Adult Bile Duct Strictures: Role of MR Imaging and MR Cholangiopancreatography in Characterization

Published Online:https://doi.org/10.1148/rg.343125211

Contrast-enhanced MR imaging with MR cholangiopancreatography can be helpful in identifying bile duct strictures in adult patients and differentiating between benign and malignant strictures.

Bile duct strictures in adults are secondary to a wide spectrum of benign and malignant pathologic conditions. Benign causes of bile duct strictures include iatrogenic causes, acute or chronic pancreatitis, choledocholithiasis, primary sclerosing cholangitis, IgG4-related sclerosing cholangitis, liver transplantation, recurrent pyogenic cholangitis, Mirizzi syndrome, acquired immunodeficiency syndrome cholangiopathy, and sphincter of Oddi dysfunction. Malignant causes include cholangiocarcinoma, pancreatic adenocarcinoma, and periampullary carcinomas. Rare causes include biliary inflammatory pseudotumor, gallbladder carcinoma, hepatocellular carcinoma, metastases to bile ducts, and extrinsic bile duct compression secondary to periportal or peripancreatic lymphadenopathy. Contrast material–enhanced magnetic resonance (MR) imaging with MR cholangiopancreatography is extremely helpful in the noninvasive evaluation of patients with obstructive jaundice, an obstructive pattern of liver function, or incidentally detected biliary duct dilatation. Some of these conditions may show characteristic findings at MR imaging–MR cholangiopancreatography that help in making a definitive diagnosis. Although endoscopic retrograde cholangiopancreatography with tissue biopsy or surgery is needed for the definitive diagnosis of many of these strictures, certain MR imaging characteristics of the narrowed segment (eg, thickened wall, long-segment involvement, asymmetry, indistinct outer margin, luminal irregularity, hyperenhancement relative to the liver parenchyma) may favor a malignant cause. Awareness of the various causes of bile duct strictures in adults and familiarity with their appearances at MR imaging–MR cholangiopancreatography are important for accurate diagnosis and optimal patient management.

©RSNA, 2014

References

  • 1. Darge K, Anupindi SA, Jaramillo D. MR imaging of the abdomen and pelvis in infants, children, and adolescents. Radiology 2011;261(1):12–29.
  • 2. Shanmugam V, Beattie GC, Yule SR, Reid W, Loudon MA. Is magnetic resonance cholangiopancreatography the new gold standard in biliary imaging? Br J Radiol 2005;78(934):888–893.
  • 3. Afdhal NH. Diseases of the gallbladder and bile ducts. In: Goldman L, Schafer AI, eds. Cecil medicine. 24th ed. Philadelphia, Pa: Saunders Elsevier, 2011.
  • 4. Cursio R, Gugenheim J. Ischemia-reperfusion injury and ischemic-type biliary lesions following liver transplantation. J Transplant 2012;2012:164329.
  • 5. Lee WJ, Lim HK, Jang KM, et al. Radiologic spectrum of cholangiocarcinoma: emphasis on unusual manifestations and differential diagnoses. RadioGraphics 2001;21(Spec No):S97–S116.
  • 6. Wallner BK, Schumacher KA, Weidenmaier W, Friedrich JM. Dilated biliary tract: evaluation with MR cholangiography with a T2-weighted contrast-enhanced fast sequence. Radiology 1991;181(3): 805–808.
  • 7. Yeh BM, Liu PS, Soto JA, Corvera CA, Hussain HK. MR imaging and CT of the biliary tract. RadioGraphics 2009;29(6):1669–1688.
  • 8. Choi JY, Lee JM, Lee JY, et al. Navigator-triggered isotropic three-dimensional magnetic resonance cholangiopancreatography in the diagnosis of malignant biliary obstructions: comparison with direct cholangiography. J Magn Reson Imaging 2008;27(1):94–101.
  • 9. Vitellas KM, Keogan MT, Spritzer CE, Nelson RC. MR cholangiopancreatography of bile and pancreatic duct abnormalities with emphasis on the single-shot fast spin-echo technique. RadioGraphics 2000; 20(4):939–957.
  • 10. Sodickson A, Mortele KJ, Barish MA, Zou KH, Thibodeau S, Tempany CM. Three-dimensional fast-recovery fast spin-echo MRCP: comparison with two-dimensional single-shot fast spin-echo techniques. Radiology 2006;238(2):549–559.
  • 11. Sahni VA, Mortele KJ. Magnetic resonance cholangiopancreatography: current use and future applications. Clin Gastroenterol Hepatol 2008;6(9): 967–977.
  • 12. Kim JY, Lee JM, Han JK, et al. Contrast-enhanced MRI combined with MR cholangiopancreatography for the evaluation of patients with biliary strictures: differentiation of malignant from benign bile duct strictures. J Magn Reson Imaging 2007;26(2): 304–312.
  • 13. Lee NK, Kim S, Lee JW, et al. Biliary MR imaging with Gd-EOB-DTPA and its clinical applications. RadioGraphics 2009;29(6):1707–1724.
  • 14. Irie H, Honda H, Kuroiwa T, et al. Pitfalls in MR cholangiopancreatographic interpretation. RadioGraphics 2001;21(1):23–37.
  • 15. Kondo H, Kanematsu M, Shiratori Y, Moriwaki H, Hoshi H. Potential pitfall of MR cholangiopancreatography: right hepatic arterial impression of the common hepatic duct. J Comput Assist Tomogr 1999;23(1):60–62.
  • 16. Moser AJ. Benign biliary strictures. Curr Treat Options Gastroenterol 2001;4(5):377–387.
  • 17. Jabłońska B, Lampe P. Iatrogenic bile duct injuries: etiology, diagnosis and management. World J Gastroenterol 2009;15(33):4097–4104.
  • 18. Khalid TR, Casillas VJ, Montalvo BM, Centeno R, Levi JU. Using MR cholangiopancreatography to evaluate iatrogenic bile duct injury. AJR Am J Roentgenol 2001;177(6):1347–1352.
  • 19. Girometti R, Brondani G, Cereser L, et al. Post-cholecystectomy syndrome: spectrum of biliary findings at magnetic resonance cholangiopancreatography. Br J Radiol 2010;83(988):351–361.
  • 20. Karvonen J, Gullichsen R, Laine S, Salminen P, Grönroos JM. Bile duct injuries during laparoscopic cholecystectomy: primary and long-term results from a single institution. Surg Endosc 2007;21(7): 1069–1073.
  • 21. Ward J, Sheridan MB, Guthrie JA, et al. Bile duct strictures after hepatobiliary surgery: assessment with MR cholangiography. Radiology 2004;231(1): 101–108.
  • 22. Chaudhary A, Negi SS, Puri SK, Narang P. Comparison of magnetic resonance cholangiography and percutaneous transhepatic cholangiography in the evaluation of bile duct strictures after cholecystectomy. Br J Surg 2002;89(4):433–436.
  • 23. Hoeffel C, Azizi L, Lewin M, et al. Normal and pathologic features of the postoperative biliary tract at 3D MR cholangiopancreatography and MR imaging. RadioGraphics 2006;26(6):1603–1620.
  • 24. Abdallah AA, Krige JE, Bornman PC. Biliary tract obstruction in chronic pancreatitis. HPB (Oxford) 2007;9(6):421–428.
  • 25. Hakimé A, Giraud M, Vullierme MP, Vilgrain V. MR imaging of the pancreas [in French]. J Radiol 2007;88(1 pt 1):11–25.
  • 26. Robinson PJ, Sheridan MB. Pancreatitis: computed tomography and magnetic resonance imaging. Eur Radiol 2000;10(3):401–408.
  • 27. Ko CW, Lee SP. Epidemiology and natural history of common bile duct stones and prediction of disease. Gastrointest Endosc 2002;56(6 suppl): S165–S169.
  • 28. Williams EJ, Green J, Beckingham I, et al. Guidelines on the management of common bile duct stones (CBDS). Gut 2008;57(7):1004–1021.
  • 29. Gallix BP, Régent D, Bruel JM. Use of magnetic resonance cholangiography in the diagnosis of choledocholithiasis. Abdom Imaging 2001;26(1):21–27.
  • 30. Shi EC, Ham JM. Benign biliary strictures associated with chronic pancreatitis and gallstones. Aust N Z J Surg 1980;50(5):488–492.
  • 31. Vitellas KM, Keogan MT, Freed KS, et al. Radiologic manifestations of sclerosing cholangitis with emphasis on MR cholangiopancreatography. RadioGraphics 2000;20(4):959–975.
  • 32. Knowlton JQ, Taylor AJ, Reichelderfer M, Stang J. Imaging of biliary tract inflammation: an update. AJR Am J Roentgenol 2008;190(4):984–992.
  • 33. Bader TR, Beavers KL, Semelka RC. MR imaging features of primary sclerosing cholangitis: patterns of cirrhosis in relationship to clinical severity of disease. Radiology 2003;226(3):675–685.
  • 34. Ito K, Mitchell DG, Outwater EK, Blasbalg R. Primary sclerosing cholangitis: MR imaging features. AJR Am J Roentgenol 1999;172(6):1527–1533.
  • 35. Walker SL, McCormick PA. Diagnosing cholangiocarcinoma in primary sclerosing cholangitis: an “evidence based radiology” review. Abdom Imaging 2008;33(1):14–17.
  • 36. MacCarty RL, LaRusso NF, May GR, et al. Cholangiocarcinoma complicating primary sclerosing cholangitis: cholangiographic appearances. Radiology 1985;156(1):43–46.
  • 37. Shimosegawa T, Chari ST, Frulloni L, et al. International consensus diagnostic criteria for autoimmune pancreatitis: guidelines of the International Association of Pancreatology. Pancreas 2011;40(3): 352–358.
  • 38. Nakazawa T, Ohara H, Sano H, Ando T, Joh T. Schematic classification of sclerosing cholangitis with autoimmune pancreatitis by cholangiography. Pancreas 2006;32(2):229.
  • 39. Vlachou PA, Khalili K, Jang HJ, Fischer S, Hirschfield GM, Kim TK. IgG4-related sclerosing disease: autoimmune pancreatitis and extrapancreatic manifestations. RadioGraphics 2011;31(5): 1379–1402.
  • 40. Sah RP, Chari ST, Pannala R, et al. Differences in clinical profile and relapse rate of type 1 versus type 2 autoimmune pancreatitis. Gastroenterology 2010; 139(1):140–148.
  • 41. Bodily KD, Takahashi N, Fletcher JG, et al. Autoimmune pancreatitis: pancreatic and extrapancreatic imaging findings. AJR Am J Roentgenol 2009;192(2):431–437.
  • 42. Kamisawa T, Egawa N, Nakajima H, Tsuruta K, Okamoto A. Extrapancreatic lesions in autoimmune pancreatitis. J Clin Gastroenterol 2005;39(10): 904–907.
  • 43. Kamisawa T, Imai M, Egawa N, Tsuruta K, Okamoto A. Serum IgG4 levels and extrapancreatic lesions in autoimmune pancreatitis. Eur J Gastroenterol Hepatol 2008;20(12):1167–1170.
  • 44. Ghazale A, Chari ST, Zhang L, et al. Immunoglobulin G4-associated cholangitis: clinical profile and response to therapy. Gastroenterology 2008;134(3): 706–715.
  • 45. Ayoub WS, Esquivel CO, Martin P. Biliary complications following liver transplantation. Dig Dis Sci 2010;55(6):1540–1546.
  • 46. Pascher A, Neuhaus P. Biliary complications after deceased-donor orthotopic liver transplantation. J Hepatobiliary Pancreat Surg 2006;13(6):487–496.
  • 47. Kitazono MT, Qayyum A, Yeh BM, Chard PS, Ostroff JW, Coakley FV. Magnetic resonance cholangiography of biliary strictures after liver transplantation: a prospective double-blind study. J Magn Reson Imaging 2007;25(6):1168–1173.
  • 48. Valls C, Alba E, Cruz M, et al. Biliary complications after liver transplantation: diagnosis with MR cholangiopancreatography. AJR Am J Roentgenol 2005; 184(3):812–820.
  • 49. Novellas S, Caramella T, Fournol M, Gugenheim J, Chevallier P. MR cholangiopancreatography features of the biliary tree after liver transplantation. AJR Am J Roentgenol 2008;191(1):221–227.
  • 50. Singh AK, Nachiappan AC, Verma HA, et al. Postoperative imaging in liver transplantation: what radiologists should know. RadioGraphics 2010;30(2): 339–351.
  • 51. Guichelaar MM, Benson JT, Malinchoc M, Krom RA, Wiesner RH, Charlton MR. Risk factors for and clinical course of non-anastomotic biliary strictures after liver transplantation. Am J Transplant 2003;3(7):885–890.
  • 52. Heffernan EJ, Geoghegan T, Munk PL, Ho SG, Harris AC. Recurrent pyogenic cholangitis: from imaging to intervention. AJR Am J Roentgenol 2009;192(1):W28–W35.
  • 53. Menias CO, Surabhi VR, Prasad SR, Wang HL, Narra VR, Chintapalli KN. Mimics of cholangiocarcinoma: spectrum of disease. RadioGraphics 2008; 28(4):1115–1129.
  • 54. Park MS, Yu JS, Kim KW, et al. Recurrent pyogenic cholangitis: comparison between MR cholangiography and direct cholangiography. Radiology 2001; 220(3):677–682.
  • 55. Jain M, Agarwal A. MRCP findings in recurrent pyogenic cholangitis. Eur J Radiol 2008;66(1):79–83.
  • 56. Kim MJ, Cha SW, Mitchell DG, Chung JJ, Park S, Chung JB. MR imaging findings in recurrent pyogenic cholangitis. AJR Am J Roentgenol 1999;173(6):1545–1549.
  • 57. Kim TK, Kim BS, Kim JH, et al. Diagnosis of intrahepatic stones: superiority of MR cholangiopancreatography over endoscopic retrograde cholangiopancreatography. AJR Am J Roentgenol 2002;179(2): 429–434.
  • 58. Chen MF, Jan YY, Wang CS, et al. A reappraisal of cholangiocarcinoma in patient with hepatolithiasis. Cancer 1993;71(8):2461–2465.
  • 59. Ahlawat SK, Singhania R, Al-Kawas FH. Mirizzi syndrome. Curr Treat Options Gastroenterol 2007; 10(2):102–110.
  • 60. Csendes A, Díaz JC, Burdiles P, Maluenda F, Nava O. Mirizzi syndrome and cholecystobiliary fistula: a unifying classification. Br J Surg 1989;76(11): 1139–1143.
  • 61. Choi BW, Kim MJ, Chung JJ, Chung JB, Yoo HS, Lee JT. Radiologic findings of Mirizzi syndrome with emphasis on MRI. Yonsei Med J 2000;41(1): 144–146.
  • 62. Kim PN, Outwater EK, Mitchell DG. Mirizzi syndrome: evaluation by MRI imaging. Am J Gastroenterol 1999;94(9):2546–2550.
  • 63. Yun EJ, Choi CS, Yoon DY, et al. Combination of magnetic resonance cholangiopancreatography and computed tomography for preoperative diagnosis of the Mirizzi syndrome. J Comput Assist Tomogr 2009;33(4):636–640.
  • 64. Keaveny AP, Karasik MS. Hepatobiliary and pancreatic infections in AIDS. I. AIDS Patient Care STDS 1998;12(5):347–357.
  • 65. Vermani N, Kang M, Khandelwal N, Singh P, Chawla YK. MR cholangiopancreatographic demonstration of biliary tract abnormalities in AIDS cholangiopathy: report of two cases. Clin Radiol 2009;64(3):335–338.
  • 66. Bilgin M, Balci NC, Erdogan A, Momtahen AJ, Alkaade S, Rau WS. Hepatobiliary and pancreatic MRI and MRCP findings in patients with HIV infection. AJR Am J Roentgenol 2008;191(1): 228–232.
  • 67. Pereira SP, Gillams A, Sgouros SN, Webster GJ, Hatfield AR. Prospective comparison of secretin-stimulated magnetic resonance cholangiopancreatography with manometry in the diagnosis of sphincter of Oddi dysfunction types II and III. Gut 2007;56(6):809–813.
  • 68. Geenen JE, Hogan WJ, Dodds WJ, Toouli J, Venu RP. The efficacy of endoscopic sphincterotomy after cholecystectomy in patients with sphincter-of-Oddi dysfunction. N Engl J Med 1989;320(2):82–87.
  • 69. Petersen BT. Sphincter of Oddi dysfunction. II. Evidence-based review of the presentations, with “objective” pancreatic findings (types I and II) and of presumptive type III. Gastrointest Endosc 2004;59(6):670–687.
  • 70. Bistritz L, Bain VG. Sphincter of Oddi dysfunction: managing the patient with chronic biliary pain. World J Gastroenterol 2006;12(24):3793–3802.
  • 71. Behar J, Corazziari E, Guelrud M, Hogan W, Sherman S, Toouli J. Functional gallbladder and sphincter of oddi disorders. Gastroenterology 2006;130(5): 1498–1509.
  • 72. Hogan WJ, Sherman S, Pasricha P, Carr-Locke D. Sphincter of Oddi manometry. Gastrointest Endosc 1997;45(3):342–348.
  • 73. Matos C, Cappeliez O, Winant C, Coppens E, Devière J, Metens T. MR imaging of the pancreas: a pictorial tour. RadioGraphics 2002;22(1):e2.
  • 74. Chung YE, Kim MJ, Park YN, et al. Varying appearances of cholangiocarcinoma: radiologic-pathologic correlation. RadioGraphics 2009;29(3):683–700.
  • 75. Liver Cancer Study Group of Japan. General rules for the clinical and pathological study of primary liver cancer, 2nd English edition. Tokyo, Japan: Kanehara, 2003. [The 2000 4th Japanese edition corresponds to the 2003 2nd English edition.]
  • 76. Sainani NI, Catalano OA, Holalkere NS, Zhu AX, Hahn PF, Sahani DV. Cholangiocarcinoma: current and novel imaging techniques. RadioGraphics 2008; 28(5):1263–1287.
  • 77. Slattery JM, Sahani DV. What is the current state-of-the-art imaging for detection and staging of cholangiocarcinoma? Oncologist 2006;11(8):913–922.
  • 78. Han JK, Choi BI, Kim AY, et al. Cholangiocarcinoma: pictorial essay of CT and cholangiographic findings. RadioGraphics 2002;22(1):173–187.
  • 79. Chhibber S, Sharma AK, Kumar N, Ghumman S, Puri SK. Pancreatic tumors: prospective evaluation using MR imaging with MR cholangiography and MR angiography. Indian J Radiol Imaging 2006;16(4):515–521.
  • 80. Bipat S, Phoa SS, van Delden OM, et al. Ultrasonography, computed tomography and magnetic resonance imaging for diagnosis and determining resectability of pancreatic adenocarcinoma: a meta-analysis. J Comput Assist Tomogr 2005;29(4): 438–445.
  • 81. Sahani DV, Shah ZK, Catalano OA, Boland GW, Brugge WR. Radiology of pancreatic adenocarcinoma: current status of imaging. J Gastroenterol Hepatol 2008;23(1):23–33.
  • 82. Sironi S, De Cobelli F, Zerbi A, et al. Pancreatic adenocarcinoma: assessment of vascular invasion with high-field MR imaging and a phased-array coil. AJR Am J Roentgenol 1996;167(4):997–1001.
  • 83. Miller FH, Rini NJ, Keppke AL. MRI of adenocarcinoma of the pancreas. AJR Am J Roentgenol 2006;187(4):W365–W374.
  • 84. Vachiranubhap B, Kim YH, Balci NC, Semelka RC. Magnetic resonance imaging of adenocarcinoma of the pancreas. Top Magn Reson Imaging 2009;20(1): 3–9.
  • 85. Ahualli J. The double duct sign. Radiology 2007;244(1):314–315.
  • 86. Kalra MK, Maher MM, Boland GW, Saini S, Fischman AJ. Correlation of positron emission tomography and CT in evaluating pancreatic tumors: technical and clinical implications. AJR Am J Roentgenol 2003;181(2):387–393.
  • 87. Kim JH, Kim MJ, Chung JJ, Lee WJ, Yoo HS, Lee JT. Differential diagnosis of periampullary carcinomas at MR imaging. RadioGraphics 2002;22(6): 1335–1352.
  • 88. Chung YE, Kim MJ, Kim HM, et al. Differentiation of benign and malignant ampullary obstructions on MR imaging. Eur J Radiol 2011;80(2): 198–203.
  • 89. Irie H, Honda H, Shinozaki K, et al. MR imaging of ampullary carcinomas. J Comput Assist Tomogr 2002;26(5):711–717.
  • 90. Tublin ME, Moser AJ, Marsh JW, Gamblin TC. Biliary inflammatory pseudotumor: imaging features in seven patients. AJR Am J Roentgenol 2007;188(1): W44–W48.
  • 91. Fujita T, Kojima M, Kato Y, et al. Clinical and histopathological study of “follicular cholangitis”: sclerosing cholangitis with prominent lymphocytic infiltration masquerading as hilar cholangiocarcinoma. Hepatol Res 2010;40(12):1239–1247.
  • 92. Soto JA, Alvarez O, Lopera JE, Múnera F, Restrepo JC, Correa G. Biliary obstruction: findings at MR cholangiography and cross-sectional MR imaging. RadioGraphics 2000;20(2):353–366.
  • 93. Masci E, Toti G, Mariani A, et al. Complications of diagnostic and therapeutic ERCP: a prospective multicenter study. Am J Gastroenterol 2001;96(2): 417–423.
  • 94. Andriulli A, Loperfido S, Napolitano G, et al. Incidence rates of post-ERCP complications: a systematic survey of prospective studies. Am J Gastroenterol 2007;102(8):1781–1788.
  • 95. Al-Mofleh IA, Aljebreen AM, Al-Amri SM, et al. Biochemical and radiological predictors of malignant biliary strictures. World J Gastroenterol 2004; 10(10):1504–1507.
  • 96. Saluja SS, Sharma R, Pal S, Sahni P, Chattopadhyay TK. Differentiation between benign and malignant hilar obstructions using laboratory and radiological investigations: a prospective study. HPB (Oxford) 2007;9(5):373–382.
  • 97. Park MS, Kim TK, Kim KW, et al. Differentiation of extrahepatic bile duct cholangiocarcinoma from benign stricture: findings at MRCP versus ERCP. Radiology 2004;233(1):234–240.
  • 98. Ferrucci JT. MRI and MRCP in pancreaticobiliary malignancy. Ann Oncol 1999;10(suppl 4):18–19.
  • 99. Souftas V, Kozadinos A, Mantatzis M, Prassopoulos P. The use of CT or MRI for the one-stage placement of stents in biliary obstructions. Diagn Interv Radiol 2010;16(3):241–244.

Article History

Received: Dec 03 2012
Revision requested: Feb 08 2013
Revision received: June 28 2013
Accepted: July 01 2013
Published online: May 2014
Published in print: May 2014