant cause. Despite this limitation, MR cholangiography helps accurately determine the status of the biliary ductal system in patients with malignant obstruction by identifying the exact site of the obstruction and the length of the stricture. In this way, MR cholangiography can help determine whether a patient should undergo percutaneous transhepatic cholangiography with antegrade stent placement or retrograde intervention. The unnecessary risks associated with multiple invasive procedures are thereby avoided.

Cholangiocarcinoma
Hilar cholangiocarcinoma (Klatskin tumor) is usually a small lesion and difficult to detect with ultrasonography or CT. MR imaging has been shown to be useful in delineating the size and extent of these tumors (17–19). MR cholangiography is useful in depicting the severity of intrahepatic duct dilatation as well as the site and extent of the stricture (Fig 1a). Furthermore, MR cholangiography can delineate dilated bile duct segments that are not opacified at conventional cholangiography (17). On T1-weighted MR images, hilar cholangiocarcinomas are typically hypo- or isointense relative to liver parenchyma. Their appearance on T2-weighted images is variable. Scirrhous tumors tend to demonstrate low signal intensity centrally and variable high signal intensity peripherally, whereas well-differentiated cholangiocarcinomas may exhibit higher signal intensity on T2-weighted images (Fig 1b). Guthrie et al (19) demonstrated that after a bolus injection of gadolinium contrast material, the tumor initially remains hypointense relative to liver parenchyma but thereafter demonstrates slow, progressive enhancement, with peak enhancement occurring 120 seconds after injection (Fig 1c). Findings that indicate that a tumor is unresectable include vascular encasement and direct extension to liver parenchyma (18,19). Other abnormalities that may be seen in cholangiocarcinoma (eg, satellite lesions in the liver, regional lymphadenopathy to pancreaticoduodenal and portocaval nodes, intraductal tumor growth, peritoneal tumor spread) are also well demonstrated with MR imaging and MR cholangiography (Fig 2).

View larger version (101K): [in this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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.

Pancreatic Adenocarcinoma and Ampullary Carcinoma
Biliary obstruction in the intrapancreatic segment of the common bile duct may be caused by pancreatic carcinoma, ampullary carcinoma, or pancreatitis. Differentiation between benign and malignant causes of distal obstruction is difficult at cross-sectional imaging and usually depends on finding a mass associated with the stricture. Irregular or "rat-tail" stenoses are more suggestive of carcinoma than of pancreatitis. A well-known cholangiopancreatographic sign that can be seen in patients with carcinoma of the head of the pancreas is the "double duct sign," which consists of dilatation of the common bile duct and pancreatic duct with biductal strictures in the head of the gland (Fig 4). MR cholangiopancreatography together with cross-sectional ("tissue") MR imaging can help determine the status of the ducts and reveal the size and margins of extra-ductal tumor, whereas conventional endoscopic retrograde or transhepatic cholangiography depicts only the ductal lumen (23). On T1-weighted images, pancreatic adenocarcinoma typically appears as a low-signal-intensity mass, and contrast between normal pancreatic parenchyma and tumor is increased with use of fat saturation (Figs 4, 5) (24–26). On T2-weighted images, the signal intensity of adenocarcinoma is similar to that of unaffected pancreatic parenchyma (Fig 4c) (27). Dynamic images obtained after administration of gadolinium contrast material improve detection of small lesions because tumor is less vascular than normal glandular tissue (26,28). Findings that indicate that a tumor is unresectable include periportal adenopathy, extension to peripancreatic vessels (Fig 6), periglandular invasion of fat planes, and liver metastases.

View larger version (104K): [in this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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.

	Biliary-Enteric Anastomoses

Top Abstract Introduction Clinical Experience Imaging Technique Malignant Obstruction Biliary-Enteric Anastomoses Conclusions References

View larger version (130K): [in this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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.

	Conclusions

Top Abstract Introduction Clinical Experience Imaging Technique Malignant Obstruction Biliary-Enteric Anastomoses Conclusions References

	Footnotes

 
Abbreviations: RARE = rapid acquisition with relaxation enhancement 3D = three-dimensional

	References

Top Abstract Introduction Clinical Experience Imaging Technique Malignant Obstruction Biliary-Enteric Anastomoses Conclusions References

 

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