Choledocholithiasis, cholangitis, and portal vein thrombophlebitis
Presentation
Right upper quadrant pain.
Patient Data
Thrombosis of right portal venous branches with periportal edema. Thickening and enhancement of the central and common hepatic/bile ducts, as well as the nondilated gallbladder (which contains a few stones). Mild dilation of the intrahepatic ducts. Subtle rounded filling defect in the common bile duct.
Annotated axial image indicates the round common bile duct stone within the center of the duct. This can be confirmed on the coronal image as a true finding (not an artifact).
Case Discussion
If you take time to account for all of the key findings, this case has the satisfying result of making sequential sense.
The patient probably started with choledocholithiasis, which resulted in cholangitis, and finally septic thrombophlebitis of the right portal venous branches. However it is most likely that you would make this diagnosis in reverse - first noticing the portal vein thrombosis, then the common duct thickening, and finally carefully looking for a stone as a potential cause of biliary inflammation.
It can be easy to overlook what is "not there" in the case of venous thrombosis, so be sure to familiarize yourself with that appearance.
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