Download Oriental Cholangiohepatitis (OCH): Radiologic Features

Lee, Ming-Yen
Gillian Lieberman, MD
September 2010
Oriental Cholangiohepatitis
(OCH): Radiologic Features
Lee, Ming-Yen,
Kaohsiung Medical University, Year IV
Gillian Lieberman, MD
Lee, Ming-Yen
Gillian Lieberman, MD
Agenda
• Patient presentation
− Initial presentation
− Radiologic findings
• Oriental Cholangiohepatitis
−
−
−
−
Pathogenesis
Differential diagnosis
Relative Roles of Imaging Tests
Management
2
Lee, Ming-Yen
Gillian Lieberman, MD
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.
3
Lee, Ming-Yen
Gillian Lieberman, MD
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
C4
BIDMC PACS
Lee, Ming-Yen
Gillian Lieberman, MD
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
5
BIDMC PACS
Lee, Ming-Yen
Gillian Lieberman, MD
Our patient: biliary ducts dilatation
with air on coronal CT
Arterial phase
Venous phase
6
BIDMC PACS
Lee, Ming-Yen
Gillian Lieberman, MD
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
7
Lee, Ming-Yen
Gillian Lieberman, MD
Oriental Cholangiohepatitis
Lee, Ming-Yen
Gillian Lieberman, MD
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 )
9
Lee, Ming-Yen
Gillian Lieberman, MD
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.
10
Website: The radiology assistant
Lee, Ming-Yen
Gillian Lieberman, MD
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
11
AJR 157:1-8, July 1991
Lee, Ming-Yen
Gillian Lieberman, MD
Comparison our p’t #2:
OCH on CT w/o contrast
• Full extent of ductal
dilatation
− Dilatation of the
extrahepatic ducts
is detected clearly.
− Central, larger
intrahepatic biliary
dilatation
− bile ducts tapering
abruptly toward
periphery
12
AJR 157:1-8, July 1991
Lee, Ming-Yen
Gillian Lieberman, MD
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 :6381%
• wall of the bile ducts
may enhance
− acute cholangitic
episode
13
AJR 157:1-8, July 1991
Lee, Ming-Yen
Gillian Lieberman, MD
Our patient: comparison OCH on CT
w/o contrast
BIDMC
PACS
• 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
14
Lee, Ming-Yen
Gillian Lieberman, MD
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
− Straightening
− Rigidity
− Multiple focal
strictures
− Decrease in
arborization
Filling defects of
stones
stricture
Facet stones
in CBD
15
AJR 157:1-8, July 1991
Lee, Ming-Yen
Gillian Lieberman, MD
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
16
Lee, Ming-Yen
Gillian Lieberman, MD
Differential diagnosis of bile duct
dilatation
17
Website: The radiology assistant
Lee, Ming-Yen
Gillian Lieberman, MD
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
RadioGraphics
2001; 21:3–22
18
Lee, Ming-Yen
Gillian Lieberman, MD
DDx2: Clonorchiasis on CT
• Clonorchiasis
− diffuse dilatation of the
intrahepatic bile ducts
with no or minimal
dilatation of the large
bile ducts
− Periductal changes are
more severe in
clonorchiasis
− Stones and flukes of C.
sinensis can be
differentiated easily.
RadioGraphics, 28, 1307-1323,
19
Lee, Ming-Yen
Gillian Lieberman, MD
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
− An obstructing mass
can be detected!!
Holland-Frei Cancer Medicine, bile duct
cancer
20
Lee, Ming-Yen
Gillian Lieberman, MD
DDx4: Sclerosing cholangitis on CT
• Sclerosing cholangitis
− dilatation is focal and discontinuous
(beaded appearance and serpiginous course)
21
The radiology assistant, Biliary Ducts : Benign and Malignant Diseases
Lee, Ming-Yen
Gillian Lieberman, MD
DDx5: Caroli disease on CT
• Caroli disease
− 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
The radiology assistant, Biliary
Ducts : Benign and Malignant
Diseases
22
Lee, Ming-Yen
Gillian Lieberman, MD
Imaging Tests: us + CT
• Sonography
− 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
− when space-occupying lesions complicate
OCH
− when hepatic resection is planned
− When imaging guidance is needed for
complex drainage procedures
23
Lee, Ming-Yen
Gillian Lieberman, MD
Imaging Tests: Direct cholangiography
• Direct cholangiography
− “Road map” in patients undergoing
surgical intervention
− Necessary for the detection of residual
stones after surgery
− Assessment of biliary stricture and
choledochoenteric fistulas
− Preprocedural biliary intervention
24
Lee, Ming-Yen
Gillian Lieberman, MD
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
25
Lee, Ming-Yen
Gillian Lieberman, MD
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
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Lee, Ming-Yen
Gillian Lieberman, MD
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
27
Lee, Ming-Yen
Gillian Lieberman, MD
Thanks for your
attention….