Oriental cholangiohepatitis

Case contributed by Dr Eric F Greif

Presentation

Patient presents with 4 days of RUQ abdominal pain, nausea, and shaking chills. She states that she has had similar complaints about 1 year prior and was treated. She has a history of remote cholecystectomy.

Patient Data

Age: 35
Gender: Female
Modality: CT

There is moderate intrahepatic biliary ductal dilatation in the right and left hepatic lobes most notably involving the right anterior and left medial hepatic segments with relative narrowing of the intrahepatic bile ducts towards the liver hilum. Pneumobilia is noted within the left hepatic lobe.  There is no visible periductal infiltrative parenchymal changes near the liver hilum. Multiple rounded hyperdense filling defects are seen within the distended intrahepatic bile ducts in the right anterior hepatic segment, resembling biliary stones. The common bile duct is slightly enlarged measuring 8 mm. The gallbladder is surgically absent.

Modality: Annotated image

Multiple rounded hyperdense filling defects are seen within the distended intrahepatic bile ducts of the right  hepatic lobe resembling biliary stones (red arrows). There are several focal intra-hepatic biliary duct strictures causing upstream duct dilation resembling the shape of an "arrowhead" (blue arrow-heads).  

Modality: Fluoroscopy

ERCP Report:

A cholangiogram was performed which revealed dilated intrahepatic ducts (IHD) with filling defects, most pronounced in the left hepatic duct.  Balloon sweeps were performed in the distal CBD and a large stone removed. 

Selective canullation of the left IHD was performed with the use of a sphincterotome and multiple balloon sweeps performed with retrieval of several stones, sludge and pus. A stricture was noted in the mid left IHD and despite multiple balloon sweeps unable to retrieve all the stones.  A straight 7 Fr * 12 cm stent was placed to bridge the stricture.

Case Discussion

35 year old Chinese female presented with 4 days of RUQ abdominal pain, nausea, and chills . She was found to be septic with bandemia - 35%. The patient has a history of cholangitis.

The CT revealed intrahepatic biliary duct dilation out of proportion to the common biliary duct dilatation. There were several hyperdense intra-hepatic biliary calculi, multiple strictures which caused focally dilated ducts shaped like an "arrowhead", and pneumobilia. ERCP demonstrated similar findings and evidence of frank pus.

The clinical history and imaging findings are consistent with oriental cholangiohepatitis, also known as recurrent pyogenic cholangitis.

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Case Information

rID: 37987
Case created: 29th Jun 2015
Last edited: 8th May 2016
Inclusion in quiz mode: Included

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