Medical Image of the Week: Ascending Cholangitis from Biliary Obstruction

Figure 1 – Sagittal view of the gallbladder on ultrasound showing gallstone (red arrow).

Figure 2 – Cholangiogram showing multiple filling defects in the gallbladder (red arrowheads) and diffuse dilatation of the common bile duct to 16mm with no contrast flow into the duodenum (arrow), suggestive of distal obstruction.

A 79 year old man with a history of quadriplegia presented to an outside hospital in septic shock.  He was found to have an elevated total bilirubin of 10 mg/dL, direct bilirubin of 7 mg/dL, alkaline phosphatase of 405 U/L, and lipase of 370 U/L.  Imaging showed cholelithiasis with likely intra- and extrahepatic biliary duct dilatation.  The patient underwent placement of a biliary drain with clinical improvement.  Additional imaging was requested prior to endoscopic retrograde cholangiopancreatography (ERCP), but magnetic resonance cholangiopancreatography (MRCP) was unavailable due to metallic implants.  Interventional radiology performed a cholangiogram using the biliary drain which confirmed biliary obstruction.  ERCP was then performed, with significant biliary sludge found and two stents placed.

Candy Wong, MD¹, Preethi William, MD² and Gordon Carr, MD¹

¹Division of Pulmonary and Critical Care Medicine

²Department of Medicine

University of Arizona

Tucson, Arizona

Reference as: Wong C, William P, Carr G. Medical image of the week: ascending cholangitis from biliary obstruction. Southwest J Pulm Crit Care. 2013;6(4):187-8. PDF