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.

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  • 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.

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