Recurrent episodes of acute pyogenic cholangitis with intra- and extrahepatic biliary pigment stones

Synonyms: Hepatolithiasis, oriental cholangiohepatitis

Intra- and extrahepatic biliary ductal dilatations with stones

Lateral segment of left lobe and posterior segment of right lobe more commonly involved

Biliary ductal thickening due to repeated inflammation

Severe atrophy of affected lobe/segment, biliary cirrhosis

Grayscale ultrasound

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  Presence of echogenic sludge/stones ± posterior acoustic shadowing in intrahepatic and extrahepatic duct

  
  
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  Periportal hypo-/hyperechogenicity due to periductal inflammation

  
  
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  Ductal rigidity and straightening, rapid tapering of peripheral intrahepatic duct

Cholangiography and MRCP

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  Intra- and extrahepatic duct dilatation with stones as filling defects

Ascending cholangitis

Sclerosing cholangitis

Cholangiocarcinoma

Intrahepatic stones secondary to biliary stricture

Caroli disease

Common symptoms/signs: Recurrent episodes of RUQ pain, fever, and jaundice

Risk of developing cholangiocarcinoma (5-6%)

Consider recurrent pyogenic cholangitis in southeast Asian patients with recurrent episodes of acute bacterial cholangitis

Imaging interpretation pearl: Intra- and extrahepatic bile duct dilatation with pigmented stones and ductal inflammation

To better demonstrate posterior acoustic shadowing of intrahepatic stones, consider turning off compounding

Echogenic sludge may be mistaken for artifact; zooming in or changing windows may help to distinguish real echoes from artifact