Duplication of the Extrahepatic Bile Duct in Association with Choledocholithiasis as Depicted by MDCT

We report here on an extremely rare case of duplicated extrahepatic bile ducts that was associated with choledocholithiasis, and this malady was visualized by employing the minimum intensity projection images with using multi-detector row CT. The presence of duplicated extrahepatic bile ducts with a proximal communication, and the ducts were joined distally and they subsequently formed a single common bile duct, has not been previously reported.

The Balloon Dilatation and Large Profile Catheter Maintenance Method for the Management of the Bile Duct Stricture Following Liver Transplantation

OBJECTIVE: We wanted to evaluate the therapeutic efficacy of the percutaneous balloon dilatation and large profile catheter maintenance method for the management of patients with anastomotic biliary strictures following liver transplant. MATERIALS AND METHODS: From May 1999 to June 2003, 12 patients with symptomatic benign biliary stricture complicated by liver transplantation were treated with the percutaneous balloon dilatation and large profile catheter maintenance method (1-6 months). The patients were eight males and four females, and their ages ranged from 20 to 62 years (mean age: 44 years). Ten patients underwent living donor liver transplantation and two underwent cadaveric liver transplantation. Postoperative biliary strictures occurred from two to 21 months (mean age: 18 months) after liver transplantation. RESULTS: The initial technical success rate was 92%. Patency of the bile duct was preserved for eight to 40 months (mean period: 19 months) in 10 of 12 (84%) patients. When reviewing two patients (17%), secondary balloon dilatations were needed for treating the delayed recurrence of biliary stricture. In one patient, no recurrent stenosis was seen during the further 10 months follow-up after secondary balloon dilatation. Another patient did not response to secondary balloon dilatation, and he was treated by surgery. Eleven of 12 patients (92%) showed good biliary patency for 8-40 months (mean period: 19 months) of follow-up. CONCLUSION: The percutaneous balloon dilatation and large profile catheter maintenance method is an effective therapeutic alternative for the treatment of most biliary strictures that complicate liver transplantation. It has a high success rate and it should be considered before surgery.

Anatomic Variation in Intrahepatic Bile Ducts: an Analysis of Intraoperative Cholangiograms in 300 Consecutive Donors for Living Donor Liver Transplantation

OBJECTIVE: To describe the anatomical variation occurring in intrahepatic bile ducts (IHDs) in terms of their branching patterns, and to determine the frequency of each variation. MATERIALS AND METHODS: The study group consisted of 300 consecutive donors for liver transplantation who underwent intraoperative cholangiography. Anatomical variation in IHDs was classified according to the branching pattern of the right anterior and right posterior segmental duct (RASD and RPSD, respectively), and the presence or absence of the first-order branch of the left hepatic duct (LHD), and of an accessory hepatic duct. RESULTS: The anatomy of the intrahepatic bile ducts was typical in 63% of cases (n=188), showed triple confluence in 10% (n=29), anomalous drainage of the RPSD into the LHD in 11% (n=34), anomalous drainage of the RPSD into the common hepatic duct (CHD) in 6% (n=19), anomalous drainage of the RPSD into the cystic duct in 2% (n=6), drainage of the right hepatic duct (RHD) into the cystic duct (n=1), the presence of an accessory duct leading to the CHD or RHD in 5% (n=16), individual drainage of the LHD into the RHD or CHD in 1% (n=4), and unclassified or complex variation in 1% (n=3). CONCLUSION: The branching pattern of IHDs was atypical in 37% of cases. The two most common variations were drainage of the RPSD into the LHD (11%) and triple confluence of the RASD, RPSD and LHD (10%).

Usefulness of MR Cholangiography in the Evaluation of Neonatal Cholestasis: Comparison with 99mTc DISIDA Scan

PURPOSE: To evaluate the diagnostic validity of MR cholangiography as a second-line imaging tool following sonography in the evaluation of neonatal cholestasis, we compared MR cholangiography with 99mTc DISIDA scan. MATERIALS AND METHODS: We retrospectively evaluated sonography, 99mTc DISIDA scan and MR cholangiography in twenty-two neonates and infants (age range, 23-103 days; mean age, 57 days) presenting with conjugated hyperbilirubinemia. Of the 22 patients, 15 were diagnosed as biliary atresia by operative cholangiography and liver biopsy and six as neonatal hepatitis by imaging finding and clinical data. Remaining one patient was diagnosed as neonatal hepatitis by operative cholangiography and liver biopsy. Two independent observers for each study were assigned to review the images of 99mTc DISIDA scan and MR cholangiography without giving the final diagnosis or other clinical data. Diagnostic accuracy and interobserver variability for each study were evaluated. RESULTS: On 99mTc DISIDA scan, biliary atresia was mistaken for neonatal hepatitis in eight patients and vice versa in four patients. On MR cholangiography, it was mistaken biliary atresia as neonatal hepatitis and vice versa in each two patients. Sensitivity, specificity, accuracy, positive and negative predictive values of 99mTc DISIDA scan were 48%, 47%, 48%, 66% and 30%, respectively, and those of MR cholangiography were 90%, 71%, 84%, 87% and 81%, respectively. Interobserver variabilities for 99mTc DISIDA scan and MR cholangiography were 0.62 and 0.85, respectively. CONCLUSION: In the evaluation of patients with neonatal cholestasis, it would be advisable to use MR cholangiography, having superior diagnostic accuracy to 99mTc DISIDA scan, as a second-line imaging tool following sonography.

Usefulness of MRCP in the Diagnosis of Common Bile Duct Dilatation caused by Non-stone or Non-tumorous Conditions

PURPOSE: To evaluate the usefulness of MRCP in the diagnosis of the variable causes of common bile duct(CBD) dilatation, except stone or tumor MATERIALS AND METHODS: Twenty-six patients(M:F=15:11, mean age; 62 years) with both MRCP and ERCP were included in this study. Dynamic MRCP(n=12) and contrast-enhanced MRI(n=10) of abdomen were also added. Dilatation of CBD, intrahepatic ducts and pancreatic duct was evaluated, including coexistence of intrahepatic ductal stone, pancreatic pseudocyst, and papillitis or papillary edema. The criteria of CBD dilatation was over than 7 mm(n=21, without cholecystectomy) or 10 mm(n=5, with cholecystectomy) in diameter on T2-weighted coronal image. RESULTS: The mean diameter of CBD was 12.7 mm without cholecystectomy(9-19 mm) and 13.0 mm with cholecystectomy(10-15 mm), respectively(p>0.05). Cholangitis(n=11, 42.3%), chronic pancreatitis(n=8, 30.8%), stenosis of distal CBD(n=6, 23.1%), periampullary diverticulum(n=3, 11.5%), stenosis of ampulla of Vater(n=2, 7.7%), dysfunction of sphincter of Oddi(n=2, 7.7%), acute focal pancreatitis in the pancreatic head(n=2, 7.7%), papillitis(n=1, 3.8%), pseudocyst in the pancreatic head(n=1, 3.8%), and ascaris in CBD(n=1, 3.8%) were noted. Pancreatic duct dilatation(n=10, 38.5%) and duodenal diverticulum(n=3, 11.5%) were also seen on MRCP. On dynamic MRCP(12 patients), distal CBD was visualized in 2 patients(16.7%), which was not shown on routine MRCP. Only 1 patient(10.0%) showed papillitis with slightly enhancing papilla on contrast-enhanced MRI(10 patients). CONCLUSION: MRCP was thought to be helpful in the evaluation of the causes of CBD dilatation, not caused by stone or tumor, especially in the cases of stenosis of distal CBD and chronic pancreatitis, dysfunction of sphincter of Oddi on dynamic MRCP, and cholangitis and pericholangitic abnormality on contrast-enhanced MRI

Recurrent Pyogenic Cholangitis: Angiographic Findings and Its Significance

PURPOSE: To analyse the angiographic findings of recurrent pyogenic cholangitis. MATERIALS AND METHODS: Hepatic arteriography and portography were performed preoperatively in 34 patients with intrahepatic stones and recurrent cholangitis. Twenty five of these underwent partial resection of the liver and in nine, the biliary tract was drained. Hepatic arteriogram and portogram findings correlated with liver atrophy and were analysed retrospectively by two radiologists; angiographic and pathologic findings also correlated. RESULTS: In the arterial phase, abnormal stained areas, were seen in 17 of 34 cases, periarterial staining in 14, mass-like staining in two and a mixed pattern in one. The hepatic artery showed spastic change in 11 of 34 cases and tortuous change in 17. Arteriovenous shunting was not seen. In the portal phase, abnormal findings of the portal veins were noted in 16 cases; decreased size and nonvisualization were seen in eleven patients, and decreased size only, in five. Fifteen cases showed liver atrophy; in 13 of these, portal vein abnormalities were also present. CONCLUSION: In recurrent pyogenic cholangitis, angiographic findings may be normal or findings of abnormal periarterial staining, mass-like staining, spastic and tortuous change of the hepatic artery, and abnormal portal vein can be present. The differential diagnosis of hepatitis, hepatic mass and cirrhosis should be considered.