Abdominal X-rays confirm the absence of calcific cholelithiasis. There is a right basal pleural effusion.

There is a non-specific bowel gas pattern with evidence of abdominal pain. X-rays are otherwise unremarkable. There is a previous sterilisation.

Upper abdominal ultrasound demonstrates :

• hepatic steatosis

• cholelithiasis, no cholecystitis

• intrahepatic and extrahepatic bile duct distention

• hepatolithiasis

• choledocholithiasis

• normal pancreas and pancreatic duct

• right basal effusion

• necrotic mesenteric, para-aortic and porta-hepatic lymph nodes (HIV positive)

Cine loops of the ultrasound demonstrate intra and extrahepatic bile duct distention, with echogenic calculi causing posterior acoustic shadowing within the intrahepatic bile ducts, common hepatic and common bile ducts.

There is necrotic porta hepatic lymph adenopathy in keeping with the positive HIV status and possible abdominal tuberculosis/ tuberculous lymph adenitis.

There is a large, right pleural effusion (10 HU), with compressive atelectasis. There is a tiny left basal effusion. There are no other thoracic abnormalities to suggest pulmonary tuberculosis.

There is hepatic steatosis, with dilated intra and extrahepatic bile ducts with a collapsed distal common bile duct (CBD). There are ill-defined punctate densities within the dilated ducts. There is no hepatomegaly.

The gallbladder is contracted with punctate calcified gallstones. There is no cholecystitis.

The pancreas and pancreatic duct are normal.

There is an isolated spenic cyst, with a normal splenic size.

There is necrotic epigastric, portahepatic, paraaortic and paracaval lymphadenopathy.

Suspected intestinal/ abdominal tuberculosis with abnormal small and large bowel including the terminal ileum.

Complex pelvic appearance suggesting pelvic sepsis (tubo-ovarian complexes/pelvic inflammatory disease/possible urogenital tuberculosis).

MRI of the upper abdomen and MRCP confirm dilated intrahepatic bile ducts with hepatolithiasis. Ductal enhancement suggests associated cholangitis.

There is a proximal common bile duct stricture. There is upstream choledocholithiasis with calculi within the common hepatic bile duct and proximal common bile duct. This is well demonstrated in the coronal sequences and reformats.

There is cholelithiasis and no cholecystitis.

The pancreas and pancreatic duct are normal.

There is a large right pleural effusion, a tiny left pleural effusion and minimal perihepatic fluid. There extra skeletal soft tissue oedema.

Image courtesy: Dr IA Nagdee