The role of gadoxetic acid-enhanced magnetic resonance cholangiography in the evaluation of postoperative bile duct injury: pictorial essay

Iatrogenic lesion of the bile ducts is a relatively common occurrence during liver surgery, increasing morbidity and mortality rates. T2-weighted magnetic resonance cholangiography and gadoxetic acid-enhanced functional magnetic resonance cholangiography (fMRC) with administration of hepatobiliary-specific contrast medium (gadoxetic acid) are fundamental to the diagnostic imaging approach in patients with such lesions. Here, we present a review of the literature and suggest an imaging approach to biliary tract injury, focusing on clinical cases in which fMRC had an impact on the decision-making process for the management of the affected patients.

Keywords:
Iatrogenic disease; Bile ducts; Magnetic resonance imaging; Contrast media

Authorship

Bruno Jucá Ribeiro Correspondence: Dr. Bruno Jucá Ribeiro. EPM-Unifesp - Departamento de Diagnóstico por Imagem. Rua Napoleão de Barros, 800, Vila Clementino. São Paulo, SP, Brazil, 04024-002. Email: brunojucar123@gmail.com.

Escola Paulista de Medicina da Universidade Federal de São Paulo (EPM-Unifesp), São Paulo, SP, Brazil.Universidade Federal de São PauloBrazilSão Paulo, SP, BrazilEscola Paulista de Medicina da Universidade Federal de São Paulo (EPM-Unifesp), São Paulo, SP, Brazil.

http://orcid.org/0000-0002-6947-1375

Aldo Maurici Araújo Alves

http://orcid.org/0000-0001-7310-5709

Rafael Santiago de Oliveira

http://orcid.org/0000-0003-0838-3731

Fernanda Velloni

http://orcid.org/0000-0002-2019-7918

Giuseppe D’Ippolito

http://orcid.org/0000-0002-2701-1928

Correspondence: Dr. Bruno Jucá Ribeiro. EPM-Unifesp - Departamento de Diagnóstico por Imagem. Rua Napoleão de Barros, 800, Vila Clementino. São Paulo, SP, Brazil, 04024-002. Email: brunojucar123@gmail.com.

SCIMAGO INSTITUTIONS RANKINGS

Figures

Figures (6)

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Figura 1
Representation of the normal time for excretion of contrast (gadoxetic acid) through the bile ducts in fMRC: 10, 20, and 40 min after the injection.

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Figura 2
Stenosis of the intrahepatic biliary tract after cholecystectomy. Axial T1-weighted fMRC sequences acquired at 20 min (A) and 4 h (B) after the injection of gadoxetic acid, showing moderate dilatation of the right biliary tract caused by stenosis in the plane of the right bile duct (arrow in B). Note that the concentration of contrast medium is higher in the parenchyma of the left hepatic lobe (asterisk in A) than in that of the right lobe, where there is a delay in the enhancement of the bile ducts (B). Diagnoses of thermal injury and bile duct ligation were considered.

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Figura 3
Stenosis of the biliary anastomosis after liver transplantation. Coronal T2-MRC and T1-weighted MRC (A and B, respectively): stenosis of the biliary anastomosis with mild dilatation of the intrahepatic biliary tree. Coronal fMRC at 40 min after the injection of gadoxetic acid (C,D): stenosis (C) and a delay in the progression of contrast to the duodenal arc (D). Obvious stenosis with a delay in the progression of the contrast medium through the biliary tract.

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Figura 4
Evaluation of biliaryenteric anastomosis (after complicated cholecystectomy). Coronal T2-weighted sequence (A), and T1- weighted fMRC sequences—axial (C) and coronal (B,D): biliary-enteric anastomosis and mild dilatation of the intrahepatic bile duct 10 min after injection of the contrast medium (arrow and arrowhead, respectively, in A), and delayed excretion of contrast (B), which was not observed until 20 min after injection of the contrast medium (C,D). Patent stenosis of the biliary-enteric anastomosis with delayed biliary excretion.

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Figura 5
Stenosis of the biliary anastomosis after liver transplantation. Coronal T1-weighted fMRC (A,B) with normal progression of contrast medium in the distal bile duct (arrow in A) and in the duodenal arc (arrow in B). The anastomosis remained patent, despite the narrowing in the plane of the anastomosis (arrowhead).

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Figura 6
Biliary fistula after cholecystectomy. Unenhanced axial T1- weighted sequence (A): no findings suggesting a lesion in the bile duct (asterisk). Axial and coronal fMRC (B and C, respectively), 10 min after the injection of gadoxetic acid, showing the extravasation of contrast from the right bile duct to the abdominal cavity (arrows), which is consistent with biliary fistula.

Figura 1 Representation of the normal time for excretion of contrast (gadoxetic acid) through the bile ducts in fMRC: 10, 20, and 40 min after the injection.

Figura 2 Stenosis of the intrahepatic biliary tract after cholecystectomy. Axial T1-weighted fMRC sequences acquired at 20 min (A) and 4 h (B) after the injection of gadoxetic acid, showing moderate dilatation of the right biliary tract caused by stenosis in the plane of the right bile duct (arrow in B). Note that the concentration of contrast medium is higher in the parenchyma of the left hepatic lobe (asterisk in A) than in that of the right lobe, where there is a delay in the enhancement of the bile ducts (B). Diagnoses of thermal injury and bile duct ligation were considered.

Figura 3 Stenosis of the biliary anastomosis after liver transplantation. Coronal T2-MRC and T1-weighted MRC (A and B, respectively): stenosis of the biliary anastomosis with mild dilatation of the intrahepatic biliary tree. Coronal fMRC at 40 min after the injection of gadoxetic acid (C,D): stenosis (C) and a delay in the progression of contrast to the duodenal arc (D). Obvious stenosis with a delay in the progression of the contrast medium through the biliary tract.

Figura 4 Evaluation of biliaryenteric anastomosis (after complicated cholecystectomy). Coronal T2-weighted sequence (A), and T1- weighted fMRC sequences—axial (C) and coronal (B,D): biliary-enteric anastomosis and mild dilatation of the intrahepatic bile duct 10 min after injection of the contrast medium (arrow and arrowhead, respectively, in A), and delayed excretion of contrast (B), which was not observed until 20 min after injection of the contrast medium (C,D). Patent stenosis of the biliary-enteric anastomosis with delayed biliary excretion.

Figura 5 Stenosis of the biliary anastomosis after liver transplantation. Coronal T1-weighted fMRC (A,B) with normal progression of contrast medium in the distal bile duct (arrow in A) and in the duodenal arc (arrow in B). The anastomosis remained patent, despite the narrowing in the plane of the anastomosis (arrowhead).

Figura 6 Biliary fistula after cholecystectomy. Unenhanced axial T1- weighted sequence (A): no findings suggesting a lesion in the bile duct (asterisk). Axial and coronal fMRC (B and C, respectively), 10 min after the injection of gadoxetic acid, showing the extravasation of contrast from the right bile duct to the abdominal cavity (arrows), which is consistent with biliary fistula.

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The role of gadoxetic acid-enhanced magnetic resonance cholangiography in the evaluation of postoperative bile duct injury: pictorial essay

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[1] Correspondence: Dr. Bruno Jucá Ribeiro. EPM-Unifesp - Departamento de Diagnóstico por Imagem. Rua Napoleão de Barros, 800, Vila Clementino. São Paulo, SP, Brazil, 04024-002. Email: brunojucar123@gmail.com.