Presentation
Abdominal pain and recurrent episodes of infection with deranged liver function tests.
Patient Data
The background liver has a nodular contour with signs of portal hypertension with multiple splenic varices and a rare ectopic varix with portosystemic communication via the diaphragmatic veins to the IVC
The biliary tree contains contrast and gas from recent ERCP examination
The left lateral (segments 2 & 3 ) intrahepatic ducts show marked dilation and contain multiple intraductal stones and ductal rim enhancement.
ERCP shows intraductal stone disease and intraductal strictures.
On the final image, we can see clearance of the extrahepatic biliary tree post ERCP intervention although the intraductal stones remain.
Case Discussion
The imaging appearances show classic features of recurrent pyogenic cholangiohepatitis.
The patient had emigrated from Southeast Asia where he was likely infected with a liver fluke. The most common organisms are Ascaris lumbricoides and Clonorchis sinensis. It has been suggested that chronic infestation of the biliary tree induces inflammatory and fibrotic changes in the bile duct walls, leading to stricture formation, bile stasis, and intrahepatic pigmented stones.
Recurrent biliary disease can result in an increased risk of cholangiocarcinoma but also chronic liver disease and fibrosis.
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