oriental cholangiohepatitis: radiologic features
TRANSCRIPT
Oriental Cholangiohepatitis (OCH): Radiologic Features
Lee, Ming-Yen, Kaohsiung Medical University, Year IVGillian Lieberman, MD
September 2010Lee, Ming-YenGillian Lieberman, MD
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Agenda• Patient presentation
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Initial presentation
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Radiologic findings
• Oriental Cholangiohepatitis−
Pathogenesis
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Differential diagnosis
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Relative Roles of Imaging Tests
−
Management
Lee, Ming-YenGillian Lieberman, MD
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Our Patient: Initial Presentation
• 83-year-old female who has a history of having undergone cholecystectomy and choledochoduodenostomy
• Apparently, over the past five years she has been having repeated episodes of cholangitis manifest as fevers and right upper quadrant abdominal pain.
Lee, Ming-YenGillian Lieberman, MD
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Our Patient: Biliary duct air on CT
• Scattered pockets of air are seen throughout the biliary tree −
consistent with the patient's prior choledochoduodenost omy.
• Diffuse dilation of the intrahepatic biliary ducts
C-
Lee, Ming-YenGillian Lieberman, MD
BIDMC PACS
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Our Patient: biliary duct dilatation on CT
• Scattered pockets of air are seen throughout the biliary tree −
consistent with the patient's prior choledochoduodenost omy.
• Diffuse dilation of the intrahepatic biliary ducts
C+ 3mins delay
Lee, Ming-YenGillian Lieberman, MD
BIDMC PACS
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Our patient: biliary ducts dilatation with air on coronal CT
Lee, Ming-YenGillian Lieberman, MD
BIDMC PACSArterial phase Venous phase
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Our patient:filling defect on ERCP• Air fills the intrahepatic
biliary ducts.
• There is markedly dilated left intrahepatic duct which demonstrates irregular filling.
• There is an irregular filling defect at the right central intrahepatic biliary duct.
BIDMC PACS
Lee, Ming-YenGillian Lieberman, MD
Oriental Cholangiohepatitis
Lee, Ming-YenGillian Lieberman, MD
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Oriental Cholangiohepatitis
• Oriental cholangiohepatitis (OCH), also known as −
Oriental cholangitis
−
recurrent pyogenic cholangitis
−
Intrahepatic pigmented stone disease
• characterized by recurrent attacks of fever, chills, abdominal pain, and jaundice (Charcot's triad of acute cholangitis )
Lee, Ming-YenGillian Lieberman, MD
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Oriental Cholangiohepatitis: pathogenesis
• The bile ducts are markedly abnormal, characterized by extrahepatic and intrahepatic ductal dilatation with focal areas of stricturing in the intrahepatic biliary tree.
• The biliary wall is fibrotic with inflammatory cell infiltration.
Lee, Ming-YenGillian Lieberman, MD
Website: The radiology assistant
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Comparison our p’t #1: OCH on ultrasound• Extrahepatic bile ducts dilation :85-100%
• Intrahepatic bile ducts dilation: 66-79%
• Stones (85-90%) : are more echogenic than the liver parenchyma and adjacent tissue
Lee, Ming-YenGillian Lieberman, MD
AJR 157:1-8, July 1991
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Comparison our p’t #2: OCH on CT w/o contrast
• Full extent of ductal dilatation −
Dilatation of the extrahepatic ducts is detected clearly.
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Central, larger intrahepatic biliary dilatation
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bile ducts tapering abruptly toward periphery
Lee, Ming-YenGillian Lieberman, MD
AJR 157:1-8, July 1991
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Comparison our p’t #3: OCH on CT w/ contrast
• Localized dilatation from obstruction by stricture or stone.−
Often the stones are hypodense detection rate :63- 81%
• wall of the bile ducts may enhance−
acute cholangitic episode
Lee, Ming-YenGillian Lieberman, MD
AJR 157:1-8, July 1991
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Our patient: comparison OCH on CT w/o contrast
• stones are detected more easily on unenhanced scans, and enhanced CT scans are better in the detection of subtle intrahepatic biliary dilatation.
Chan F-L, Man S-W, Leong LLY, Fan S-T. Evaluation ofrecurrent pyogenic cholangitis with CT: analysis of 50 patients. Radiology 1989;170: 165-1 69
Lee, Ming-YenGillian Lieberman, MD
BIDMC PACS
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Comparison our p’t #4: OCH on ERCP
• Disproportionately severe dilatation of the extrahepatic ducts with mild or no dilatation of the intrahepatic ducts −
Acute tapering
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Straightening−
Rigidity
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Multiple focal strictures
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Decrease in arborization
Lee, Ming-YenGillian Lieberman, MD
AJR 157:1-8, July 1991
Facet stones in CBD
Filling defects of stones
stricture
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Our patient :ERCP• There is markedly
dilated left intrahepatic duct which demonstrates irregular filling.
• Irregular filling defect at the right central intrahepatic biliary duct.
• Stones! Strictures! Acute tapering!
BIDMC PACS
Lee, Ming-YenGillian Lieberman, MD
17Website: The radiology assistant
Differential diagnosis of bile duct dilatation
Lee, Ming-YenGillian Lieberman, MD
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DDx.1: gallstones caused dile duct dilatation on CT
• Gallstones passed into the extrahepatic duct−
dilatation mainly proximal to the stone−
In OCH: dilated diffusely regardless of the level of the stone
Lee, Ming-YenGillian Lieberman, MD
RadioGraphics 2001; 21:3–22
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DDx2: Clonorchiasis on CT
• Clonorchiasis−
diffuse dilatation of the intrahepatic bile ducts with no or minimal dilatation of the large bile ducts
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Periductal changes are more severe in clonorchiasis
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Stones and flukes of C. sinensis can be differentiated easily.
Lee, Ming-YenGillian Lieberman, MD
RadioGraphics, 28, 1307-1323,
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DDx3: cholangio CA. on CT
• Biliary obstruction by malignant tumors−
cholangiocarcinoma and cancer of the pancreas or ampulla of Vater
−
The entire biliary tree proximal to the mass is dilated
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An obstructing mass can be detected!!
Lee, Ming-YenGillian Lieberman, MD
Holland-Frei Cancer Medicine, bile duct cancer
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DDx4: Sclerosing cholangitis on CT • Sclerosing cholangitis
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dilatation is focal and discontinuous (beaded appearance and serpiginous course)
Lee, Ming-YenGillian Lieberman, MD
The radiology assistant, Biliary Ducts : Benign and Malignant Diseases
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DDx5: Caroli disease on CT• Caroli disease
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A developmental anomaly • segmental saccular dilatation of the intrahepatic
ducts• Result in stasis, cholangitis, liver abscess, and stone
formation−
Occurs in a younger age group−
Differentiation is possible by noting the dilated saccules in the intrahepatic bile ducts
Lee, Ming-YenGillian Lieberman, MD
The radiology assistant, Biliary Ducts : Benign and Malignant Diseases
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Imaging Tests: us + CT• Sonography
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the main technique used for screening and diagnosis in suspected OCH
• CT is not a screening procedure, but it is recommended when −
sectional imaging is mandatory but sonography is not confirmative or is equivocal
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when space-occupying lesions complicate OCH
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when hepatic resection is planned
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When imaging guidance is needed for complex drainage procedures
Lee, Ming-YenGillian Lieberman, MD
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Imaging Tests: Direct cholangiography
• Direct cholangiography−
“Road map” in patients undergoing surgical intervention
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Necessary for the detection of residual stones after surgery
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Assessment of biliary stricture and choledochoenteric fistulas
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Preprocedural biliary intervention
Lee, Ming-YenGillian Lieberman, MD
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Mangement of our patient• Treatment of acute complications ,such
as cholangitis−
fluid resuscitation, antibiotics, and biliary drainage.
• Prevention of the long-term complications−
Clearance of stones
−
Hepatic resection
Lee, Ming-YenGillian Lieberman, MD
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Reference• Jae Hoon Lim, Oriental Cholangiohepatitis: Pathologic, Clinical, and Radiologic
Features,AJR 157:1-8, July 1991
• Uptodate, Oriental cholangiohepatitis
• Chan F-L, Man S-W, Leong LLY, Fan S-T. Evaluation ofrecurrent pyogenic cholangitis with CT: analysis of 50 patients. Radiology 1989;170: 165-1 69
• Gillian Lieberman, MD, G. Lieberman’s Primary Care Radiology. http://eradiology.bidmc.harvard.edu
• Cheng YF; Lee TY; Sheen-Chen SM; Huang TL; Chen TY, Treatment of complicated hepatolithiasis with intrahepatic biliary stricture by ductal dilatation and stenting: long-term results, World J Surg 2000 Jun;24(6):712-6.
• Mary Ann Turner, MD, Ann S. Fulcher, MD, The Cystic Duct: Normal Anatomy and Disease Processes, RadioGraphics 2001; 21:3–22
• Donald W Kufe, MD,Raphael E Pollock, et al. Holland-Frei Cancer Medicine,6th
edition, Section 28: Gastrointestinal Tract, Bile Duct Cancer, http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=cmed6
• The radiology assistant, http://www.radiologyassistant.nl, Biliary Ducts : Benign and Malignant Diseases, Angela D. Levy MDChief Gastrointestinal Radiology, University Department of Radiologic Pathology, Armed Forces Institute of Pathology, Washington DC
Lee, Ming-YenGillian Lieberman, MD
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Acknowledgements• Gillian Lieberman, MD
• Robert Sheiman, MD
• Girish Tyagi, MD
• Leo Tsai, MD, PhD, MSc
• David Glazier, MD
• Elizabeth Asch, MD
• Wabmaster, Larry Barbaras
• Emily Hanson Acting Medical Student Education Coordinator
Lee, Ming-YenGillian Lieberman, MD
Thanks for your attention….
Lee, Ming-YenGillian Lieberman, MD