Intrahepatic biliary stones

Case contributed by Dr Mostafa El-Feky

Presentation

Right hypochondrial pain.

Patient Data

Age: 45 years
Gender: Female
MRI

MRCP

The liver shows cirrhotic changes in the form of nodular contours and parenchymal dysmorphism, as well as widening of the interlobar fissure. No focal lesion in either T2 or diffusion images.

The intrahepatic portal branches show loss of T2 signal void, the main portal vein shows partial loss of its T2 signal void signal apart from marginal crescent area suggestive of partial portal thrombosis.

Periportal ill-defined T2 hyperintense signal is seen reflecting associated portal triad inflammatory changes.

Multiple intrahepatic biliary strictures with interrupted segments of dilatation, notably involving the right anterior duct reaching the capsule and harboring multiple stones around 4 mm. Normal configuration of the gall bladder with no luminal signal defects.

The spleen is mildly enlarged measuring 14 cm.

MRI

HASTE 3D Images

Multiple intrahepatic biliary strictures with signal voids representing intraductal stones.

Case Discussion

Intrahepatic biliary stones are rare; common location of stone is in large-caliber ducts mostly in the left hepatic lobe or posterior segment of the right hepatic lobe. The intrahepatic biliary strictures may suggest primary sclerosing cholangitis. Biliary strictures are one of the causes of primary intrahepatic bile duct stones.

It's difficult in this case to confirm PV thrombus, as vessels can show artifactual signals due to slow flow and some diseases can make hemodynamic changes like cirrhosis. On such case, if the signal change is well-defined (like the high T2 signal of the portal vein with eccentric flow void), we can suggest partial thrombosis and we need to recommend contrast study for confirmation (CT or MRI) or portal vein Doppler.

Usually, T2 flow void signal is seen at patent vessels, however, it is not alone a sure sign of patency. Signal changes should be seen on at least two MRI sequences to suspect thrombosis. 

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Case information

rID: 54180
Published: 28th Jun 2017
Last edited: 8th Nov 2019
Inclusion in quiz mode: Included

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