Oriental Cholangiohepatitis (OCH): Radiologic Features

Lee, Ming-Yen, Kaohsiung Medical University, Year IVGillian Lieberman, MD

September 2010Lee, Ming-YenGillian Lieberman, MD

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Agenda• Patient presentation

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Initial presentation

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Radiologic findings

• Oriental Cholangiohepatitis−

Pathogenesis

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Differential diagnosis

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Relative Roles of Imaging Tests

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Management

Lee, Ming-YenGillian Lieberman, MD

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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.

Lee, Ming-YenGillian Lieberman, MD

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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

C-

Lee, Ming-YenGillian Lieberman, MD

BIDMC PACS

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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

Lee, Ming-YenGillian Lieberman, MD

BIDMC PACS

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Our patient: biliary ducts dilatation with air on coronal CT

Lee, Ming-YenGillian Lieberman, MD

BIDMC PACSArterial phase Venous phase

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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

Lee, Ming-YenGillian Lieberman, MD

Oriental Cholangiohepatitis

Lee, Ming-YenGillian Lieberman, MD

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Oriental Cholangiohepatitis

• Oriental cholangiohepatitis (OCH), also known as −

Oriental cholangitis

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recurrent pyogenic cholangitis

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Intrahepatic pigmented stone disease

• characterized by recurrent attacks of fever, chills, abdominal pain, and jaundice (Charcot's triad of acute cholangitis )

Lee, Ming-YenGillian Lieberman, MD

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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.

Lee, Ming-YenGillian Lieberman, MD

Website: The radiology assistant

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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

Lee, Ming-YenGillian Lieberman, MD

AJR 157:1-8, July 1991

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Comparison our p’t #2: OCH on CT w/o contrast

• Full extent of ductal dilatation −

Dilatation of the extrahepatic ducts is detected clearly.

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Central, larger intrahepatic biliary dilatation

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bile ducts tapering abruptly toward periphery

Lee, Ming-YenGillian Lieberman, MD

AJR 157:1-8, July 1991

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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 :63- 81%

• wall of the bile ducts may enhance−

acute cholangitic episode

Lee, Ming-YenGillian Lieberman, MD

AJR 157:1-8, July 1991

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Our patient: comparison OCH on CT w/o contrast

• 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

Lee, Ming-YenGillian Lieberman, MD

BIDMC PACS

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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

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Straightening−

Rigidity

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Multiple focal strictures

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Decrease in arborization

Lee, Ming-YenGillian Lieberman, MD

AJR 157:1-8, July 1991

Facet stones in CBD

Filling defects of stones

stricture

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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

Lee, Ming-YenGillian Lieberman, MD

17Website: The radiology assistant

Differential diagnosis of bile duct dilatation

Lee, Ming-YenGillian Lieberman, MD

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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

Lee, Ming-YenGillian Lieberman, MD

RadioGraphics 2001; 21:3–22

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DDx2: Clonorchiasis on CT

• Clonorchiasis−

diffuse dilatation of the intrahepatic bile ducts with no or minimal dilatation of the large bile ducts

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Periductal changes are more severe in clonorchiasis

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Stones and flukes of C. sinensis can be differentiated easily.

Lee, Ming-YenGillian Lieberman, MD

RadioGraphics, 28, 1307-1323,

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DDx3: cholangio CA. on CT

• Biliary obstruction by malignant tumors−

cholangiocarcinoma and cancer of the pancreas or ampulla of Vater

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The entire biliary tree proximal to the mass is dilated

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An obstructing mass can be detected!!

Lee, Ming-YenGillian Lieberman, MD

Holland-Frei Cancer Medicine, bile duct cancer

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DDx4: Sclerosing cholangitis on CT • Sclerosing cholangitis

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dilatation is focal and discontinuous (beaded appearance and serpiginous course)

Lee, Ming-YenGillian Lieberman, MD

The radiology assistant, Biliary Ducts : Benign and Malignant Diseases

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DDx5: Caroli disease on CT• Caroli disease

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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

Lee, Ming-YenGillian Lieberman, MD

The radiology assistant, Biliary Ducts : Benign and Malignant Diseases

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Imaging Tests: us + CT• Sonography

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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

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when space-occupying lesions complicate OCH

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when hepatic resection is planned

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When imaging guidance is needed for complex drainage procedures

Lee, Ming-YenGillian Lieberman, MD

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Imaging Tests: Direct cholangiography

• Direct cholangiography−

“Road map” in patients undergoing surgical intervention

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Necessary for the detection of residual stones after surgery

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Assessment of biliary stricture and choledochoenteric fistulas

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Preprocedural biliary intervention

Lee, Ming-YenGillian Lieberman, MD

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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

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Hepatic resection

Lee, Ming-YenGillian Lieberman, MD

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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

Lee, Ming-YenGillian Lieberman, MD

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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

Lee, Ming-YenGillian Lieberman, MD

Thanks for your attention….

Lee, Ming-YenGillian Lieberman, MD