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MR Imaging Features of Primary Sclerosing Cholangitis: Patterns of Cirrhosis in Relationship to Clinical Severity of Disease¹

¹ From the Departments of Radiology (T.R.B., R.C.S.) and Internal Medicine (K.L.B.), University of North Carolina at Chapel Hill, 101 Manning Dr, CB 7510, Chapel Hill, NC 27599-7510; and Department of Radiology, University of Vienna, Austria (T.R.B.). Received October 2, 2001; revision requested December 18; final revision received June 19, 2002; accepted October 9. T.R.B. supported by a grant from the Max Kade Foundation, New York, NY. Address correspondence to R.C.S. (e-mail: richsem@med.unc.edu).

View larger version (125K): [in a new window]   Figure 1a. MR images in a 57-year-old man with a large macronodular pattern of liver cirrhosis. Three large nodules (straight arrows), each measuring more than 3 cm, are visible in the central area of the liver and have low signal intensity on (a) a transverse fat-suppressed T2-weighted half-Fourier RARE MR image (/90) and isointense signal on (b) a transverse T1-weighted SGE MR image (140/4.1). The rightmost nodule has a small central area of low signal intensity on b that is consistent with an area of iron deposition. The nodules show decreased gadolinium enhancement on (c) a transverse SGE MR image (140/4.1) obtained immediately after gadolinium chelate administration and (d) a transverse fat-suppressed MR image (147/4.1) obtained 2 minutes after gadolinium chelate administration. This enhancement behavior is typical of regenerative nodules. The peripheral bile ducts (curved arrows) are dilated, show irregular strictures (beading), and appear to be centrally obstructed by the large nodules.

View larger version (107K): [in a new window]   Figure 1b. MR images in a 57-year-old man with a large macronodular pattern of liver cirrhosis. Three large nodules (straight arrows), each measuring more than 3 cm, are visible in the central area of the liver and have low signal intensity on (a) a transverse fat-suppressed T2-weighted half-Fourier RARE MR image (/90) and isointense signal on (b) a transverse T1-weighted SGE MR image (140/4.1). The rightmost nodule has a small central area of low signal intensity on b that is consistent with an area of iron deposition. The nodules show decreased gadolinium enhancement on (c) a transverse SGE MR image (140/4.1) obtained immediately after gadolinium chelate administration and (d) a transverse fat-suppressed MR image (147/4.1) obtained 2 minutes after gadolinium chelate administration. This enhancement behavior is typical of regenerative nodules. The peripheral bile ducts (curved arrows) are dilated, show irregular strictures (beading), and appear to be centrally obstructed by the large nodules.

View larger version (117K): [in a new window]   Figure 1c. MR images in a 57-year-old man with a large macronodular pattern of liver cirrhosis. Three large nodules (straight arrows), each measuring more than 3 cm, are visible in the central area of the liver and have low signal intensity on (a) a transverse fat-suppressed T2-weighted half-Fourier RARE MR image (/90) and isointense signal on (b) a transverse T1-weighted SGE MR image (140/4.1). The rightmost nodule has a small central area of low signal intensity on b that is consistent with an area of iron deposition. The nodules show decreased gadolinium enhancement on (c) a transverse SGE MR image (140/4.1) obtained immediately after gadolinium chelate administration and (d) a transverse fat-suppressed MR image (147/4.1) obtained 2 minutes after gadolinium chelate administration. This enhancement behavior is typical of regenerative nodules. The peripheral bile ducts (curved arrows) are dilated, show irregular strictures (beading), and appear to be centrally obstructed by the large nodules.

View larger version (122K): [in a new window]   Figure 1d. MR images in a 57-year-old man with a large macronodular pattern of liver cirrhosis. Three large nodules (straight arrows), each measuring more than 3 cm, are visible in the central area of the liver and have low signal intensity on (a) a transverse fat-suppressed T2-weighted half-Fourier RARE MR image (/90) and isointense signal on (b) a transverse T1-weighted SGE MR image (140/4.1). The rightmost nodule has a small central area of low signal intensity on b that is consistent with an area of iron deposition. The nodules show decreased gadolinium enhancement on (c) a transverse SGE MR image (140/4.1) obtained immediately after gadolinium chelate administration and (d) a transverse fat-suppressed MR image (147/4.1) obtained 2 minutes after gadolinium chelate administration. This enhancement behavior is typical of regenerative nodules. The peripheral bile ducts (curved arrows) are dilated, show irregular strictures (beading), and appear to be centrally obstructed by the large nodules.

View larger version (124K): [in a new window]   Figure 2a. MR images in a 60-year-old woman with a diffuse pattern of liver cirrhosis. The liver contour is minimally irregular, and the caudate lobe is slightly enlarged; these findings are demonstrated on (a) a transverse fat-suppressed T2-weighted half-Fourier RARE MR image (/90). (Because of inhomogeneous fat suppression and use of a phased-array body coil, anterior subcutaneous fat shows relatively high signal intensity in this image). Peripheral wedge-shaped areas (arrows) without parenchymal atrophy show high signal intensity in this image and isointense signal on (b) a transverse T1-weighted SGE MR image (140/4.1). (c) On a transverse SGE MR image (140/4.1) obtained immediately after gadolinium chelate adminstration, these areas (arrows) are slightly hyperenhancing. (d) This slight hyperenhancement (arrow) persists mildly on a transverse fat-suppressed MR image (147/4.1) obtained 2 minutes after gadolinium chelate administration. Segmental biliary ductal dilatation is visualized as low-signal-intensity tubular structures (arrowheads) in this image.

View larger version (95K): [in a new window]   Figure 2b. MR images in a 60-year-old woman with a diffuse pattern of liver cirrhosis. The liver contour is minimally irregular, and the caudate lobe is slightly enlarged; these findings are demonstrated on (a) a transverse fat-suppressed T2-weighted half-Fourier RARE MR image (/90). (Because of inhomogeneous fat suppression and use of a phased-array body coil, anterior subcutaneous fat shows relatively high signal intensity in this image). Peripheral wedge-shaped areas (arrows) without parenchymal atrophy show high signal intensity in this image and isointense signal on (b) a transverse T1-weighted SGE MR image (140/4.1). (c) On a transverse SGE MR image (140/4.1) obtained immediately after gadolinium chelate adminstration, these areas (arrows) are slightly hyperenhancing. (d) This slight hyperenhancement (arrow) persists mildly on a transverse fat-suppressed MR image (147/4.1) obtained 2 minutes after gadolinium chelate administration. Segmental biliary ductal dilatation is visualized as low-signal-intensity tubular structures (arrowheads) in this image.

View larger version (105K): [in a new window]   Figure 2c. MR images in a 60-year-old woman with a diffuse pattern of liver cirrhosis. The liver contour is minimally irregular, and the caudate lobe is slightly enlarged; these findings are demonstrated on (a) a transverse fat-suppressed T2-weighted half-Fourier RARE MR image (/90). (Because of inhomogeneous fat suppression and use of a phased-array body coil, anterior subcutaneous fat shows relatively high signal intensity in this image). Peripheral wedge-shaped areas (arrows) without parenchymal atrophy show high signal intensity in this image and isointense signal on (b) a transverse T1-weighted SGE MR image (140/4.1). (c) On a transverse SGE MR image (140/4.1) obtained immediately after gadolinium chelate adminstration, these areas (arrows) are slightly hyperenhancing. (d) This slight hyperenhancement (arrow) persists mildly on a transverse fat-suppressed MR image (147/4.1) obtained 2 minutes after gadolinium chelate administration. Segmental biliary ductal dilatation is visualized as low-signal-intensity tubular structures (arrowheads) in this image.

View larger version (109K): [in a new window]   Figure 2d. MR images in a 60-year-old woman with a diffuse pattern of liver cirrhosis. The liver contour is minimally irregular, and the caudate lobe is slightly enlarged; these findings are demonstrated on (a) a transverse fat-suppressed T2-weighted half-Fourier RARE MR image (/90). (Because of inhomogeneous fat suppression and use of a phased-array body coil, anterior subcutaneous fat shows relatively high signal intensity in this image). Peripheral wedge-shaped areas (arrows) without parenchymal atrophy show high signal intensity in this image and isointense signal on (b) a transverse T1-weighted SGE MR image (140/4.1). (c) On a transverse SGE MR image (140/4.1) obtained immediately after gadolinium chelate adminstration, these areas (arrows) are slightly hyperenhancing. (d) This slight hyperenhancement (arrow) persists mildly on a transverse fat-suppressed MR image (147/4.1) obtained 2 minutes after gadolinium chelate administration. Segmental biliary ductal dilatation is visualized as low-signal-intensity tubular structures (arrowheads) in this image.

View larger version (123K): [in a new window]   Figure 3a. MR images in a 40-year-old man with a diffuse nodular pattern of liver cirrhosis. Multiple regenerative nodules smaller than 3 cm are seen in the entire liver, resulting in a nodular liver contour. Fibrous tissue between the nodules forms a reticular pattern that shows high signal intensity on (a) a transverse short inversion time inversion-recovery MR image (5,110/76/170) and low signal intensity on (b) a transverse T1-weighted SGE MR image (140/4.1). (c) Some strands of fibrous tissue (arrows) show enhancement on a transverse SGE MR image (140/4.1) obtained immediately after gadolinium chelate administration. (d) On a transverse fat-suppressed SGE MR image (147/4.1) obtained 2 minutes after gadolinium chelate administration, progressive enhancement of fibrous tissue, revealing a high-signal-intensity reticular patchwork, is seen. This patient’s spleen (S) is enlarged, and perihepatic ascites (A) appears with high signal intensity in a (a T2-weighted MR image) and low signal intensity in b-d (T1-weighted MR images).

View larger version (108K): [in a new window]   Figure 3b. MR images in a 40-year-old man with a diffuse nodular pattern of liver cirrhosis. Multiple regenerative nodules smaller than 3 cm are seen in the entire liver, resulting in a nodular liver contour. Fibrous tissue between the nodules forms a reticular pattern that shows high signal intensity on (a) a transverse short inversion time inversion-recovery MR image (5,110/76/170) and low signal intensity on (b) a transverse T1-weighted SGE MR image (140/4.1). (c) Some strands of fibrous tissue (arrows) show enhancement on a transverse SGE MR image (140/4.1) obtained immediately after gadolinium chelate administration. (d) On a transverse fat-suppressed SGE MR image (147/4.1) obtained 2 minutes after gadolinium chelate administration, progressive enhancement of fibrous tissue, revealing a high-signal-intensity reticular patchwork, is seen. This patient’s spleen (S) is enlarged, and perihepatic ascites (A) appears with high signal intensity in a (a T2-weighted MR image) and low signal intensity in b-d (T1-weighted MR images).

View larger version (115K): [in a new window]   Figure 3c. MR images in a 40-year-old man with a diffuse nodular pattern of liver cirrhosis. Multiple regenerative nodules smaller than 3 cm are seen in the entire liver, resulting in a nodular liver contour. Fibrous tissue between the nodules forms a reticular pattern that shows high signal intensity on (a) a transverse short inversion time inversion-recovery MR image (5,110/76/170) and low signal intensity on (b) a transverse T1-weighted SGE MR image (140/4.1). (c) Some strands of fibrous tissue (arrows) show enhancement on a transverse SGE MR image (140/4.1) obtained immediately after gadolinium chelate administration. (d) On a transverse fat-suppressed SGE MR image (147/4.1) obtained 2 minutes after gadolinium chelate administration, progressive enhancement of fibrous tissue, revealing a high-signal-intensity reticular patchwork, is seen. This patient’s spleen (S) is enlarged, and perihepatic ascites (A) appears with high signal intensity in a (a T2-weighted MR image) and low signal intensity in b-d (T1-weighted MR images).

View larger version (119K): [in a new window]   Figure 3d. MR images in a 40-year-old man with a diffuse nodular pattern of liver cirrhosis. Multiple regenerative nodules smaller than 3 cm are seen in the entire liver, resulting in a nodular liver contour. Fibrous tissue between the nodules forms a reticular pattern that shows high signal intensity on (a) a transverse short inversion time inversion-recovery MR image (5,110/76/170) and low signal intensity on (b) a transverse T1-weighted SGE MR image (140/4.1). (c) Some strands of fibrous tissue (arrows) show enhancement on a transverse SGE MR image (140/4.1) obtained immediately after gadolinium chelate administration. (d) On a transverse fat-suppressed SGE MR image (147/4.1) obtained 2 minutes after gadolinium chelate administration, progressive enhancement of fibrous tissue, revealing a high-signal-intensity reticular patchwork, is seen. This patient’s spleen (S) is enlarged, and perihepatic ascites (A) appears with high signal intensity in a (a T2-weighted MR image) and low signal intensity in b-d (T1-weighted MR images).

View larger version (113K): [in a new window]   Figure 4a. MR images in a 35-year-old woman with a peripheral wedge-shaped area of parenchymal atrophy. Large nodules (straight arrows) in the central area of the liver show low signal intensity on (a) a transverse fat-suppressed T2-weighted half-Fourier RARE MR image (/90) and isointense signal on (b) a transverse T1-weighted SGE MR image (140/4.1). A peripheral wedge-shaped area of parenchymal atrophy (curved arrows) in the left lobe of the liver shows high signal intensity in a, low signal intensity in b, and some heterogeneity. (c) Hyperenhancement (arrows) is revealed on a transverse MR image (140/4.1) obtained immediately after gadolinium chelate administration. A small central area of fibrosis is spared. (d) On a transverse fat-suppressed MR image (147/4.1) obtained 2 minutes after gadolinium chelate administration, the central large nodules are minimally hypoenhancing and the rest of the liver is isoenhancing. Dilated bile ducts (arrowheads) in the periphery of the liver are best visualized on this image.

View larger version (98K): [in a new window]   Figure 4b. MR images in a 35-year-old woman with a peripheral wedge-shaped area of parenchymal atrophy. Large nodules (straight arrows) in the central area of the liver show low signal intensity on (a) a transverse fat-suppressed T2-weighted half-Fourier RARE MR image (/90) and isointense signal on (b) a transverse T1-weighted SGE MR image (140/4.1). A peripheral wedge-shaped area of parenchymal atrophy (curved arrows) in the left lobe of the liver shows high signal intensity in a, low signal intensity in b, and some heterogeneity. (c) Hyperenhancement (arrows) is revealed on a transverse MR image (140/4.1) obtained immediately after gadolinium chelate administration. A small central area of fibrosis is spared. (d) On a transverse fat-suppressed MR image (147/4.1) obtained 2 minutes after gadolinium chelate administration, the central large nodules are minimally hypoenhancing and the rest of the liver is isoenhancing. Dilated bile ducts (arrowheads) in the periphery of the liver are best visualized on this image.

View larger version (100K): [in a new window]   Figure 4c. MR images in a 35-year-old woman with a peripheral wedge-shaped area of parenchymal atrophy. Large nodules (straight arrows) in the central area of the liver show low signal intensity on (a) a transverse fat-suppressed T2-weighted half-Fourier RARE MR image (/90) and isointense signal on (b) a transverse T1-weighted SGE MR image (140/4.1). A peripheral wedge-shaped area of parenchymal atrophy (curved arrows) in the left lobe of the liver shows high signal intensity in a, low signal intensity in b, and some heterogeneity. (c) Hyperenhancement (arrows) is revealed on a transverse MR image (140/4.1) obtained immediately after gadolinium chelate administration. A small central area of fibrosis is spared. (d) On a transverse fat-suppressed MR image (147/4.1) obtained 2 minutes after gadolinium chelate administration, the central large nodules are minimally hypoenhancing and the rest of the liver is isoenhancing. Dilated bile ducts (arrowheads) in the periphery of the liver are best visualized on this image.

View larger version (99K): [in a new window]   Figure 4d. MR images in a 35-year-old woman with a peripheral wedge-shaped area of parenchymal atrophy. Large nodules (straight arrows) in the central area of the liver show low signal intensity on (a) a transverse fat-suppressed T2-weighted half-Fourier RARE MR image (/90) and isointense signal on (b) a transverse T1-weighted SGE MR image (140/4.1). A peripheral wedge-shaped area of parenchymal atrophy (curved arrows) in the left lobe of the liver shows high signal intensity in a, low signal intensity in b, and some heterogeneity. (c) Hyperenhancement (arrows) is revealed on a transverse MR image (140/4.1) obtained immediately after gadolinium chelate administration. A small central area of fibrosis is spared. (d) On a transverse fat-suppressed MR image (147/4.1) obtained 2 minutes after gadolinium chelate administration, the central large nodules are minimally hypoenhancing and the rest of the liver is isoenhancing. Dilated bile ducts (arrowheads) in the periphery of the liver are best visualized on this image.