0:01

So here we have a 60-year-old patient

0:04

with elevated liver function tests.

0:06

An MRI was obtained to evaluate

0:08

the etiology of these findings.

0:11

I'm going to start off with our

0:12

axial coronal T2 hay sequences.

0:15

Certainly going to look at all the organs,

0:16

but we'll be focused on the bile ducts.

0:20

You can already see here that the bile duct

0:22

is visible, and whenever it's visible, most

0:25

likely it's dilated because normal bile

0:27

ducts are very, very tough to see on these T2

0:29

weighted sequences because they're so small.

0:31

Scroll a little bit lower and you

0:32

can definitely see that the biliary

0:33

ducts are dilated.

0:36

You can see here that there's almost a

0:38

trifurcation variation as a side where

0:40

both the anterior, posterior, and left

0:42

seem to be coming to a specific spot.

0:44

But again, we don't need to

0:45

worry too much about that.

0:46

This patient is not somebody who's

0:48

being considered for a liver resection.

0:51

The common bile duct is dilated as well, and you can see

0:54

the cystic duct coming and joining it over

0:56

here, and you can go all the way down the

0:59

common bile duct is dilated, but over time

1:01

it sort of slowly tapers until it gets

1:04

to the ampulla right at the duodenum.

1:06

When we look at the biliary

1:09

tree, we notice that there's no

1:11

apparent etiology for these findings.

1:14

There's no filling defects inside

1:15

of it to suggest choledocholithiasis.

1:17

I'm not seeing layering sludge inside of it.

1:21

There is biliary ductal dilatation,

1:23

but the etiology is uncertain.

1:25

Let's look at it on the coronal

1:27

images, see if that helps us at all.

1:29

Again, we can see biliary ductal dilatation,

1:32

the right hepatic ducts and some of

1:34

the left hepatic ducts are dilated.

1:36

The extrahepatic biliary tree is dilated, and

1:38

you can see it coming all the way down and

1:40

right into the ampulla with no apparent

1:43

etiology that we can figure out.

1:45

We also did a 3D MRCP sequence over here,

1:49

which shows the findings very beautifully.

1:51

However, as we go all the way

1:53

down the extrahepatic biliary tree,

1:55

no apparent etiology identified.

1:57

And we have a whole bunch of post-contrast

1:59

sequences as well in this instance,

2:00

and really no etiology identified for

2:03

the ductal dilatation in this patient.

2:05

One of the things, when you dig deeper

2:07

into this, in the history of this

2:08

patient, is you realize the patient has

2:11

been infected with HIV and, in fact, has AIDS.

2:14

And so one of the things to consider in

2:16

patients with that history is this entity of

2:18

biliary ductal dilatation and this history,

2:21

which is AIDS cholangiopathy.

2:25

And what this is, is inflammation of

2:28

the bile ducts related to AIDS-related

2:32

opportunistic infections thought to be

2:35

potentially Cryptosporidium or cytomegalovirus.

2:39

And as a result of that inflammation, you can

2:41

get biliary strictures and potentially papillary

2:45

stenosis right where the bile ducts enter the

2:49

ampulla, right at that location at the major

2:53

papilla, you can get some papillary stenosis.

2:55

And if that occurs, the bile ducts upstream

2:58

from it, all this stuff can dilate.

3:01

Now there's a variety of imaging patterns that

3:03

have been described with AIDS cholangiopathy.

3:06

Certainly, papillary stenosis is one

3:08

of them, which is something that this

3:09

patient may have had and can account

3:10

for some of the imaging findings we see.

3:13

But you can also get areas of intrahepatic

3:18

biliary ductal stricturing and dilatation.

3:19

And in fact, it can have an appearance

3:21

that is very similar to primary

3:24

sclerosing cholangitis, a case that we've

3:26

already covered in this master course.

3:28

And so, I think in this instance, if you see

3:31

that sort of pattern, it's very important

3:34

to dig in deep for the clinical history.

3:36

If it's a patient who has low CD4 counts,

3:40

and you have a primary sclerosing

3:41

cholangitis picture, consider that in fact the

3:45

imaging appearance is not due to sclerosing

3:48

cholangitis, but rather AIDS cholangiopathy.

3:51

Be that as it may, in this instance, these

3:53

dilated ducts don't have the appearance

3:55

of primary sclerosing cholangitis.

3:56

They're dilated all the way to the ampulla,

3:59

and given the history in this patient,

4:01

likely there's some element of papillary

4:04

stenosis resulting in this ductal dilatation.