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Abdomen » Liver & Biliary System
Recurrent pyogenic cholangitis
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Author(s) :
S. Manohar, MD, DMRD
Presentation A 50 year old man with chronic pain in the epigastric region of 6 years duration. He is a non-drinker, had been scanned three years ago and was advised surgery, but he declined. Now the patient presented again with pain and an abdominal ultrasound was performed.
Caption: Views of the gallbladder
Description: Non shadowing mobile calculi are seen in the gallbladder.
Caption: Sagittal image of the liver
Description: Multiple rounded echogenic contents are seen in the right lobe of liver. They appear to be within the intrahepatic biliary radicles.
Caption: Oblique scan of the liver
Description: There is segmental dilatation of the biliary radicles in the left lobe.
Caption: Sagittal image of the right lobe
Description: The right lobe of the liver with the echogenic areas seen again in this image.
Caption: View of the spleen
Description: There is evidence of splenomegaly.
Caption: Transverse view of the liver
Description: The dilated ducts seem to be filled with a considerable amount of echogenic material.
Differential Diagnosis Sclerosing cholangitis, recurrent pyogenic cholangitis, cholangiocarcinoma
Final Diagnosis Recurrent pyogenic cholangitis
Discussion Recurrent pyogenic cholangitis, also called as hepatolithiasis or oriental cholangio- hepatitis, is characterized by chronic biliary obstruction which leads to stasis, intrahepatic stone formation and recurrent episodes of acute pyogenic cholangitis.

Incidence: People of Southeast & East Asian descent.

Site: Lateral segment of left lobe of the liver is the most common site.

Ultrasound features:
-  Dilated ducts filled with sludge & stones confined to one or more segment of the liver.
- Multiple echogenic masses in the liver.
- Contents of the dilated ducts are hypoechoic or hyperechoic & the stones need not shadow.
- Severe atrophy of the affected segment with very little liver parenchyma present and the crowded, stone-filled ducts may appear as a single heterogeneous mass.

Acute complications: Sepsis may occur that may be fatal.

Chronic complications: Chronic stasis that occurs may lead to:
I) Severe atrophy of the affected segment
II) Biliary cirrhosis
III) Cholangiocarcinoma 

When the patient presents with acute complications, urgent percutaneous biliary decompression or surgery is needed. In patients presenting with chronic complications repeated biliary dilation and stone removal is required.
Case References 1. D Rohan Jeyarajah. Recurrent Pyogenic Cholangitis. Current Treatment Options in Gastroenterology 2004, 7:91-98.
2. Patrick I Okolo, MD. Recurrent Pyogenic Cholangitis. http://www.emedicine.com/med/topic2666.htm
Follow Up Biliary cirrhosis occuring as a chronic complication in this patient was confirmed by a liver biopsy.
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