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So this is an interesting case of a gentleman

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in his 60s who had a liver transplant and

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now presents with elevated liver function tests.

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And so an MRI was requested in order

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to evaluate potential etiologies.

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So I'm going to start off

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with the T2-weighted sequence.

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This is done with fat saturation.

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You can see there's a little bit of

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ascites over here in the upper abdomen.

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And again, I'm going to focus on the bile ducts.

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And as we come right on this image, we

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can see that the bile ducts are dilated.

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The intrahepatic biliary tree is visible here and

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they look a little bit bigger than they should be.

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As we go even more inferiorly, you

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can see some of the bile ducts that

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are dilated here, dilated here.

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And very much dilated as they sort

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of converge to the porta hepatis.

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And right here is probably the common

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hepatic duct, which looks quite dilated.

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This is the cystic duct coming here.

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We're going to go downwards,

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downwards, downwards.

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You can see the bile duct very nicely here.

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And then all of a sudden you lose it

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and it comes out here and it's small again.

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And let's follow the small bile duct

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nicely all the way to the ampulla.

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And so what's interesting in this case

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is that you're really just seeing two

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calibers of the bile duct with quite

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an abrupt transition right over here.

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It looks really big.

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All of a sudden you lose it.

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And right over here, it looks very small.

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This sort of relationship can be nicely depicted

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on our coronal T2-weighted images as well.

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Let's sort of focus right on

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this slice over here and zoom up.

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Dilated bile ducts, dilated bile ducts,

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abrupt narrowing, and relatively normal

1:49

bile ducts seem more caudal to it.

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As we scroll through this, it becomes

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quite apparent that there's something

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going on very focally resulting in, uh,

1:58

the ductal dilatation and the patient

1:59

also has some lab values that support that.

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I thought the MRCP sequences here also show

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this probably the best in this instance

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of dilated bile ducts, intrahepatic ducts,

2:10

common hepatic duct, something open going

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on here, abrupt narrowing, some stricturing.

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And then caudal to it again,

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the biliary tree looks very good.

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So I think I'm pretty convinced based on the

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T2-weighted sequences that we've presented.

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You can look at it on the

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post-contrast sequences.

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Again, showing you that the bile

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ducts are dilated, dilated, dilated.

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Abrupt transition right around here.

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And then a normal caliber of the biliary tree.

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So as I'd mentioned in presenting this case,

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this patient has a history of liver transplant

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and oftentimes right at the biliary anastomosis,

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you can see some degree of mismatch.

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That is, the donor liver and the recipient liver

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who's getting the liver may have

3:00

relatively different calibers

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of their respective bile ducts.

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And so when you have that anastomosis,

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one set of bile ducts may

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be slightly bigger than the other.

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In this instance, though, that sort of

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mismatch between the donor and the recipient

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is quite pronounced.

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And moreover, there's actual ductal

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dilatation seen superior to it.

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The patient also has elevated

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liver function tests.

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And so all these things suggest

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that right at that anastomosis,

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some stricturing has developed.

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One last observation that I'll point out

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on this image, and then I'll talk a little

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bit more about in another case coming up,

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is that right cephalad to where we think

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that stricture is at the anastomosis,

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there are a few filling defects here.

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And so whenever you see filling defects

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inside the bile ducts, they form

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because there's some degree of stasis.

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Of course, filling defects can also

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occur if there are stones

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or other content in the biliary tree.

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But in this instance, in the post-transplant

3:58

patient, the gallbladder has been taken out,

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and so whatever's forming here is due to

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stasis.

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And that's another clue that there indeed is

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a stricture that is clinically significant.

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And so this patient then went on to get an ERCP.

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And I thought it would be good to sort of

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show you some of the ERCP images just to

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give you a sense of what that looks like.

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And so here we have the scope here,

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injecting the common bile duct,

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and we can see very nicely, abrupt

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narrowing right at that anastomosis.

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Upstream from the anastomosis, bile ducts

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are dilated; caudal to it, relatively normal

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caliber. This was dilated with a balloon,

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and subsequently a stent was placed in

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order to open up that area of stricturing.

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So once again, this is a nice case of a

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patient with biliary anastomotic stricture

4:53

that developed post liver transplant.