Sex: male
Age: 81 years
History
Status post cholecystectomy 17 years before. Aneurysm of the abdominal aortaSudden loss of weight within the last 4 weeks.
Laboratory data
Fever 39°C, Leukocytes 6900, AP 567, GGT 1258, Bili 37, CEA 80 (Int.Units)
Physical findings
Slightly enlarged liver. Otherwise normal findings.
Case text
81-year-old patient in healthy condition. Admitted as an emergency with pain in the upper right abdomen, fever
Image 1-3
CT.
Post-contrast CT scans of the upper abdomen.
Image 4-5
MRCP.
Image 1-3
1. What is the abnormality present on the post-contrast CT scan?
Dilated biliary tract in the central portion of the liver and the distal hepatobiliary duct.
2. What is your diagnosis?
Biliary dilatation after cholecystectomy.
3. What is the differential diagnosis?
Stone disease, stenosis in the papillar region, tumor of the head of pancreas.
4. What is your next step?
ERCP - none diagnostic caused by a diverticulum in the papillar region !
PTC - by technical problems not available.
5. What is your next step ?
MRCP.
Image 4-5
6. What is the abnormality present on the MRCP scan?
Dilatation of the intrahepatic ducts and meniscal type of stenosis of the distal biliary tract.
Final diagnosis
Stone disease within the distal biliary duct.
Differential diagnosis
Tumor of the head of the pancreas.
Discussion
Usually diagnosis of biliary duct stones is an easy one: by ultrasound they can be detected by an increased proximal signal intensity and the typical shadowing in the distal part. However, caused by air in the biliary tract after cholecystectomy the intra- and extrahepatic parts were invisible. The intravenous cholangiogram was negative for stones. In the CT-examination the diameter of the intrahepatic ducts was increased within the hilar region, however, a percutaneous transhepatic cholangiography (PTC) failed in the acute phase. The initial ERCP failed to overcome the papilla, located within a diverticulum. Only the none-invasive MR-cholangiography demonstrated a stenosis of the distal duct: To reduce artifacts of the bowel , the examination had to be achieved after application of oral contrast media ( Abdoscan® / ferristene -Nycomed Amersham). The typical meniscus at the border of the stone allowed to exclude tumor disease. Some days later, with increasing diameter of the biliary ducts, a second PTC and combined ERCP confirmed the first and a second stone. MRCP together with suppression of bowel artifacts is an excellent and none invasive tool in visualizing the biliary and pancreatic duct system especially in case of technical difficulties with ERCP and PTC.