• Jorge A. Soto
Part of the Medical Radiology book series (MEDRAD)


 Acute biliary tract pathology remains as one of the most common worldwide causes of emergency room visits. Emergency room physicians, surgeons and radiologists devote considerable time and effort to rapidly and accurately diagnose these conditions in order to avoid mistakes that may lead to considerable morbidity and mortality. Fortunately, rapid advances in technology and refinements in invasive and non-invasive methods have improved our ability to provide precise and timely diagnoses. Ultrasonography (US) remains as the premier modality for initial (and often definitive) evaluation, but in order to maximize the accuracy of this technique, a meticulous and thorough evaluation by the operator is necessary. As the utilization of computed tomography (CT) in the emergency setting has grown exponentially in recent years, it is not surprising that many patients ultimately diagnosed with acute biliary diseases are evaluated initially with CT. Magnetic resonance (MR) and nuclear scintigraphy are usually second tier examinations, reserved for specific clinical situations or as complementary tests following an initial US or CT. However, the use of MR cholangiopancreatography (MRCP) in the emergency setting has also increased substantially in recent years. Endoscopic retrograde and percutaneous cholangiography are reserved mainly for therapeutic interventions after a precise diagnosis has been reached through a judicious use of imaging tests. This chapter reviews the appearance of common acute biliary conditions on the various imaging modalities. Emphasis is placed on discussing the most appropriate test for each disease. Potential sources of error and imaging pitfalls are also discussed in detail.


Biliary Tract Cystic Duct Acute Cholecystitis Bile Duct Stone Gallbladder Wall 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. Abou-Saif A, Al-Kawas F (2002) Complications of gallstone disease: Mirizzi syndrome, cholecystocholedochal fistula, and gallstone ileus. Am J Gastroenterol 97:249–254PubMedCrossRefGoogle Scholar
  2. Altun E, Semelka RC, Elias J Jr, Braga L, Voultsinos V, Patel J, Balci NC, Woosley JT (2007) Acute cholecystitis: MR findings and differentiation from chronic cholecystitis. Radiology 244:174–183PubMedCrossRefGoogle Scholar
  3. Ananian C, Dunn A, Mansourian V, Caride VJ (2006) Scintigraphic gallbladder visualization with gangrenous acalculous cholecystitis. Clin Nucl Med 31:701–703PubMedCrossRefGoogle Scholar
  4. Anderson SW, Lucey BC, Varghese JC, Soto JA (2006) Accuracy of MDCT in the diagnosis of choledocholithiasis. AJR Am J Roentgenol 187:174–180PubMedCrossRefGoogle Scholar
  5. Anderson SW, Rho E, Soto JA (2008) Detection of biliary duct narrowing and choledocholithiasis: accuracy of portal venous phase multidetector CT. Radiology 247:418–427PubMedCrossRefGoogle Scholar
  6. Anderson SW, Soto JA, Lucey BC, Ozonoff A, Jordan JD, Ratevosian J, Ulrich AS, Rathlev NK, Mitchell PM, Rebholz C, Feldman JA, Rhea JT (2009) Abdominal 64-MDCT for suspected appendicitis: the use of oral and IV contrast material versus IV contrast material only. AJR Am J Roentgenol 193:1282–1288PubMedCrossRefGoogle Scholar
  7. Anderson SW, Rhea JT, Milch HN, Ozonoff A, Lucey BC, Soto JA (2010) Influence of body habitus and use of oral contrast on reader confidence in patients with suspected acute appendicitis using 64 MDCT. Emerg Radiol 17:445–453PubMedCrossRefGoogle Scholar
  8. Barie PS, Eachempati SR (2010) Acute acalculous cholecystitis. Gastroenterol Clin North Am 39:343–357PubMedCrossRefGoogle Scholar
  9. Baron RL, Stanley RJ, Lee JK et al (1982) A prospective comparison of the evaluation of biliary obstruction using computed tomography and ultrasonography. Radiology 145:91–98PubMedGoogle Scholar
  10. Baron RL, Rohrmann CA Jr, Lee SP, Shuman WP, Teefey SA (1988) CT evaluation of gallstones in vitro: correlation with chemical analysis. AJR Am J Roentgenol 151:1123–1128PubMedGoogle Scholar
  11. Becker CD, Hassler H, Terrier F (1984) Preoperative diagnosis of the Mirizzi syndrome: limitations of sonography and computed tomography. AJR 143:591–596PubMedGoogle Scholar
  12. Becker CD, Grossholz M, Becker M et al (1997) Choledocholithiasis and bile duct stenosis: diagnostic accuracy of MR cholangiopancreatography. Radiology 205:523–530PubMedGoogle Scholar
  13. Brook OR, Kane RA, Tyagi G, Siewert B, Kruskal JB (2011) Lessons learned from quality assurance: errors in the diagnosis of acute cholecystitis on ultrasound and CT. AJR Am J Roentgenol 196:597–604PubMedCrossRefGoogle Scholar
  14. Chan YL, Chan ACW, Lam WWM et al (1996) Choledocholithiasis: comparison of MR cholangiography and endoscopic retrograde cholangiography. Radiology 200:85–89PubMedGoogle Scholar
  15. Chan WC, Joe BN, Coakley FV et al (2006) Gallstone detection at CT in vitro: effect of peak voltage setting. Radiology 241:546–553PubMedCrossRefGoogle Scholar
  16. Denecke T, Degutyte E, Stelter L, Lehmkuhl L, Valencia R, Lopez-Hänninen E, Felix R, Stroszczynski C (2006) Minimum intensity projections of the biliary system using 16-channel multidetector computed tomography in patients with biliary obstruction: comparison with MRCP. Eur Radiol 16:1719–1726PubMedCrossRefGoogle Scholar
  17. Flancbaum L, Choban PS (1995) Use of morphine cholescintigraphy in the diagnosis of acute cholecystitis in critically ill patients. Intensive Care Med 21:120–124PubMedCrossRefGoogle Scholar
  18. Garcia-Sancho Tellez L, Rodrigues-Montes JA, Fernandes LS et al (1999) Acute emphysematous cholecystitis: report of twenty cases. Hepatogastroenterology 46:2144–2148PubMedGoogle Scholar
  19. Griffin N, Wastle ML, Dunn WK, Ryder SD, Beckingham IJ (2003) Magnetic resonance cholangiopancreatography versus endoscopic retrograde cholasngiopancreatography in the diagnosis of choledocholithiasis. Eur J Gastroenterol Hepatol 15:809–813PubMedGoogle Scholar
  20. Jeffrey RB, Laing FC, Wong W, Callen PW (1983) Gangrenous cholecystitis: diagnosis by ultrasound. Radiology 148:219–221PubMedGoogle Scholar
  21. Keyzer C, Cullus P, Tack D, De Maertelaer V, Bohy P, Gevenois PA (2009) MDCT for suspected acute appendicitis in adults: impact of oral and IV contrast media at standard-dose and simulated low-dose techniques. AJR Am J Roentgenol 193:1272–1281PubMedCrossRefGoogle Scholar
  22. Kim JH, Kim MJ, Park SII et al (2002) MR cholangiography in symptomatic gallstones: diagnostic accuracy according to clinical risk group. Radiology 224:410–416PubMedCrossRefGoogle Scholar
  23. Laituri CA, Fraser JD, Aguayo P, Fike FB, Garey CL, Sharp SW, Ostlie DJ, St Peter SD (2011) The lack of efficacy for oral contrast in the diagnosis of appendicitis by computed tomography. J Surg Res Mar 12. [Epub ahead of print]Google Scholar
  24. Lee SY, Coughlin B, Wolfe JM, Polino J, Blank FS, Smithline HA (2006) Prospective comparison of helical CT of the abdomen and pelvis without and with oral contrast in assessing acute abdominal pain in adult emergency department patients. Emerg Radiol 12:150–157PubMedCrossRefGoogle Scholar
  25. Mitchell SE, Clark RA (1984) A comparison of computed tomography and sonography in choledocholithiasis. AJR Am J Roentgenol 142:729–733PubMedGoogle Scholar
  26. Morse BC, Smith JB, Lawdahl RB, Roettger RH (2010) Management of acute cholecystitis in critically ill patients: contemporary role for cholecystostomy and subsequent cholecystectomy. Am Surg 76:708–712PubMedGoogle Scholar
  27. Mun S, Ernst RD, Chen K, Oto A, Shah S, Mileski WJ (2006) Rapid CT diagnosis of acute appendicitis with IV contrast material. Emerg Radiol 12:99–102PubMedCrossRefGoogle Scholar
  28. Neitlich JD, Topazian M, Smith RC, Gupta A, Burrell MI, Rosenfield AT (1997) Detection of choledocholithiasis: comparison of unenhanced helical CT and endoscopic retrograde cholangiopancreatography. Radiology 203:753–757PubMedGoogle Scholar
  29. Nino-Murcia M, Jeffrey RB Jr (2001) Imaging the patient with right upper quadrant pain. Semin Roentgenol 36:81–91PubMedCrossRefGoogle Scholar
  30. Park MS, Yu JS, Kim YH, Kim MJ, Kim JH, Lee S, Cho N, Kim DG, Kim KW (1998) Acute cholecystitis: comparison of MR cholangiography and US. Radiology 209:781–785PubMedGoogle Scholar
  31. Paulson EK (2000) Acute cholecystitis: CT findings. Semin Ultrasound CT MR 21:56–63PubMedCrossRefGoogle Scholar
  32. Paulson EK, Kliewer MA, Hertzberg BS, Paine SS, Carroll BA (1994) Diagnosis of acute cholecystitis with color Doppler sonography: significance of arterial flow in thickened gallbladder wall. AJR Am J Roentgenol 162:1105–1108PubMedGoogle Scholar
  33. Pedrosa I, Rofsky NM (2003) MR imaging in abdominal emergencies. Radiol Clin North Am 41:1243–1273PubMedCrossRefGoogle Scholar
  34. Pedrosa I, Guarise A, Goldsmith J, Procacci C, Rofsky NM (2003) The interrupted rim sign in acute cholecystits: a method to identify the gangrenous form with MRI. J Magn Reson Imaging 18:360–363PubMedCrossRefGoogle Scholar
  35. Puc MM, Tran HS, Wry PW, Ross SE (2002) Ultrasound is not a useful screening tool for acute acalculous cholecystitis in critically ill trauma patients. Am Surg 68:65–69PubMedGoogle Scholar
  36. Regan F, Fradin J, Khazan R, Bohlman M, Magnuson T (1996) Choledocholithiasis: evaluation with MR cholangiography. AJR Am J Roentgenol 167:1441–1445PubMedGoogle Scholar
  37. Reinhold C, Taourel P, Bret PM (1998) Choledocholithiasis: evaluation of MR cholangiography for diagnosis. Radiology 209:435–442PubMedGoogle Scholar
  38. Schiller VL, Turner RR, Sarti DA (1996) Color doppler imaging of the gallbladder wall in acute cholecystitis: sonographic-pathologic correlation. Abdom Imaging 21:233–237PubMedCrossRefGoogle Scholar
  39. Shakespear JS, Shaaban AM, Rezvani M (2010) CT findings of acute cholecystitis and its complications. AJR Am J Roentgenol 194:1523–1529PubMedCrossRefGoogle Scholar
  40. Shapiro MJ, Luchtefeld WB, Kurzweil S, Kaminski DL, Durham RM, Mazuski JE (1994) Acute acalculous cholecystitis in the critically ill. Am Surg 60:335–339PubMedGoogle Scholar
  41. Simeone JF, Brink JA, Mueller PR, Compton C, Hahn PF, Saini S, Silverman SG, Tung G, Ferrucci JT (1989) The sonographic diagnosis of acute gangrenous cholecystitis: importance of the Murphy sign. AJR Am J Roentgenol 152:289–290PubMedGoogle Scholar
  42. Singh AK, Sagar P (2005) Gangrenous cholecystitis: prediction with CT imaging. Abdom Imaging 30:218–221PubMedCrossRefGoogle Scholar
  43. Soto JA, Alvarez O, Munera F, Velez SM, Valencia J, Ramirez N (2000a) Diagnosing bile duct stones: comparison of unenhanced helical CT, oral contrast-enhanced CT cholangiography and MR cholangiography. AJR Am J Roentgenol 175:1127–1134Google Scholar
  44. Soto JA, Barish MA, Alvarez O, Medina S (2000b) Detection of choledocholithiasis with MR cholangiography: comparison of three-dimensional fast spin-echo and single- and multisection half-Fourier rapid acquisition with relaxation enhancement sequences. Radiology 21:737–745Google Scholar
  45. Summers SM, Scruggs W, Menchine MD et al (2010) A prospective evaluation of emergency department bedside ultrasonography for the detection of acute cholecystitis. Ann Emerg Med 56:114–122PubMedCrossRefGoogle Scholar
  46. Takada T, Yasuda H, Uchiyama K et al (1989) Pericholecystic abscess: classification of US findings to determine the proper therapy. Radiology 172:693–697PubMedGoogle Scholar
  47. Tkacz JN, Anderson SA, Soto J (2009) MR imaging in gastrointestinal emergencies. Radiographics 29:1767–1780PubMedCrossRefGoogle Scholar
  48. Trowbridge RL, Rutkowski NK, Shojania KG (2003) Does this patient have acute cholecystitis. JAMA 289:80–86PubMedCrossRefGoogle Scholar
  49. Varghese JC, Farrell MA, Courtney G, Osborne H, Murray FE, Lee MJ (1999) A prospective comparison of magnetic resonance cholangiopancreatography with endoscopic retrograde cholangiopancreatography in evaluation of patients with suspected biliary tract disease. Clin Radiol 54:513–520PubMedCrossRefGoogle Scholar
  50. Wang ZJ, Chen KS, Gould R, Coakley FV, Fu Y, Yeh BM (2011) Positive enteric contrast material for abdominal and pelvic CT with automatic exposure control: What is the effect on patient radiation exposure? Eur J Radiol Apr 12. [Epub ahead of print]Google Scholar
  51. Watanabe Y, Nagayama M, Okumura A, Amoh Y, Katsube T, Suga T, Koyama S, Nakatani K, Dodo Y (2007) MR imaging of acute biliary disorders. Radiographics 27:477–495PubMedCrossRefGoogle Scholar
  52. Wermke W, Schulz HJ (1987) Sonographic diagnosis of bile duct calculi: results of a prospective study of 222 cases of choledocholithiasis. Ultraschall Med 8:116–120PubMedCrossRefGoogle Scholar
  53. Wolfe JM, Smithline H, Lee S, Coughlin B, Polino J, Blank F (2006) The impact of body mass index on concordance in the interpretation of matched noncontrast and contrast abdominal pelvic computed tomographic scans in ED patients with nontraumatic abdominal pain. Am J Emerg Med 24:144–148PubMedCrossRefGoogle Scholar
  54. Ziessman HA (2003) Acute cholecystitis, biliary obstruction, and biliary leakage. Semin Nucl Med 33:279–296PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2011

Authors and Affiliations

  1. 1.Department of RadiologyBoston Medical Center, Boston University School of MedicineBostonUSA

Personalised recommendations