Ischemic Bile Duct Injury

 Solitary or multifocal strictures of variable length

• Cholangiography: Gold standard for diagnosis
image Appearance may be identical to PSC with “beading” of biliary tree (alternating stenosis, normal ducts, and mild dilatation)

image Biliary casts appear as filling defects within duct lumen

• CT: Scattered irregular biliary dilatation with bile duct wall thickening and hyperenhancement
image Presence of intrahepatic biloma or liver infarct should prompt careful assessment for HAT/HAS

image Bile duct casts appear as intraductal hyperdense material

image CT not sensitive for early stage ischemic injury

• MR: Linear high T1 signal intensity may be visualized within dilated central ducts, characteristic of biliary cast


• Classically due to hepatic artery thrombosis, but possible without arterial compromise (ischemic-type biliary lesions)

• Also associated with prolonged warm and cold ischemic time, ABO incompatibility, and chronic rejection


• Initial treatment: Endoscopic or percutaneous dilatation/stenting of strictures and clearing of biliary casts

• Roux-en-Y hepaticojejunostomy for extrahepatic strictures unresponsive to dilatation/stenting

• Retransplantation may be necessary in patients with secondary biliary cirrhosis, recurrent cholangitis, or progressive cholestasis

(Left) Coronal CECT MIP reconstruction in a liver transplant patient demonstrates abrupt occlusion of the hepatic artery image near its origin from the celiac artery.

(Right) Cholangiogram in the same patient demonstrates features of ischemic cholangiopathy due to hepatic artery occlusion, including a dominant stricture in the common duct image and irregularity of the intrahepatic ducts.

(Left) ERCP of a patient with jaundice after liver transplant shows a filling defect in the hilum, representing a hilar biliary cast image, and diffusely irregular intrahepatic ducts. The patient’s course was complicated by portal vein thrombosis and rejection, but the hepatic artery was patent on US.

(Right) T1WI FS MR of the same patient shows a typically high signal cast image at the duct bifurcation. Multiple ischemic and immunological insults may result in the strictures and casts that are characteristic of ischemic cholangiopathy.



• Ischemic cholangitis, ischemic cholangiopathy


• Nonanastomotic biliary strictures in liver allograft originally described in setting of hepatic artery thrombosis (HAT) or stenosis (HAS), but now known to occur due to a wide variety of other microangiopathic and immunological injuries


General Features

• Best diagnostic clue
image Nonanastomotic biliary strictures in liver allograft

• Location
image Can involve intrahepatic &/or extrahepatic ducts

image Predominant involvement of middle 1/3 of common bile duct and hepatic duct confluence > intrahepatic ducts

image 2 common patterns
– Strictures beginning at hilum and extending peripherally

– Multiple scattered intrahepatic strictures

• Morphology
image Can be solitary or multifocal strictures

image Variable length: Short or long segment

Radiographic Findings

• Cholangiography (ERCP or PTC) is gold standard for diagnosis of ischemic cholangitis
image Cholangiographic appearance may be nearly identical to primary sclerosing cholangitis

image Luminal irregularity of bile ducts with beaded appearance (alternating sites of stenosis, normal ducts, and mild dilatation)
– Strictures evolve over time, beginning as sites of irregularity and developing into fibrotic strictures

– Ductal narrowing with upstream dilatation

– Rare diffuse duct necrosis and biliary sloughing

image Biliary casts appear as filling defects within duct lumen

image May demonstrate communication of bile ducts with intrahepatic bilomas

CT Findings

• Scattered irregular biliary dilatation with bile duct wall thickening and hyperenhancement
image Presence of intrahepatic biloma or liver infarct in post-transplant setting should prompt careful assessment of hepatic artery for HAT/HAS
– Doppler US to screen, then CTA confirmation if Doppler positive

image Bile duct casts, highly suggestive of ischemic cholangiopathy, appear as linear hyperdense material within bile duct
– May not be readily distinguishable from stone on CT (both may appear hyperdense)

image Biliary necrosis, debris, and bilomas with advanced ischemia (particularly in setting of HAS/HAT)

• CT not sensitive for early stage ischemic-type biliary lesions (ITBL)
image Transplanted liver may not develop biliary dilatation despite severe ductal stenosis

image If high clinical suspicion for ITBL, proceed to cholangiography (ERCP, PTC, or MRCP)

• CTA can show hepatic artery narrowing or thrombosis

MR Findings

• Strong correlation between MRCP and cholangiography
image High sensitivity, specificity, and predictive values for evaluation of ischemic-type biliary injury

• Hepatobiliary contrast agents (i.e., Eovist) can be used for cholangiographic images in hepatobiliary phase
image Most often utilized to evaluate for strictures at hepaticojejunostomy

• T2WI, MRCP, and T1WI C+ Eovist cholangiographic images demonstrate luminal irregularity, stenosis, and scattered biliary ductal dilatation

• May be associated with T2-hyperintense intrahepatic bilomas or liver infarcts

• Linear high T1 signal intensity may be visualized within dilated central ducts, characteristic of biliary cast
image Extremely uncommon in absence of ischemic cholangiopathy and virtually diagnostic

image MR allows distinction between cast (T1 hyperintense) and stones (hypointense on all pulse sequences)

• Advantage of noninvasively evaluating other biliary complications (anastomotic stricture, stones, leak, etc.)

• MRA can show hepatic artery thrombosis or stenosis

Ultrasonographic Findings

• Grayscale ultrasound
image Poor sensitivity for early stage ischemic-type biliary injury

image May show intrahepatic ductal dilatation and thickening

image Biliary casts appear as echogenic material within dilated bile ducts

image Advanced biliary ischemia due to HAT or HAS may result in presence of intrahepatic fluid collections (bilomas)

image Extrahepatic biliary dilatation is nonspecific finding in post-transplant liver and does not necessarily imply ischemic cholangiopathy
– Nonobstructive dilatation of extrahepatic ducts (without intrahepatic biliary dilatation) may be due to papillary dyskinesia or discrepancy between size of donor and recipient ducts

• Pulsed Doppler
image Evaluate for evidence of HAT or HAS
– Hepatic artery stenosis (or chronic HAT with collaterals)
image Turbulent flow within hepatic artery with focal aliasing at site of stenosis

image Usually occurs at or near anastomosis and affects 11% of patients (mean 3 months after surgery)

image Tardus parvus waveform (systolic acceleration time > 100 msec): Rounded spectral Doppler waveforms with delayed systolic upstrokes

image Intrahepatic arterial resistive index < 0.5

image Peak anastomotic systolic velocity > 200 cm/sec

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Nov 16, 2016 | Posted by in GASTROINTESTINAL IMAGING | Comments Off on Ischemic Bile Duct Injury

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