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E³ 418 - Bile ducts imaging: not so simple

Wednesday, March 1, 16:00 - 17:30 Room: M 4 Session Type: E³ - ECR Academies: Tips and Tricks in Liver, Bile Ducts and Pancreas Imaging Topics: Imaging Methods, Abdominal Viscera Moderator: S. A. Jackson (Plymouth/UK) Add session to my schedule In your schedule (remove)


Chairman's introduction

S. A. Jackson; Plymouth/UK

Learning Objectives



Despite rapid technological advances, which have resulted in significant improvements when imaging the biliary tree, the accurate assessment and diagnosis of bile duct pathology still offers challenges for the clinical radiologist. Multi-modality imaging techniques remain central to optimal multi-disciplinary patient management with this interactive ECR academy covering the presentation and imaging appearances of both benign and malignant biliary diseases. In particular, lectures will focus on the imaging features of cholangiocarcinoma and the underlying differential diagnosis of patients presenting with chronic cholangitis. Tips and tricks for accurate diagnosis and the importance of clear diagnostic algorithms will also be emphasised using a range of challenging illustrative clinical cases.


A. Cholangiocarcinoma

S. Kim; Seoul/KP

Learning Objectives

1. To become familiar with the different presentations of cholangiocarcinoma (including hilar and peripheral) tumours.
2. To learn about the role of imaging in staging the lesion and its limitations.
3. To understand the principle of surgical and non-surgical treatment.


Cholangiocarcinoma (CCA) is a malignant epithelial neoplasm with biliary differentiation, which arises from any portion of the biliary system including epithelium and peribiliary gland. Although it shows the highest incidence in Asia, the incidence appears to be increasing recently in western countries. Of late, the concepts of CCA has been progressed regarding precancerous lesions of CCA, biliary disease with a pancreatic counterpart, and the relationship of CCA with cancer stem cells. Based on its anatomic location, CCA is classified as intrahepatic (iCCA), perihilar (pCCA), and distal (dCCA) CCA. CCA exhibits three growth patterns: mass-forming (MF), periductal infiltrating (IF), and intraductal growing (IG). The list of radiologic differential diagnosis is varied according to its gross morphology. For MF CCA, tumours with abundant fibrosis such as metastasis, sclerosing HCC, combined HCC-CC are important mimickers. PI CCA looks similar to sclerosing cholangitis. IG CCA has various morphology depending on tumour location and mucin production. Patients with CCA are usually treated with surgery. Because of its various morphology, infiltrative nature and underlying diseases, it can be a challenge to diagnose and stage CCA accurately. Although contrast-enhanced CT and MRI play an important role to assess resectability, a multidisciplinary approach is needed to accomplish best results.


B. Chronic cholangitis

M. Ronot; Clichy/FR

Learning Objectives

1. To understand the appropriate technique for the non-invasive evaluation of bile ducts.
2. To become familiar with the main causes for chronic cholangitis, including primary sclerosing, autoimmune and ischaemic cholangitis.


Chronic cholangitis are a group of diseases resulting in a chronic inflammation of the bile ducts, with variable causes and consequences. They can be roughly divided into two main groups: sclerosing cholangitis (SC) and secondary cholangitis. The first group includes primary and IgG4-related SC. They correspond to the biliary lesion of chronic extrahepatic/systemic diseases, respectively, inflammatory bowel diseases and IgG4-related disease. Secondary cholangitis is associated with specific identified causes: biliary ischaemia, trauma, chronic infections, iatrogeny, etc. The diagnosis of chronic cholangitis is difficult and relies on four pillars: laboratory tests, associated diseases and medical history, pathology, and of course imaging. The latter plays a central role. Magnetic resonance imaging including MR cholangiography is now considered as the best imaging technique. On imaging, the affected segments demonstrate irregular stenosis, focal, or diffuse circumferential thickening of the wall with contrast enhancement. Ultrasound can be useful to detect small biliary lesions and stones. It remains difficult to distinguish IgG4-SC from primary SC or bile duct malignancy based on imaging features alone. Careful analysis of cholangiograms can be helpful. Nevertheless, biopsy should be used in all patients with a suspicion of malignancy.


C. Tough clinical cases

E. M. Merkle; Basle/CH

Learning Objectives

1. To be able to define the most likely diagnosis facing an unknown case.
2. To understand the diagnostic strategy.


In this interactive session, various clinical cases that focused on the biliary system will be presented. Case presentations will include a wide range of pathologic entities, both benign and malignant. Images will be shown from various modalities including but not limited to percutaneous ultrasound, computed tomography, magnetic resonance imaging including magnetic resonance cholangiography and positron emission tomography. Case presentations are intended to represent typical clinical scenarios; as such information regarding the patient's history and physical exam will be shown first, followed by laboratory data. Subsequently, the audience will be asked to recommend the most appropriate imaging modality and to participate in solving these cases!

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