Portal biliopathy, magnetic resonance imaging and magnetic resonance cholangiopancreatography findings: a case series

Mass-Forming Portal Biliopathy Presenting as Extreme Wall-Thickening of the Common Bile Duct

Portal biliopathy refers to biliary tree abnormalities in patients with peribiliary collateral vessels and non-neoplastic extrahepatic portal vein occlusion. These biliary abnormalities are caused by vascular compression and ischemic damage of the biliary tree, which can result in bile duct compression, stenosis, fibrotic strictures, bile duct dilation, and thickening of the bile duct wall. Portal biliopathy is difficult to distinguish from cholangiocarcinoma, IgG4-related disease, and sclerosing cholangitis. Although most patients are asymptomatic, portal biliopathy can lead to serious complications, such as recurrent cholangitis. This case illustrates the importance of including portal biliopathy in the differential diagnosis at an early stage, especially in patients with portal hypertension. With early recognition, the need for additional invasive diagnostic procedures such as biopsies is minimized. Pathogenesis, clinical presentation, diagnostics, and treatment options of portal biliopathy are described in the article.

Diagnostic yield of magnetic resonance imaging for cholangiocarcinoma in primary sclerosing cholangitis: a meta-analysis

Aim of the study

Combined magnetic resonance imaging and magnetic resonance cholangiopancreatography (MRI/MRCP) can identify biliary strictures and diagnose primary sclerosing cholangitis (PSC). Diagnosis of cholangiocarcinoma in patients with PSC remains challenging, and the accuracy of MRI/MRCP has not been completely established. We aimed to determine the sensitivity and specificity of MRI/MRCP in the diagnosis of cholangiocarcinoma among patients with PSC from the published literature.

Material and methods

We searched Embase, PubMed, Cochrane, Scopus, ClinicalTrials.gov, and abstracts from relevant scientific meetings and performed a systematic review and meta-analysis to estimate the diagnostic yield of MRI/MRCP in patients with PSC. Sensitivity and specificity were calculated from pooled estimates of cholangiocarcinoma cases identified and lesions missed. Modifying variables were included in a meta-regression model.

Results

Our literature search yielded 302 articles and 9 conference abstracts; 8 studies involving 846 liver patients from 5 countries were included in the final analysis. Of those, 531 had PSC and received MRI/MRCP. Thirty-six (6.8%) patients were diagnosed with cholangiocarcinoma (33 true positive, 3 false negative and 1 false positive). Pooled sensitivity was 98.9% (95% CI: 98.6-99.3%). Cholangiocarcinoma cases missed by MRI/MRCP were diagnosed as beading irregularities of the central hepatic ducts, or PSC-related diffuse stricture. Metaregression revealed that neither publication year, study design, nor sample size had a significant effect on observed cancer rates (p = 0.9, 0.3, and 0.3, respectively).

Conclusions

MRI/MRCP followed by endoscopic retrograde cholangiopancreatography (ERCP) is a sensitive and specific tool to diagnose cholangiocarcinoma among patients with PSC. Further research should estimate MRI/MRCP diagnostic accuracy for cholangiocarcinoma using prospective methodology and longer term outcomes.

Therapeutic approaches for portal biliopathy: A systematic review

Portal biliopathy (PB) is defined as the presence of biliary abnormalities in patients with non-cirrhotic/non-neoplastic extrahepatic portal vein obstruction (EHPVO) and portal cavernoma (PC). The pathogenesis of PB is due to ab extrinseco compression of bile ducts by PC and/or to ischemic damage secondary to an altered biliary vascularization in EHPVO and PC. Although asymptomatic biliary abnormalities can be frequently seen by magnetic resonance cholangiopancreatography in patients with PC (77%-100%), only a part of these (5%-38%) are symptomatic. Clinical presentation includes jaundice, cholangitis, cholecystitis, abdominal pain, and cholelithiasis. In this subset of patients is required a specific treatment. Different therapeutic approaches aimed to diminish portal hypertension and treat biliary strictures are available. In order to decompress PC, surgical porto-systemic shunt or transjugular intrahepatic porto-systemic shunt can be performed, and treatment on the biliary stenosis includes endoscopic (Endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy, balloon dilation, stone extraction, stent placement) and surgical (bilioenteric anastomosis, cholecystectomy) approaches. Definitive treatment of PB often requires multiple and combined interventions both on vascular and biliary system. Liver transplantation can be considered in patients with secondary biliary cirrhosis, recurrent cholangitis or unsuccessful control of portal hypertension.

An Unusual Case of Gastrointestinal Bleeding from Isolated Gallbladder Varices in a Patient with Pancreatic Cancer Complicated by Portal Biliopathy

Portal biliopathy is the complex of abnormalities of extrahepatic and intrahepatic bile ducts, cystic duct, and gallbladder, arising as a result of extrahepatic portal vein obstruction and noncirrhotic portal fibrosis, which can be caused by coagulopathies, tumors, inflammation, postoperative complications, dehydration, and neonatal umbilical vein catheterization. We report a case of a 55-year-old male patient with the history of pancreatic cancer and cholecystoenteric anastomosis presenting with gastrointestinal bleeding from gallbladder varices via the anastomosis.

Portal biliopathy

Portal biliopathy refers to cholangiographic abnormalities which occur in patients with portal cavernoma. These changes occur as a result of pressure on bile ducts from bridging tortuous paracholedochal, epicholedochal and cholecystic veins. Bile duct ischemia may occur due prolonged venous pressure effect or result from insufficient blood supply. In addition, encasement of ducts may occur due fibrotic cavernoma. Majority of patients are asymptomatic. Portal biliopathy is a progressive disease and patients who have long standing disease and more severe bile duct abnormalities present with recurrent episodes of biliary pain, cholangitis and cholestasis. Serum chemistry, ultrasound with color Doppler imaging, magnetic resonance imaging with magnetic resonance cholangiopancreatography and magnetic resonance portovenography are modalities of choice for evaluation of portal biliopathy. Endoscopic retrograde cholangiography being an invasive procedure is indicated for endotherapy only. Management of portal biliopathy is done in a stepwise manner. First, endotherapy is done for dilation of biliary strictures, placement of biliary stents to facilitate drainage and removal of bile duct calculi. Next portal venous pressure is reduced by formation of surgical porto-systemic shunt or transjugular intrahepatic portosystemic shunt. This causes significant resolution of biliary changes. Patients who persist with biliary symptoms and bile duct changes may benefit from surgical biliary drainage procedures (hepaticojejunostomy or choledechoduodenostomy).