Pictorial review of Benign Biliary tract abnormality on MRCP/MRI Liver with Endoscopic (including splyglass) and Endoscopic Ultrasound correlation Poster No.: C-2617 Congress: ECR 2015 Type: Educational Exhibit Authors: N. Jabbar, S. Chawla, O. noorullah, N. stern, A. Katti ; 1 1 2 2 3 1 1 3 Liverpool/UK, 7AL/UK, liverool/uk Keywords: Education and training, Endoscopy, Ultrasound, MR, Liver DOI: 10.1594/ecr2015/C-2617 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 30
Learning objectives To illustrate the imaging and endoscopic findings of common and unusual benign bile duct pathologies, encountered in our institution. Background With increasing use of cross sectional imaging techniques like MRI and MRCP, a wide variety of benign biliary pathologies are increasingly being detected. These include morphological anomalies such as Caroli's disease, inflammatory, ischemic and autoimmune related strictures, iatrogenic injuries, intraductal calculi and external artefacts simulating disease. The challenge remains to confidently distinguish a benign from a malignant process which is complemented by biliary endoscopy including cholangioscopy and EUS. Cholangioscopy allows direct mucosal and luminal visualisation while at the same time providing targeted tissue diagnosis. The therapeutic role of endoscopy has made it an invaluable tool especially in the management of those patients presenting with obstructive symptoms. We present a pictorial review of a cohort of cases depicting the complementary role of cross sectional and endoscopic imaging modalities in the accurate diagnosis of patients with common and unusual benign bile duct pathologies. Hence we also aim to guide the clinicians for appropriate management options available. EPIDEMIOLOGY: The exact prevalence of bile duct strictures is not known. The commonest benign stricture is postoperative. Its incidence is 0.2%-0.3% after open cholecystectomy and 0.4% to 0.6% after laparoscopic cholecystectomy. These figures are comparable for North America and Europe. There is an equal sex incidence of postoperative strictures. However biliary strictures due to PSC and Pancreatitis are more common in men. ETIOLOGY: Page 2 of 30
1. Iatrogenic: post cholecystectomy and post liver transplantation 2. Intraductal calculi 3. Inflammatory: Pancreatitis 4. Autoimmune: PSC 5 Radiation 6. HIV Cholangiopathy 7. Infective: TB 8. Ischaemic 8. Post traumatic: abdominal trauma 9. Others: Extrinsic compression 10. Idiopathic PATHOPHYSIOLOGY: The insult may be due to an acute event such as abdominal trauma or damage during surgery, a recurring condition, such as pancreatitis or bile duct stones; or a chronic disease, such as PSC. After the injury, an inflammatory cascade is initiated, which is followed by collagen deposition, fibrosis, and narrowing of the bile duct lumen. Findings and procedure details Page 3 of 30
ROLE OF IMAGING: Ultrasound (US) is the initial imaging modality of choice. This can show biliary dilatation but may not necessarily show the cause of biliary dilatation. Multidetector CT (MDCT) has high sensitivity for detecting biliary obstruction. It also has the added advantage of diagnosing any other associated pathology. MRI with MRCP is more sensitive than CT due to its superior contrast and tissue resolution. MRCP is extremely accurate in localising the site and detecting the cause of the biliary obstruction. Endoscopic tests complement the imaging tests. As these are invasive tests, they are usually performed after CT/MRI. They are also useful when it is not possible to distinguish a benign stricture from a malignant stricture, on imaging alone. ENDOSCOPIC PROCEDURES: ERCP is the most commonly performed endoscopic procedure. It can delineate the extent of the biliary pathology, enable brushings, biopsy and stent placement for therapeutic benefit to the patient. However, ERCP cannot assess the proximal biliary tree and has only a 50% rate of sensitivity for the brush cytology. To overcome these limitations, Endoscopic Ultrasound (EUS) and Intraductal Ultrasound are employed. EUS has a greater sensitivity for cytological diagnosis than ERCP as more accurate FNA can be performed. Spy Glass Endoscopy is a new technique for cholangioscopy which allows direct intraductal visualisation. Compared to other cholangioscopic techniques, Spy Glass Endoscopy offers better image quality and scope manoeuvrability. Page 4 of 30
The sidebar shows cross-sectional images with corresponding endoscopic images depicting biliary strictures due to a varied etiology. Images for this section: Fig. 1: Patient presented with intermittent painless jaundice. CT showed an intraductal filling defect in the CBD. Page 5 of 30
Fig. 2: CBD lesion appeared as a benign intraductal mucinous type lesion on ERCP. Page 6 of 30
Fig. 3: Young male with a history of ulcerative colitis had an MRCP for evaluation of abnormal liver function tests. MRCP showed alternating stricturing and beading of the intrahepatic biliary ducts in keeping with Primary Sclerosing Cholangitis (PSC). Page 7 of 30
Fig. 4: Cholangiography at ERCP confirmed PSC. Page 8 of 30
Fig. 5: MRI showing a large intraductal calculus in a patient presenting with Cholangitis. Page 9 of 30
Fig. 6: ERCP confirmed a large impacted intraductal calculus at the junction of cystic duct and Common Hepatic Duct (CHD). Page 10 of 30
Fig. 7: Patient underwent an MRCP for evaluation of possible choledocholithiasis prior to laparoscopic cholecystectomy. CHD stricture shown on MRCP. Page 11 of 30
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Fig. 8: ERCP was normal, and the apparent 'stricture' on MRI was attributed to external compression. Fig. 9: Incidental finding of marked intrahepatic biliary dilatation on CT. On this arterial phase examination, a prominent vascular loop is seen crossing the CHD. Page 13 of 30
Fig. 10: ERCP confirmed biliary dilatation due to extrinsic compression. Page 14 of 30
Fig. 11: Post orthotopic liver transplant, patient had abnormal liver function tests. MRCP showed proximal biliary stricture. Page 15 of 30
Fig. 12: Post liver transplant biliary stricture, treated with balloon on ERCP. Page 16 of 30
Fig. 13: A patient presented with right upper quadrant pain and cholestatic liver function tests. MRCP demonstrated right hepatic duct stricture with intrahepatic ductal dilatation and intraductal calculi. Page 17 of 30
Fig. 14: MRCP demonstrating right hepatic duct stricture with intrahepatic ductal dilatation and intraductal calculi. Page 18 of 30
Fig. 15: Spy Glass Endoscopy showing normal mucosa of the biliary duct. Page 19 of 30
Fig. 16: Malignant stricture showed on Spy Glass Endoscopy. Page 20 of 30
Fig. 17: Benign stricture shown on Spy Glass Endoscopy. Page 21 of 30
Fig. 18: Patient presented with acute on chronic right upper quadrant pain. CT showed multiple gallstones in a thick walled gallbladder. The intrahepatic ducts were also dilated. Page 22 of 30
Fig. 19: MRCP showed a CHD stricture. There was the impression of extrinsic compression of the CHD. Page 23 of 30
Fig. 20: ERCP nicely demonstrated a smooth extrinsic impression on the CHD. The patient was diagnosed as Mirizzi's syndrome, the extrinsic compression being caused by a gallstone impacted in the cystic duct. Page 24 of 30
Fig. 21: Patient presented with painless progressive jaundice. CT showed a distal CBD stricture with intra and extrahepatic biliary dilatation. No mass lesion was seen. Page 25 of 30
Fig. 22: MRCP confirmed CT findings of intra and extrahepatic duct dilatation. Page 26 of 30
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Fig. 23: Stricture proved to be IgG cholangiopathy on brushings taken at ERCP. Page 28 of 30
Conclusion Benign duct strictures are a challenging clinical condition which requires a multidisciplinary team input from Gastroenterologists, Surgeons and Radiologists. The role of imaging is to diagnose the stricture, assess the extent of pathology and illustrate the cause. Imaging complements endoscopic procedures in differentiating benign from malignant aetiology and determining the extent of disease. ERCP is commonly used in diagnosis of biliary strictures but cannot completely evaluate proximal bile duct disease. EUS and Spy Glass Endoscopy overcome these limitations and help improve the diagnostic accuracy of ERCP. Personal information Dr.Nadya Jabbar Nadya.Jabbar@whh.nhs.uk Dr.Sumita Chawla Sumita.Chawla@aintree.nhs.uk Dr.Omar Noorullah Omar.Noor@aintree.nhs.uk Dr.Nick Stern Nick.Stern@aintree.nhs.uk Dr.Ashok Katti Ashok.Katti @aintree.nhs.uk References 1.Benign biliary strictures: Acurrent comprehensive clinical and imaging review. Page 29 of 30
American Journal of Roentgenology 2011;197:W295-W306. 2. A prospective comparison of the diagnostic accuracy of ERCP, MRCP, CT and EUS in biliary strictures. Gastrointestinal Endoscopy 2002 June;55(7):870-6. 3. Current endoscopic approach to indeterminate biliary strictures. World Journal of Gastroenterology 2012 Nov 21;18(43):6197-205. 4. Endoscopic evaluation of bile duct strictures. Gastrointestinal Endoscopy Clinics of North America 2013 Apr;23(2):277-93. Page 30 of 30