CHAPTER 19 
Magnetic resonance imaging of the liver, biliary
tract, and pancreas
Scott R. Gerst and Richard Kinh Gian Do
Magnetic resonance imaging (MRI) is a cross-sectional multi-
planar imaging technique (Fig. 19.1). MRI uses magnetic fields
and radiofrequency pulses to generate images with outstanding
tissue contrast and excellent spatial resolution. The principles
of nuclear magnetic resonance were first described in the 1940s
by Bloch and colleagues (1946) and Purcell and colleagues
(1946) as a method for in vitro chemical analysis. Several
decades later, Damadian (1971) and Lauterbur (1973) applied
some of these basic principles to design MRI to allow in vivo
imaging. Today, MRI is used extensively as a medical imaging
tool throughout the body to visualize and distinguish normal
and pathologic tissue.
PRINCIPLES OF MAGNETIC
RESONANCE IMAGING
MRI harnesses the signal available from the magnetic moment
or spin present in certain nuclei, including hydrogen atoms.
When placed in a large static magnetic field, the nuclei align
themselves in a parallel or antiparallel direction to the field and
also rotate or spin at a precise frequency termed the Larmor
frequency. This frequency depends on the specific type of nuclei
imaged and the strength of the magnetic field. The most com-
monly imaged nucleus in clinical practice is hydrogen (H1)
because of its great abundance in the human body, mostly in
the form of water. Other nuclei that may be imaged by MRI
include phosphorus (P31), sodium (Na23), and carbon (C13).
When unperturbed in a static magnetic field, nuclei with
magnetic spins are in equilibrium: An almost an equal number
of nuclei are in an “up” (parallel) or “down” (antiparallel)
alignment. The slight difference between the two states creates
a net magnetic moment. A measurable signal is generated from
the magnetic moment after excitation by a radiofrequency (RF)
pulse at the resonance Larmor frequency. This signal is gener-
ated as the excited nuclei in the body return to equilibrium,
releasing energy in the form of an electromagnetic field that is
captured by a receiver coil. The strength of this emitted signal
determines the signal intensity (SI) of a tissue. The precise
tissue SI depends on several factors, including longitudinal
relaxation (T1), transverse relaxation (T2), proton density
(essentially the number of nuclei present), and flow. Some of
these factors can be manipulated (e.g., through T1 and T2
weighing) to create images highlighting various soft tissue
properties.
All tissues have an intrinsic T1 value for relaxation along the
longitudinal magnetic axis, which varies between 200 and 800
milliseconds. T2 time, or transverse relaxation, is a measure of
signal loss perpendicular to the long axis of the magnetic field
and typically varies between 20 and 200 millisecconds for most
358
tissues. Differences in T1 and T2 times intrinsic to various soft
tissues can be exploited to improve image contrast and diag-
nostic accuracy. For example, free water, which has a long T1
relaxation, is low signal on standard T1-weighted imaging and
markedly high signal on T2-weighted imaging. Thus so-called
heavily T2-weighted imaging sequences, such as those used in
MR cholangiopancreatography, highlight high water content
structures, such as bile and pancreatic ducts, while reducing
the signals of other organs.
Diffusion-weighted MRI (DWI) is an alternative tissue con-
trast mechanism that produces images dependent on the local
magnitude of water diffusion. DWI of the liver may be used to
help detect focal hepatic lesions, especially metastases, and may
also be used to assess changes in the liver parenchyma, such as
liver fibrosis. Tremendous interest in this sequence first arose
due to its increased sensitivity to early changes in the brain after
a cerebrovascular accident compared with more traditional T1-
or T2-weighted imaging. Applications for DWI in body imaging,
initially hampered by hardware and software limitations, were
addressed in the mid-2000s. With new advances in receiver coil
design, improved gradient coils used to acquire images, and
motion correction through respiratory or navigator techniques,
DWI has flourished as a functional imaging sequence in hepa-
topancreatobiliary imaging (Taouli et al, 2010).
MAGNETIC RESONANCE IMAGING SAFETY
MRI is safe for most patients. However, physicians and
patients should be aware of some important considerations,
such as MR contrast safety, and the risk of interactions
between the patient (including their implants) with the strong
static magnetic field of the scanner as well as the RF field
used to generate images. The magnetic field interactions are
potentially dangerous by causing the motion of ferromagnetic
aneurysm clips or causing electronic malfunctioning of cardiac
pacing devices and defibrillators. Many MRI facilities have
screening programs in place to address potentially contraindi-
cated devices, under new MRI safety guidelines proposed by
the American College of Radiology (Expert Panel on MR
Safety, 2013). However, referring physicians should be aware
of their local imaging centers’ approach to MRI safety, such
as their ability to scan patients with MR-conditional or
MR-unsafe pacemakers, for example.
MRI has a role in patients with minimal or mild renal insuf-
ficiency. Iodinated contrast used in CT is associated with a risk
of contrast-induced nephropathy; however, administration of
intravenous gadolinium contrast agents in patients with severe
renal insufficiency carries a risk of nephrogenic systemic fibrosis
(NSF). NSF is a serious and potentially fatal complication
 Chapter 19  Magnetic resonance imaging of the liver, biliary tract, and pancreas 359

C
FIGURE 19.1.  Multiplanar T2-weighted images through the liver in a patient with multiple hepatic metastases. A, Axial image. B, Sagittal image.
C, Coronal image. A variety of techniques can be used to obtain these images. Note that fluid-containing structures, including small bowel (curved
arrow, A), gallbladder, biliary tree, and pancreatic duct (arrow, C), are bright.

related to free gadolinium deposition within soft tissues and
organs, with resulting scleroderma-like fibrosis. The exact
causal mechanism of NSF remains unknown, but the risk of
NSF increases in patients with a glomerular filtration rate
(GFR) less than 30 mL/min, and particularly in patients with
severe, end-stage disease (GFR < 15 mL/min). In addition,
linear agents with lower thermodynamic stability carry a greater
risk than others. If available, more stable, lower-risk macrocy-
clic agents can be used in patients with a GFR less than 30 mL/
min. Gadolinium contrast usage in patients with a GFR less
than 15 mL/min should only be performed if essential, after
careful evaluation of risks versus benefits, and with consultation
with a nephrologist, if available. Since NSF was initially
described, the rapid international investigation, dissemination
of information, and swift adjustment to policy have led to a
precipitous drop of reported NSF cases. In multiple countries,
NSF has essentially disappeared since 2009 (Bennett et al,
2012; Grobner, 2006; Idee et al, 2014).
MAGNETIC RESONANCE IMAGING
CHOLANGIOPANCREATOGRAPHY
MR cholangiopancreatography (MRCP) is an imaging tech-
nique used to evaluate the bile and pancreatic ducts and plays
an important role in imaging benign disorders, as well as com-
prehensive evaluation of malignancies of the biliary system
(Mandelia et al, 2013; Singh et al, 2014; Vaishali et al, 2004).
Heavily T2-weighted images are used to provide an overview
of biliary and pancreatic ductal anatomy, removing the signal
of surrounding structures. Excellent diagnostic-quality images
are obtainable, with high sensitivity and specificity for evalua-
tion of ductal dilatation, strictures, and intraductal abnormali-
ties (Hekimoglu et al, 2008; Palmucci et al, 2010a; Palmucci
et al, 2010b; Sandrasegaran et al, 2010). Cross-sectional
images and maximum intensity projection images (Fig. 19.2)
are produced with current MRCP techniques, and projection
images are similar to direct contrast-enhanced cholangiograms
obtained with either endoscopic retrograde cholangiopancrea-
tography (ERCP) or percutaneous transhepatic cholangiogra-
phy (PTC; see Chapter 18). MRCP is noninvasive, eliminating
the potential morbidity associated with ERCP or PTC (Zhong
et al, 2004).
The basic principle of MRCP is to use T2-weighted imaging
to highlight stationary or slowly moving fluid, including bile, as
high in signal intensity; surrounding tissues, including retroperi-
toneal fat and the solid visceral organs, with shorter T2 values,
are markedly reduced in signal. In addition to heavilyT2-weighted
sequences, MRCP protocols also include routine intermediate
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A B

C D
FIGURE 19.2.  Mixed main- and branch-duct intraductal papillary mucinous neoplasm (IPMN) of the pancreatic tail. A, Coronal T2 image. A lesion
with high T2 signal indicating cystic contents involves the pancreatic tail and shows multiple thin septations (arrow). B, Coronal three-dimensional
maximum intensity projection T2-weighted magnetic resonance cholangiopancreatography image. The multiseptated cystic pancreatic tail mass is
apparent (arrow). C, Axial T2 image. Multiple septations are apparent with dilated main pancreatic duct (star). Incidental note is made of a right renal
cyst with thin septations (open circle). D, Axial T1-weighted fat saturation image postintravenous gadolinium contrast. The numerous septations
enhance within the lesion (arrow). Some components appeared nodular, and the lesion was resected. Histopathology revealed an IPMN with a focus
of noninvasive mucinous cancer.

T2-weighted sequences and T1-weighted sequences to evaluate
surrounding structures. MR-specific techniques for obtaining
cholangiographic images include breath-hold, as well as respira-
tory and navigator gated techniques, which can generate images
in a patient during free breathing.
MAGNETIC RESONANCE IMAGING
CONTRAST AGENTS
MRI contrast agents work primarily by altering the intrinsic T1
relaxation times of various soft tissues where contrast accumu-
lates. In the hepatobiliary system, MRI contrast agents can
improve the detection of liver lesions and improve the charac-
terization of focal liver abnormalities. MRI contrast agents for
hepatobiliary imaging are divided into two basic categories:
extracellular fluid contrast (ECF) agents, and those with addi-
tional hepatobiliary excretion. In the past, the most commonly
used contrast agents were the ECF agents, such as gadopen-
tetate dimeglumine (gadolinium diethylenetriaminepentaacetic
acid [Gd-DTPA]), which is distributed within the intravascular
compartment initially and rapidly diffuses through the extra-
vascular space, similar to the action of iodinated contrast agents
in computed tomography (CT; see Chapter 18). Differences in
enhancement patterns between benign and malignant liver
lesions have been well reported and are discussed in individual
entities later.
Several new hepatobiliary-specific contrast agents have been
developed to add additional functional information compared
with traditional ECF contrast agents. These hepatobiliary spe-
cific contrast agents are taken up to varying degrees by function-
ing hepatocellular tissue and are excreted in bile as well as
through the kidneys. Hepatobiliary specific agents include
mangafodipir trisodium, gadobenate dimeglumine, and gadox-
etic acid (Gd-EOB-DTPA). Both gadobenate dimeglumine
(MultiHance; Bracco Imaging, Cranbury Township, NJ) and
gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid
(Eovist/Primovist; Bayer Healthcare, Wayne, NJ) have been
approved in the United States. These contrast agents are all
administered intravenously, although the dose and pharmaco-
kinetics are different. These two agents are sometimes referred
to as combination agents because of their dual capacity for
imaging both in the dynamic phase (as done routinely with ECF
agents) and in the delayed, hepatocyte-specific phase. These
agents provide comprehensive information about the hepatic
parenchyma, bile ducts, and liver vasculature (Burke et al,
2013; Seale et al, 2009).
 Chapter 19  Magnetic resonance imaging of the liver, biliary tract, and pancreas 361

NORMAL HEPATIC APPEARANCE ON
MAGNETIC RESONANCE IMAGING
MRI is routinely used to evaluate diffuse and focal liver abnor-
malities. With liver MRI, a combination of precontrast T1, T2,
and DWI sequences are used. Normal hepatic parenchyma is
brighter (hyperintense) than the spleen on T1-weighted images,
whereas on T2-weighted images, the spleen is relatively brighter
than the liver (Fig. 19.3). Although most hepatic lesions are
low in signal intensity on T1-weighted images, they have more
variable intensity on T2-weighted images, with cysts and hem-
angiomas having the highest T2 signal intensity in general.
Precontrast and postcontrast T1-weighted imaging is also per-
formed to assess enhancement patterns of the liver parenchyma
and liver lesions. If a hepatobiliary contrast agent is used, addi-
tional delayed hepatobiliary phase images are acquired.
DIFFUSE HEPATIC DISEASE
Fatty Liver
Fat may accumulate within hepatocytes for many reasons,
including alcohol intake, diabetes, medications, and obesity (see
Chapters 71 and 100). Hepatic steatosis may be diffuse, patchy,
or focal. The pattern of fatty liver is related to regional differ-
ences in perfusion. It may be difficult to distinguish focal fat
from focal hepatic lesions on CT because both appear low in
attenuation. Additionally, focal fatty sparing may appear similar
to an enhancing neoplasm on contrast-enhanced CT. Although
geographic margins and location may aid in the diagnosis, this
is more readily distinguished on MRI due to different signal
characteristics. T1-weighted in-phase and out-of-phase imaging
allows differentiation of signals from fat and water when they
are present in the same voxel, as it exploits minute differences
in resonance frequencies between fat and water protons (Fig.
19.4). Using fast gradient-echo techniques, fat and water
protons that share the same voxel will be imaged both “in phase”
or 180 degrees “out of phase.” Tissues that have relatively equal
quantities of fat and water will appear dark on the out-of-phase
sequence because the signals from fat and water are “opposed
in phase” and can cancel each other out (Boll et al, 2009;
Springer et al, 2010). Areas of fatty sparing will remain hyper-
intense relative to the surrounding fatty liver on out-of-phase
imaging. On standard T1-weighted imaging, areas of focal fat
can show increased signal. The appearance on T2-weighted
images depends on the type of sequence acquired and whether
fat saturation is used. The ability of MRI to exploit those signal

A B

C
FIGURE 19.3.  Normal hepatic magnetic resonance image. A, T1-weighted spin-echo image. The liver is brighter (hyperintense) relative to the signal
of the spleen. There are normal flow voids that appear as dark areas in the visualized vessels (straight arrow, intrahepatic portion of the inferior vena
cava; curved arrow, aorta). B, T2-weighted fast spin-echo image. Because of reversal of the liver/spleen contrast, the normal spleen is brighter than
the liver. Note the flow voids within the vessels (straight arrow, intrahepatic portion of the inferior vena cava; curved arrow, aorta). C, Postcontrast
T1-weighted gradient-echo image. Normal enhancement in the liver and spleen is evident, and the parenchyma of both is about equal in this phase
of the injection. All the vessels are bright as a result of the T1 shortening effect of gadolinium (straight arrow, intrahepatic portion of the inferior vena
cava; curved arrow, aorta).
362 PART 2  DIAGNOSTIC TECHNIQUES

A B

C D

E
FIGURE 19.4.  Focal fat within the liver. A, Non–contrast-enhanced computed tomography image in a young adult with history of testicular cancer
shows heterogeneous regions of low attenuation in the right hepatic lobe (arrows). B, T1-weighted in-phase image at the same level now shows
signal abnormality in this region. C, T1-weighted out-of-phase image shows geographic areas (arrow) that have lost signal. On the out-of-phase
images, a black line “India ink effect” surrounds tissue interfaces. D, T1-weighted fat saturation precontrast image also shows mild signal loss in this
area (arrow). E, T1-weighted fat saturation postcontrast image. The area in question has normal vascularity coursing through it; no mass was
present—the typical appearance of fatty infiltration.
 Chapter 19  Magnetic resonance imaging of the liver, biliary tract, and pancreas 363
differences, as well as to apply diffusion-weighted and postcon-
trast imaging, offers an advantage over CT when evaluating for
focal lesions on a background of hepatic steatosis.
Newer, breath-hold three-dimensional (3D) T1 techniques
with interpolation allow fast single breath-hold acquisition with
added fat and water separation (Bashir et al, 2012). Enhance-
ment characteristics also aid in the diagnosis, as focal fatty liver
enhancement should parallel surrounding normal hepatic
parenchyma. This is important because other lesions, including
hepatocellular carcinoma (HCC) and adenoma, may contain
small quantities of fat within them (see Chapters 90A and 91).
Iron Deposition Disease
Hepatic iron deposition may occur from primary genetic hemo-
chromatosis or from secondary nongenetic systemic overload
(see Chapter 76). Primary hemochromatosis is an autosomal
recessive genetic disorder characterized by abnormal intestinal
iron absorption, with accumulation of iron in the nonreticulo-
endothelial organ system. This predominantly occurs in hepa-
tocytes later in the disease when other viscera, including the
pancreas and heart, are more likely to be involved. The liver
shows abnormally low signal intensity compared with spleen on
T1-weighted in-phase sequences. T1-weighted gradient-echo
sequences are very sensitive for detecting the presence of iron
within the hepatic parenchyma due to the local field inhomo-
geneities caused by the presence of iron. Primary, or genetic,
hemochromatosis is important to diagnose because this entity
may be unnoticed until late in the disease process, and its long-
term sequelae include fibrosis, cirrhosis, and HCC.
Nongenetic systemic iron overload from secondary causes
can sometimes be distinguished from primary hemochromato-
sis based on the pattern of organ involvement. Nongenetic
systemic iron overload is typically associated with multiple
blood transfusions, myelodysplastic syndrome (MDS), or
abnormal iron absorption in patients with cirrhosis (Queiroz-
Andrade et al, 2009). In secondary iron overload, there is pre-
dominant accumulation of iron in the reticuloendothelial
system (RES), with splenic and bone marrow iron deposition
early and hepatic deposition later. If the iron deposition is
limited to the RES only, it is termed hemosiderosis. If non-RES
organ involvement is seen, it is termed secondary hemochroma-
tosis. These distinguishing characteristics and the patient’s
history often allow correct differentiation. MRI is excellent for
identifying the abnormal signal intensity due to iron deposition,
and gradient-echo imaging has been shown to reliably quantify
hepatic iron load (Fig. 19.5) (Mavrogeni et al, 2013; Queiroz-
Andrade et al, 2009). Iron quantification may have indirect
added uses; for example, limited data suggest it may help
predict nonrelapse mortality prior to allogeneic stem cell trans-
plant in patients with MDS and acute myeloid leukemia
(Wermke et al, 2012).
FOCAL HEPATIC LESIONS
The advantage of MRI over CT is in the improved characteriza-
tion of liver lesions by improved soft tissue contrast combined
with novel tissue contrast mechanism. We will discuss common
benign and malignant liver lesions and emphasize distinguish-
ing imaging characteristics. Familiarity with typical lesion T1
and T2 signal, as well as enhancement characteristics, will aid
the clinician in developing an approach to assess the most com-
monly encountered hepatic lesions.
Cysts
Cysts are common hepatic lesions that may be sporadic (see
Chapters 75 and 90B) or associated with polycystic disease of
the kidney (Fig. 19.6). Small cysts (<1 cm) may be difficult to
characterize on CT because of volume averaging but are easily
diagnosed by MRI. The MRI criteria for a simple cyst is a
nonenhancing lesion that is homogeneously low in signal inten-
sity on T1-weighted images and homogeneously very bright on
T2-weighted images, similar to cerebrospinal fluid. Cysts main-
tain their markedly high signal on heavily T2-weighted images,
similar to fluid in the cerebrospinal fluid, bile ducts, and pan-
creatic duct.
Hemangioma
Hepatic hemangiomas (see Chapter 90A) are benign tumors of
the liver with an estimated incidence of 20% (Albiin, 2012).
Most hemangiomas are thus commonly found incidentally on
other imaging studies, such as CT or ultrasound. MRI is ideal
for characterizing hemangiomas and is the preferred modality
for imaging. On T1-weighted images, hemangiomas are hypoin-
tense compared with the surrounding hepatic parenchyma,
have smooth, well-marginated borders, and are frequently lob-
ulated. Hemangiomas are markedly hyperintense compared
with normal liver on T2-weighted images. Hemangiomas also
tend to retain a high signal on more heavily T2-weighted
sequences, almost to the same degree as cysts, and become
more conspicuous compared with surrounding liver paren-
chyma. After the administration of contrast, the presence of
peripheral nodular discontinuous enhancement, with either
partial or complete filling in on successive postcontrast phases,
has been shown to be highly accurate for the diagnosis of hem-
angioma (Fig. 19.7; Silva et al, 2009).
Dynamic contrast-enhanced MRI after administration of
intravenous gadolinium is useful for increasing the specificity
of diagnosis of hepatic hemangioma and for differentiating this
lesion from others, including metastases and HCCs (Albiin,
2012). Larger hemangiomas tend to follow these criteria more
frequently, although giant hemangiomas also may have variable
signal intensity and a central scar (Prasanna et al, 2010). Prob-
lems arise with smaller hemangiomas, however, which may
“flash fill” and appear as hypervascular, homogeneous lesions.
These smaller lesions (usually <1 cm) may be distinguished by
both their T2 signal characteristics and enhancement pattern
paralleling enhancing vessels (Albiin, 2012). In addition, hem-
angiomas have higher apparent diffusion coefficient values
obtained from DWI than metastases (Miller et al, 2010).
Caution must be used when assessing enhancement using the
hepatobiliary contrast agent gadoxetate disodium, however, as
the overlapping extracellular phase and hepatobiliary excretion
of this contrast may confound the typical hemangioma enhance-
ment and lead to “pseudowashout” in late dynamic phase,
making characterization more difficult (Goshima et al, 2010).
For this reason, we prefer not to use gadoxetate as the contrast
agent for initial liver lesion characterization and use a tradi-
tional ECF agent instead.
Sclerosed hemangiomas represent a diagnostic challenge,
often mimicking malignancies in the liver; limited data suggest
that increasing sclerosis shows corresponding decreased T2
signal and less avid enhancement, probably corresponding to
areas of fibrosis. Adjacent capsular retraction and adjacent
wedge-shaped transient perfusional changes, as well as size
364 PART 2  DIAGNOSTIC TECHNIQUES

A B

C D

E F

G
FIGURE 19.5.  Iron deposition. A, T1-weighted in-phase gradient-echo image (echo time [TE] 4.8) shows abnormal liver/spleen contrast. The liver
is homogeneously darker than the spleen from preferential deposition of iron within the hepatic parenchyma. This is a pediatric patient who had
undergone numerous transfusions while undergoing therapy for cancer. Note the difference from Figure 19.X. B, T1-weighted out-of-phase gradient-
echo image (TE 2.2) shows the liver/spleen contrast reverses, with the liver being brighter than spleen. This is opposite from Figure 19.X and shows
iron deposition disease within the liver. C, Axial T2-weighted fast spin-echo sequence shows marked low T2 signal within both liver and spleen. D-G,
Using T2-weighted multigradient-echo technique, there is progressive signal loss in the liver. This type of multiecho imaging allows estimation of iron
quantification using computer software.
 Chapter 19  Magnetic resonance imaging of the liver, biliary tract, and pancreas 365

A B
FIGURE 19.6.  Hepatic cysts associated with polycystic kidney disease. A, Axial T2-weighted image at the level of the kidneys shows bilaterally
enlarged kidneys with multiple hyperintense cysts. Little normal renal parenchyma is present at this level, and multiple small hepatic cysts (arrow)
are seen. B, Coronal T2-weighted images through the kidneys show similar findings of enlarged kidneys containing multiple cysts (black arrows),
and small hepatic cysts are identified (white arrow).

decrease over time, may all offer clues to suggest the diagnosis,
but biopsy may be necessary for confirmation, depending on
the clinical picture (Ridge et al, 2014).
Focal Nodular Hyperplasia
Focal nodular hyperplasia (FNH; see Chapter 90A) is the
second most common benign tumor of the liver after heman-
gioma. Pathologically, FNH contains all the elements of normal
liver and may have a central fibrous scar, which shows delayed
enhancement, and is surrounded by hepatocytes and small bile
ducts (see Chapter 89). FNH has been associated with oral
contraceptive use (Scalori, 2002) as well as chemotherapy in
the pediatric age group (Do et al, 2011; Sudour et al, 2009).
Most FNH are isointense to normal liver parenchyma on T1-
and T2-weighted images, and a few are mildly T1 hypointense
or minimally hyperintense on T2-weighted images (Fig. 19.8A
and B). When discussing relative T1 and T2 signal, a normal
background liver parenchyma is assumed. In a liver with iron
deposition, which diffusely lowers the signal intensity of the
liver parenchyma, T1 and T2 relative hyperintensity can be
expected. This may be seen, for example, in pediatric oncologic
patients who have concomitant iron deposition (Do et al,
2011). Frequently, FNH is visualized by displacement of the
normal hepatic vasculature, and classic FNH shows strong
arterial peak enhancement following administration of an intra-
venous contrast agent, with lack of washout in portal venous or
late dynamic phase imaging.
A common feature of FNH is the presence of a central scar.
This distinguishing feature is hypointense on T1-weighted
images and hyperintense on T2-weighted images with enhance-
ment on delayed imaging beginning at approximately 3 minutes
by using ECF contrast agents (Fig. 19.8C) (Karam et al,
2010). The presence of enhancement, similar to or higher-
than-normal parenchyma, during the delayed hepatobiliary
phase with a hepatocyte-specific contrast agent is expected for
the majority of FNHs. Of note, with the hepatobiliary agent
gadoxetate disodium, a central scar, if present, does not usually
enhance relative to the hepatocytes present in this lesion.
Hepatic Adenoma
Hepatocellular adenomas (HCAs) (see Chapter 90A) also are
benign liver lesions, but unlike FNH, are associated with com-
plications, including abdominal pain, bleeding, and rarely,
malignant degeneration. HCAs are strongly associated with oral
contraceptive or steroid use and are more common in women
of childbearing age. Newer low-dose oral contraceptives have
a less strong association with HCAs. Although HCA may be
large at presentation, they are increasingly incidentally discov-
ered and often less than 4 cm in diameter (Grazioli et al, 2012).
Hemorrhage may be life threatening if it extends into the peri-
toneum. Although imaging characteristics vary, a combination
of features, including enhancement characteristics, intralesional
lipid, and hypointensity on delayed hepatobiliary phase imaging,
may help increase diagnostic confidence (Mohajer et al, 2012).
Nonetheless, small adenomas without hemorrhage may be dif-
ficult to differentiate from FNH without a central scar and from
well-differentiated HCC.
Recently, distinct genetic subtypes of adenomas have been
described and show differing behaviors, histopathology, and
imaging features. These include inflammatory, hepatocyte
nuclear factor-1α (HNF-1α–mutated), and β-catenin–mutated
HCAs (see Chapter 89). Of note, some adenomas may be both
β-catenin mutated and inflammatory. A group remains unclas-
sified and encompasses other HCAs without any genetic abnor-
malities (Grazioli et al, 2013). Inflammatory HCA, the most
common subtype (30% to 50% of HCAs) typically seen in
women with a history of oral contraceptive use, is generally
hypointense on T1 images, hyperintense on T2, and frequently
heterogeneous. They usually show moderate arterial enhance-
ment, persistent dynamic phase enhancement, and variable
uptake in delayed hepatobiliary phase (Grazioli et al, 2013).
The enhancement pattern may reflect a mix of poorly function-
ing hepatocytes, arterioles without accompanying veins,
inflamed bile ducts, and dilated sinusoids. On MRI, small
amounts of intralesional lipid may be seen. A small percentage
of these HCA show contrast washout in late dynamic phases,
whereas others retain contrast similar to hemangiomas. Delayed
366 PART 2  DIAGNOSTIC TECHNIQUES

A B C

D E F
FIGURE 19.7.  Hepatic hemangioma undergoing sclerosis. A, Heavily T2-weighted image (echo time [TE] 150) shows a mass (m) that is hyperintense
to hepatic parenchyma with well-defined margins. B, Precontrast T1-weighted fat saturation image at the same level shows the mass to be low
signal compared with background parenchyma. C, T1-weighted postcontrast image in early portal venous phase shows peripheral nodular enhance-
ment within this mass (arrows). Portions of the lesion fail to show enhancement during this phase. D, Equilibrium phase T1-weighted image post-
contrast shows the lesion has partially filled in toward the central portion. This constellation of findings is typical for hepatic hemangioma. 
E-F, The same lesion 5 years later on T1-weighted postcontrast scans in portal venous and equilibrium phase imaging shows less avid enhancement
and has shown slight size decrease, consistent with developing sclerosis. Sclerosing hemangiomas may show size decrease with less avid enhance-
ment, associated capsular retraction, and lower T2 signal than nonsclerosed hemangiomas.

peripheral rim enhancement in hepatobiliary phase may also be
seen (Grazioli et al, 2013).
Hepatocyte nuclear factor-1α mutated HCAs (30% to 35%
of HCAs) are almost exclusively seen in women and often show
large amounts of intralesional lipid. They enhance less avidly
in arterial phase than inflammatory HCA and typically are
homogeneously low in signal on delayed hepatobiliary phase.
They may also remain low signal in portal venous or equilib-
rium dynamic phases, but that may be due to the opposed-
phase property of postcontrast T1-weighted imaging (Grazioli
et al, 2013).
β-Catenin–mutated HCAs (10% to 15% of HCAs) are asso-
ciated with glycogen storage disease, androgen use, and have a
male predilection; they also have a higher chance of undergoing
malignant degeneration. They show moderate, often heteroge-
neous arterial phase enhancement, which may persist but is
variable in late dynamic and delayed phases. Although T1
hypointensity and T2 hyperintensity are common, it is often
heterogeneous. These lesions show diffuse glutamine synthetase
expression from upregulation, although it may be heteroge-
neous. This is in contradistinction to FNH, which shows map-
like glutamine synthetase expression distribution adjacent to
hepatic veins (Agarwal et al, 2014; Balabaud et al, 2013; Grazi-
oli et al, 2013).
Unclassified HCA (10% of HCAs) have no specific genetic
or histopathologic abnormalities. No specific imaging features
have been identified for these lesions, although experience
remains limited due to their infrequent diagnosis.
 Chapter 19  Magnetic resonance imaging of the liver, biliary tract, and pancreas 367

A B

C D
FIGURE 19.8.  Focal nodular hyperplasia (FNH). A, T2-weighted image shows a mass that is isointense to hepatic parenchyma (arrows). Centrally,
within this mass is a linear, hyperintense focus (arrowhead). B, A precontrast, T1-weighted gradient-echo image shows the mass (arrows) to be
mildly hypointense to liver. C, Arterial dominant phase T1-weighted gradient-echo sequence shows that the mass enhances intensely with respect
to hepatic parenchyma (arrows). The central focus, which was bright on the T2-weighted images, does not show enhancement on this phase of the
injection (arrowhead). D, Postcontrast equilibrium phase image shows the mass to be isointense to background hepatic parenchyma. The central
portion of scar shows delayed enhancement (arrowhead) characteristic of FNH.

Hepatic Abscess/Infection
CT is generally the modality of choice in recent postoperative
patients in whom there is a clinical suspicion of a hepatic
abscess (see Chapter 72). Patients with more atypical symptoms
may present a diagnostic dilemma. Although some patients
show symptoms suggesting abscesses, others do not, but
patients suspicious for abscesses or bile leaks may be imaged
with MRI. Abscesses are usually hyperintense on T2-weighted
images with an irregular rim of intermediate signal intensity
surrounding a hyperintense outer rim. Abscesses are generally
hypointense on T1-weighted images, unless they have hemor-
rhage or proteinaceous debris within them. After administration
of contrast material, the rim enhances, whereas the central
portion does not. The imaging findings may overlap with malig-
nancies, including gallbladder cancer. Infected cystic hepatic
lesions also may occur, such as parasitic echinococcal infec-
tions. Echinococcal cysts are typically multiloculated with inter-
nal thin-walled daughter cysts, and typically show no internal
enhancement. A peripheral low T1 and T2 signal rim, as well
as correlation with a history of possible exposure, may provide
added clues to the diagnosis (see Chapter 74) (Qian et al,
2013).
Hepatic Metastases
The liver is the most common site for the hematogenous spread
of malignant neoplasms (see Chapters 92 to 94). Other hepatic
lesions, including hemangiomas or focal fat, may appear similar
to metastases when imaged with CT or ultrasound. In general,
metastases are mildly hypointense on T1-weighted images and
are mildly hyperintense on T2-weighted images. Unless they are
necrotic, mucinous, or cystic, metastases are not as bright on
T2-weighted images as hemangiomas or cysts and often become
less conspicuous with greater (longer echo time [TE]) T2
weighting. A number of metastases are hypervascular and best
seen on arterial phase imaging, such as those arising from a
primary neuroendocrine tumor, renal cell carcinoma, or intra-
hepatic metastases from hepatocellular carcinoma. Most
metastases, however, are hypovascular and tend to have less
well-defined borders after contrast enhancement than other
benign lesions (Fig. 19.9). During contrast administration,
metastases often show early peripheral marginal enhancement.
These peripheral rims may wash out and appear hypointense on
delayed images (Fig. 19.10). Larger metastases tend to have a
thick irregular rim of enhancement representing viable tumor
with areas of central necrosis. Multiple studies have demon-
strated superior accuracy of hepatobiliary agent contrast-
enhanced MRI over contrast-enhanced CT (Lafaro et al, 2013).
Both ECF and hepatobiliary agent contrast-enhanced MRI has
shown higher sensitivity and specificity than CT–positron-emis-
sion tomography (PET) imaging as well, particularly for small
(<1 cm) lesions, and hepatobiliary contrast-enhanced MRI
combined with PET imaging may offer added benefit (Donati
368 PART 2  DIAGNOSTIC TECHNIQUES

A B

C D
FIGURE 19.9.  Hepatic metastasis from colorectal carcinoma. A, T1-weighted image shows a low signal intensity metastasis (arrow) within segment
IVB of the liver. B, T2-weighted image shows the mass is mildly brighter than background hepatic parenchyma. C, Post–contrast-enhanced,
T1-weighted fat saturation image shows the lesion as centrally hypointense, in contrast to the normal surrounding hepatic parenchyma, with minimal
areas of marginal enhancement. D, Fused computed tomography/fluorodeoxyglucose–positron-emission tomography image confirms avid tracer
uptake within the lesion, consistent with active tumor. Note the differences in appearance from hemangioma (see Fig. 19.7).

et al, 2010; Maegerlein et al, 2015; Seo et al, 2011). Arterial
phase imaging may also provide anatomic detail preoperatively;
however, CT angiography offers improved spatial resolution
over MRI.
Hepatocellular Carcinoma
The diagnosis of HCC (see Chapter 91) on CT and ultrasound
can be challenging. It is often associated with cirrhosis and
parenchymal heterogeneity (Fig. 19.11), increasing the diffi-
culty in distinguishing focal hepatic lesions. Cirrhotic livers
show both nodular hepatic contour and parenchymal multi-
nodular change. These nodules represent a spectrum, from
regenerative or dysplastic nodules to HCC. These nodular
lesions are generally thought to constitute a multistep spectrum
of disease, progressing from benign to malignant, which occurs
in response to hepatic parenchymal damage and scarring (Lee
et al, 2012). The advantage of MRI in the evaluation of HCC
is that areas of carcinoma show differences in signal intensity,
diffusion, blood pool, and functional hepatocyte enhancement
and growth compared with regenerative or dysplastic nodules,
or background cirrhotic parenchyma. MRI also has an advan-
tage over other modalities in assessing vascular invasion.
Although HCC generally is hypointense on T1-weighted
and hyperintense on T2-weighted images, and shows arterial
phase hyperenhancement with delayed dynamic phase washout,
signal intensity may be variable (Silva et al, 2009), particularly
for early HCC measuring less than 2 cm (Rhee et al, 2012).
On T2-weighted images, larger, more poorly differentiated
 Chapter 19  Magnetic resonance imaging of the liver, biliary tract, and pancreas 369

A B

C D
FIGURE 19.10.  Hepatic metastasis from breast carcinoma. A, T2-weighted image shows a small lesion within the liver (straight arrow) that is mildly
hyperintense. Portal lymphadenopathy also is present (curved arrow). B, Pre-contrast-enhanced, T1-weighted gradient-echo image shows a well-
defined mass (arrow) that is hypointense to liver. C, T1-weighted gradient-echo image after the administration of contrast shows the peripheral portion
that enhanced irregularly during the arterial dominant phase (not shown) beginning to wash out, suggesting an early target appearance (arrow). D,
Delayed postcontrast gradient-echo image shows continued filling of the central portion of this lesion; the periphery has washed out (arrow).

A B
FIGURE 19.11.  Liver with cirrhotic configuration. A, T1-weighted spin-echo image at the level of the portal vein shows hypertrophy of the left lobe
and caudate with atrophy of the right lobe of the liver. B, T2-weighted image of the liver at the same level shows mildly heterogeneous signal in the
atrophied right lobe, making exclusion of an underlying mass difficult. Note also the focal hepatic scarring (arrow).
370 PART 2  DIAGNOSTIC TECHNIQUES

A B
FIGURE 19.12.  Large hepatocellular carcinoma showing the mosaic pattern. A, T1-weighted image shows a large heterogeneous mass (m) in the
liver. Note the hypertrophied left hepatic lobe and caudate. B, T2-weighted image also shows the mass (m) to be heterogeneous, with islands of
tissue that are hyperintense with respect to other portions of the same mass. This pattern is known as the mosaic pattern, and it can be seen in
hepatocellular carcinoma, especially when the lesion is large.

A B
FIGURE 19.13.  Hepatocellular carcinoma containing intracellular lipid. A, T1-weighted in-phase gradient-echo image shows a mass in the liver
that is darker than normal parenchyma, with a small internal area of brighter signal (arrow). B, T1-weighted out-of-phase gradient-echo image shows
the same area (arrow) has lost signal, which is consistent with an admixture of fat and water-containing tissue.

HCCs may be heterogeneous due to areas of necrosis (Fig.
19.12). Areas of heterogeneity may indicate moderate to poorly
differentiated tumors (Witjes et al, 2012). HCC may show high
T1 signal (Fig. 19.13) (Basaran et al, 2005), and lesions with
intracellular lipid show signal loss on out-of-phase T1-weighted
imaging. Intracellular lipid may be an important clue to small
HCCs without typical enhancement patterns, as early HCC are
sometimes hypovascular in arterial phase (Rhee et al, 2012).
Contrast washout in portal venous or later dynamic phase
MRI, as well as heterogeneous enhancement, has been associ-
ated with moderate to poorly differentiated tumors; a higher
percentage of well-differentiated tumors may not demonstrate
washout (Okamoto et al, 2012; Tan et al, 2011; Witjes et al,
2012). In addition to washout, peritumoral capsules, which are
low in signal intensity on the arterial dominant phase and
enhance later, are also associated with microvascular invasion,
an important feature with clinical significance (Witjes et al,
2012). These are distinguishing features in contrast to benign
or dysplastic nodules. Although dysplastic nodules may also
hyperenhance, they tend to be more homogeneous and isoin-
tense to background liver parenchyma during the equilibrium
phase, often show low T2 signal, and are variable on delayed
hepatobiliary phase imaging (Cruite et al, 2010). In HCC,
hepatocyte contrast agents generally show hypointensity in
delayed hepatobiliary phase imaging compared with surround-
ing liver in the vast majority of cases, with a small percentage
showing variable internal uptake, which may reflect either the
grade of tumor differentiation or specific enzyme production
and tumor receptors. (Cruite et al, 2010) Rarely, well-
differentiated HCC may show tracer concentration in delayed
hepatobiliary phase with areas of increased signal intensity.
Due to the complexity of imaging features and overlap, as
well as multimodality availability, there have been organized
efforts to improve report standardization and communication
regarding imaging findings, as well as recommendations regard-
ing surveillance imaging and screening. The American Associa-
tion for the Study of Liver Diseases (AASLD) issued revised
recommendations in 2010, recommending HCC screening for
 Chapter 19  Magnetic resonance imaging of the liver, biliary tract, and pancreas 371
patients at risk with ultrasound (US) every 6 months combined
with serum α-fetoprotein (AFP). MRI imaging has an emphasis
on arterial phase hyperenhancement and washout, with biopsy
improving sensitivity for indeterminate lesions (Tan et al,
2011). The Liver Imaging Reporting and Data System (LI-
RADS), an initiative supported by the American College of
Radiology, as well as the Liver and Intestinal Organ Transplant
Committee (OPTN) have also issued guidelines regarding
HCC classification. LI-RADS was revised in 2014 to better
incorporate OPTN and AASLD guidelines regarding growth
and lesion detection on screening ultrasound. Ancillary fea-
tures, including nodule-in-nodule or mosaic appearance, intra-
lesional fat, diffusion restriction, and perilesional or coronal
enhancement, for example, are also incorporated into the
LI-RADS imaging interpretation algorithm (http://nrdr.acr.org/
lirads/). Although continued revisions are inevitable, consensus
guidelines will encourage report standardization, improve com-
munication, and ultimately improve decision making. Agree-
ment among readers using newer algorithms tends to be
moderate to substantial for expert readers but lower among
novices, suggesting implementation of criteria may require a
learning curve (Davenport et al, 2014).
Fibrolamellar Carcinoma
Fibrolamellar HCC (FLHCC), a rare variant, occurs in young
adults, and is distinct from conventional HCC on multiple
levels, including molecular and clinical differences (see Chapter
91). The average age at presentation is 25 years, and the pres-
ence of nodal metastases is common (Ganeshan et al, 2014).
FLHCC may have a central scar, and these scars tend to be
low in signal intensity on T1-weighted and T2-weighted images
due to fibrous changes. FNH also may have a central scar,
although FNH scars generally show increased T2 signal;
however, it is not always a reliable differentiating feature (Gane-
shan et al, 2014; Kim et al, 2009). FLHCC may show early
heterogeneous enhancement with variable washout and may
show partial hepatocyte agent concentration in delayed hepa-
tocyte phase imaging (Meyers et al, 2011). Metastatic disease
is also common at presentation, both in the abdomen and chest,
with adenopathy being prominent (>2 cm) in a majority of
cases (Do et al, 2014).
LESS COMMON HEPATIC TUMORS
Lymphoma
Non-Hodgkin lymphoma accounts for most hepatic lympho-
mas. MRI shows masses of varying size, which are generally
low in signal intensity on T1-weighted images and hyperintense
on T2-weighted images (Coenegrachts et al, 2005; Rizzi et al,
2001), but not as great as with other benign hepatic lesions,
such as hemangiomas or cysts. This difference in signal inten-
sity makes it relatively easy to determine the malignant nature
of the lesion but not the specific tumor type. Lymphoma may
be relatively hypoenhancing in early dynamic phases, with
isointensity in later phases (Coenegrachts et al, 2005). The
imaging characteristics of lymphoma overlap with other malig-
nant hepatic lesions.
Angiomyolipoma
Hepatic angiomyolipoma (HAML) is an uncommon tumor,
more frequent in females, which currently presents a diagnostic
challenge for imaging diagnosis (see Chapters 89 and 90).
Although extracellular lipid is typical in HAMLs, they often
show brisk, avidly enhancing soft tissue components with
washout, which overlaps with other liver malignancies, such as
hepatocellular carcinoma. HAML is generally considered a
benign, solitary tumor comprising three elements: smooth
muscle, thick-walled blood vessels, and mature adipose tissue
(Cai et al, 2013), although they can also present without fat
(Butte et al, 2011). Limited data suggest a well demarcated,
lipid-containing tumor with a thin peripheral enhancing rim,
lack of peritumoral capsule, and an early draining vein that may
offer clues to the diagnosis, particularly in patients without cir-
rhosis or elevated serum AFP (Fig. 19.14) (Cai et al, 2013; Du
et al, 2012). Surgical excision remains preferable, as there have
been reports of HAML hemorrhage and capsular rupture, as
well as venous obstruction or Budd-Chiari syndrome from mass
effect. Furthermore, pathologic analysis remains essential for
diagnostic confirmation; immunohistochemical stains for
markers may offer increased accuracy (Du et al, 2012).
Mesenchymal Tumors
Rarely, tumors of mesenchymal origin, including hepatic angio-
sarcoma (HAS), leiomyosarcoma, and fibrous histiocytoma,
may be present within the liver (Anderson et al, 2009). The
MRI appearance of these tumors is nonspecific; they are gener-
ally of low intensity on T1-weighted images and hyperintense
on T2-weighted images, with heterogeneous enhancement.
HAS typically shows hyperenhancement, often peripheral, but
sometimes central and irregular, with progressive fill-in on more
delayed phases following blood pool. Although similar to cav-
ernous hemangiomas, HAS may also show centrifugal or
“reverse” enhancement patterns and show greater degrees of
variance and heterogeneity, with more disordered peripheral
enhancement than nodular, discontinuous, clump-like enhance-
ment typically seen in benign hemangiomas. HAS is typically
multiple, of varying size, involving both hepatic lobes, and
rapidly growing, as median survival has been reported as less
than 6 months (Huang et al, 2014; Pickhardt et al, 2015).
Epithelioid Hemangioendothelioma
Epithelioid hemangioendothelioma (EH) is a rare tumor of
adults that should be distinguished from infantile hemangioen-
dothelioma, which occurs in infants and children. The progno-
sis is better for EH than for other parenchymal tumors, such
as sarcoma, although extrahepatic metastases do occur. EH is
generally low in signal intensity on T1-weighted images and
hyperintense on T2-weighted images but not as hyperintense
as hemangiomas. They also may show a distinct target sign on
T1- and T2-weighted images (Economopoulos et al, 2008).
After Gd-DTPA administration, an irregular nodular and con-
centric enhancement may be seen. Capsular retraction also may
be seen with EH, helping to elucidate the diagnosis (Lin et al,
2010) (see Chapter 89).
Biliary Cystadenoma and Biliary Cystadenocarcinomas
Biliary cystadenomas and biliary cystadenocarcinomas are rare
tumors of the liver that present as a predominantly cystic mass
containing enhancing septations (Fig. 19.15; see Chapters 89
and 90B). These lesions may be of low, intermediate, or
increased signal on T1-weighted images, depending on the
protein or hemorrhagic content within the mass, and they are
usually hyperintense on T2-weighted sequences. Enhancing
mural or internal irregular soft tissue nodularity, as well as
372 PART 2  DIAGNOSTIC TECHNIQUES

A B

C D
FIGURE 19.14.  Angiomyolipoma. A, T1-weighted in-phase image shows a high-signal right hepatic mass (arrow). B, T1-weighted out-of-phase
image shows low signal at its margin due to chemical shift artifact between the mass and surrounding liver, confirming the presence of bulk fat. 
C, Axial T2-weighted image with fat saturation shows the mass is dark. D, Axial T1-wieghted fat saturation image shows the mass is dark as well.

internal hemorrhage, has been shown in to be more often asso-
ciated with cystadenocarcinomas; however, differentiation may
not be possible (Arnaoutakis et al, 2015; Qian et al, 2013;
Wang et al, 2012). Communication with the biliary ductal
system on delayed hepatobiliary phase imaging with hepatocyte
contrast agents has been reported, helping to differentiate these
tumors from nonneoplastic simple hepatic cysts. (Billington
et al, 2012; Marrone et al, 2011). Infectious cysts may also
communicate with the biliary tree, however, such as with
complex cysts from echinococcal disease.
BILIARY TUMORS
Gallbladder Carcinoma
MRI offers improved characterization of gallbladder cancer
compared with other modalities. However, its differentiation
from inflammatory conditions, which may occur concurrently,
may be difficult (see Chapters 33 and 49). As opposed to the
inflammatory associated wall thickening with maintained
mucosal and submucosal layers, with differential enhancement,
gallbladder cancer typically shows irregular intermediate to
high T2 signal thickening of the gallbladder wall, with early and
prolonged heterogeneous enhancement, often in patients with
multiple gallstones (Tan et al, 2013). Cholelithiasis is a predis-
posing condition. Evidence of liver invasion and spread to
regional lymph nodes also may be identified with MRI, which
is optimal for evaluation of these lesions because of its out-
standing tissue contrast, ability to image directly in multiple
planes (Dai et al, 2009; Sikora et al, 2006), with DWI offering
added sensitivity and specificity for the primary tumor as well
as nodal or hepatic metastatic disease (Tan et al, 2013). Fluo-
rodeoxyglucose (FDG) PET imaging may also provide
improved sensitivity and specificity for nodal or distant meta-
static disease (Lee et al, 2010).
Bile Duct Cancer
Bile duct tumors (see Chapters 50, 51, and 59) are well
depicted on MRI and may be intrahepatic, hilar, or extrahe-
patic, with a mass-forming appearance or as periductal infil-
trating or papillary intraductal morphologies (Chung et al,
2009). Tumors may show focal nodular thickening along
ductal walls or be discrete intrahepatic masses. Central hilar
 Chapter 19  Magnetic resonance imaging of the liver, biliary tract, and pancreas 373

A B

C
FIGURE 19.15.  Biliary cystadenoma. A, Coronal T2-weighted image shows a lobulated mass (m) in close proximity to the left hepatic duct (arrow-
head). B, Projection image in the coronal oblique plane shows the well-defined hyperintense mass to be in continuity with a mildly dilated left-sided
biliary radicle (straight arrow). The normal right-sided biliary radicle (curved arrow) is easily seen with this technique. C, Postcontrast, T1-weighted
gradient-echo image shows no enhancement within this mass (m).

cholangiocarcinomas are the most common and are generally
associated with biliary ductal dilation. Bile duct tumors may
be seen as intermediate, mildly increased T2 signal (Fig.
19.16), however, less so than the surrounding biliary dilata-
tion. The level of obstruction and continuity of the tumor with
the vasculature are well evaluated with MRI (Peporte et al,
2013), although CT angiography with multiphasic imaging
offers improved spatial resolution and similar accuracy to MRI
to assess vascular involvement, and exceeds MRI accuracy
when assessing for nodal and distant metastases (Aljiffry et al,
2009). Focused assessment of ductal, portal venous, and
hepatic arterial involvement is performed in staging and pre-
operative imaging.
Peripheral, mass-forming intrahepatic cholangiocarcinomas
occur in approximately 10% of cases and generally have high
T2 signals, lobulated heterogeneous masses with peripheral
enhancement, and gradual centripetal fill-in (Fig. 19.17)
(Hennedige et al, 2014, Kang et al, 2012) (see Chapter 50).
Satellite lesions are common within the liver, and these lesions
tend to show low signal intensity on delayed hepatocyte imaging
phase (Chung et al, 2009; Kim et al, 2011; Peporte et al,
2013). Intrahepatic cholangiocarcinomas may show adjacent
capsular retraction as well as vascular encasement, typically
without tumor thrombus (Chung et al, 2009). Smaller tumors
may show early, more uniform arterial enhancement, particu-
larly when less than 4 cm in size (Kim et al, 2011). Intraductal
papillary neoplasm of the bile duct is an uncommon subtype of
bile duct cancer with characteristics similar to pancreatic intra-
ductal mucinous neoplasms. The majority of tumors occur near
the hilum or in extrahepatic ducts, and the clinical outcomes
are better than conventional bile duct cancers (Rocha et al,
2012).
BENIGN DISEASES OF THE BILIARY TRACT
Cholelithiasis and Choledocholithiasis
Gallstones are well identified on T2-weighted images and on
MRCP sequences (Fig. 19.18; see Chapters 32, 33, and 36).
They usually appear as low signal intensity structures in a
fluid-filled gallbladder. Ultrasound is usually the modality of
choice in the evaluation of uncomplicated cholelithiasis or cho-
lecystitis due to its high sensitivity and lower cost, but choledo-
cholithiasis is more effectively imaged by MRI (Johnson et al,
2010; Samaraee et al, 2009). Coronal T2-weighted imaging,
374 PART 2  DIAGNOSTIC TECHNIQUES

A B

C
FIGURE 19.16.  Hilar mass. A, Axial T2-weighted image shows dilatation of the left hepatic duct and a low to intermediate–intensity mass expand-
ing the right hepatic duct (arrow). B, T1-weighted late arterial phase postcontrast image shows early enhancement of the tumor (arrow). C, Portal
venous phase postcontrast T1-weighted imaging shows the mass (arrow) is hypoenhancing to liver. Biopsy of a more superior intrahepatic mass in
this patient with cirrhosis showed poorly differentiated hepatocellular carcinoma. Extension into the biliary ducts with ductal expansion and obstruc-
tion is an uncommon finding in hepatocellular carcinoma (HCC). Although HCC and cholangiocarcinoma may exist simultaneously as two distinct
tumors, a distinct subtype of mixed HCC-cholangiocarcinoma is increasingly recognized.

performed routinely with MRI, readily identifies common duct
stones (Fig. 19.19). MRCP can also be obtained to evaluate
whether retained stones are present after cholecystectomy,
although clips may limit examinations in the perioperative time
period. If no stones are present on MRCP, this may obviate the
need for ERCP.
Choledochal Cysts
Choledochal cysts (see Chapter 46) represent dilatation of the
extrahepatic bile ducts with possible associated intrahepatic
biliary duct dilatation. This entity is a relatively uncommon
congenital anomaly that usually presents before 10 years of age.
The classic triad includes a palpable mass, abdominal pain, and
jaundice. Cysts may be associated with chronic inflammation
and increase the risk for cholangiocarcinoma. Five types of cysts
have been described (Lee et al, 2009; Todani et al, 1977): type
I has been subdivided into A, B, and C, in addition to types II,
III, IVa, IVb, and V. Recently, there have been advocates for
dropping the numeric classification system, instead using a
more descriptive, clinically meaningful nomenclature (Visser
et al, 2004). MRI is well suited not only to diagnose these cysts,
but also to classify the type of cyst. Not only can 3D MR chol-
angiograms depict the normal and abnormal anatomy, but
direct coronal imaging and delayed scans post–hepatocyte-
specific gadolinium-based contrast agents can be obtained for
further evaluation (Gupta et al, 2010).
Postoperative Biliary Complications
Complications from surgical procedures include bile leaks,
abscess formation, and biliary strictures (see Chapters 27 and
 Chapter 19  Magnetic resonance imaging of the liver, biliary tract, and pancreas 375

A B C

D E F
FIGURE 19.17.  Mass forming intrahepatic cholangiocarcinoma. A, T1-weighted in-phase gradient-echo image shows a peripheral hypointense
mass (m) with capsular retraction. B, A T2-weighted fat saturation image shows increased signal intensity within the mass. C, Diffusion-weighted
image shows restricted diffusion within the mass, which is brighter than liver. D, T1-weighted fat saturation post–contrast-enhanced image in late
arterial phase shows peripheral enhancement. E, T1-weighted post–contrast-enhanced image in late portal venous phase shows only partial filling
of the mass. F, T1-weighted post–contrast-enhanced image in late portal venous phase at a separate level shows an additional satellite lesion (arrow),
smaller in size with marginal enhancement, typical of intrahepatic metastasis.

A B
FIGURE 19.18.  Choledocholithiasis. A, Coronal T2-weighted single-shot fast spin-echo image through the common duct in a patient after chole-
cystectomy shows multiple stones within the common bile duct. Note the distal stone impacted at the level of the ampulla (arrow). B, Axial T2-weighted
image with the same technique also shows a stone, surrounded by bile, in the distal common bile duct (arrow).
376 PART 2  DIAGNOSTIC TECHNIQUES
A pseudopapillary tumors, may provide clues to the diagnosis.
B evaluated on MRI and MRCP. T2, diffusion-weighted, and
FIGURE 19.19.  Afferent loop syndrome. A, Coronal T2-weighted
sequence in a patient after pancreaticoduodenectomy for pancreatic
carcinoma. The patient has a hepaticojejunostomy with a patent anas-
tomosis (white arrow). The afferent loop is markedly dilated (black arrow)
compared with other loops of bowel. No mechanical obstruction was
noted. B, Axial T2-weighted image through the level of the anastomosis
(arrow) shows the site to be patent without evidence of a stricture. The
afferent loop is dilated.
30). Although using other imaging modalities in the immediate
postoperative setting to assess for bile leaks and abscesses may
be prudent, MRI is uniquely suited for the assessment of the
postoperative biliary tract. Bile duct injuries after surgery can
be caused by a number of things, but these may all lead to the
same result—a stricture at the anastomotic site. MRCP is
uniquely suited for addressing this problem. Surgical clips near
the anastomosis may create streak artifacts during CT scan-
ning, but currently used clips are less problematic for MRI.
MRI has multiplanar capabilities and superior tissue contrast,
and MRCP sequences can minimize susceptibility to artifacts
to allow improved visualization of the region of the anastomosis
and improved diagnostic confidence (see Fig. 19.19). More
recently, hepatocyte contrast agents also allow delayed hepato-
biliary phase scans by opacifying the biliary tree, which may
improve diagnostic confidence to evaluate for active biliary leak,
anatomic variants, and choledocholithiasis (Boraschi & Donati,
2014; Gupta et al, 2010).
PANCREAS
Solid Tumors of the Pancreas
Pancreatic solid tumors include both neoplastic and nonneo-
plastic origins (see Chapter 59). Although MRI characteristics
alone may help predict etiologies, there may be imaging-feature
overlap between entities. Imaging characteristics combined
with clinical presentation and demographic data often guide
therapy and predict the diagnosis. Neoplastic etiologies include
tumors arising in the pancreas, such as adenocarcinoma, solid
pseudopapillary tumor, neuroendocrine tumors, or pancreatic
lymphoma. Metastases, lymphomas, and other rare tumors
may involve the pancreas (Low et al, 2011). In addition to
enhancement characteristics, such as early arterial enhance-
ment in neuroendocrine tumors, precontrast signal character-
istics, such as hemorrhage with increased T1 signal in solid
Nonneoplastic etiologies include focal pancreatitis, accessory
spleen, focal fat, congenital anomalies, and other rare etiolo-
gies. Intrapancreatic splenic tissue shows signal intensity and
enhancement characteristics paralleling that of spleen on all
MRI sequences. Focal pancreatitis may mimic pancreatic ade-
nocarcinoma; however, restricted diffusion on DWI is typically
seen in adenocarcinoma (Fattahi et al, 2009; Kartalis et al,
2009), compared with focal pancreatitis. Focal pancreatitis may
also cause irregular narrowing of the main pancreatic duct, as
opposed to the abrupt cutoff and upstream dilatation with
associated parenchymal atrophy noted in adenocarcinoma
(Low et al, 2011; Siddiqi et al, 2007).
Pancreatic Cancer
Pancreatic adenocarcinoma (see Chapters 59 and 62) is well
dynamic contrast-enhanced T1-weighted MRI sequences are
particularly helpful to characterize pancreatic cancer and stage
patients (Tamm et al, 2012). MRI is generally thought to be
highly accurate in assessing for vascular invasion or encasement
(tumor surrounds >50% of the vessel circumference), local-
regional tumor extension, and liver metastases (Tamm et al,
2012), although recent data have suggested MRI may under-
estimate tumor size (Hall et al, 2013; Legrand et al, 2015).
Similar to other modalities, accuracy is limited for assessment
of lymph node metastases with MRI techniques. Pancreatic
cancer subtypes may be predicted based on imaging features,
patient demographics, and clinical presentation, particularly
neuroendocrine tumors; however, there is overlap in the imaging
appearance and location of solid and cystic neoplasms. Prelimi-
nary data suggest grade of tumor enhancement may correlate
with tumor grade in adenocarcinomas (Lauenstein et al, 2010).
Cystic Lesions of the Pancreas
Detection of pancreatic cystic lesions (see Chapter 60) has
increased in recent years with increased imaging and improved
spatial resolution. They are increasingly found incidentally.
Benign lesions may also progress to malignant lesions over
time. Diagnostic possibilities include benign lesions, such as
pseudocysts, serous cystadenomas, and true epithelial cysts; to
 Chapter 19  Magnetic resonance imaging of the liver, biliary tract, and pancreas 377
benign lesions with potential for malignant degeneration, such
as intraductal mucinous or parenchymal mucinous cystic neo-
plasms; to malignant lesions, such as rare cystic or necrotic
adenocarcinomas or cystic neuroendocrine tumors (Kucera
et al, 2012). Multiple imaging modalities may be used to iden-
tify and characterize pancreatic cystic lesions, including ultra-
sound, CT, and MRI.
Intraductal Papillary Mucinous Neoplasms
Cystic lesions arising from intraductal papillary mucinous neo-
plasms (IPMNs) of either branch-duct, main-duct, or mixed
type have been increasingly discovered (Campbell et al, 2015),
and the International Association of Pancreatology has pub-
lished consensus guidelines for their management, which were
last revised in 2012 (see Chapter 60). The International Asso-
ciation of Pancreatology stratifies patients based on “high risk”
or “worrisome” features, with guidelines regarding resection,
endoscopic ultrasound, and imaging follow-up (Tanaka et al,
2012). A recent revision includes main duct dilatation greater
than 5 mm (without obvious cause) as a worrisome feature, but
also downgraded size greater than or equal to 3 cm from high
risk to worrisome (Tanaka et al, 2012). Soft tissue contrast is
improved with MRI imaging, which permits optimal depiction
of features deemed worrisome or high risk, such as septations,
thick enhancing walls, nodularity, or soft tissue components.
The single-shot fast spin-echo T2-weighted sequence is par-
ticularly useful, as cystic lesions are high in T2 signal and bright
on these sequences, and communication with the main duct
may be more evident (Acar et al, 2011; Campbell et al, 2015).
Although branch-duct IPMNs have a lower incidence of malig-
nancy compared with main- or mixed-duct subtypes, recent
meta-analysis has shown mural nodules in branch-duct IPMNs
to have a higher association with malignancy; their presence
may warrant surgical excision (Kim et al, 2014). Evaluation
after contrast administration helps assess cyst wall irregularity
or enhancement of soft tissue components. Molecular analysis
of cyst contents to assess for genetic mutations or gene silencing
associated with IPMN may offer improved accuracy in diag-
nostic workup (Freeny et al, 2014).
Autoimmune Pancreatitis
An increasing incidence of autoimmune pancreatitis is most
likely due to increased awareness and thereby increased detec-
tion (Vlachou et al, 2011) (see Chapter 59). Imaging features
may suggest the diagnosis and are correlated with clinical
features, including elevated serum immunoglobulin G4, rela-
tively indolent clinical presentation, and response to corticoste-
roid therapy. Autoimmune pancreatitis may be diffuse, focal,
or multifocal, and often shows heterogeneous T1 hypointensity,
slight T2 hyperintensity, and delayed enhancement due to asso-
ciated fibrosis. Fibrosis may also show diffuse T2 hypointensity
(Vlachou et al, 2011). Diffuse main pancreatic ductal narrow-
ing or irregularity, and upstream common bile duct dilatation
or wall thickening, may be present. There may also be a peri-
pancreatic halo, which appears hypointense on T1- and
T2-weighted imaging postcontrast (Heyn et al, 2012). Focal
disease, particularly when involving the head with associated
upstream pancreatic and main bile duct dilatation, may mimic
ductal adenocarcinoma. Extrapancreatic manifestations may
also be present within the spectrum of immunoglobulin G G4-
related sclerosing disease, including bile duct, renal, and retro-
peritoneal involvement (Kim et al, 2013).
References are available at expertconsult.com.
 Chapter 19  Magnetic resonance imaging of the liver, biliary tract, and pancreas 377.e1
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 CHAPTER 20 
Direct cholangiography: approaches, techniques, and
current role
Robert H. Siegelbaum and Robin B. Mendelsohn
DIRECT CHOLANGIOGRAPHY OVERVIEW
Direct cholangiography, the introduction of contrast medium
into the biliary system, can be performed under fluoroscopic
guidance percutaneously, endoscopically, or intraoperatively
via surgically placed catheters. The nonoperative techniques are
percutaneous transhepatic cholangiography (PTC) and endo-
scopic retrograde cholangiopancreatography (ERCP). Cur-
rently, noninvasive magnetic resonance imaging (MRI) and
contrast-enhanced computed tomography (CECT) have virtu-
ally eliminated the indications and need for direct cholangiog-
raphy (Bakhal et al, 2009; Miller et al, 2007; Stroszczynski &
Hünerbein, 2005) (see Chapters 18 and 19). Today, ERCP and
PTC are typically performed only as part of a planned inter-
ventional procedure, such as biliary drainage, stent placement,
stone extraction, or stricture dilation (see Chapters 29 and 30).
Imaging evaluation of the biliary tree with magnetic reso-
nance cholangiopancreatography (MRCP) or CECT is nonin-
vasive, does not require sedation, and is generally regarded as
safe. Imaging protocols with multiplanar reconstruction allow
a large field of view that enables visualization of the entire
biliary tree and pancreatic duct (Fig. 20.1). Reconstructed
three-dimensional data sets can be displayed in an appearance
similar to a diagnostic cholangiogram, with the added benefit
of being able to rotate the images to further delineate the
anatomy of the bile duct and pancreatic duct. In comparison,
injection of contrast dye under fluoroscopic guidance is limited
to visualization of structures in direct continuity with the opaci-
fied, nonisolated segments of the biliary tree (Fig. 20.2). While
performing direct cholangiography with PTC, simultaneous
cross-sectional imaging may be required to ensure that the
entire biliary tree has been opacified, even with multiple per-
cutaneous puncture sites and injections. Cross-sectional
imaging of the liver can be performed in a fluoroscopy room
with rotational angiography or by direct CT imaging if there is
an in-line CT scanner. In addition, MRCP and CECT typically
provide superior diagnostic accuracy when compared with PTC
or ERCP, allowing visualization of the bile duct wall, structures
contiguous to the biliary tree (such as cysts and neoplasms),
and structures adjacent to the liver.
PERCUTANEOUS TRANSHEPATIC
CHOLANGIOGRAPHY
History
The first report of fluoroscopic imaging of the biliary tree was
presented by Burckhardt and Müller in 1921, who performed
cholecystocholangiography through percutaneous puncture of
378
the gallbladder. The first report of PTC was by Huard and
Do-Xuan-Hop in 1937, who performed cholangiography with
the suboptimal contrast agent Lipiodol. The use of transhe-
patic cholangiography as a diagnostic tool gained popularity
15 years later, after Carter and Saypol’s (1952) discussion of
PTC with the use of a water-soluble contrast agent. In the
ensuing years, many investigators (Flemma & Shingleton,
1966; Glenn et al, 1962; Mujahed & Evans, 1966; Seldinger,
1966; Shaldon et al, 1962; Weicher, 1964) described a variety
of different methodologic details, including the use of sheathed
or unsheathed needles of various sizes and different puncture
sites with varying directions of puncture. The procedure
remained associated with a significant risk of bile peritonitis,
especially in obstructed biliary systems, and less frequently,
hemorrhage. The use of fine needle technique was developed
at Chiba University and was first presented by Ohto and
Tsuchiya (1969), and later by Tsuchiya (1969). Numerous
additional reports have also described decreased complications
with fine needle transhepatic access, and the fine needle tech-
nique has been generally accepted as the standard (Benjamin
et al, 1978; Ferrucci et al, 1976; Fraser et al, 1978; Gold &
Price, 1980; Harbin et al, 1980; Hinde et al, 1977; Jain et al,
1977; Pereiras et al, 1977).
Transhepatic cholangiography has essentially been sup-
planted by noninvasive imaging techniques for the evaluation
of the biliary tree. In 1985, Kadir reported that less than 5%
of patients referred for evaluation of biliary disease required
concomitant drainage procedures. With continued advance-
ment of cross-sectional imaging techniques, in particular
MRCP (see Chapter 19) (Park et al, 2004; Romagnuolo et al,
2003; Simone et al, 2004; Vaishali et al, 2004; Zhong et al,
2003), percutaneous fluoroscopic imaging of the biliary tree is
typically only performed as part of a planned radiologic inter-
ventional procedure.
Imaging evaluation of the biliary tree with MRCP or CECT
is noninvasive, does not require sedation, and is generally
regarded as safe (see Chapters 18 and 19). With direct puncture
and contrast injection in the biliary tree, only bile ducts in
continuity with the punctured duct are visualized. Multiple
percutaneous punctures may be required to visualize the entire
biliary tree in the presence of bile duct isolation (see Fig. 20.2).
Even with multiple transhepatic bile duct punctures, CT
imaging performed at the time of the procedure can be helpful
to ensure that the biliary tree has been completely assessed.
Alternatively, MRI and CECT can image the entire biliary
system and can demonstrate the presence and severity of bile
duct isolation (see Fig. 20.1). Furthermore, by also visualizing
the bile duct wall, liver, and surrounding structures, additional
anatomic information is provided with MRI or CECT.
 Chapter 20  Direct cholangiography: approaches, techniques, and current role 379
FIGURE 20.1.  Magnetic resonance cholangiopancreatography. Three-
dimensional maximum intensity projection image showing marked dilata-
tion of the intrahepatic and extrahepatic biliary tree, as well as the
pancreatic duct, in a patient with a head of pancreas mass.
FIGURE 20.2.  Hilar cholangiocarcinoma involving first-order right and
left hepatic ducts. Separate needle punctures were required to fill the
right and left ducts.
Preprocedural Preparation
Ideally, all patients should undergo cross-sectional imaging
(CECT or MRI) prior to PTC. This imaging is particularly
important in patients who have undergone prior liver resection.
MRI or CECT are the imaging modalities of choice due to their
diagnostic accuracy in depicting the level of obstruction, posi-
tion of the liver, portal vein patency, the relationship of the liver
and bile ducts to other structures, and presence of tumors or
lobar atrophy, all of which could greatly facilitate successful
puncture.
Coagulation parameters and platelet count should be
checked prior to the procedure and corrected if necessary.
Informed consent is obtained in accordance with institutional
policy, including a discussion of the risks and benefits of the
procedure. Patients generally receive conscious sedation con-
sisting of an anxiolytic, such as midazolam, and an opiate, such
as fentanyl. All patients should receive broad-spectrum intra-
venous antibiotic coverage (according to institutional prefer-
ence), which should be administered approximately 1 hour
before the procedure to ensure appropriate blood levels at the
time of procedure.
Procedure
Although not always present in modern fluoroscopy suites,
PTC is ideally performed on a tilting fluoroscopic table. As the
specific gravity of contrast material is greater than that of bile,
less contrast dye is typically required to fully delineate the
biliary tree when the table is tilted.
Right-Sided Puncture
After the patient has been prepared and draped in a sterile
fashion, a puncture site is selected in the right midaxillary line,
typically one or two interspaces below the costophrenic angle.
Puncture sites are generally kept below the ninth intercostal
space to avoid inadvertent entry into the pleural space. One
percent lidocaine is infused subcutaneously, and a small derma-
totomy is made with a No. 11 scalpel. A 21- or 22-gauge, 15- to
20-cm Chiba-style needle is advanced under fluoroscopic guid-
ance superior to the closest rib to the target puncture site, to
avoid laceration of an intercostal vessel. Real-time ultrasound
guidance can be helpful for the initial puncture in the presence
of bile duct dilatation (Covey & Brown, 2008). The puncture
site and direction are chosen based on evaluation of the patient’s
cross-sectional imaging studies (Fig. 20.3A and B).
Care should be taken to avoid puncture of the gallbladder
or extrahepatic bile duct. A small amount of water-soluble
contrast agent is injected while slowly withdrawing the needle
until a bile duct is identified. Injection of contrast agent into a
bile duct has the appearance of oil being dropped in water.
Inadvertent opacification of a vascular structure is recognized
by the rapid clearance of the contrast agent. If a bile duct is not
entered during withdrawal of the needle, the needle is reintro-
duced in a slightly different direction. It is generally recom-
mended not to withdraw the needle completely from the liver,
to minimize the number of punctures through the liver capsule.
When opacification of the biliary tree is challenging, particu-
larly in the case of a nondilated biliary tree, the same puncture
site may be used multiple times prior to selecting a new percu-
taneous access site. If successful puncture of a bile duct is
unlikely from that site after multiple attempts, a new site should
be chosen. In patients with biliary obstruction, gentle injection
of 10 mL of iodinated contrast is typically sufficient for bile
duct opacification. A larger volume of contrast material is typi-
cally required in nonobstructed systems. When the bile ducts
are visualized, fluoroscopic images should be acquired and
stored in multiple projections to identify specific portions of the
biliary tree and to completely delineate abnormal findings, if
present.
Left-Sided Puncture
There is considerable variation in size and anatomic position
of the left lateral segments of the liver, and careful review of
380 PART 2  DIAGNOSTIC TECHNIQUES

LOGIQ
preprocedural cross-sectional imaging is recommended to
E9 select an optimal puncture site. Although left-sided punctures
can be performed through the right liver via an anterior axillary
line approach to the segment IV bile ducts, the generally pre-
21 ferred method is a subxiphoid approach to a bile duct in
segment II or segment III. As in punctures of right sided bile
ducts, percutaneous access to the biliary tree can be simplified
by using real-time ultrasound guidance in the presence of
dilated bile ducts (Covey & Brown, 2008).

–21 Success Rate and Accuracy

cm/s Percutaneous opacification of the biliary tree is successful in
95% to 100% of patients with biliary obstruction (Harbin et al,
A 1980; Jain et al, 1977; Mueller et al, 1981). A success rate of
60% to 95% is reported for nondilated biliary systems. The
LOGIQ likelihood of success in a nondilated system is increased by the
E9 number of needle passes performed (Jaques et al, 1980). No
current radiologic descriptions of obstructed bile ducts are
pathognomonic for differentiation of benign and malignant
disease (Hadjis et al, 1985; Wetter et al, 1991). Bile cytology
and review of cross-sectional imaging can be helpful in conjunc-
tion with fluoroscopic images in diagnosing the cause of the
obstruction.

B
FIGURE 20.3.  Real-time ultrasound guidance can be helpful for the
initial puncture in the presence of bile duct dilatation. A, Color Doppler
image of the left liver revealing a dilated segment III bile duct. B, Static
grayscale ultrasound image taken during puncture of the dilated bile duct
with an echogenic 21-gauge needle.
Pitfalls in Interpretation
Lack of Opacification
Failure to inject adequate volume of contrast agent can result
in false interpretation of the level of obstruction. This pitfall
can occur in the setting of complete obstruction and can be
recognized by the presence of a hazy margin at the level of the
apparent (false) obstruction (Fig. 20.4) (Kittredge & Baer,
1975). In high bile duct obstruction, especially when associated
with variant anatomy, isolated segments of the biliary tree can
be visualized only by direct puncture. If the wrong bile duct is
selected, or if puncture of an additional bile duct is needed but

A B
FIGURE 20.4.  Ampullary carcinoma. A, With the patient supine, contrast pools proximally, giving a false impression of a high bile duct obstruction.
The spurious nature of the level is suggested by the hazy inferior margin to the contrast column. B, With the patient sitting semierect, the contrast
pools at the true point of obstruction, which is sharply defined.
 Chapter 20  Direct cholangiography: approaches, techniques, and current role 381
not performed, the diagnosis of bile duct injuries and bile leaks
can be missed.
Ductal Dilatation
The absence of bile duct dilatation does not exclude the pres-
ence of clinically significant biliary obstruction. Disorders such
as sclerosing cholangitis, acquired immunodeficiency syn-
drome, and chemotherapy-induced biliary sclerosis can present
with bile duct fibrosis, impeding the ability of the bile ducts to
become dilated. Conversely, bile duct dilatation does not
always imply the presence of an obstructed biliary system. For
example, dilatation that may be seen in patients with Caroli
disease, or choledochal cysts, can have the radiographic appear-
ance of bile duct dilation without the presence of obstruction.
Complications
Serious complications of PTC are rare and occur in approxi-
mately 3% of patients (Harbin et al, 1980). The most common
major complications are bile leak (1% to 2%), sepsis (2% to
3%), and hemorrhage (0.2% to 0.4%). Other rare complica-
tions include pneumothorax, biliothorax, injury to the colon
related to the puncture, and abscess formation. Puncture below
the ninth intercostal space will clearly decrease the incidence
of pleural and lung complications. The risk of infectious com-
plications such as sepsis and abscess formation can be mitigated
with proper antibiotic coverage. Care should be taken to not
overdistend the biliary tree, as opacification and incomplete
drainage of the biliary tree can be a source of cholangitis (Covey
& Brown, 2008), particularly in the presence of bile duct
isolation.
ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREATOGRAPHY
History
Endoscopic retrograde cholangiopancreatography (ERCP) (see
Chapter 29) was first described in 1968 (McCune et al, 1968)
and rapidly became accepted as an important diagnostic modal-
ity for patients with hepatobiliary and pancreatic diseases
(Cotton, 1977; Cotton et al, 1972; Freeney, 1988; Oi et al,
1970). Over the last 4 decades, multiple advances in technology
and training have enhanced and expanded the scope of ERCP.
The improvement of the side-viewing duodenoscope with an
elevator helped facilitate cannulation of the papilla of Vater
(Kasugai et al, 1971; Ogoshi et al, 1970; Takagi et al, 1970).
In addition, the development of therapeutic applications
through ERCP, including sphincterotomy (Classen et al, 1975;
Cotton et al, 1976; Kawai et al 1974) and stenting (Laurence
et al, 1980; Soehendra et al, 1980), has evolved ERCP from a
diagnostic into a therapeutic procedure. ERCP is considered to
be an advanced procedure, requiring skills more difficult to
learn than routine endoscopic procedures, and is offered as an
additional year of training beyond the standard gastroenterol-
ogy fellowship.
Indications
With the exception of a few scenarios, diagnostic ERCP has
largely been replaced by noninvasive imaging techniques. In
2002, the National Institutes of Health sponsored a consensus
conference on ERCP and issued a statement proposing the
indications for ERCP (Cohen et al, 2002). They concluded
that ERCP, MRCP, and endoscopic ultrasound have compa-
rable sensitivity and specificity in the diagnosis of common bile
duct (CBD) stones. With newer diagnostic imaging technolo-
gies, however, ERCP has evolved into a predominantly thera-
peutic procedure. They stated that avoidance of unnecessary
ERCPs is the best way to reduce the number of complications
and that endoscopists performing ERCPs should have appro-
priate training and expertise. In 2005, the American Society of
Gastrointestinal Endoscopy published guidelines, stating that
based on expert opinion, ERCP is primarily a therapeutic pro-
cedure for the management of pancreaticobiliary disorders
(Adler et al, 2005). Therefore ERCP is rarely performed
without a therapeutic component.
Technique
Most ERCPs are performed as outpatient procedures in a hos-
pital setting, although they can be performed in ambulatory
centers as well. Given that ERCP is a complex procedure,
requiring special equipment and training, the risks and benefits
of the procedure must be heavily considered prior to proceed-
ing. Patients should be alert, oriented, and able to give informed
consent. In the rare cases where patients are unable to give
informed consent, the next of kin can provide consent. Patient
age and clinical picture are important. Elderly patients can
safely undergo ERCP; they have the same risks of bleeding and
perforation as younger patients and actually have a lower risk
of pancreatitis (Badalov et al, 2009).
Once consent is obtained, the patient is brought into a room
with a C-arm for availability of fluoroscopy during the proce-
dure. Intravenous sedation is given under monitored control.
In the past, drug combinations of narcotics, such as meperidine
and droperidol, and benzodiazepines, such as midazolam or
diazepam, were used. More recently, this has been replaced by
propofol, a short-acting sedative and amnestic with a rapid
recovery profile. Studies have shown that propofol is more
effective than sedation with midazolam, is safe, and is associ-
ated with a faster postprocedure recovery (Fanti et al, 2004;
Wehrman et al, 1999). In some centers, general anesthesia may
be used if the endoscopic procedure is expected to be difficult,
the patient has significant comorbid medical conditions, or if
there are any signs of functional or mechanical intestinal
obstruction. Oxygen is administered by nasal cannula to avoid
hypoxemia, which has been described in 40% of patients under-
going ERCP (Woods et al, 1989). The patient’s electrocardio-
gram, blood pressure, oxygen saturation, and overall condition
are continually monitored throughout the procedure by a dedi-
cated nurse. Antibiotics are not given routinely for diagnostic
procedures. All endoscopic equipment used for this procedure,
including the endoscopes, is either chemically disinfected or gas
sterilized.
The patient is placed in a semiprone position with special
positioning of the arms, to help optimize access to the ampulla
of Vater. A side-viewing duodenoscope is used to afford excel-
lent visualization of the ampulla of Vater. In patients with a
Billroth II type gastrojejunostomy, a standard forward-viewing
upper endoscope or pediatric colonoscope may be needed to
successfully approach the ampulla. An initial endoscopic evalu-
ation of the stomach and duodenum is performed before can-
nulation of the ampulla. The ampulla is usually located in the
second portion of the duodenum but, in rare instances, may be
found more proximal or distal. It is usually easily identified,
although, in some cases, it may be distorted due to malignancy
382 PART 2  DIAGNOSTIC TECHNIQUES
A B
C D
FIGURE 20.5.  Pancreatic duct stent placement. A, Wire placement into the pancreatic duct. B, Contrast injection to confirm position in pancreatic
duct. C, Placement of a 5-Fr × 5-cm pancreatic duct stent with a full external pigtail and a single internal flap. D, Endoscopic view of 5-Fr pancreatic
duct stent.
or edema from pancreatitis, hidden behind a fold, or within a
diverticulum. The orifice of the CBD is usually located on the
left upper corner of the ampulla. In most patients, the CBD
and main pancreatic duct share a common channel. In a minor-
ity of patients, the orifices are separate. The minor papilla is
located about 1 to 2 cm above the major papilla. The CBD is
selectively cannulated with either a cannula or sphincterotome.
Studies have shown that access to the biliary tree is easier and
faster with a sphincterotome compared with a cannula (Kara-
manolis et al, 2005; Laasch et al, 2003; Rossos et al, 1993).
More recently, some endoscopists have been using guidewire-
assisted cannulation. It remains controversial whether insertion
of a guidewire, as opposed to the more conventional technique
of contrast injection, should be the preferred technique to
access the bile ducts. A guidewire does not produce the hydro-
static pressure associated with contrast injection and decreases
the risk of trauma to the pancreatic duct, thereby theoretically
decreasing the risk of post-ERCP pancreatitis. The data,
however, are mixed. A recent meta-analysis looking at 12 ran-
domized trials with 3450 patients concluded that wire-guided
technique had a higher cannulation success rate (84% vs. 77%)
and a lower risk of post-ERCP pancreatitis (3.5% vs. 6.7%)
(Tse et al, 2013). However, a prospective trial with 1249
patients showed no significant difference in post-ERCP pancre-
atitis in the guidewire group (5.2%) compared with the contrast
injection group (4.4%) (Mariani et al, 2012).
In the event of a difficult cannulation, there are techniques
to help facilitate access to the bile duct. Excess duodenal
motility can be controlled by bolus injections of 0.25 to 1 mg
of intravenous glucagon. If the pancreatic duct is inadvertently
cannulated, placement of a pancreatic duct stent may help can-
nulation by both blocking the pancreatic duct orifice as well as
by providing more information to the endoscopist about the
angle of the bile duct, especially in cases of distorted anatomy
(Fig. 20.5) (Goldberg et al, 2005). Another technique involves
placing a guidewire into the pancreatic duct, which adds more
information about the optimal angle to approach cannulation
(Fig. 20.6). The studies are limited, but this technique
does not appear to increase the risk of post-ERCP pancreatitis
(Draganov et al, 2005; Saad, 2004). Other more invasive
maneuvers, including precut sphincterotomy with or without
pancreatic duct stent placement, may also improve success rate
but is associated with an increased risk of complications, includ-
ing bleeding, perforation, and pancreatitis, even in experienced
hands (Harewood et al, 2002).
Duodenal diverticula are common and almost always are
located near the papilla in the descending duodenum. Although
usually asymptomatic, diverticula have been shown to be asso-
ciated with choledocholithiasis. Periampullary diverticula
may make cannulation more difficult, but the data are mixed
(Rajnakova et al, 2003; Tham & Kelly, 2004).
In patients with surgically altered anatomy, ERCP may be
quite challenging. In patients with a Billroth II gastrojejunos-
tomy, success rates for bile duct cannulation are much lower
(Forbes et al, 1984). The papilla is found in the afferent limb,
which may be difficult to traverse. In addition, the orientation
 Chapter 20  Direct cholangiography: approaches, techniques, and current role 383

A B C
FIGURE 20.6.  Guidewire placement in pancreatic duct to facilitate bile duct cannulation. A, Wire placement into pancreatic duct. B, This provided
more information to the endoscopist about the angle of the bile duct, and the cannulatome was adjusted under fluoroscopic guidance. C, Contrast
injection confirmed position in common bile duct.

of the ampulla is upside down compared with standard ERCP.

In patients with Roux-en-Y gastrectomies, it is often difficult
even to reach the papilla, given the long Roux limb. If the
papilla is identified, cannulation may still be extremely difficult
due to the location and position of the ampulla (Byron et al,
2002). Recently, double-balloon enteroscopy has been reported
to be successful in enabling access to the afferent limb (Sato
et al, 2005). This is mostly only offered in tertiary care centers.
ERCP after bariatric surgery is extremely difficult, and most
consider it too complex to attempt.
Once the bile duct is selectively cannulated, a contrast agent
is injected under fluoroscopic control, with subsequent radio-
graphic images obtained of the duct anatomy. Choice of con-
trast agent differs among endoscopists. Many choose to use half
strength contrast when looking for stones. Material for patho-
logic and cytologic evaluation can be obtained from either the
biliary or pancreatic duct system with a variety of dedicated
endoscopic biopsy forceps and cytology brushes. Pathologic
and cytologic material may be obtained from the ampulla of
Vater, duodenum, and stomach for diagnostic purposes during
the procedure as well.

Pancreatography
Imaging the pancreatic duct can be an important adjunct to
cholangiography during ERCP. Strictures, stones, and other
obstructing lesions can be identified. Most recommend guide-
wire cannulation of the pancreatic duct over contrast injection
as this produces less hydrostatic pressure in the duct, possibly
decreasing the risk of post-ERCP pancreatitis. In general, the
pancreatic duct is about 20 cm in length and variable in caliber.
With increasing age comes progressive atrophy and fibrosis of
the pancreas. The diameter of the main pancreatic duct also
increases with age, although one study found no difference in
pancreatic duct length among patients younger than 40 years
compared with older patients. Duct diameter throughout the
pancreas was significantly greater, however, in patients older
than 40 years (Anand et al, 1989).
Anatomic variations, such as pancreas divisum (Fig. 20.7),
also may be identified on a pancreatogram (see Chapter 2). This
abnormality has been described in 7.5% of ERCP procedures
and can be confirmed by cannulation of the main pancreatic
duct through the orifice in the minor papilla (Bernard et al,
1990).
FIGURE 20.7.  Pancreas divisum. The cannula is in the major papillary
orifice, and contrast injection opacifies the proximal portion of the major
pancreatic duct (Wirsung). Injection through the minor papillae allows
opacification of the duct of Santorini and the distal duct of Wirsung.
Cholangioscopy and Pancreatoscopy
Cholangioscopy and pancreatoscopy involve using miniature
endoscopes through the channel of the duodenoscope, allowing
direct visualization of the bile and pancreatic ducts, respec-
tively. A new skill set is necessary to perform these procedures,
given that this technique uses two different endoscopes. Diag-
nostic cholangioscopy may be used to evaluate indeterminate
biliary strictures and filling defects. Similarly, diagnostic pan-
creatoscopy may be used to evaluate pancreatic strictures and
intraductal papillary mucinous neoplasms. Studies have shown
that it is an accurate diagnostic tool for patients with pancreati-
cobiliary disorders (Fukuda et al, 2005; Itoi et al, 2010; Yamao
384 PART 2  DIAGNOSTIC TECHNIQUES
et al, 2003). One prospective multicenter study of 87 patients
reported that endoscopists were able to distinguish benign from
malignant indeterminate biliary lesions 92.1% of the time with
cholangioscopy with visualization alone (Osanai et al, 2013).
Complications of cholangiopancreatoscopy include bacteremia,
bleeding, and pancreatitis. One retrospective study reported
that complications of cholangiopancreatoscopy are increased
compared with ERCP alone and are associated with a much
higher risk of cholangitis (Sethi et al, 2011).
Complications
Complications of ERCP include those associated with endo-
scopic procedures in general as well as those specific to ERCP.
Incidence rates of complications vary in the literature. A sys-
tematic survey of prospective studies reviewed 21 studies with
16,855 patients and reported a specific complication rate of
6.9% and a mortality rate of 0.33% (Andriulli et al, 2007). The
experience of the endoscopist and case volume also has an
impact on the complication rate. In a study conducted in
Austria, endoscopists performing more that 50 ERCP proce-
dures per year were compared with those performing fewer than
50 per year. Those in the higher case-volume group had a
significantly higher success rate (86.9% vs. 80.3%; P < .001)
and a lower overall complication rate (10.2% vs. 13.6%; P =
.007) (Kapral et al, 2008).
Pancreatitis
The most common complication of ERCP is pancreatitis, with
reported incidences ranging from 1% to 40%, but most fre-
quently reported around 3% to 5% (Andriulli et al, 2007;
Cheng et al, 2006; Christensen et al, 2004; Freeman et al
2001; Loperfido et al, 1998) (see Chapter 54). The incidence
of post-ERCP pancreatitis in children is quite low, about 2.5%
in one study (Iqbal et al, 2008). The consensus classification
defined post-ERCP pancreatitis as the clinical picture of new
or worsened abdominal pain with amylase at least three times
normal at 24 hours after the procedure and requiring hospital-
ization (Cotton et al, 1991). They further defined it as mild if
hospitalization is 2 to 3 days, moderate if hospitalization is 4
to 10 days, and severe if hospitalization is more than 10 days,
if there is a pseudocyst or hemorrhagic pancreatitis, or if an
intervention is required. Post-ERCP pancreatitis should be dis-
tinguished from transient asymptomatic hyperamylasemia,
which occurs in 40% to 75% of cases and disappears within 1
to 2 days (Classen & Demling, 1975; Okuno et al, 1985). Most
cases of post-ERCP pancreatitis are mild and usually resolve in
a few days with conservative measures of bowel rest and intra-
venous fluids. The management is the same as for pancreatitis
from other causes.
There have been multiple potential mechanisms proposed
to explain the pathogenesis of post-ERCP pancreatitis. Mechan-
ical injury to the pancreatic duct from manipulation of the
papilla, instrumentation of the pancreatic duct, or injection of
the pancreatic duct likely plays a role (Johnson et al, 1997).
Similarly, thermal injury from electrocautery leading to edema
and possible obstruction of the duct has been invoked (Ratani
et al, 1999). Hydrostatic pressure from contrast injection
leading to injury is also likely a component. The contrast itself
theoretically may cause a chemical or allergic injury. However,
the use of nonionic contrast medium of low osmolarity has
shown no advantage over the less expensive ionic contrast
medium in preventing ERCP-related pancreatitis (Hannigan
et al, 1985), and a meta-analysis showed no significant differ-
ence in post-ERCP pancreatitis among different contrast media
(George et al, 2004).
Although it remains unclear whether these mechanisms
work independently or in conjunction, recent data have helped
to elucidate both patient- and procedure-related risk factors
that are independently associated with post-ERCP pancreatitis.
These risk factors are additive (Freeman et al, 2001). Patient-
related factors include younger age, female sex, normal serum
bilirubin, recurrent pancreatitis, history of post-ERCP pancre-
atitis, and sphincter of Oddi dysfunction. Procedure-related
factors include difficult cannulation, pancreatic duct injection,
precut sphincterotomy, pancreatic sphincterotomy, minor
papilla sphincterotomy, balloon sphincteroplasty, ampullec-
tomy, and sphincter of Oddi manometry. One study showed
that trainee participation was an independent risk factor (Cheng
et al, 2006). Most studies, however, have not shown a correla-
tion between case volume and rates of pancreatitis (Freeman
et al, 2001; Loperfido et al, 1998; Testoni et al, 2010).
Specific techniques and measures to decrease the risk of
pancreatitis have been studied. The risk is reduced by minimiz-
ing the number of attempts of cannulation, avoiding pancreatic
duct cannulation if not necessary, and by avoiding overdisten-
sion or “acinarization” of the pancreatic duct by minimizing
the volume of contrast medium into the pancreatic duct.
Placement of a temporary pancreatic duct stent may also
reduce the risk. One meta-analysis demonstrated that the use
of pancreatic duct stents in high-risk patients decreased the rate
of post-ERCP pancreatitis by about two thirds (Singh et al,
2004). Their use is not routinely recommended but is reserved
for high-risk patients. Studies have shown a benefit of pancre-
atic duct stents in biliary sphincterotomy for sphincter of Oddi
dysfunction, precut sphincterotomy, balloon sphincteroplasty,
endoscopic ampullectomy, and difficult cannulation (Fazel
et al, 2003; Freeman et al, 2004; Singh et al, 2004).
Many pharmacologic agents have been studied. A recent
systematic review included 85 randomized clinical trials and 28
meta-analyses evaluating pharmacologic prevention of post-
ERCP pancreatitis. They concluded that rectal nonsteroidal
antiinflammatory drugs (NSAIDs) were beneficial, especially in
high-risk patients. Data on bolus-administered somatostatin,
sublingual nitroglycerin, and some protease inhibitors were
considered promising, but confirmatory studies are necessary
(Kubiliun et al, 2015).
NSAIDs inhibit prostaglandin synthesis, phospholipase A2
activity, and neutrophil/endothelial cell attachment, which are
all thought to play a major role in the pathogenesis of pancre-
atitis, and thus may have a role in post-ERCP pancreatitis
prevention. A meta-analysis that included 10 randomized con-
trolled trials with a total of 2269 patients concluded that
NSAID use decreased the risk of post-ERCP pancreatitis (risk
ratio, 0.57; 95% confidence interval [CI], 0.38 to 0.86; P =
.007) (Ding et al, 2012). However, these studies were extremely
heterogeneous in regard to type of NSAID as well as to route
and timing of administration. A randomized, placebo-
controlled, double-blind clinical trial of high-risk patients
showed that patients who received rectal indomethacin imme-
diately after the procedure were less likely to develop post-
ERCP pancreatitis than the control group (9.2% vs. 16.9%;
P = .0005) and were less likely to develop moderate to severe
pancreatitis (4.4% vs. 8.8%; P = .03) (Elmunzer et al, 2012).
A meta-analysis that specifically looked at studies of rectal
 Chapter 20  Direct cholangiography: approaches, techniques, and current role 385
indomethacin included four studies with 1470 patients showed
that the rate of pancreatitis was significantly lower using indo-
methacin compared with placebo (odds ratio, 0.49; CI, 0.34 to
.71; P = .0002) (Yaghoobi et al, 2013). A network meta-analysis
compared rectal indomethacin to pancreatic duct stenting and
concluded that rectal indomethacin alone was superior to pan-
creatic duct stenting in post-ERCP prevention (odds ratio,
0.48; 95% CI, 0.26 to 0.87) (Akbar et al, 2013). The European
Society of Gastrointestinal Endoscopy guidelines recommend
routine prophylactic use of rectal NSAIDs immediately before
or after ERCP in all patients without a contraindication
(Dumonceau et al, 2014).
Somatostatin and its analogue octreotide inhibit pancreatic
secretions, decrease sphincter of Oddi pressure, modulate
cytokines, and lead to apoptosis of pancreatic acinar cells, and
therefore may be protective against post-ERCP pancreatitis.
They have been studied extensively with conflicting results.
One meta-analysis included seven homogeneous high-quality
studies involving 3130 patients and concluded that somatosta-
tin administered as a bolus was effective in prevention of post-
ERCP pancreatitis (Rudin et al, 2007). A more recent
meta-analysis looked at 17 studies with a total of 3818 patients
and found that somatostatin and high-dose octreotide pre-
vented post-ERCP pancreatitis if given over 12 hours or in
bolus form (Omata et al, 2010). Subsequent randomized trials
have yielded mixed results. One double-blinded, placebo-
controlled, randomized study involved 391 patients in three
hospitals. Patients were randomized to receive 3 mg of soma-
tostatin in 500 mL normal saline infused for 12 hours, starting
30 minutes before the ERCP or 500 mL normal saline infused
for 12 hours, starting 30 minutes before the ERCP. They
found a significantly lower risk of pancreatitis in the soma-
tostatin group (3.6% vs. 9.6% in the placebo group; P = .02)
(Lee et al, 2008). Another study involved 133 patients who
were randomized to a bolus of somatostatin infusion before
ERCP, followed by continuous infusion for 12 hours, a bolus
of somatostatin before ERCP only, and placebo alone; no sig-
nificant differences were found among the three groups (Chan
et al, 2008). A recent randomized trial of 510 patients ran-
domized to an intravenous bolus of 250 µg of somatostatin
prior to cannulation, followed by a 4-hour continuous infusion
of the drug at 250 µg/hr, or placebo with normal saline showed
no significant difference in rates of post-ERCP pancreatitis
(Concepcion et al, 2014). In addition, when pancreatitis has
developed, the use of somatostatin does not improve its clini-
cal course (Phillip et al, 1985). Future research is necessary to
elucidate the role of somatostatin in prevention of post-ERCP
pancreatitis.
Nitroglycerin acts as a smooth muscle relaxant and subse-
quently may decrease sphincter of Oddi pressures, thereby
decreasing the risk of post-ERCP pancreatitis. Only three out
of seven randomized controlled studies showed that nitroglyc-
erin was effective, but two of the three positive studies used
sublingual nitroglycerin (Kubiliun et al, 2015). One compared
2 mg sublingual nitroglycerin given 5 minutes prior to endos-
copy with placebo in 186 patients and found a lower incidence
of pancreatitis in the nitroglycerin group (7/90 vs. 17/96; P <
.05) (Sudhindran et al, 2001). The second one enrolled 74
patients and randomly assigned them to 5 mg sublingual glyc-
eryl trinitrate versus 100 mg vitamin C, 5 minutes prior to the
ERCP. They found a significant difference in post-ERCP pan-
creatitis in the study group (7.9%) compared with placebo
(25%; P = .012) (Hao et al, 2009). In both studies, however,
the consensus definition for pancreatitis was not used, which
may account for the high rates of pancreatitis in the control
groups. One recent randomized controlled trial of 300 patients
showed that the combination of rectal indomethacin and sub-
lingual nitroglycerin was superior to rectal indomethacin alone
at prevention of post-ERCP pancreatitis (6.7% vs. 15.3%; P =
.016) (Sotoudehmanesh et al, 2014). More studies are needed
to further clarify the benefit of nitroglycerin in post-ERCP
pancreatitis.
Protease inhibitors, such as gabexate mesylate, nafamostat
mesylate, and ulinastatin, have been investigated, given that
activation of proteolytic enzymes likely contributes to the
pathogenesis of pancreatitis. A meta-analysis of 18 studies with
a total of 4966 patients showed a significant, yet small, risk
reduction in post-ERCP pancreatitis with the protease inhibi-
tors (Seta & Noguchi, 2011). They stated there was no solid
evidence to support their use at this time. A recent pilot study
investigated whether aggressive periprocedural hydration
reduced the risk of post-ERCP pancreatitis and found that
none of the patients in the aggressive hydration group devel-
oped pancreatitis compared with 17% of patients in the stan-
dard hydration group (Buxbaum et al, 2014). Larger studies
are needed to corroborate these findings. Many other agents
have been investigated, including secretin, corticosteroids, allo-
purinol, and topical epinephrine, with conflicting results, and
are not recommended at this time.
Infection
A serious complication of ERCP is the development of post-
procedure infectious complications, most commonly cholangi-
tis and cholecystitis. In a systematic survey of 21 prospective
studies with 16,855 patients, the incidence of infectious com-
plications was 1.4% (Andriulli et al, 2007).
Cholangitis most commonly occurs when there is failed or
incomplete biliary drainage. The risk is increased in patients
with hilar obstruction and sclerosing cholangitis, given the
increased risk of incomplete drainage (Bangarulingam et al,
2009; Rerknimitr et al, 2004). Other risk factors include jaun-
dice, small endoscopy center, and delay in performing ERCP
(Loperfido et al, 1998; Navaneethan et al, 2013). Treatment
involves supportive care with antibiotics and decompression of
the obstruction. Studies have shown that prophylactic antibiot-
ics significantly reduce the frequency of procedure-related bac-
teremia but have not shown a difference in rates of cholangitis
(Sauter et al, 1990). Two meta-analyses failed to demonstrate
a benefit of giving routine prophylactic antibiotics (Bai et al,
2009; Harris et al, 1999). Antibiotics added to the injected
radiographic contrast medium are also of no benefit (Jendrze-
jewski et al, 1980).
It has also been found that endoscopic instruments used in
ERCP can be the source of serious infections (Earnshaw et al,
1985). Salmonella species are the most common organisms
transmitted by contaminated endoscopes (Axon, 1991), and for
this reason, it is imperative to ensure that the endoscopic equip-
ment used for ERCP is adequately disinfected or sterilized.
Bleeding
Bleeding is a rare complication of diagnostic ERCP and is
most commonly seen with sphincterotomy. Risk factors for
postsphincterotomy bleeding include bleeding during the
procedure, concomitant thrombocytopenia or coagulopathy,
386 PART 2  DIAGNOSTIC TECHNIQUES

anticoagulation started within 3 days of the sphincterotomy, confluence (Figs. 20.10 and 20.11B). A right sectoral duct
and low case volume of the endoscopist (Freeman et al, 1996). crosses to the left to join the left hepatic duct in 28% of cases,
Rarely, there may be a Mallory-Weiss tear from scope trauma according to Healey and Schroy (1953); in 22%, this is the
or submucosal hemorrhage from manipulation of the papilla posterior sectoral duct (see Figs. 20.9B and 20.11B), and in
(Loperfido et al, 1998). There have been case reports of intra- 6%, this is the anterior duct (see Figs. 20.9C and 20.11D).
peritoneal hemorrhage from injury to abdominal vessels, liver, Occasionally, a right sectoral or segmental duct, posterior more
and spleen (Lo et al, 1994; Wu & Katon, 1993). often than anterior, courses inferiorly and enters the common
hepatic duct directly (Fig. 20.12). The confluence of the right
Perforation and left ducts takes the form of a trifurcation rather than a
The most common type of perforation associated with ERCP bifurcation in 12% of cases according to Couinaud (1957; see
is retroperitoneal perforation and is usually associated with Fig. 20.9A).
sphincterotomy, with an incidence ranging from 0.5% to 2.1% In the left lobe, the superior and inferior lateral segment
(Cotton et al, 1991). In their systematic survey of 21 prospec- ducts, segments II and III, unite in the line of, or to the right
tive studies with 16,855 patients, Loperfido and colleagues
(1998) reported 101 perforations (0.6%) and 10 deaths from
perforation (0.06%). Free bowel wall perforation is quite rare
and is usually associated with a structural abnormality such as TABLE 20.1  Segmental Nomenclature
a stricture or Billroth II gastrectomy (Wilkinson et al, 1994). I Caudate lobe
The management of the perforation depends on the size, II Left lateral superior segment
location, and clinical picture. Free bowel wall perforations III Left lateral inferior segment
usually require surgery. Use of endoscopic clips for the treat- IV Left medial segment or quadrate lobe
ment of duodenal perforations has also been reported V Right anterior inferior segment
(Katsinelos et al, 2005; Solomon et al, 2012). VI Right posterior inferior segment
VII Right posterior superior segment
DIRECT CHOLANGIOGRAPHY AND VIII Right anterior superior segment
PANCREATOGRAPHY BY PERCUTANEOUS
TRANSHEPATIC CHOLANGIOGRAPHY OR
ENDOSCOPIC RETROGRADE RPSD
CHOLANGIOPANCREATOGRAPHY RHD
LHD
The anatomy of the bile ducts is discussed in Chapter 2. LHD
Knowledge of the common variations of ductal branching is
essential for accurate interpretations of cholangiograms, and CHD
these are shown in Figures 20.8 and 20.9; segmental nomen-
RASD Sectoral
clature is summarized in Table 20.1. In the right lobe, the
duct
posterior segments lie more laterally than the anterior seg- A D
ments, so that the most lateral ducts on a cholangiogram are
usually segments VI inferiorly and VII superiorly. The posterior RPSD
sectoral duct is often recognizable by an arched course near the
RHD
II
RPSD LHD
III
VII VIII
II RASD
IV
I B E

VI
V IV III RHD
RPSD
II
RASD LHD

IV III
RHD
LHD

CHD
FIGURE 20.8.  Standard intrahepatic ductal anatomy. The seg-
ments are numbered according to Couinaud’s description (see Table
20.1). CHD, Common hepatic duct; LHD, left hepatic duct; RASD, right
anterior sectoral duct; RHD, right hepatic duct; RPSD, right posterior
sectoral duct.
RASD
C F
FIGURE 20.9.  Variations of perihilar ductal anatomy. CHD, Com-
mon hepatic duct; LHD, left hepatic duct; RASD, right anterior sectoral
duct; RHD, right hepatic duct; RPSD, right posterior sectoral duct.
 Chapter 20  Direct cholangiography: approaches, techniques, and current role 387
FIGURE 20.10.  Hilar cholangiocarcinoma involving first-order right
hepatic duct, proximal common hepatic duct, and faintly opacified left
hepatic duct (arrowhead). Note the characteristic arched course of the
right posterior sectoral duct (arrow).
TABLE 20.2  Average Duct Diameters Measured Directly from
50 Normal Percutaneous Transhepatic Cholangiography
Examinations
Duct Diameter (mm)
Right hepatic = 4.7
Left hepatic = 5.2
Common hepatic = 6.5
Common bile = 7.6
From Okuda K, et al: Frequency of intrahepatic arteriovenous fistula as a sequela to percutaneous
needle puncture of the liver, Gastroenterology 74:1204–1207, 1978.
of, the umbilical fissure in 92% of cases. In the latter instance,
the quadrate lobe, segment IV, may drain wholly or partially
into the segment II duct. Rarely, segment II and III ducts join
at or close to the confluence (see Figs. 20.9E and 20.11C), and
segment IV drains directly into the common hepatic duct in
1% of cases (see Fig. 20.9F) (Healey & Schroy, 1953).
The caudate ducts are often difficult to identify. Usually two
or three ducts drain most commonly into the right posterior
sectoral duct, right hepatic duct, or left hepatic duct (Healey
& Schroy, 1953). The recognizable caudate ducts are usually a
few centimeters long and drain downward or to the right.
The left hepatic duct (average length, 17 mm) is consider-
ably longer than the right hepatic duct (average length, 9 mm)
and has a longer extrahepatic course. The normal diameters of
the main bile ducts as measured at PTC are shown in Table
20.2. These figures are greater than the true duct dimensions
because of some distension produced by direct cholangiogra-
phy, together with considerable magnification occurring on any
fluoroscopic “spot film.” The magnification is of the order of
40% (Nichols & Burhenne, 1984) and affects all structures in
the image, including calculi, tubes, and strictures.
The upper limits of normal for the diameter of the extrahe-
patic bile ducts as measured by ERCP vary between 9 and
14 mm (Niederau et al, 1984). Combined radiologic and
manometric studies (Poralla et al, 1985) have shown that even
in the absence of extrahepatic cholestasis, the diameter of the
bile ducts and the pressure difference therein increases with
advancing age. The diameter of the bile ducts as measured by
ultrasonography is less than those measurements obtained
during ERCP (Niederau et al, 1984). Anatomic abnormalities
of the hepatobiliary system include cystic dilations (Fig. 20.13)
of the bile duct or of the intrahepatic bile ducts (Caroli disease;
see Chapter 46). There is a wide variation in where the cystic
duct joins the common hepatic duct. A low junction with a
correspondingly long cystic duct (Fig. 20.14) may result in
difficulties if not recognized. This is especially true when a
cholecystojejunostomy is performed as a palliative biliary bypass
for carcinoma of the head of the pancreas, and the jaundice
either is not relieved or recurs rapidly in the postoperative
period.
Interpretations
Because of its inherent weakness of only allowing visualization
of the bile duct lumen, the main problem with the use of direct
cholangiography is its lack of specificity. There are few, if any,
pathognomonic radiologic findings. Many disease entities, from
benign to malignant, overlap greatly in their cholangiographic
appearances. The combination of history, blood markers, asso-
ciated radiologic findings, and clinical scenario can often sig-
nificantly narrow the differential diagnosis. However, it must
be stressed strongly that because the cholangiographic appear-
ance of many biliary diseases may be indistinguishable, biopsy
is often required to rule out malignancy or to confirm suspected
diagnosis.
Bile Leaks
Bile leaks are seen as sites of free extravasation of contrast
agent at a site of bile duct injury. Injury may be secondary to
trauma, but most commonly it is iatrogenic in nature. Associ-
ated bilomas may be seen at the point of bile leak. Diagnosis
of bile leak can usually be made by noninvasive imaging
techniques such as ultrasound, CT or MRI, but because the
intrahepatic bile ducts are usually not dilated, a bile leak may
not be evident on imaging. Cholescintography with techne-
tium 99m–hepatic iminodiacetic acid (HIDA scan) may be
useful for diagnosis when the other imaging modalities are
inconclusive. ERCP can diagnose bile duct leaks effectively
but is usually reserved for cases when a therapeutic interven-
tion is anticipated.
Filling Defects
Air Bubbles, Blood Clots, Calculi, Primary and Secondary Bile
Duct Cancers, and Parasitic Diseases
Air bubbles, although confusing, most commonly declare
themselves by their perfectly circular shape and their distribu-
tion to nondependent structures. Blood clots in the bile duct
are seen more frequently with PTC than with ERCP. Hemobi-
lia can sometimes take more than 48 hours to resolve, and when
it is more severe, it can be castlike and may mask other filling
defects (see Chapter 125).
Calculous disease (see Chapters 36 and 39) remains the
most common filling defect in the biliary system. Distinguishing
characteristics of gallstones and primary bile duct calculi
388 PART 2  DIAGNOSTIC TECHNIQUES

A B

C D
FIGURE 20.11.  Postcholecystectomy strictures graded according to Bismuth. A, Grade I (>2 cm from the confluence of the right and left hepatic
ducts; arrowheads): Calculi lie above and below the stricture (arrow). B, Grade II (<2 cm from the confluence): There has been a previous hepato-
jejunostomy; the right posterior sectoral duct (arrowhead) has an exaggerated arched course and enters the left hepatic duct as a normal variant.
C, Grade III (the confluence is involved by stricture, but the right and left hepatic ducts are not completely separated): Ducts of segment II (white
arrow) and segment III (black arrow) join the confluence independently as a normal variant. D, Grade IV (the right and left ducts are separated by
the stricture): The right anterior sectoral duct (A) is draining into the left hepatic duct (L), which is separated from the right posterior sectoral duct (P)
by the stricture (arrows).

include a faceted appearance and disposition to move to gravity-
dependent positions. Calculi may be seen as discrete filling
defects (Figs. 20.15 and 20.16) or castlike structures filling
entire ducts, as occurs in recurrent pyogenic cholangitis, cystic
diseases of the bile ducts, or even proximal to strictures of any
etiology. Impacted calculi may be difficult to differentiate from
strictures or tumors.
Primary bile duct cancer (see Chapter 51), specifically papil-
lary cholangiocarcinomas, can also present as cholangiographic
filling defects (Fig. 20.17). T-shaped filling defects may also be
detected (Fig. 20.18 ) (Torok & Gores, 2001), and papillary
bile duct cancers may cause filling defects as a result of mucin
production (Fig. 20.19). Other malignancies, including mela-
noma and intraductal metastases, such as colon cancer, are also
more unusual causes of cholangiographic filling defects (Riopel,
1997).
Parasitic infections, such as hydatid disease (see Chapter 74)
and infections with Ascaris lumbricoides or Clonorchis sinensis (see
Chapter 45), are diseases with worldwide distribution that can
also present cholangiographically as intraductal filling defects.
A proportion of hepatic hydatid cysts (5% to 10%) rupture into
the bile ducts and may simulate choledocholithiasis. Calcified
cysts are easy to recognize on radiographs, and daughter cysts
can cause biliary obstruction. When the calcified cyst is not
obvious, biliary strictures with obstruction may be noted on
cholangiogram. The biliary ducts can show considerable irregu-
larities in caliber and extensive displacement of the intrahepatic
branches secondary to the mass effect of a large hydatid cyst
 Chapter 20  Direct cholangiography: approaches, techniques, and current role 389

FIGURE 20.12.  Pancreatitis producing a typical, incomplete long stric-

ture of the common bile duct. The right posterior sectoral duct has a
low entrance into the common hepatic duct, an uncommon but impor-
tant normal variant. FIGURE 20.13.  Choledochal cyst.

FIGURE 20.14.  Long cystic duct. FIGURE 20.15.  Choledocholithiasis.

390 PART 2  DIAGNOSTIC TECHNIQUES
FIGURE 20.16.  Benign stricture of the right hepatic duct (arrow) with
multiple ductal calculi proximal to it. The hepatojejunostomy is partially
strictured.
FIGURE 20.18.  “Golf tee” appearance of a papillary bile duct cancer
(arrow) involving the common hepatic duct.
FIGURE 20.17.  Papillary hilar cholangiocarcinoma (arrowheads). Only
the right ducts are opacified.
FIGURE 20.19.  Nasobiliary cholangiogram opacifying left hepatic
ducts. Main left hepatic duct contains a small mucin-secreting papillary
cholangiocarcinoma (arrow). The mucin results in expansion of the
common bile duct below the tumor and appears as strandlike filling
defects. (Courtesy Dr. A. Speer.)
 Chapter 20  Direct cholangiography: approaches, techniques, and current role 391
FIGURE 20.20.  Liver flukes in the distal bile duct presenting as “biliary
sludge.”
(Cottone et al, 1978; Dyrszka & Sanghavi, 1983; Ibrahim &
Kawanishi, 1981).
Ascaris lumbricoides is a commonly seen helminth with a
prevalence of 90% in some parts of Africa and Asia (see Chapter
45). If the worm passes through the sphincter of Oddi, it may
cause acute pancreatitis or a cholestasis syndrome (Winters
et al, 1984). In the acute stage, the worm occasionally may be
found and extracted from the ampulla, and it can be detected
in the biliary tract by cholangiography.
Eating raw meat has been associated with Clonorchis sinensis
infestation. The prevalence of this disease has been estimated
to be 60% of the general population of Hong Kong, based on
stool ova examinations. This worm can penetrate through the
papilla into the bile ducts. In an ERCP study of 31 consecutive
patients, the typical filamentous, wavy, or elliptic appearance
of the worm in the bile ducts was believed to be pathogno-
monic. Other common cholangiographic findings include
widely dilated extrahepatic bile ducts, which are filled with
FIGURE 20.21.  Extracted liver flukes.
biliary sludge and stones, and intrahepatic duct strictures,
which are predominantly found in the branches of the left
hepatic duct (Yellin & Donovan, 1981). The eggs of C. sinensis
act as a nucleus for the development of the bile duct stones
(Lam et al, 1978). Naval and colleagues (1984) reported suc-
cessful endoscopic biliary lavage to eliminate the eggs.
Invasion of Fasciola hepatica into the biliary tract also may
cause serious lesions (see Chapter 45). In the chronic stage, F.
hepatica infection can resemble sclerosing cholangitis (Hauser
& Bynum, 1984). The appearance on ERCP is that of dilated
bile ducts with unexplained sludge in the distal bile duct (Figs.
20.20 and 20.21).
CONCLUSION
The role of direct cholangiography in the diagnosis of biliary
disease has for the most part been supplanted by less invasive
imaging modalities, such as MR cholangiography and CT with
contrast. The ability to visualize the entire biliary tree, the bile
duct wall, and other structures other than the bile duct lumen
increases the diagnostic accuracy and clinical utility of these
noninvasive techniques, which have become the gold standard
for cholangiography. Direct cholangiography is generally
reserved for clinical scenarios involving concomitantly planned
therapeutic interventions.
References are available at expertconsult.com.
 Chapter 20  Direct cholangiography: approaches, techniques, and current role 391.e1
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 CHAPTER 21 
Diagnostic angiography in hepatobiliary and
pancreatic disease: indications
Hooman Yarmohammadi
OVERVIEW
Indications for catheter angiography have substantially
changed. This is mainly due to the development of noninvasive
imaging modalities such as multidetector computed tomogra-
phy (MDCT) (see Chapter 18) and magnetic resonance
imaging (MRI) (see Chapter 19). These imaging techniques
can accurately demonstrate the visceral arterial and venous
structures and are not associated with the morbidities of cath-
eter angiography.
Catheter angiography was commonly used for evaluation of
the hepatic arterial anatomy, preoperative planning before liver
resection, assessment of vascular invasion by pancreatic cancer
or cholangiocarcinoma and to ascertain the organ of origin of
an abdominal mass. However, CT angiography (see Chapter
18) and magnetic resonance angiography (MRA) (see Chapter
19) have completely replaced catheter angiography for these
indications. Currently, the main indications for catheter angi-
ography are for treatment and intervention purposes, including
embolization of gastrointestinal bleeding (see Chapters 27, 124,
and 125), hepatic artery embolization and chemoembolization
(see Chapter 96A), pretreatment mapping and arterial anatomy
assessment prior to radioembolization (see Chapter 96B), and
chemoperfusion (see Chapters 99 and 102).
Recent progress in imaging technology, including advances
in C-arm cone-beam technology, has enabled the visualization
of three-dimensional (3D) vascular anatomy with a single
acquisition by using nonselective C-arm computed tomography
(CBCT). Such capability allows visualization of the vascular
tree associated with the target tumor from multiple projections
during an embolization procedure. In addition to these
advances, another technologic advance is the development of
hybrid imaging. Hybrid imaging, or fusion of images, couples
two imaging modalities to create unique images that can provide
information that would not be available with either technique
alone. Catheter angiography can be coupled with a cross-
sectional imaging modality, usually MDCT and, occasionally,
MRI. The images can be postprocessed and rendered in a 3D
format to provide an anatomic depiction that would not be
available by either technique alone.
In this chapter, we will discuss angiographic anatomy relevant
to hepatobiliary and pancreatic surgery and discuss the main
current indications for performing catheter angiography relevant
to hepatobiliary and pancreas. Additionally, we will discuss
localization of occult neuroendocrine tumors of the pancreas.
Our discussion on splanchnic veins will include venographic
anatomy, venous sampling, techniques of catheter-based venous
imaging, and venous imaging before surgical or percutaneous
venous interventions.
392
ANGIOGRAPHY TECHNIQUE
During the past few years, the angiography suites have been
updated with state-of-the-art imaging technology. Cut-film
angiography has been replaced with digital flat-panel detectors
and biplane angiography units. Biplane angiography is capable
of producing high-quality images in 3D views. These advances
in technology allow for less contrast and minimum radiation
exposure to the patients and the interventionalists.
Depending on the procedure, catheter angiography may be
performed under conscious sedation or general anesthesia.
Most procedures are performed as an outpatient procedure;
however, some patients may require overnight stay predomi-
nantly for pain control. All patients are seen in the clinic before
the diagnostic or interventional catheter angiography proce-
dure. During this clinic visit, indications for performing the
procedure are reviewed. Additionally, patients are assessed for
any history of heart disease, lung disease, or renal problems.
Prior history of angiography or other surgical interventions are
also assessed. Thorough physical examination, which includes
detailed pulse examination and assessment of airways, lungs,
and heart, is performed. Finally, patients’ performance status is
evaluated. Most institutions either use Eastern Cooperation
Oncology Group performance status or the Karnofsky perfor-
mance status. The procedure is explained to the patient in
detail, and after reviewing the risks and benefits of the proce-
dure, consent is obtained.
The relevant laboratory parameters include serum creatinine
or estimated glomerular filtration rate, hematocrit level, platelet
count, and international normalized ratio (INR), and these
should be reviewed. Additionally, at our practice a baseline 12
lead electrocardiogram is obtained.
In patients with significant morbidities, a cardiology or
geriatric consult may be requested before the procedure to
ensure safety of conscious sedation or general anesthesia.
If the patient has impairment of renal function, a number of
prophylactic measures have been recommended to diminish the
risk of contrast-induced renal failure. These measures include
intravenous hydration with a sodium bicarbonate solution as
well as the administration of N-acetyl cysteine. The effective-
ness of these prophylactic measures is controversial; however,
they carry a minimal risk to the patient and have been adopted
by the majority of practitioners.
The risk of bleeding from the puncture site is low, and
hematomas complicate 1% of femoral punctures and 3% of
upper extremity punctures. An abnormal bleeding profile related
to thrombocytopenia or prolongation of the INR increases
the risk of hemorrhage. The necessity to correct an underlying
coagulopathy is dependent upon the specific procedure to be
 Chapter 21  Diagnostic angiography in hepatobiliary and pancreatic disease: indications 393

performed and the preference of the angiographer. Based on the

recommendations from the Society of Interventional Radiology
(SIR) consensus guideline, catheter angiography (arterial inter- RHA
vention with access size up to 7 Fr) is classified as a category II
CyA LHA
procedure with moderate risk of bleeding. SIR recommends
platelet count higher than 50,000 × 106 per liter and an INR of
LGA
1.5 or less (Patel et al, 2013). Patients are advised to stop eating
6 hours prior to the procedure. Intravenous hydration is recom- CHA
RGEA GDA
mended before, during, and after the arteriogram to diminish
adverse effects of contrast media on renal function. The patient RGA SA
should also be encouraged to drink plenty of fluids following CA
the procedure.
The right common femoral artery is the most common
puncture site. The left common femoral artery, axillary artery,
brachial artery, or radial artery may be used as alternatives
when clinically appropriate. In the past few years, the radial
artery puncture site is becoming more favorable, particularly
with interventional cardiology procedures. A transradial FIGURE 21.1  Conventional celiac artery anatomy. CA, Celiac axis;
approach with regard to bleeding complications allows immedi- CHA, common hepatic artery; CyA, cystic artery; GDA, gastroduodenal
ate postprocedure ambulation, which is usually appreciated by artery; LGA, left gastric artery; LHA, left hepatic artery; RGA, right gastric
the patients. Additionally, recent studies demonstrate similar artery; RGEA, right gastroepiploic artery; RHA, right hepatic artery; SA,
procedural and clinical outcomes compared with a transfemoral splenic artery.
approach (Kiemeneij et al, 1997). The desired puncture area is
cleansed, and the patient is draped in sterile fashion. In most
centers, arterial entry is performed under real-time ultrasound
guidance by using a 21 gauge micropuncture set. The use of
ultrasonography allows assessment of the quality of the common
femoral artery, depicts the position of the profunda femoris,
and detects the presence of aberrant veins extending ventral to II
the puncture site. Following entry into the vessel, the appropri-
ate catheter is inserted for catheterization of the desired vessel. VIII IV
III
After diagnostically adequate images are obtained, the catheter
V
is removed, and one of a variety of closure devices is deployed
VII LHA
to seal the arteriotomy. Patients are observed in a postproce- RHA
dural area until they have recovered from sedation, and most
VI PHA
can be discharged home 2 to 4 hours later.

HEPATOBILIARY AND PANCREATIC

ARTERIAL ANATOMY
Arterial Anatomy
Arterial anatomy has been discussed elsewhere (see Chapters
1 and 2) and will be only briefly reviewed here. The most fre-
quently encountered anatomy (Fig. 21.1) is the left gastric
artery, splenic artery, and common hepatic artery (CHA),
taking origin from the celiac axis. The CHA divides into the
gastroduodenal artery (GDA) and proper hepatic artery, with
the latter dividing into the right and left hepatic arteries. The
right gastric artery most often originates from the base of the
left hepatic artery, and the cystic artery most often originates
from the right hepatic artery (RHA), but considerable varia-
tions in the origins of these arteries exist (Kobayashi et al,
2014). Moreover, accessory duodenal arteries, either represent-
ing a supraduodenal or a retroduodenal artery, are frequently
encountered; this is critical to recognize when embolization,
chemoembolization, and radioembolization are planned.
The normal arterial supply to the liver is shown in Fig. 21.2,
which shows the commonly recognized variations of the left
hepatic artery (LHA), taking origin from the left gastric artery,
and the RHA, taking origin from the superior mesenteric artery
(SMA). It is important to recognize that either a part or the
entirety of the right and left hepatic arteries may have these
FIGURE 21.2  Arterial anatomy of the liver. LHA, Left hepatic artery;
PHA, proper hepatic artery; RHA, right hepatic artery. Additional vessels
are labeled in accordance to the Couinaud segment they supply.
variant origins. When the entire vessel has a variant origin, it is
termed replaced. If the entire trunk does not take a variant
origin, the vessel is termed accessory. For example, if the right
lobe is supplied by a RHA originating from the CHA, as well
as a RHA taking origin from the SMA, the latter would be
termed an accessory RHA. If the entire right lobe was supplied
by an artery taking origin from the SMA, it would be called a
replaced RHA.
In most patients, the arteries to Couinaud segments I, II,
III, and IV are branches of the LHA, and arteries to segments
V, VI, VII, and VIII are branches of the RHA. The most variable
segmental branch is to segment IV. Although most frequently
the artery to segment IV takes origin from the LHA, it may also
take origin from the RHA, assuming the misnomer of a “middle
394 PART 2  DIAGNOSTIC TECHNIQUES
hepatic” artery in older works. Separate origins of segment IVA,
usually from the LHA, and segment IVB from the RHA are
frequently identified. Also, a branch from the segment IV artery
is often seen extending outside of the liver, supplying the
falciform ligament. Recognition of this vessel is important when
embolization, chemoembolization, or radioembolization are
conducted to avoid nontarget embolization.
The RHA conventionally divides into an anterior (ventral)
and a posterior (dorsal) branch. The anterior branch usually is
more vertically oriented and supplies segments V and VIII. The
posterior branch is usually more horizontally oriented and
supplies segments VI and VII. More than one projection is
usually required to ascertain with certainty which is the anterior
branch and which the posterior branch. In the right anterior
oblique projection, the anterior branch moves medially and the
posterior branch moves laterally when compared with the
posteroanterior projection. The entire segmental arterial supply
to the liver should be accounted for before hepatic arterial
therapy (see Chapters 96 and 99), major hepatic resection,
partial hepatectomy (see Chapter 103), or living-donor liver
transplantation (see Chapters 104 and 117).
The arterial supply to the pancreas is somewhat variable.
The most consistent supply is to the pancreatic head, through
an arcade formed by the inferior pancreaticoduodenal branch
of the SMA to the anterior- and posterior-superior pancreati-
coduodenal branches of the GDA (Fig. 21.3). The transverse
pancreatic artery runs along the middle portion of the long axis
of the pancreas and may take origin from the arterial arcade in
the head of the pancreas, directly from the GDA, or as a branch
of the dorsal pancreatic artery, which variably originates from
the CHA or the splenic artery (Fig. 21.4). A number of small
branches from the splenic artery supply the pancreatic body
and tail, but the number and location of these arteries vary and
must be identified in each individual patient when clinically
relevant.
Venous Anatomy
The splenic vein and superior mesenteric vein (SMV) join
to form the main portal vein (see Chapter 2). The inferior
mesenteric vein usually enters the splenic adjacent to the
GDA
RGA
PSPD
ASPD
FIGURE 21.3  Arterial anatomy of the pancreas. ASPD, Anterior-
superior pancreaticoduodenal artery; GDA, gastroduodenal artery;
PSPD, posterior-superior pancreaticoduodenal artery; RGA, right gastric
artery.
confluence, but it may also enter the SMV either at or just
caudal to the confluence. The coronary vein most often drains
into the cephalic aspect of the main portal vein just beyond the
confluence of the SMV and splenic vein. The number and
location of veins draining the pancreas is variable. Multiple
small, unnamed veins drain directly into the splenic vein. Typi-
cally, the anterior-superior pancreaticoduodenal vein drains
directly into the portal vein, and the posterior-superior pancre-
aticoduodenal vein drains into the SMV. The inferior pancre-
aticoduodenal veins drain into the SMV at the caudal margin
of the pancreas, and the portal vein courses obliquely cephalad
from near the midline toward the liver, where it divides to
supply the right and left lobes. This division, as well as the
division into segmental branches, is variable and must be
delineated when clinically relevant for each individual patient.
ANGIOGRAPHY INDICATIONS
As mentioned earlier in this chapter, historic indications
for performing diagnostic catheter angiography have been
replaced by multidetector computed tomography angiography
(MDCTA), including visceral angiography to assess the resect-
ability of pancreatic and biliary tract tumors by demonstrating
presence or absence of vascular invasion; angiography for
diagnosis of a hepatic mass, such as differentiating a cavernous
hemangioma from a hepatocellular carcinoma; and preopera-
tive arterial mapping of the arterial anatomy of the liver prior
to major hepatic resection. MDCTA provides higher sensitivity
and diagnostic accuracy for these indications. On rare occa-
sions, there is a specific piece of critical anatomic information
that cannot be ascertained with certainty by MDCTA, such as
the origin and course of the artery to segment IV prior to a
living-donor partial hepatectomy. In this circumstance, catheter
angiography can be useful to answer the question.
On extremely rare occasions, large tumors are identified on
cross-sectional imaging, but the organ of origin cannot be
determined. The majority of these are large sarcomas of the
retroperitoneum, but excluding a pancreatic source may be
difficult. A similar situation can occur with large right adrenal
or renal tumors blending with the hepatic parenchyma. In these
DP
TP
FIGURE 21.4  Arterial anatomy of the pancreas. DP, Dorsal pancreatic
artery; TP, transverse pancreatic artery.
 Chapter 21  Diagnostic angiography in hepatobiliary and pancreatic disease: indications 395
highly selected cases, catheter angiography can be useful in
delineating the organ of origin by demonstrating the primary
arterial supply.
In recent years, the most common indication for arteri­
ography is planning an arterial-based intervention, such as
embolization, chemoembolization, radioembolization, or che-
moperfusion, to treat a primary or metastatic hepatic malig-
nancy. These specific interventions will be discussed elsewhere
in this book (see Chapters 96 and 99). Accurate delineation of
arterial anatomy is remarkably important in procedures such as
embolization, chemoembolization, and radioembolization.
Inadvertent administration of embolic particles, radiation par-
ticles, or chemotherapeutic agents into arteries supplying the
stomach or duodenum can lead to significant adverse outcomes
(Riaz et al, 2009). Communications from intrahepatic branches
to the lower esophagus, stomach, and diaphragm are of equal
importance (Miyayama et al, 2009).
As explained earlier in this chapter, most modern angiogra-
phy suites are equipped with CBCT imaging technology. This
technology uses a fixed C-arm system equipped with a flat-
panel detector and requires 3D CT volumetric images (Tacher
et al, 2015). CBCT has improved the feasibility, effectiveness,
and safety of many image-guided procedures by allowing the
interventionalist to identify extrahepatic perfusion from aber-
rant hepatic arterial branches (Fig. 21.5).
Other current indications of performing catheter angiogra-
phy in the hepatobiliary and pancreatic system are as follows:
1. Treatment of bleeding/hemorrhage from liver, spleen, and
pancreas
2. Diagnosis of arterial occlusive diseases
3. Diagnosis and treatment of arterial stenosis
4. Treatment of visceral arterial aneurysms
A B
FIGURE 21.5  Extrahepatic perfusion detected with C-arm computed tomography (CCT). A, Selective cystic arteriogram shows the gallbladder and
several branches extending medially (arrow). B, CCT performed during contrast injection of the cystic artery confirms aberrant perfusion of the
duodenum (arrowheads). (Courtesy Daniel Sze, Stanford University.)
5. Diagnosis of vasculitis
6. Diagnosis of other visceral vascular disease
7. Localization of functional pancreatic neuroendocrine tumors
Treatment of Bleeding/Hemorrhage
Bleeding from the liver, spleen or pancreas is most often sec-
ondary to iatrogenic or noniatrogenic trauma (see Chapters 122
to 125), but it may occur spontaneously in patients with mycotic
aneurysms or pancreatitis. Angiography is usually not used to
ascertain whether arterial hemorrhage is present, but rather to
precisely localize and treat the bleeding vessel. Embolization of
arterial bleeding will be discussed elsewhere in this book, but
salient features will be reviewed in this chapter.
Splenic Bleeding
The most common cause of bleeding from the spleen is blunt
trauma, and nonoperative management is currently the stan-
dard of practice. Splenic artery embolization has been estab-
lished as a method to increase the success rate of nonoperative
management of traumatic splenic injuries (Schnuriger et al,
2011). A comparative study between two cohorts consisting of
625 patients during a 15 year period revealed an improved
success rate of nonoperative management from 77% to 96%
with the advent of splenic embolization (Rajani et al, 2006).
The indications for splenic arteriography and splenic arterial
embolization are based upon CT findings and include active
contrast blush beyond or within the splenic parenchyma,
pseudoaneurysm, an associated large hemoperitoneum, and a
high-grade splenic injury (Schnuriger et al, 2011). Moreover,
the American Association for the Surgery of Trauma recom-
mends angiography for grade III, IV, and V splenic injuries
(Raikhlin et al, 2008).
396 PART 2  DIAGNOSTIC TECHNIQUES
Two techniques are used to perform splenic embolization:
the first is occlusion of the proximal splenic artery with coils or
Amplatzer plugs (AGA Medical, Plymouth, MN), and the
second is selective small intrasplenic arterial embolization with
a gelatin sponge or coils. Collaterals through the short gastric
arteries and the gastroepiploic arcade usually maintain splenic
viability following occlusion of the proximal splenic artery.
Intrasplenic embolization generally results in a variable degree
of splenic infarction, depending upon the size of the artery
occluded, as intrasplenic arteries have no significant collateral
routes. Both techniques have equivalent rates of major infarc-
tions and infections requiring splenectomy (Ekeh et al, 2013).
Distal splenic embolization is associated with higher rates of
infarction; however, these infarctions are limited to the seg-
ments just distal to the site of embolization with questionable
clinical relevance. In summary, the current literature is incon-
clusive regarding whether the proximal or distal embolization
should be used. Minor complications including fever, pleural
effusion, and partial splenic infarction have been reported in as
many as 34% of patients. Major complications including
splenic abscesses, splenic infarction, splenic atrophy, and post-
procedure bleeding have been observed in 14% of patients
(Ekeh et al, 2013).
Hepatic Bleeding
Hemorrhage from the liver may be encountered from blunt or
penetrating trauma (see Chapter 122) but is most commonly
due to an iatrogenic injury related to a biopsy (see Chapter 22)
or percutaneous transhepatic biliary drainage (PTBD) (see
Chapters 30 and 52). Arteriographic findings indicating a
source of hemorrhage include extravasation, pseudoaneurysm
formation, and/or arteriovenous fistula (see Chapter 124).
Superselective catheterization by using coaxial microcatheters
to deposit coil-spring emboli both distal and proximal to the
area of injury is the preferred technique for embolization when
a discrete bleeding site can be identified. In contrast to the
spleen, a rich collateral network exists in the hepatic arterial
bed, making proximal occlusion of the offending artery ineffec-
tive in many cases. For more diffuse injuries with multiple
bleeding sites secondary to blunt trauma, using particulate
embolization with a gelatin sponge may be a useful adjunct.
As with blunt splenic injuries, nonoperative management
has become the preferred method of management of hemody-
namically stable patients. The success rate of this management
exceeds 90% (Christmas et al, 2005). Two main indications for
hepatic angioembolization are primary hemostatic control in a
hemodynamically stable patient that has radiographic evidence
of active arterial hemorrhage and adjunctive hemostatic control
following surgical exploration and packing of a hepatic paren-
chymal injury with evidence of continued bleeding or hemody-
namic instability. Additionally, patients who are seen with
hemodynamic instability who can be successfully resuscitated
can be treated effectively with transcatheter embolization (Mis-
selbeck et al, 2009). The yield of arteriography in identifying
an arterial injury amenable to embolization is higher when the
CT scan suggests a vascular injury.
Complications following embolization of a hepatic arterial
injury secondary to blunt trauma are relatively frequent
(Letoublon et al, 2011). In a retrospective study, Letoublon
and colleagues reported a 70% liver complication rate. These
complications include hepatic ischemia, infarction, hepatic
failure, gallbladder ischemia, bile leak, and abscess formation.
Obviously, the contribution of the embolization to these com-
plications may be difficult to distinguish from sequelae of the
underlying traumatic injury.
Iatrogenic injury to the hepatic artery is suspected when a
biliary drainage tube puts out blood following placement, or
melena secondary to hemobilia develops in the patient follow-
ing an intervention through the hepatic parenchyma. CT in
these patients may or may not reveal an abnormality, and
patients should undergo hepatic arteriography when a clinical
suspicion of a hepatic arterial injury exists. Patients with iatro-
genic injuries usually have a single, discrete bleeding source that
can be addressed with superselective embolization techniques.
Complications related to the embolization procedure tend to
be lower when compared with patients who have had blunt
trauma, as the traumatic injury to the liver is less extensive.
Pancreas Bleeding
Bleeding is more commonly encountered in patients with
pancreatitis (see Chapter 56) or pancreatic surgery (see Chap-
ters 66 and 67). Posttrauma bleeding from the pancreas is not
common. Hemorrhage can occur in the retroperitoneum, or it
may extend from the retroperitoneum into the peritoneal cavity
or into the gastrointestinal tract via communication with the
pancreatic duct (hemosuccus pancreaticus). Vascular complica-
tions are seen in 25% of patients suffering from pancreatitis and
are usually arterial in origin. Proteolytic enzymes coupled with
intense inflammation can erode small arterial branches and
create foci of extravasation or create small pseudoaneurysms.
Although this complication is encountered in only 2% to 5%
of cases, it may be life threatening. Pseudocysts may erode small
arterial branches, leading to hemorrhage within the pseudocyst,
or it may erode into larger arterial branches and create a large
pseudoaneurysm (Fig. 21.6). These pseudoaneurysms are most
frequently identified in the splenic artery or its branches (60%
to 65%), followed by the GDA (20% to 25%), pancreaticoduo-
denal arteries (10% to 15%), hepatic artery (5% to 10%), and
left gastric artery (2% to 5%) (Aswani et al, 2015; Kirby et al,
2008).
MDCT has been reported to have 90% sensitivity in detect-
ing pseudoaneurysms in patients with acute pancreatitis;
however, tiny aneurysms in the intrapancreatic arteries may
not be visible (Hyare et al, 2006). When a patient has clinical
evidence of significant hemorrhage, or a CT scan reveals a
pseudoaneurysm, arteriography followed by embolization is
indicated. When the bleeding site is identified angiographically,
it can be controlled with embolotherapy in as many as 88% of
patients (Mansueto et al, 2007).
Angiography and embolization are feasible and safe in treat-
ment of hemorrhagic complications following pancreatic surgery
(Casadei et al, 2014; Yekebas et al, 2007). Yekebas and col-
leagues (2007) reported significant hemorrhage in 5.7% of 1669
consecutive patients following partial or total pancreatectomy.
In a more recent study, Casadei and colleagues (2014) reported
significant hemorrhage in 9.8% of 182 patients following pan-
creatic resection for pancreatic and periampullary diseases.
Bleeding may manifest clinically as gastrointestinal hemorrhage,
retroperitoneal or intraperitoneal bleeding, or bleeding through
percutaneous or surgically placed drains. When a pancreatico-
jejunal anastomosis has been created, disruption of the anasto-
mosis may lead to false localization of the bleeding site.
Specifically, an extraluminal bleeding site may drain into the
bowel through the dehisced anastomosis, or bleeding from the
 Chapter 21  Diagnostic angiography in hepatobiliary and pancreatic disease: indications 397

A B

C
FIGURE 21.6  Pseudoaneurysm secondary to pancreatitis treated with coil embolization. A, Contrast-enhanced computed tomography reveals a
pseudoaneurysm in the pancreatic head (arrow). B, Selective gastroduodenal arteriogram reveals the pseudoaneurysm (arrow) taking origin from a
branch of the anterior-superior pancreaticoduodenal artery. C, The pseudoaneurysm is occluded with coils (arrowheads).

bowel at the anastomosis may extend outside the lumen to cause
an intraperitoneal hematoma or hemorrhage through a drain.
Angiography can be extremely useful in the diagnosis and
treatment of these patients. In 25 of 43 patients undergoing
angiography to diagnose and treat postpancreatectomy hemor-
rhage, a bleeding site was located and embolized with an 80%
success rate in controlling the hemorrhage (Yekebas et al,
2007). The relatively low rate of positive angiograms may be
explained by the high incidence of venous bleeding encountered
in the postpancreatectomy patient. Regional portal hyperten-
sion develops in many of these patients as a result of splenic or
superior mesenteric venous compression or occlusion second-
ary either to the underlying pathology or a surgical complica-
tion. Venous extravasation is rarely identified by arteriography
but may be suggested by CT. If the underlying etiology is
compression of the splenic vein, percutaneous transhepatic
stenting of the splenic vein may be potentially useful.
Diagnosis of Arterial Occlusive Disease
Many arterial disorders that involve the primary branches of
the celiac trunk, as well as the SMA, can be assessed adequately
with MDCT or MRA. However, delineation of pathology in
smaller branches, such as with vasculitis, or subtle pathologic
changes may require the increased morphologic detail afforded
by catheter angiography.
Arterial occlusive disease as a result of atherosclerosis and
compression of the celiac axis by a median arcuate ligament are
common diseases that do not generally influence the conduct
398 PART 2  DIAGNOSTIC TECHNIQUES
of hepatobiliary or pancreatic surgery. The principle exception
is in the performance of orthotopic liver transplantation (OLT),
when preservation of brisk hepatic arterial flow is essential. In
that circumstance, the inflow must be corrected either by surgi-
cal or endovascular interventions. Another potential area of
concern is pancreaticoduodenectomy, particularly in jaundiced
patients. In this situation, sacrifice of the GDA is required,
which interrupts the retrograde arterial flow from the SMA to
the liver and could result in hepatic ischemia and necrosis.
Likewise, fibromuscular dysplasia may rarely involve the SMA,
but associated clinical sequelae are extremely uncommon. The
SMA may also be compromised in very rare circumstances by
a median arcuate ligament.
Diagnosis and Treatment of Arterial Stenosis
Hepatic arterial anastomotic stenoses are observed in as many
as 11% to 12% of patients following OLT (see Chapters 116
and 120) (Duffy et al, 2009; Kim et al, 2012). Although these
stenoses are usually detected by surveillance duplex ultrasound
and confirmed with MDCTA, catheter angiography is often
performed to improve morphologic delineation and assess the
degree of stenosis in preparation for endovascular treatment
(Vaidya et al, 2007). Stenosis of the hepatic artery anastomosis
usually leads to allograft dysfunction, and stenoses of the
hepatic artery may also be more diffuse (Fig. 21.7). Severe
stenosis may lead to hepatic artery thrombosis. The hepatic
artery supplies the bile duct, and the bile duct has been ren-
dered devoid of collateral arterial supply during donor hepatec-
tomy. Arterial insufficiency typically leads to biliary strictures
and to potentially diffuse biliary ductal infarction. Hepatic
artery thrombosis may lead to irretrievable allograft damage
and may necessitate retransplantation. When a hepatic arterial
stenosis is identified before advanced biliary injury, endovascu-
lar therapy with either balloon angioplasty and/or stent place-
ment is warranted.
FIGURE 21.7  Hepatic artery stenosis following orthotopic liver trans-
plantation. Celiac arteriogram shows mild diffuse narrowing of the
hepatic artery with two areas of critical stenosis (arrowheads).
Treatment of Visceral Arterial Aneurysms
Visceral artery aneurysms are rare entities that involve the
celiac, splenic, superior mesenteric, or inferior mesenteric
arteries and their branches (see Chapter 124). The prevalence
of visceral artery aneurysm is 0.1% to 2% (Hemp & Sabri,
2015; Tulsyan et al, 2007). True aneurysms involve all three
vessel walls and are usually atherosclerotic or developmental
in origin and differ from those encountered in pancreatic
inflammatory disease, which are typically pseudoaneurysms.
Depending on the size and location of the aneurysm, mortal-
ity from rupture ranges from 25% to 100% (Cordova &
Sumpio, 2013).
The splenic artery is the most common affected artery,
followed by the hepatic artery. Splenic artery aneurysms in
women of childbearing age are of particular concern because
of their propensity to rupture during childbirth. Most splenic
aneurysms are saccular and located in the mid to distal segment
of the artery (Nosher et al, 2006). The rate of rupture ranges
from 3% to 20% (Lagana et al, 2006). Endovascular treatment
of splenic artery aneurysms depends on the tortuosity and
location of the aneurysm. Stent placement is used for more
proximal disease and distal disease in a tortuous vessel is usually
treated with coil embolization (Hemp & Sabri, 2015).
Traditionally, surgical resection or ligation of the visceral
aneurysms was the gold standard of therapy; however, endovas-
cular treatments have largely replaced open resection. Large
studies have reported technical success rates ranging from 89%
to 98% (Hemp & Sabri, 2015; Sachdev et al, 2006; Tulsyan
et al, 2007). Endovascular treatments are associated with
shorter hospital stay, when compared with surgical repair: 3.8
versus 12 days, respectively.
Diagnosis of Vasculitis
Vasculitis
Vasculitides that involve the hepatic arterial system may require
the spatial resolution provided by catheter angiography for
definitive diagnosis, because the characteristic microaneurysms
and areas of arterial narrowing may not be apparent by MDCT.
The most common vasculitis with hepatic involvement is
polyarteritis nodosa, which may not lead to symptoms despite
involvement of the visceral arteries, although pancreatitis,
cholecystitis, and hepatic dysfunction may be observed.
Arterial abnormalities in the liver have also been identified
in patients with systemic lupus erythematosus and Wegener
granulomatosis. In most patients, the underlying diagnosis is
apparent, and the angiographic findings do not represent a
diagnostic dilemma.
Diagnosis of Other Visceral Vascular Disease
Segmental Arterial Mediolysis
A rare vascular disorder, segmental arterial mediolysis, may also
require catheter angiography for definitive diagnosis. This dis-
order is characterized pathologically by noninflammatory
destruction of smooth muscle cytoplasm, leading to arterial
dissection and aneurysm formation. Multifocal lesions with
skip areas involving the superior mesenteric, hepatic, renal, and
middle colic arteries in patients in their fourth to sixth decades
are typical (Fig. 21.8). Clinically, these lesions are prone to both
occlusion by dissection as well as rupture, leading to cata-
strophic abdominal hemorrhage. Treatment with coil emboliza-
tion within noncritical arterial beds has been reported (Davran
et al, 2010).
 Chapter 21  Diagnostic angiography in hepatobiliary and pancreatic disease: indications 399
Hereditary Hemorrhagic Telangiectasia
Hereditary hemorrhagic telangiectasia (HHT) also known as
Osler-Weber-Rendu syndrome, is an autosomal dominant vascular
disease, characterized by telangiectasias of the skin and mucous
membranes. HHT is also associated with arteriovenous malfor-
mations in the pulmonary and hepatic circulation that may be
life-threatening. Diagnosis is usually based on family history
and clinical criteria. Cross-sectional imaging, including ultra-
sound, CT or MRI, plays a fundamental role in detecting vis-
ceral involvement in HHT. The hepatic arterial malformations
that shunt blood into the hepatic venous system may be initially
noted on a cross-sectional imaging study, but the findings may
be nonspecific. Catheter angiography can be diagnostic by
FIGURE 21.8  Segmental arterial mediolysis (SAM). Abdominal aorto-
gram reveals a dissection with a small aneurysm in the celiac artery
(arrow) as well as undulating irregularity of the common hepatic artery
(arrowhead) typical of SAM.
A B
FIGURE 21.9  Hereditary hemorrhagic telangiectasia (HHT). A, Selective hepatic arteriogram shows disorganized and dilated intrahepatic vessels
typical of HHT. Coils are being placed preoperatively for impending liver transplantation. B, Slightly later in the sequence, early opacification of the
hepatic vein is visible (arrowheads).
depicting the malformations shunting hepatic arterial blood
into the hepatic venous system (Fig. 21.9) (Memeo et al, 2008).
Although this disorder has been treated with transcatheter
techniques, embolotherapy has currently fallen out of vogue
because of the risk of precipitating hepatic failure. OLT is
curative if high-output cardiac failure develops in the patient.
Peliosis Hepatitis
Peliosis is an abnormality of the reticuloendothelial system that
is most commonly encountered in the liver (peliosis hepatis)
(see Chapter 89). Pathologically, it is characterized by blood-
filled cystic spaces that range in size from a few millimeters to
almost a centimeter. This abnormality has been associated with
human immunodeficiency virus infection as well as with the use
of certain drugs, including immunosuppressives, antimetabo-
lites, and oral contraceptives. Although usually benign, it has
been associated with spontaneous massive hemorrhage and
therefore may be encountered angiographically during the
investigation of hepatic bleeding (Choi et al, 2009). Angio-
graphically (Fig. 21.10), the lesions are easily visible as a dis-
organized collection of amorphous channels not dissimilar to
those observed in HHT or hemangioma; however, the lack of
shunting to the hepatic venous system distinguishes it from
HHT, and the absence of sharp definition with persistence into
the late venous phase distinguishes it from hemangioma.
Localization of Functional Pancreatic Neuroendocrine
Tumors (See Chapter 65)
Calcium stimulation arteriography was developed and described
in 1991 (Doppman et al, 1991). Although unnecessary when
imaging can confidently detect the offending pancreatic lesion,
it is an extremely useful adjunct when the location of the lesion
cannot be defined with confidence (Fig. 21.11). When 1 mL of
10% calcium gluconate is injected into an artery supplying the
pancreas, tumor cells degranulate and release insulin into the
portal venous circulation. Sequential blood samples obtained
from the hepatic vein will demonstrate a significant rise in the
concentration of insulin when the portion of the pancreas
400 PART 2  DIAGNOSTIC TECHNIQUES
containing the tumor is injected. By sequentially injecting the
arterial supplies to different regions of the pancreas, it is pos-
sible to ascertain the location of the tumor. The GDA supplies
the head of the pancreas, the SMA supplies the head and
uncinate process, and the splenic artery supplies the body
and tail. The origin of small branches supplying the pancreas
from the splenic artery and CHA are important to note in
RIGHT
FIGURE 21.10  Peliosis hepatitis. Multiple small contrast collections
can be seen within the hepatic parenchyma. This patient had spontane-
ous hemorrhage that created displacement of the hepatic parenchyma
(arrowheads).
A B
FIGURE 21.11  Insulinoma. A, Selective gastroduodenal arteriogram shows no definite abnormality during the arterial phase. B, A subtle area of
hypervascularity is identified during the capillary phase, possibly representing an insulinoma (arrowheads). This was confirmed as the region of tumor
by calcium stimulation with venous sampling.
determining the approximate areas of pancreatic arterial supply.
In the article by Guettier and colleagues (2009), calcium stimu-
lation arteriography was the most sensitive technique for local-
izing surgically proven insulinomas, with an accuracy of 84%,
a false-negative rate of 11%, and a false-positive rate of 4%.
Percutaneous transhepatic sampling of the splenic, superior
mesenteric, and portal venous system can be performed to
diagnose occult neuroendocrine tumors of the pancreas. This
may be done in conjunction with calcium stimulation as
described earlier, or it may be performed without stimulation
because of the higher concentration of the hormone when
obtained directly or adjacent to the venous tributary.
Insulinomas
Greater than 90% of insulinomas are single, benign tumors for
which surgical resection is curative. These tumors are the most
common tumors originating from the islets of Langerhans (see
Chapter 65). The most effective method of diagnosing these
tumors is a combination of dual-phase thin-section CT scan and
endoscopic ultrasonography (EUS) (Jackson, 2005). Advances
in imaging technology have improved the sensitivity of CT and
MRI to greater than 80% and 70%, respectively (Nikfarjam
et al, 2008). The sensitivity of EUS in detecting and localizing
insulinomas ranges from 82% to 94% (McLean, 2004).
Gastrinomas
Gastrin-secreting tumors are the cause of Zollinger-Ellison
syndrome and in approximately one-third of the cases occur in
association with multiple endocrine neoplasia (MEN) type 1.
Fifty percent of gastrinomas occur in the pancreas, with the
duodenum being the most common extrapancreatic location.
Approximately 60% to 90% of gastrinomas are malignant.
When a sporadic gastrinoma is identified, surgical resection is
indicated. The role of surgery in patients with MEN type 1 is
 Chapter 21  Diagnostic angiography in hepatobiliary and pancreatic disease: indications 401
A B
FIGURE 21.12  Arterial portography in a patient with cavernous transformation of the main portal vein. A, Venous phase of superior mesenteric
arterial injection shows the superior mesenteric vein (arrow) and cavernous transformation of the main portal vein. B, Venous phase of splenic arterial
injection from the same patient shows the splenic vein (arrow).
more controversial because of multiplicity of tumors and lack
of an established survival benefit.
The diagnosis and location of a gastrinoma can be estab-
lished with a combination of somatostatin receptor scintigraphy
and EUS in approximately 90% of patients. When an occult
gastrinoma is encountered, angiography has been used for
localization. The principles are identical to the localization of
insulinomas; however, secretin has been used in addition to
calcium gluconate as the stimulating agent. Sensitivities of
arterial stimulation venous sampling (ASVS) in the detection
of gastrinomas have ranged from 70% to 100% (Cohen et al,
1997; Turner et al, 2002).
Angiographically, gastrinomas are less hypervascular and
more difficult to detect in comparison to insulinomas. Sensitiv-
ity of angiography alone without ASVS is less than 50%.
Moreover, the 50% extrapancreatic location makes detection
more difficult, often requiring superselective catheterization to
evaluate the duodenum.
Glucagonoma
Glucagonomas may occur sporadically or may be associated
with MEN type 1. These tumors are usually larger than gastri-
nomas or insulinomas at presentation; therefore localization can
generally be achieved with cross-sectional imaging or EUS.
Equchi and colleagues (2012) reported eight patients with
pancreatic hypervascular tumor and elevated serum glucagon
level that glucagonomas were successfully localized using ASVS.
Venographic Technique
MDCT, magnetic resonance venography, and ultrasound are
usually sufficient for depiction of the major visceral venous
trunks and their primary branches in the vast majority of
patients. Cross-sectional imaging can accurately depict the
relationship of a mass in the pancreas to both the splenic and
superior mesenteric veins. It also has the advantage of simulta-
neous opacification of all of the venous structures. However, in
certain clinical situations, it is desirable to visualize the venous
structures with a higher level of clarity. These situations include
planning of percutaneous venous intervention in situations
where occlusions are suspected or occasionally to plan a surgi-
cal portosystemic shunt.
The most common technique to visualize the splanchnic
vein is transarterial portography, in which selective splenic and
superior mesenteric arteriograms are performed with delayed
imaging into the venous phase, depicting the splenic and supe-
rior mesenteric veins, respectively (Fig. 21.12). When detailed
visualization of the venous anatomy is required, a higher dose
of contrast media can be used for the arterial injection, increas-
ing the clarity of venous opacification.
When an extremely detailed evaluation is required, a com-
bination of transarterial portography during MDCT can be
performed (Fig. 21.13). The increased contrast sensitivity of the
MDCT coupled with multiplanar and 3D reconstruction allows
visualization of the veins that cannot be achieved by any other
single technique. This is particularly useful in the presence of
portal vein occlusion, when a complex venous reconstruction
or bypass is being considered.
Direct venography of the splanchnic veins can be achieved
by three routes: transjugular, transhepatic, and transsplenic. In the
transjugular approach, a catheter is placed into the jugular vein
and advanced into a hepatic vein. Free and wedged hepatic
pressures can be obtained through this catheter. Using these
402 PART 2  DIAGNOSTIC TECHNIQUES
FIGURE 21.13  Multidetector computed tomography with three-
dimensional reconstruction following superior mesenteric arterial injec-
tion. The superior mesenteric vein and cavernous transformation are
easily visualized.
two pressures, the corrected sinusoidal pressure can be calcu-
lated and can be used to assess portal hypertension. A biopsy
of the hepatic parenchyma (transjugular liver biopsy) may be
performed when desirable. Injection of carbon dioxide through
a catheter wedged in a hepatic vein or through a balloon cath-
eter will often yield an image of the portal vein. If direct por-
tography is warranted, one of several specially designed needles
can be inserted to puncture the portal vein through the inter-
vening hepatic parenchyma and through catheters advanced
into the portal, splenic, or superior mesenteric venous system.
This procedure is performed almost exclusively in patients
undergoing a transjugular intrahepatic portosystemic shunt, but
it is also used to manage selected patients with portal and SMV
thrombosis (Liu et al, 2009).
The portal venous system may also be accessed by a percu-
taneous transhepatic approach (Semiz-Oysu et al, 2007). After
sterile preparation of the right upper quadrant, an intrahepatic
portal venous radicle is punctured under real-time ultrasono-
graphic guidance, permitting a vascular access sheath to be
placed by using a Seldinger technique. Standard guidewire and
catheter manipulations are then used through the sheath for
selectively catheterizing the splenic vein and the SMV or its
branches. Once the diagnostic images have been taken or
venous interventions have been performed, the catheter is
removed. The transhepatic tract is then occluded by a variety
of techniques, including insertion of Gelfoam pledgets, deploy-
ment of coils, or injection of fibrin glue. The transhepatic
venographic procedure is usually performed as part of a direct
pancreatic venous sampling, lobar portal venous embolization
to stimulate contralateral hypertrophy before major hepatic
resection, assessment and management of an anastomotic
portal venous stenosis following OLT, pharmacomechanical
lysis of a splanchnic vein thrombosis, or, rarely, to control
bleeding from a splanchnic vein.
Percutaneous injection of the splenic parenchyma can also
be used to delineate the anatomy of the splenic and portal veins
as well as the draining tributaries. This examination is somewhat
antiquated and has been generally replaced by MDCT or
magnetic resonance venography. In infants, cross-sectional
imaging may be inconclusive, and transarterial portography is
risky because of the diminutive size of the femoral arteries;
however, it remains an alternative in planning a portosystemic
shunt procedure.
Percutaneous catheterization of the splanchnic veins is also
possible from a transsplenic approach using a technique identi-
cal to that described for transhepatic catheterization (Tuite
et al, 2007). This procedure is usually done in conjunction with
a percutaneous procedure to assess a portal vein stenosis or
occlusion following OLT, but it may also be used in conjunction
with the assessment and treatment of a splenorenal venous
bypass, when access cannot be achieved from the systemic
venous circulation.
References are available at expertconsult.com.
 Chapter 21  Diagnostic angiography in hepatobiliary and pancreatic disease: indications 402.e1
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