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Recurrent Pyogenic Cholangitis: Comparison between MR Cholangiography and Direct Cholangiography¹

¹ From the Department of Diagnostic Radiology, the Research Institute of Radiological Science (M.S.P., J.S.Y., K.W.K., M.J.K., S.W.Y., J.J.C., J.T.L., H.S.Y.) and the Department of Internal Medicine (J.P.C.), Yonsei University College of Medicine, YongDong Severance Hospital, 146-92, Dokok-Dong, Kangnam-Ku, Seoul, 135-270, South Korea. From the 2000 RSNA scientific assembly. Received July 17, 2000; revision requested September 5; final revision received February 23, 2001; accepted February 26. Address correspondence to J.S.Y.

	ABSTRACT

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
PURPOSE: To compare the accuracy of magnetic resonance (MR) cholangiography with that of direct cholangiography for the evaluation of recurrent pyogenic cholangitis.

MATERIALS AND METHODS: Twenty-four patients with recurrent pyogenic cholangitis underwent MR cholangiography before surgery, and 18 of these 24 also underwent direct cholangiography. Two reviewers evaluated MR cholangiograms and direct cholangiograms and focused on identifying intrahepatic ductal dilatation, stricture, and calculi, as well as coexistent parenchymal abnormalities, on the basis of the classification of the internal lobes and segments of the liver. These observations were compared with surgical findings.

RESULTS: According to examination results in the surgical specimens, 24 patients had 46 segmental abnormalities. MR cholangiography depicted all 46 (100%) segments with ductal dilatation, 22 (96%) of 23 segments with focal ductal stricture, and 43 (98%) of 44 segments with ductal calculi. Eighteen patients who underwent direct cholangiography had 32 segmental abnormalities according to examination results in the surgical specimens. Direct cholangiography depicted 15 (47%) of 32 segments with ductal dilatation, eight (44%) of 18 segments with focal ductal stricture, and 14 (45%) of 31 segments with ductal calculi.

CONCLUSION: MR cholangiography is superior to direct cholangiography for accurate topographic evaluation of recurrent pyogenic cholangitis because it is able to depict all of the biliary tree, despite obstruction or stenosis.

Index terms: Bile ducts, calculi, 768.289 • Bile ducts, stenosis or obstruction, 768.2886 • Bile ducts radiography, 768.1222, 768.1226 • Cholangitis, 768.288 • Magnetic resonance (MR), cholangiopancreatography, 768.121411

	INTRODUCTION

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
Recurrent pyogenic cholangitis is a complex hepatobiliary disease known by various synonyms, such as oriental cholangiohepatitis, intrahepatic pigmented calculus disease, or hepatolithiasis. Recurrent pyogenic cholangitis is characterized by recurrent attacks of abdominal pain, fever, and jaundice caused by intrahepatic ductal strictures and calculi (1). Repeated medical and surgical treatments are frequently required in patients with recurrent pyogenic cholangitis. The therapeutic goal for the management of recurrent pyogenic cholangitis should include the complete clearance of calculi and debris from the biliary tract and the elimination of bile stasis to prevent recurrent attacks of the disease. Therefore, for effective treatment, accurate topographic evaluation of the distribution of the disease is required prior to surgical intervention.

Direct cholangiography, such as endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography, has been the most accurate way to define biliary ductal anatomy by depicting strictures, calculi, and ductal ectasia (2). However, the technique has limitations, especially in cases of high-grade stenosis, impacted calculi, or complete ductal obstruction (1,3), and it is invasive.

Recently, magnetic resonance (MR) imaging technology has made it possible to depict the biliary system without the use of contrast material or endoscopy. Authors of several studies (4) have compared the usefulness of MR cholangiopancreatography with that of ERCP for the evaluation of biliary and pancreatic disorders. To our knowledge, however, there are no studies in which MR cholangiography and direct cholangiography have been compared in terms of the diagnosis of recurrent pyogenic cholangitis. The aim of this study was to compare the accuracy of MR cholangiographic assessment with that of direct cholangiographic assessment of recurrent pyogenic cholangitis.

	MATERIALS AND METHODS

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Patient Population
Between March 1996 and November 1999, 45 patients with recurrent pyogenic cholangitis underwent MR cholangiography at Severance Hospital, Seoul, South Korea. The accuracy of MR cholangiographic depiction of hepatic disease was confirmed by means of surgery in 24 of 45 patients. These 24 patients (13 men, 11 women; age range, 48–67 years; mean age, 59 years) constituted the study population. Six of them had previously undergone cholecystectomy, and two of them had undergone subtotal gastrectomy. All 24 patients had acute cholangitis with abdominal pain, fever, or jaundice at the time of admission. Nineteen of them had had recurrent attacks of the disease on more than three occasions, and the remaining five patients had had them two times.

All 24 patients underwent MR cholangiography. Fifteen of the 24 patients also underwent ERCP: The remaining nine patients were unable to undergo ERCP because of septic condition, previous subtotal gastrectomy, technical failure, and patient intolerance. Of these nine patients who were unable to undergo ERCP, three subsequently underwent percutaneous transhepatic cholangiography and percutaneous transhepatic biliary drainage for preoperative decompression. In summary, 18 patients underwent both MR cholangiography and direct cholangiography, and six patients underwent only MR cholangiography before surgery.

Imaging Studies
The study protocol was approved by the institutional review board of our hospital. The scientific purpose of this study was explained to each patient, and each patient provided informed consent.

MR imaging was performed with a 1.5-T superconducting unit (Magnetom Vision, Siemens Medical Systems, Erlangen, Germany; or Horizon, GE Medical Systems, Milwaukee, Wis) and a phased-array multicoil. MR cholangiography was performed by using half-Fourier rapid acquisition with relaxation enhancement and a single-shot fast spin-echo sequence.

We used a sequential multiple thin-section technique (3–5-mm section thickness) followed by a maximum intensity projection reconstruction and a single thick-slab technique (50–70-mm section thickness). Imaging parameters were as follows: /85–95 (repetition time msec/echo time msec) and 2,000–17,000/915–1,050 for half-Fourier rapid acquisition with relaxation enhancement and the single-shot fast spin-echo sequence, respectively; 256 x 256 matrix; and field of view of 30–36 cm. Fat saturation was routinely used. All of the source, maximum intensity projection, and single thick-slab images were available for review on an independent workstation (GE Medical Systems). Patients were asked to fast for a minimum of 4 hours. Perorally administered contrast agents and antispasmodic agents were not used. The contrast medium used for ERCP and percutaneous transhepatic cholangiography was 76% amidotrizoate sodium meglumine (76% Urografin; Schering, Osaka, Japan).

All ERCP examinations were performed by one of two experienced gastroenterologists (J.P.C.) with technologist-assisted fluoroscopy. The standard ERCP procedure was used. All percutaneous transhepatic cholangiographic examinations were performed by one experienced interventional radiologist (J.S.Y.) with technologist-assisted fluoroscopy. The standard percutaneous transhepatic cholangiographic procedure was used. All printed images were included for review.

Image Analysis
Hard-copy MR cholangiograms and direct cholangiograms were interpreted separately in a blinded retrospective fashion. The readers were two experienced radiologists (M.S.P., J.S.Y.), and final conclusions were reached by means of consensus.

MR cholangiograms were reviewed by two radiologists (M.S.P., J.S.Y.) who were blinded to the patients’ clinical information and direct cholangiographic findings. The focus of image analysis was to identify intrahepatic ductal dilatation and stricture, intrahepatic ductal calculi and common ductal calculi, and coexistent parenchymal abnormalities, such as parenchymal atrophy, abscess, biloma, and cancer. The distribution of the intrahepatic abnormalities was interpreted on the basis of the classification of the internal lobes and segments of the liver (four segments: left lateral, left medial, right anterior, and right posterior). The diseased segments were recorded for each patient. Intrahepatic ductal dilatation was diagnosed when ductal diameter was more than 3 mm (5), and stricture was diagnosed when focal caliber change was present at any segment. Calculi were considered present on MR cholangiograms when a signal void was identified within the bile duct in at least two different projections.

Randomized direct cholangiograms were then reviewed by the same two radiologists (M.S.P., J.S.Y.) without knowledge of the patients’ clinical information and MR cholangiographic findings. The focus of image analysis was to identify intrahepatic ductal dilatation and stricture, intrahepatic ductal calculi, and common ductal calculi, as was performed with the MR cholangiograms. The distribution of intrahepatic ductal abnormalities was evaluated on the basis of the division of four segmental branches (left lateral, left medial, right anterior, and right posterior). In cases of nondepiction of the intrahepatic duct at direct cholangiography, we investigated the reason for those abnormal findings. Coexistent parenchymal abnormalities, such as abscess and biloma that communicated with the bile duct, were also evaluated.

Results of surgical exploration were used to confirm the presence of cholangitis with findings of dilated, thick, and intra- and extrahepatic ducts containing pigmented calculi and biliary debris and coexistent parenchymal lesions. The MR cholangiographic and direct cholangiographic findings were compared with the corresponding surgical and pathology records, including intraoperative cholangiograms, by one author (M.S.P.). These findings were compared with respect to intrahepatic ductal abnormalities, calculi, and coexistent parenchymal abnormalities on the basis of the classification of the internal lobes and segments of the liver.

The significance of the differences in the rate of detectable intrahepatic ductal abnormalities (dilatation, stricture, and calculi) between MR cholangiography and direct cholangiography was calculated with the ² test. A P value less than .05 was considered to indicate a statistically significant difference for both tests. In the statistical analysis, only the patients who underwent both MR cholangiography and direct cholangiography were included.

	RESULTS

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According to examination results in the surgical specimens, 24 patients had 46 diseased segments: left lateral segment only (n = 4); right posterior segment only (n = 2); both left lateral and right posterior segments (n = 9); both left lateral and left medial segments (n = 4); both right posterior and right anterior segments (n = 1); one left lateral, one right posterior, and one right anterior segment each in three patients; and one left lateral, one left medial, and one right posterior segment. Intrahepatic bile ductal dilatation was present in all 46 segments in all 24 patients, stricture was present in 23 of 46 segments in 17 of 24 patients, and intrahepatic ductal calculi were present in 44 of 46 segments in all 24 patients. Common bile ductal calculi and ductal dilatation were present in 15 patients. Parenchymal atrophy was present in 37 of 46 segments in 20 of 24 patients, and hepatic abscesses were present in seven segments in five patients. Cholangiocarcinoma was present in one patient, and biloma was present in another patient.

MR cholangiography depicted all 46 (100%) segments in 24 patients with ductal dilatation, 22 (96%) of 23 segments with focal ductal stricture, 43 (98%) of 44 segments with ductal calculi, 14 (93%) of 15 common bile ductal calculi, all 37 (100%) segments with atrophy, and six (86%) of seven segments with abscesses, one cholangiocarcinoma, and one biloma. There was no false-positive case at MR cholangiography.

Of the 15 patients who underwent ERCP, images obtained in two were not adequate to evaluate the hepatobiliary system owing to incomplete filling. For the three patients who underwent percutaneous transhepatic cholangiography, all of the percutaneous transhepatic cholangiograms were adequate. Therefore, images from 16 direct cholangiographic examinations were analyzed. Sixteen patients who underwent adequate direct cholangiography had 32 segmental abnormalities according to examination results in the surgical specimens. Direct cholangiography depicted 15 (47%) of 32 segments with ductal dilatation, eight (44%) of 18 segments with focal ductal stricture, 14 (45%) of 31 segments with ductal calculi, and all 15 (100%) common bile ductal calculi. Seventeen (53%) of the 32 segmental abnormalities were not depicted at direct cholangiography owing to high-grade stenosis (Fig 1) or impacted calculi (Fig 2, Table 1). Coexistent parenchymal abnormalities, such as abscess or biloma that communicated with the bile duct, were not seen (Fig 3). There was no false-positive finding at direct cholangiography. The results of delineation of the intrahepatic ductal abnormalities at MR cholangiography and direct cholangiography are compared in Table 2.

View larger version (111K): [in this window] [in a new window] [Download PPT slide]   Figure 1a. Recurrent pyogenic cholangitis with typical appearance in a 53-year-old woman. (a) Anteroposterior ERCP image shows abrupt tapering of the left lateral segmental duct (arrows) without depiction of calculus and the peripheral duct, which results in an arrowhead appearance and missing duct, and it fails to show any intrahepatic ductal abnormality in the right lobe. (b) Right posterior oblique coronal single-shot fast spin-echo MR cholangiogram (2,047/1,040 [effective], 50-mm section thickness) shows irregular crowding of dilated ducts, with multiple filling defects and severe strictures in both the left lateral segmental duct (arrow) and the peripheral branch duct of the right posterior segment (arrowhead).

View larger version (69K): [in this window] [in a new window] [Download PPT slide]   Figure 1b. Recurrent pyogenic cholangitis with typical appearance in a 53-year-old woman. (a) Anteroposterior ERCP image shows abrupt tapering of the left lateral segmental duct (arrows) without depiction of calculus and the peripheral duct, which results in an arrowhead appearance and missing duct, and it fails to show any intrahepatic ductal abnormality in the right lobe. (b) Right posterior oblique coronal single-shot fast spin-echo MR cholangiogram (2,047/1,040 [effective], 50-mm section thickness) shows irregular crowding of dilated ducts, with multiple filling defects and severe strictures in both the left lateral segmental duct (arrow) and the peripheral branch duct of the right posterior segment (arrowhead).

View larger version (146K): [in this window] [in a new window] [Download PPT slide]   Figure 2a. Right posterior ductal abnormalities in a 44-year-old man depicted only at MR cholangiography. (a) Anteroposterior ERCP image does not show any ductal abnormality, such as calculus, stricture, or abrupt tapering, except for slight dilatation of the entire duct. A circular filling defect (arrow) is part of a balloon catheter. (b) Coronal single-shot fast spin-echo MR cholangiogram (16,366/1,004 [effective], 50-mm section thickness) shows multiple calculi (arrowheads) with dilatation in the peripheral branch of the right posterior duct.

View larger version (135K): [in this window] [in a new window] [Download PPT slide]   Figure 2b. Right posterior ductal abnormalities in a 44-year-old man depicted only at MR cholangiography. (a) Anteroposterior ERCP image does not show any ductal abnormality, such as calculus, stricture, or abrupt tapering, except for slight dilatation of the entire duct. A circular filling defect (arrow) is part of a balloon catheter. (b) Coronal single-shot fast spin-echo MR cholangiogram (16,366/1,004 [effective], 50-mm section thickness) shows multiple calculi (arrowheads) with dilatation in the peripheral branch of the right posterior duct.

View larger version (151K): [in this window] [in a new window] [Download PPT slide]   Figure 3a. Recurrent pyogenic cholangitis with abscess in a 65-year-old woman. (a) Anteroposterior percutaneous transhepatic cholangiogram shows severe stricture (arrow), with dilated ducts, multiple filling defects, and abrupt tapering in the right anterior segment. (b) Coronal MR image obtained with a thin-section half-Fourier rapid acquisition with relaxation enhancement (/95 [effective], 5-mm section thickness) sequence shows severe stricture (arrows) with dilated ducts, multiple filling defects, and abrupt tapering, which are similar to the findings in a. (c) Right posterior oblique coronal MR image obtained with a thin-section half-Fourier rapid acquisition with relaxation enhancement (/95 [effective], 5-mm section thickness) sequence shows parenchymal foci of high signal intensity that were confirmed as abscess (arrowheads), in addition to ductal abnormalities (arrow).

View larger version (136K): [in this window] [in a new window] [Download PPT slide]   Figure 3b. Recurrent pyogenic cholangitis with abscess in a 65-year-old woman. (a) Anteroposterior percutaneous transhepatic cholangiogram shows severe stricture (arrow), with dilated ducts, multiple filling defects, and abrupt tapering in the right anterior segment. (b) Coronal MR image obtained with a thin-section half-Fourier rapid acquisition with relaxation enhancement (/95 [effective], 5-mm section thickness) sequence shows severe stricture (arrows) with dilated ducts, multiple filling defects, and abrupt tapering, which are similar to the findings in a. (c) Right posterior oblique coronal MR image obtained with a thin-section half-Fourier rapid acquisition with relaxation enhancement (/95 [effective], 5-mm section thickness) sequence shows parenchymal foci of high signal intensity that were confirmed as abscess (arrowheads), in addition to ductal abnormalities (arrow).

View larger version (142K): [in this window] [in a new window] [Download PPT slide]   Figure 3c. Recurrent pyogenic cholangitis with abscess in a 65-year-old woman. (a) Anteroposterior percutaneous transhepatic cholangiogram shows severe stricture (arrow), with dilated ducts, multiple filling defects, and abrupt tapering in the right anterior segment. (b) Coronal MR image obtained with a thin-section half-Fourier rapid acquisition with relaxation enhancement (/95 [effective], 5-mm section thickness) sequence shows severe stricture (arrows) with dilated ducts, multiple filling defects, and abrupt tapering, which are similar to the findings in a. (c) Right posterior oblique coronal MR image obtained with a thin-section half-Fourier rapid acquisition with relaxation enhancement (/95 [effective], 5-mm section thickness) sequence shows parenchymal foci of high signal intensity that were confirmed as abscess (arrowheads), in addition to ductal abnormalities (arrow).

	DISCUSSION

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In the past decade, advances in hepatobiliary imaging, the availability of flexible choledochoscopy, application of calculus-fragmentation technology, and innovative surgical approaches to the biliary tract have modified the management of this condition. Some researchers have suggested that a combination of all of the treatment modalities, on a selective basis, is required to achieve optimum results, and they reported an improvement in treatment results for recurrent pyogenic cholangitis by using a systemic approach (2,8). It is essential, therefore, to know the accurate distribution of bile ductal calculi, ductal changes, and coexistent parenchymal lesions prior to surgical intervention.

Direct cholangiography has been an important imaging study in patients with recurrent pyogenic cholangitis, because it demonstrates the full spectrum of ductal changes and calculi (1). The abnormal ductal changes of recurrent pyogenic cholangitis at cholangiography include disproportionately severe dilatation of the extra- and intrahepatic ducts, with acute tapering, straightening, and rigidity of the ducts; decreased branching pattern; and multiple severe focal strictures (1). Calculi produce filling defects in the opacified bile ducts. When the calculi completely obstruct the orifice of the segmental or subsegmental bile ducts, they cannot be detected (missing duct sign) (1). Similarly, when there is a severe stricture at the segmental or subsegmental bile ducts, proximal bile ducts cannot be opacified, which may lead to an erroneous interpretation of no ductal calculus or stricture (1).

Complete obstruction of the intrahepatic ducts because of stricture or impacted calculi is one of the hallmarks of recurrent pyogenic cholangitis. In our study, direct cholangiography failed to depict such ducts, as many as 17 (53%) of the segmental ducts, whereas MR cholangiography depicted all such ducts. Because MR cholangiography can depict proximal and distal parts of the obstruction or stricture (9,10), it is much more accurate at delineating the entire biliary tree in patients with recurrent pyogenic cholangitis, especially in those with obstruction or stricture.

In our study, patients with recurrent pyogenic cholangitis had a relatively high prevalence of septic conditions and previous gastrectomies, probably because of high-grade obstruction of bile ducts and the common endemic area of stomach cancer and recurrent pyogenic cholangitis. Therefore, ERCP was not possible in a relatively large number of patients (n = 9). On the other hand, MR cholangiography has no complications or contraindications because it is noninvasive and requires no contrast material. Thus, MR cholangiography is much more usable than ERCP in patients with recurrent pyogenic cholangitis.

Recurrent pyogenic cholangitis has a high prevalence of coexistent parenchymal abnormalities, such as segmental atrophy, abscess, biloma, and cancer. Parenchymal atrophy is seen as a slightly hyperintense area with reduced volume and with or without crowding of dilated ducts or calculi at MR cholangiography. Some researchers (10) reported that mild enhancement was seen on delayed gadolinium-enhanced images, probably because of increased fibrosis with decreasing normal parenchyma. In our study, MR cholangiography was more accurate than direct cholangiography for detection of abscess and biloma. The reason may be that MR cholangiography, in contrast with direct cholangiography, is able to depict abscess and biloma regardless of their communication with the bile duct.

There was a limitation in our study. We chose to use surgical and pathologic findings as the reference standard to confirm our imaging data, but there is a possibility of false-negative results, even at surgery, because a pathologic investigation of the entire liver, except for the resected segments, cannot be performed. At surgery, however, there was an effort to directly inspect and palpate the unresected segments, and intraoperative cholangiography was used to supplement these findings. Therefore, surgical results can be used as a reference standard, despite the fact that they are not complete results.

In conclusion, MR cholangiography is superior to direct cholangiography for accurate topographic evaluation of recurrent pyogenic cholangitis. MR cholangiography is able to depict the entire biliary tree, despite obstruction or stenosis; it is not associated with complications, provided that patients undergo preprocedural screening for contraindications such as cerebral aneurysm clips and pacemakers; and it can show coexistent parenchymal atrophy. We believe that MR cholangiography should replace purely diagnostic direct cholangiography, especially ERCP, as a road map in patients with recurrent pyogenic cholangitis.

	FOOTNOTES

 
Abbreviation: ERCP = endoscopic retrograde cholangiopancreatography

Author contributions: Guarantor of integrity of entire study, M.S.P.; study concepts and design, M.S.P., J.S.Y.; literature research, M.S.P.; clinical studies, M.J.K., K.W.K.; data acquisition, S.W.Y.; data analysis/interpretation, M.S.P.; statistical analysis, M.S.P.; manuscript preparation, M.S.P.; manuscript definition of intellectual content, J.T.L., H.S.Y., M.J.K.; manuscript editing, J.J.C.; manuscript revision/review, J.P.C., K.W.K.; manuscript final version approval, J.S.Y.

	REFERENCES

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5. Turner MA. Examination technique and normal anatomy. In: Gore RM, Levine MS, Laufer I, eds. Textbook of gastrointestinal radiology. Philadelphia, Pa: Saunders, 1994; 1570-1593.
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This Article Abstract Figures Only Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Park, M.-S. Articles by Yoo, H. S. Search for Related Content PubMed PubMed Citation Articles by Park, M.-S. Articles by Yoo, H. S.