Presentation
Multiple episodes of fever, jaundice, and right upper quadrant (RUQ) pain.
Patient Data
There is moderate intrahepatic biliary tree dilatation, with multiple intrahepatic dense lesions noted along the course of the dilated biliary tract, suggesting stones associated with fat stranding and free fluid noted in the porta hepatis. No definite enhancing mass lesion in porta hepatis . No obvious extrahepatic biliary tree dilatation.
The pancreatic duct is not dilated.
The liver shows heterogeneous areas of attenuation on the arterial phase that become homogenous on delayed images with prominent-size hepatic arteries that show collaterals and tortuosity at porta hepatis (THAD).
Small hyperenhancing lesion seen in left liver lobe segment 2 measuring 10x10 mm with no washout, suggesting flash-filling hemangioma.
Ultrasound shows hepatolithiasis, thick intraductal sludge/pus, and biliary dilatation.
Case Discussion
This patient, with a remote history of cholecystectomy and recurrent bouts of acute illness (Charcot triad), had a clinical diagnosis of ascending cholangitis. The presence of hepatolithiasis indicates stasis within the biliary system, which can be a result or a cause of infection.
An important feature in this case is the lack of extrahepatic biliary dilatation, or, in other words, the intrahepatic dilatation is out of proportion to the extrahepatic biliary dilatation.
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