R e s i d e n t s ’ S e c t i o n • S t r u c t u r e d R ev i ew
O’Connor et al.
Biliary Tract Imaging
Residents’ Section
Structured Review
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Residents
inRadiology Imaging of Biliary Tract Disease
Owen J. O’Connor 1 Educational Objectives
Siobhan O’Neill2 and Key Points
Michael M. Maher 1,2,3 1. Imaging of biliary disease often requires
a multimodality imaging approach, with
O’Connor OJ, O’Neill S, Maher MM increasing use of MRCP reducing the re-
quirement for diagnostic ERCP.
2. Biliary imaging in the setting of obstruc-
tive jaundice seeks to diagnose the level of
obstruction and its severity and cause.
3. The objective of this review is to learn the
imaging features of primary sclerosing
cholangitis and cholangiocarcinoma.
4. Cholangitis is usually secondary to bili-
ary obstruction, and imaging features of
cholangitis in the setting of biliary ob-
struction are described.
The biliary tract is subject to a wide vari-
ety of pathologic abnormalities. This article
Keywords: biliary disease, cholangiocarcinoma,
will focus primarily on the imaging of choled-
cholangitis, choledocholithiasis, CT abdomen, ERCP, ocholithiasis, primary and secondary cholan-
MRCP, MRI abdomen, ultrasound abdomen gitis, and cholangiocarcinoma; imaging of the
gallbladder and pancreas will not be covered.
DOI:10.2214/AJR.10.4341
To investigate such a wide variety of patholog-
Received January 26, 2010; accepted after revision ic abnormalities, biliary tract imaging often
October 11, 2010. requires a multimodality approach. We will
primarily discuss the ultrasound, CT, MRI,
1
Department of Radiology, University College Cork, MRCP, and ERCP aspects of biliary imaging.
College Road, Cork, Ireland. Address correspondence to
M. M. Maher (m.maher@ucc.ie).
Epidemiology and Pathophysiology
2
Department of Radiology, Cork University Hospital, Choledocholithiasis is one of the most
Cork, Ireland. common pathologic abnormalities affecting
3
the biliary tract. Other conditions include in-
Department of Radiology, Mercy University Hospital,
Wilton, Cork, Ireland.
flammatory, infectious, malignant, congeni-
tal, and iatrogenic disease (Table 1). Chole-
CME lithiasis is usually asymptomatic, but an
This article is available for CME credit. estimated 10–15% of symptomatic patients
See www.arrs.org for more information.
have choledocholithiasis [1]. Therefore,
WEB choledocholithiasis is likely to be relatively
This is a Web exclusive article. common, given that approximately 700,000
cholecystectomies are performed annually in
AJR 2011; 197:W551–W558 the United States [2]. The natural history of
choledocholithiasis is poorly understood, but
0361–803X/11/1974–W551
complications include biliary obstruction,
© American Roentgen Ray Society pancreatitis, and cholangitis, with chronic
AJR:197, October 2011 W551
disease believed to increase the risk of cho-
langiocarcinoma [3].
Sclerosing cholangitis often presents with
clinical features of biliary obstruction, such
as jaundice and pruritus, but usually in the
absence of signs of infection. Primary scle-
rosing cholangitis tends to involve the intra-
hepatic bile ducts to a greater extent than the
extrahepatic ducts. Approximately 15% of
patients with primary sclerosing cholangitis
develop cholangiocarcinoma [4].
Cholangiocarcinoma is less common than
other hepatic and cholecystic malignancies,
representing approximately 1% of all malig-
nancies. Most cholangiocarcinomas are ade-
nocarcinomas [5]. Most patients with cholan-
giocarcinoma present between the sixth and
seventh decades of life; however, patients with
primary sclerosing cholangitis can develop
cholangiocarcinoma at a younger age [5]. The
extrahepatic biliary ducts are affected more
commonly than the intrahepatic ducts [5]. An
increased serum CA19-9 level can also be ob-
served in patients with cholangiocarcinoma,
whereas elevated α-fetoprotein levels are as-
sociated with hepatocellular carcinoma rather
than cholangiocarcinoma [5].
Biliary obstruction is most commonly due
to choledocholithiasis. Obstruction may also
be a consequence of biliary strictures, ma-
lignancy, iatrogenic disease, and parasitic
disease [6]. Biliary obstruction precipitates
acute suppurative cholangitis by causing
hepatovenous reflux and subsequent bac-
teremia [7]. The organisms most common-
ly associated with acute suppurative chol-
angitis include Escherichia coli, Klebsiella
species, Proteus species, Bacteroides spe-
cies, and Pseudomonas aeruginosa [8]. The
classic clinical presentation is of right upper
quadrant pain, fever, and jaundice (Charcot
triad), sometimes with hypotension and al-
tered consciousness (Reynolds pentad) [6,
9]. Acute suppurative cholangitis may lead
 O’Connor et al.

to hepatic abscess formation due to bacte-
rial seeding through portal vein bacteremia.
The sensitivity of CT and ultrasound for the
detection of hepatic abscess is greater than
90%, and MRI is believed to be at least as
sensitive as CT [4].
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Imaging Strategies
Initial imaging of patients with suspected
acute biliary disease (including gallbladder
disease) should be performed primarily with
ultrasound, which has a sensitivity for patho-
logic processes of 83%, significantly superi-
or to that of CT (39%) in this clinical setting
[10]. Diagnostic ultrasound usually obvi-
ates CT or further imaging unless there are
atypical signs or where concurrent liver, bili-
ary, or pancreatic disease is suspected. Ultra-
sound has a sensitivity of 99% for detecting

TABLE 1:  Biliary Tract Diseases

Category Disease
Calculus and inflammation Choledocholithiasis, Mirizzi syndrome, milk of calcium bile, and sclerosing cholangitis (primary form may be idiopathic,
associated with ulcerative colitis, Crohn disease, retroperitoneal fibrosis, or Reidel stroma, or it may be secondary to calculi,
biliary surgery, or recurrent infection)
Infection Acute suppurative cholangitis, recurrent pyogenic cholangitis, parasitic cholangitis (Clonorchis sinensis or Ascaris lumbicoides),
and AIDS cholangiopathy (cryptosporidium, cytomegalovirus, Mycobacterium avium–intracellulare, or Candida species)
Obstruction or trauma Intrahepatic (sclerosing cholangitis, infectious, ischemic, or neoplastic strictures), hilar (hepatic or cholangiocarcinoma),
extrahepatic (surgically induced [ligation, leak, edema, or fibrosis], postoperative anastomotic stricture, cholangitis, adenopa-
thy, malignancy [gallbladder, pancreas, liver, and duodenum], and distal [in addition to extrahepatic causes; ampullary
carcinoma or pancreatitis]), biloma, and hemobilia
Primary neoplasia Biliary cystadenoma or carcinoma, cholangiocarcinoma (adenocarcinoma or squamous carcinoma, carcinoid, leiomyocarci-
noma, or rhabdomyosarcoma), ampullary carcinoma, and biliary intraductal papillary mucinous tumor
Congenital Biliary atresia, choledochal cyst, and Caroli disease
Iatrogenic Chemotherapy cholangitis and posthepatic transplant (bile leak and obstruction)
Note—Adapted with permission from [5].

Fig. 1—70-year-old man with choledocholithiasis

with history of previous cholecystectomy.
A, Ultrasound shows echogenic lesion (arrow) in
common bile duct (CBD), which casts acoustic
shadow, and there is CBD dilatation.
B, ERCP shows several well circumscribed
free-floating calculi in CBD consistent with
choledocholithiasis. Cholecystectomy clips are
projected just above arrowhead.
A B

Fig. 2—47-year-old woman with recurrent

cholangitis due to anastomotic stricture at level of
hepaticojejunostomy after choledochal cyst excision.
A, MRCP shows intrahepatic biliary dilatation
(arrow), but anastomosis obscures visualization of
distal biliary tree.
B, Percutaneous transhepatic cholangiography
shows extensive dilatation of intrahepatic bile
ducts (chevron) and stenosis at level of anastomosis
(arrow). Stenosis was successfully relieved after
dilatation of stricture with cutting balloon.
A B

W552 AJR:197, October 2011

 Biliary Tract Imaging

Fig. 3—65-year-old woman with primary sclerosing

cholangitis associated with ulcerative colitis.
A, Ultrasound shows intrahepatic biliary dilatation
(arrow), but no specific cause was confirmed.
B, CT confirms intrahepatic biliary dilatation
(arrowhead).
C, MRCP shows segmental biliary dilatation
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(arrowhead) with beading of intrahepatic bile ducts

(chevron), particularly in left lobe of liver.
D, MRCP finding of segmental biliary dilatation
(arrowhead) was confirmed at ERCP.

A B

C D

Fig. 4—77-year-old man with jaundice due to

cholangiocarcinoma.
A, Ultrasound shows large echogenic lesion
(arrowhead) in common bile duct (CBD) that does not
cast well-defined acoustic shadow.
B, CT shows poorly enhancing lesion (arrowhead) in
CBD with associated biliary obstruction.

A B

Fig. 5—84-year-old man with periampullary

cholangiocarcinoma.
A, Ultrasound shows echogenic lesion (arrow) in
distal common bile duct (CBD) that does not cast
posterior acoustic shadow.
B, CT shows soft-tissue mass (arrowhead) in
ampullary region protruding into proximal CBD.
A B

AJR:197, October 2011 W553

 O’Connor et al.

Fig. 6—79-year-old woman with infiltrating

extrahepatic bile duct cholangiocarcinoma.
A, CT shows soft-tissue lesion (arrow) at bifurcation
of portal vein encasing its right main branch with
associated intrahepatic biliary dilatation.
B, On ERCP, extrahepatic bile ducts and proximal
common bile duct were not seen (arrowhead) because
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of tumor encasement. There is biliary dilatation

proximal to lesion.

A B
ductal dilatation but is not sensitive for detect-
ing choledocholithiasis, partly because of dif-
ficulties in visualizing the distal common bile
duct [11]. The normal diameter of the com-
mon bile duct is variable, but a diameter of
greater than 7 mm is generally indicative of
bile duct obstruction among patients without
previous cholecystectomy [12]. Although CT
is not the best technique for imaging choledo-
cholithiasis, it is frequently performed for the
assessment of jaundice. Widely variable sen-
sitivities have been reported, ranging from
A B 20% to 78% [13, 14]. Identification of cho-
ledocholithiasis should prompt clinical cor-
relation and ERCP for stone removal where
feasible. ERCP remains the reference stan-
dard for definitive diagnosis of many biliary
diseases; however, MRCP has proven accu-
racy for diagnosis of most biliary conditions
and has significantly limited the requirement
of diagnostic ERCP [10, 15]. Biliary imaging
with CT cholangiography may be performed
by means of either direct or indirect contrast
agent instillation. Direct CT cholangiography
requires biliary injection of contrast agent
through a percutaneous catheter or by ERCP.
Noninvasive positive-contrast CT cholangiog-
raphy is performed using iodipamide meglu-
mine infused IV over a 30-minute period,
supplemented with IV hyoscine just before
imaging, to relax the sphincter of Oddi [16].
C D The sensitivity and specificity of indirect CT
Fig. 7—49-year-old woman who presented with obstructive jaundice due to cholangiocarcinoma. cholangiography are reported to be 92% [17].
A, Ultrasound shows gross intrahepatic biliary dilatation (arrow), and there is apparent mass at bile duct CT cholangiography is less prone to artifact
confluence. than is MRCP, and the primary indication for
B, CT shows hypoattenuating mass (arrow) at confluence of main hepatic ducts.
contrast-enhanced CT cholangiography is the
C, One minute after IV administration of contrast agent, T1-weighted MRI confirmed presence of hypovasular
mass (arrow). No delayed enhancement was observed. definition of second-order bile duct anatomy
D, ERCP shows obstruction of main hepatic duct and proximal common bile duct (arrow). before liver transplantation [16]. CT cholangi-

W554 AJR:197, October 2011

 Biliary Tract Imaging

ography can also be performed without the re- Imaging Appearances

quirement for IV biliary contrast agent, with
the use of minimal-intensity-projection recon-
struction techniques, where bile can act as a
negative contrast within the lumen of the bil-
iary tract [18]. Because CT cholangiography
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Choledocholithiasis is typically identi-
fied on CT or MRI in the dependent por-
tions of the biliary tract [16]. Calculi often
have angulated shapes and a laminated ap-
pearance on CT or may be bound anteriorly

is less commonly performed than ultrasound, by a crescent-shaped collection of bile or gas

ERCP, and MRCP, further discussion of it is [16]. Differentiating a calculus from pneu-
beyond the scope of this review. mobilia is more reliable with CT than MRI
MRCP is performed using heavily T2- because choledocholithiasis, hemobilia, and
weighted sequences, supplemented by fat- locules of gas can appear as low-signal fill-
saturated T1- and T2-weighted MRI, and ing defects surrounded by high-signal bile at
with steady-state gradient-echo acquisitions MRCP [19] (Fig. 1). There may be coexisting
Fig. 8—56-year-old man with acute suppurative
(true fast imaging with steady-state preces- signs of biliary inflammation in the presence cholangitis and cholangitic abscess formation.
sion), which are less susceptible to flow arti- of choledocholithiasis, including periductal CT of abdomen shows dilatation of intrahepatic bile
facts [19]. It is recommended that images in edema, thickening of the biliary wall, and ducts in right lobe of liver with bulbous dilatation of
proximal portions of involved ducts (arrow) due to
two separate planes be acquired for defini- mural enhancement after IV administration abscess formation.
tive identification of gallstones in the extra- of contrast agent [16]. Typically, portal vein
hepatic bile ducts on MRCP [20]. MRCP is branches are surrounded by fluid when there
particularly useful in patients with complete is intrahepatic periportal edema; however, a CT, stones may be hyperattenuating because
biliary obstruction after biliary-enteric anas- portal vein flanks only one side of a dilat- of calcification, isoattenuating relative to bile
tomosis, where ERCP is frequently not fea- ed bile duct when there is biliary obstruction because of cholesterol deposition, or hypoat-
sible, or in patients for whom ERCP or per- [5]. Calculi have variable signal characteris- tenuating because of nitrogen gas [16].
cutaneous transhepatic cholangiography has tics on T1-weighted MRI but are uniformly Biliary strictures produce stenosis of the
failed or is unsuitable [20]. In patients with low in signal on T2-weighted imaging. On ductal lumen, with or without intra- or extra-
significant symptoms or complicated bili-
ary disease, MRCP or MRI is often indicated
when CT and ultrasound findings are incon-
clusive [19]. The presence of pneumobilia is
a potential limitation of MRI in postoperative
cases or in those with biliary-enteric anasto-
mosis and can significantly reduce sensitivi-
ty and specificity for detection of gallstones.
It can be helpful to remember that, typically,
air is visualized in nondependent locations,
and calculi should lie in a dependent position
within bile ducts [20].
MRCP without the use of an IV contrast
agent can present the reviewer with difficul- A B
ty in differentiating ascites, perihepatic fluid
collections, and edema from a bile leak and
biloma, especially in the presence of extensive
inflammatory change [20]. Bile leaks tend to
occur after biliary surgery, particularly chole-
cystectomy, because of poor clip placement,
dislodgement of surgical clips, and injury of
right-sided biliary radicals in the liver bed
[20]. In this situation, T1-weighted MRCP af-
ter IV administration of hepatocyte-specific
contrast agents that are preferentially excreted
into bile, such as mangafodipir trisodium or
C D
gadoxetate disodium, helps provide function-
Fig. 9—63-year-old woman with Fasciola hepatica infiltration of liver during hepatic phase of disease.
al and anatomic information that can be used A, Arterial phase CT of abdomen shows hypoattenuating tubular and rounded lesions (arrowhead) in right lobe
to identify bile leaks and bile collections [20]. of liver.
Generally, the intrahepatic bile ducts and the B, There is no filling on portal venous phase imaging (arrowhead).
common bile ducts should be well depicted C, T1-weighted MRI of liver after IV administration of contrast agent shows absence of filling within cystic
lesions (arrowhead).
within 20 minutes of injection in patients with D, Coronal T1-weighted maximum intensity projection MRI shows common hepatic and common bile ducts but
normal liver function. no filling of lesions (arrowhead).

AJR:197, October 2011 W555

 O’Connor et al.

Fig. 10—64-year-old man with type IV choledochal cyst containing calculus.

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A, CT shows gross dilatation of common bile duct (CBD), which contains hyperattenuating calculus (arrow).
B, Calculus is seen as low-signal filling defect (arrowhead) in CBD on T2-weighted MRI.
C, MRCP shows extent of choledochal cyst (chevron) involving intra- and extrahepatic bile ducts.

A B C

hepatic bile duct dilatation (2 and 7 mm, re-
spectively), abrupt transition without gentle ta-
pering, visible confluence of intrahepatic bile
ducts at the hilum, or absence of part of the
duct [5] (Fig. 2). Benign strictures tend to have
smooth symmetric luminal narrowing and in-
volve short bile duct segments compared with
malignant strictures [16]. There is a tendency
to overestimate the degree and length of steno-
sis on MRCP. In the assessment of biliary ob-
struction, identification of the proximal level
of obstruction is of most importance. Biliary
collapse distal to the site of obstruction is com-
mon, and the presence of calculi or sludge may
also complicate interpretation [20].
Primary sclerosing cholangitis is a well-de-
scribed cause of biliary strictures. Sclerosing
cholangitis may be primary (i.e., associated
with inflammatory bowel disease, retroper-
itoneal fibrosis, and Reidel stroma) or sec-
ondary to choledocholithiasis, infection, or
surgery [5, 20] (Fig. 3). The characteristic im-
aging features of primary sclerosing cholan-
gitis are of biliary beading and pruning due
to periductal fibrosis, which produces stric-
tured intermittently dilated segments of in-
trahepatic and extrahepatic bile ducts. Other
imaging features of primary sclerosing chol-
angitis include thickening of the extrahepat-
ic biliary ducts, hepatic perfusion abnormal-
ities, segmental atrophy, enlargement of the
caudate lobe, and cirrhosis [4]. It should also
be noted that the imaging features of prima-
ry sclerosing cholangitis can be mimicked
by cholangiocarcinoma, IgG cholangiopathy,
and acute pancreatitis [21]. A rapid increase
in the degree of segmental ductal dilatation is to necrosis and mucin, respectively [5]. Infil-
a recognized sign of cholangiocarcinoma in a trative cholangiocarcinoma is usually scleros-
patient with known primary sclerosing chol- ing in nature and is most commonly located at
angitis [5]. the confluence of the right and left bile ducts
In practice, distinguishing cholangiocar- (Klatskin tumor) with biliary obstruction but
cinoma from hepatocellular carcinoma, bili- little detectable mass [5] (Fig. 6). Infiltrative
ary cystadenoma, and metastases is often pos- cholangiocarcinoma tends to be hypovascular
sible, but in cases of diagnostic uncertainty, and shows low signal intensity on all sequenc-
percutaneous biopsy or endoscopic brush- es on MRI [5] (Fig. 7).
ings are required to obtain cytologic speci- Cholangiocarcinoma tends to present with
mens for definitive diagnosis [5] (Fig. 4). The atrophy of a segment or lobe of the liver or
sensitivity of CT for the detection of cholan- with segmental portal vein obstruction due
giocarcinoma is 40% [22] (Fig. 5). Cholan- to tumor infiltration and stenosis, rather than
giocarcinoma may present as a mass or an in- thrombosis, as seen with hepatocellular car-
filtrative lesion and may be either central or cinoma [5, 21]. The scirrhous nature of infil-
peripheral in location and may show delayed trative lesions can produce central low sig-
enhancement after IV administration of con- nal on T2-weighted MRI and also delayed
trast agent [5]. Masslike lesions tend to have enhancement after the IV administration
peripheral heterogeneous enhancement, with of contrast agent. Delayed imaging (10–20
foci of hypo- and hyperattenuation on CT or minutes) is said to show preferential contrast
low and high signal on T2-weighted MRI due retention in 40% of cholangiocarcinomas,
TABLE 2:  Classification of Choledochal Cysts
Designation Description
I Dilatation of the CBD; includes cystic dilatation of the common hepatic duct and CBD,
distal CBD, and fusiform dilatation of the CBD
II Diverticulum of the CBD
III Intraduodenal CBD dilatation (choledochocele)
IV
A Multiple intrahepatic bile duct and extrahepatic bile duct cysts
B Multiple extrahepatic bile duct cysts
V Multiple cysts of intrahepatic bile ducts (Caroli disease)
Note—Adapted with permission from [21]. CBD = common bile duct.

W556 AJR:197, October 2011


compared with surrounding liver [16]. Imag-
ing is heavily relied on for both the detection
and staging of cholangiocarcinoma by as-
sessing the extent of biliary and vascular in-
volvement. Differentiation of calculus from
tumor in the common bile duct may be dif-
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ficult with standard MRI sequences. Tumor
enhancement after IV administration of con-
trast agent is a helpful feature that is not ob-
served with calculi [5]. Coronal steady-state
coherent imaging may also help in this situa-
tion by showing low signal in a calculus and
intermediate signal in malignant lesion [19].
In the fasting patient, normal bile contains
less water and greater concentrations of bile
acids, resulting in higher MRI signal than CSF
on T1-weighted MRI [5]. In the nonfasting
patient, bile has similar signal characteristics
to CSF on T1-weighted MRI [5]. Acute sup-
purative cholangitis is characterized on MRI
by low-signal biliary contents compared with
liver on T2-weighted MRI and intermediate
signal on T1-weighted MRI, with periportal
edema on black-blood T2-weighted MRI [23].
In acute suppurative cholangitis, dilated bile
ducts filled with echogenic purulent materi-
al are observed on ultrasound, dense biliary
contents are seen on CT, and thickened en-
hancing walls are seen on both CT and MRI
[19] (Fig. 8). The purpose of imaging in acute
suppurative cholangitis is to detect the cause
of biliary obstruction and to identify compli-
cations such as abscess formation [4]. A uni-
or multiloculated hypoattenuating collection
with peripheral rim enhancement is charac-
teristic for abscess formation on CT [4]. A
cluster sign may also be observed as the re-
sult of coalescence of several abscesses [5].
On MRI, a lesion surrounded by a rim of in-
creased signal on T2-weighted MRI and con-
taining decreased signal on T1-weighted MRI
with peripheral capsular or rim enhancement
after IV administration of contrast agent has
imaging features of hepatic abscess [4].
Dilated peripheral ducts in the absence of
central duct dilatation can be seen in cholan-
gitis due to parasitic infection. On CT, Fasciola
­hepatica is characterized by abnormal geo-
graphic areas containing cystic and tubular hy-
poattenuating necrotic cavities extending to the
surface of the liver [24] (Fig. 9). These appear-
ances, termed the “tunnels and caves sign,” are
seen during the hepatic phase of the disease
[24]. The lesions typically do not coalesce but
have varied signal on MRI, and typical signal
characteristics have yet to be agreed on.
A masslike lesion of the intrahepatic or ex-
trahepatic biliary tree, or both, containing flu-
AJR:197, October 2011 W557
Biliary Tract Imaging
Ultrasound
Dilated bile Suspected
ducts mass
Bile duct No cause
CT
stone found
Suspected
ERCP
stone
Suspected bile duct stricture
or PSC/congenital abnormality
Fig. 11—Algorithm for the assessment of suspected biliary pathologic abnormality. EUS = endoscopic
ultrasound, PSC = primary sclerosing cholangitis, PTC = percutaneous transhepatic cholangiography.
id with bile-type signal on all sequences is a
characteristic feature of a choledochal cyst,
five different types of which have been de-
scribed [21] (Table 2 and Fig. 10). IV con-
trast-enhanced T1-weighted MRI can char-
acterize choledochal cysts in equivocal
cases because the lumen of choledochal cysts
should enhance in a similar manner to bile
ducts [25]. Hepatocyte-specific MRI con-
trast can be beneficial in this circumstance.
Standard IV contrast agents, such as gado-
pentetate dimeglumine, are weakly protein
bound, rapidly excreted by the kidneys, and
almost completely confined to the intravas-
cular and interstitial spaces, with little bili-
ary excretion [26]. T1-weighted contrast-en-
hanced MRCP may also be performed using
contrast agents that have significant biliary
excretion, such as gadobenate dimeglumine,
gadoxetate disodium, or mangafodipir triso-
dium, 15–90 minutes after IV injection [15].
T1-weighted MRCP after IV administration
of hepato-specific contrast agent may also be
useful for the diagnosis of biliary hamarto-
mas, which have the signal characteristics of
bile [25, 27]. Dilated bile duct hamartomas,
also known as von Meyenberg complexes,
are sometimes misinterpreted as multiple he-
patic metastases [27]. In the absence of he-
patic cirrhosis, the finding of multiple liver
lesions measuring less than 1.5 cm in diame-
ter should raise suspicion for this entity [27].
On ultrasound, these lesions may be hypo- or
hyperechoic, and an association with poly-
cystic kidney disease has been described. On
Suspected Suspected
bile duct infection
neoplasm
MRI or Drain or
MRCP cholecystostomy
ERCP or PTC
EUS or ERCP or EUS
biopsy biopsy or
brushing
MRCP or
MRI
CT, these lesions typically appear hypoatten-
uating and lack enhancement.
Conclusion
Ultrasound remains the first-line imaging
tool for investigation of suspected biliary ob-
struction; however, recent advances in MRI
have changed practice, and ERCP in patients
with biliary disease is increasingly reserved
for therapeutic purposes (Fig. 11). Biliary
imaging often requires a multimodality ap-
proach. Irrespective of imaging technique,
an appreciation of the pathologic basis of bil-
iary disease, combined with careful inspec-
tion of the imaging appearances, is vital for
the correct interpretation of biliary studies.
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