Ascending Cholangitis

Preliminary Diagnosis: Ascending Cholangitis

I. What imaging technique is first-line for this diagnosis?

• Ultrasound of the biliary tree.

II. Describe the advantages and disadvantages of this technique for diagnosis of Ascending Cholangitis.

Advantages

• Highly portable imaging modality.

• Does not expose patients to ionizing radiation.

• May help guide percutaneous intervention and biopsy that will help clinch diagnosis of ascending cholangitis.

Disadvantages

• Highly operator dependent.

• Limited in evaluating the surrounding soft tissues.

• Ascending cholangitis diagnosis is clinched with a histological diagnosis.

III. What are the contraindications for the first-line imaging technique?

• No specific contraindications to sonographic imaging exist.

IV. What alternative imaging techniques are available?

• Magnetic resonance cholangiopancreatography (MRCP).

• CT imaging.

• Cholangiography.

• Endoscopic retrograde cholangiopancreatography (ERCP).

V. Describe the advantages and disadvantages of the alternative techniques for diagnosis of Ascending Cholangitis.

MRCP

Advantages

• Offers exquisite visualization of the intrahepatic and extrahepatic biliary tree.

• Does not expose patients to ionizing radiation.

• May be performed without contrast in patients who cannot receive contrast medium.

• Diagnostic imaging modality.

Disadvantages

• May be subject to motion and susceptibility weighted imaging, degrading image quality.

• Less sensitive to mineralized and air densities.

• Expensive.

• Time-consuming..

• Ascending cholangitis is a histological diagnosis.

CT imaging

Advantages

• Offers exquisite visualization of the surrounding soft tissues, osseous structures, and vasculature.

• Highly sensitive to mineralized and air densities often present in the biliary system.

• May help guide percutaneous intervention and treatment.

Disadvantages

• Exposes patients to ionizing radiation.

• Ascending cholangitis is a histological diagnosis.

Cholangiography

Advantages

• Offers both diagnostic and therapeutic capabilities simultaneously.

• Offers the ability for histological diagnosis and imaging diagnosis to be done simultaneously.

Disadvantages

• Highly operator dependent.

• Exposes patients to increased morbidity and mortality from being an invasive procedure.

Endoscopic retrograde cholangiopancreatography (ERCP)

Advantages

• Gold standard in diagnosing and treating ascending cholangitis.

Disadvantages

• May not be available at all institutions as ERCP must be performed by trained gastroenterology specialists.

• Risk for trauma to common bile duct and pancreatic duct from procedure.

VI. What are the contraindications for the alternative imaging techniques?

MRCP

May be contraindicated in patients with non-MR compatible hardware.

CT imaging

May be contraindicated in pregnant patients.

Cholangiography

Contraindicated in patients in a severe hypocoagulable state.

ERCP

Contraindicated in patients in a severe hypocoagulable state.