INVESTIGATIONS

Imaging the liver and

biliary tract

Whats new?
C

Mo Malaki
C

Kamarjit Mangat
C

Abstract
Several imaging modalities are used to investigate the liver and biliary
tract. The commonest is ultrasound, which is safe, cheap and readily
available. It is often used as a screening modality. Computed tomography
or magnetic resonance imaging or both are often the next modalities of
choice, and are used to explore any unusual findings detected on ultrasound. Fluoroscopic imaging procedures, such as percutaneous cholangiography and endoscopic retrograde cholangiopancreatography, are often
used when intervention is required, usually for therapeutic reasons.
In this article, we describe the role of the each of these imaging modalities in benign and malignant hepatobiliary disease, summarize their use
in commonly encountered conditions, such as gallstones, cirrhosis and
focal liver lesions, and delineate their advantages and disadvantages.
Often, a combination of different modalities is required to reach the
final diagnosis. We also describe the complementary role of other less
commonly used modalities.

The availability of three-dimensional imaging allowing reconstructions in any plane

Newer, more liver-specific magnetic resonance imaging (MRI)
contrast agents
Diffusion-weighted MRI and positron emission tomographycomputed tomography for further characterization of focal
lesions

non-invasive, quick, and easy. No ionizing radiation is involved.

It is the ideal modality for gallstones, biliary dilatation and for
image-guided procedures.
The gallbladder (GB) can be visualized clearly in the fasting
state in most patients (Figure 1). It appears as an oval hypoechoic
structure with a thin uniform smooth wall. It may be invisible
because of a contracted GB, agenesis of the GB, calcified GB wall
or the presence of intramural or intraluminal gas.
On US, most gallstones are highly reflective, cause an acoustic
shadow and are generally mobile (Figure 2). False-negatives
occur when stones are smaller than 3 mm, hidden behind a GB
fold or cystic duct, if there is sludge present within the GB, or due
to technical factors, such as patient habitus or operator inexperience. False-positives are uncommon but occur because of
polyps, folds (spiral valve at the neck of the GB) or cholesterolosis of the GB. US provides no information about GB or cystic
duct pathway function.
US has a positive predictive value and a negative predictive
value of 92% and 95% respectively in patients with a clinical
diagnosis of cholecystitis and a positive Murphys sign1
(Figure 2). It is also of value in diagnosis of complications of
cholecystitis, such as GB perforation, gangrenous cholecystitis
and emphysematous cholecystitis. Other GB pathologies identifiable on US include carcinoma and adenomyomatosis. In
chronic cholecystitis, the GB is contracted, fibrosed and thickwalled, and differentiation from GB neoplasm may be difficult.

Keywords bile ducts; computed tomography; diffuse liver disease;

focal liver disease; gallstones; liver function tests; magnetic resonance
imaging; ultrasound

Imaging of the gallbladder and biliary tree

Plain radiography
This is rarely used in investigating liver and biliary pathology.
Only 10e20% of gallstones are calcified enough to be seen on
a plain abdominal radiograph. Calcifications may be due to
gallstones, a porcelain gallbladder, which predisposes to
cancer, or milk of calcium bile. Occasionally, the biliary system is
seen to contain air, which may be caused by endoscopic retrograde cholangiopancreatography (ERCP), biliary enteric-fistula
or biliary infections.
Ultrasonography (US)
Biliary disease: US is the commonest imaging investigation
used in the initial assessment of hepatobiliary disease. It is

Mo Malaki MB BCh MRCS FRCR is a Specialist Registrar in Clinical Radiology

at Queen Elizabeth Hospital, Birmingham, UK. Interests are
Hepatobiliary Imaging and Interventional Radiology. Conflicts of
interest: none declared.
Kamarjit Mangat MB BCh FRCS FRCR is a Consultant Interventional
Radiologist with Specialist Interest in Hepatobiliary Imaging and
Interventional Radiology at Queen Elizabeth Hospital, Birmingham, UK.
Conflicts of interest: none declared.

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Figure 1 A normal gallbladder (GB) in the fasting state is distended and

has a thin wall.

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Figure 2 Acute cholecystitis with gallstone and acoustic shadow. Note the thickened wall (**) of the gallbladder and the acoustic shadowing caused by the
gallstone (arrow). Not all stones cause a shadow on ultrasound as demonstrated in b (arrow).

US is also reliable in assessing for biliary duct dilatation. The

common hepatic duct (CHD) measures 4e5 mm in diameter and
is seen in almost all patients. The intrahepatic ducts (IHD) are
seen only if they are dilated (Figure 3). The common bile duct
(CBD) is usually seen within the head of the pancreas (Figure 4).
The presence of gas in overlying stomach or transverse colon
may hinder good visualization.
The CBD usually measures up to 6 mm in diameter up to the
age of 60 with a further allowance of 1 mm per decade of age
thereafter.2 Previous surgery in the region, in particular cholecystectomy, can also account for non-pathological increases in
diameter. Other causes of duct dilatation include intestinal
hypomobility, hyperalimentation and prolonged fasting.
If true dilatation is found, an obstructive lesion should be
considered. A double duct sign refers to a dilated pancreatic
duct and a dilated CBD, and is usually due to ampullary or

pancreatic head neoplasia. Conversely, bile duct obstruction

without dilatation is seen in patients with low-grade or intermittent obstruction resulting from stricture or small stones and in
patients with sclerosing cholangitis.
US is only 21e63% accurate for detecting bile duct stones3,4;
if no obvious cause for obstruction is seen further investigation is
mandatory.
Liver disease: US is used as a screening tool for suspected diffuse
or focal liver disease. It allows the architecture of the liver to be
easily assessed. A normal liver has a uniform homogenous
echotexture. The echogenicity is affected by several factors, such
as the equipment, the transducer frequency and the setting on
the US. It is best to compare the echogenicity against internal
structures, most commonly the right renal cortex. The liver is
slightly hyperechoic or isoechoic with respect to the renal cortex,
provided the latter is normal (Figure 5).
US is highly sensitive in differentiating cystic from solid
lesions, but not as sensitive as CT or MRI in characterizing focal
solid liver lesions (Figure 6). The sensitivity for detecting liver
metastases is 40e70%.5 It is generally unable to detect lesions

Figure 3 Normally the intrahepatic ducts (IHD) are not seen on ultrasound.
When visualized it is usually indicative of biliary obstruction (arrow). Note
the adjacent portal vein (pv). The proximity of the dilated IHD to the pv
produces the so-called parallel sign.

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Figure 4 The normal portal vein (pv) and common bile duct (**).

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Figure 5 The liver is normally slightly isoechoic or hyperechoic to the right kidney (a). In disease states, such as a fatty liver (b), the liver appears brighter
than the adjacent kidney. Fatty liver is a non-specific appearance and can result from a range of conditions such as diabetes, hypercholesterolaemia and
excessive alcohol intake.

smaller than 1 cm. The presence of diffuse liver disease lowers

the sensitivity of US for detection of focal lesions.

diastolic flow because of the low impedance and is in the same

directions as normal portal vein. In patients with transplanted
livers, the waveform of the hepatic artery is important in detecting
stenosis or thrombosis in the blood supply of the allograft. Colour
flow imaging and Duplex are also of use in detecting thrombus,
fistulas and aneurysms within the hepatic vasculature in patients.
Despite the potential advantages of US contrast agents, their
use remains limited in clinical practice, largely due to the need
for intravenous injection and the narrow window of time within
which the scan has to be performed after contrast injection.
Applications include the assessment of flow from tumours such
as hepatocellular carcinoma (HCC) and the detection and characterization of hepatic lesions.6
Intraoperative US and laparoscopic US are highly sensitive for
detecting liver lesions not seen on routine pre-operative imaging
and are regularly used before hepatic resection. Endoscopic US
(EUS) is useful in evaluating the left lobe of the liver and lymph
nodes in the gastro-hepatic ligament, and for fine needle aspiration of liver lesions. EUS is also useful for assessing lesions
near the ampulla, pancreatic or hilar lesions and it can also be
used to look for small CBD stones or biliary sludge.

Doppler and colour US: colour flow and Duplex are used to assess
hepatic vessels and tumour vascularity. The velocity and waveform of the portal veins, hepatic vein and the hepatic artery can be
reliably assessed. The portal veins are of low velocity (10e20 cm/
second) with a respiratory variation (Figure 7). In portal hypertension, there is loss or attenuation of the portal vein flow. On
Duplex US, the hepatic veins have a triphasic flow pattern similar
to the inferior vena cava (IVC) with respiratory and cardiac cycle
variation. The normal flow in the hepatic veins is towards the IVC.
In tricuspid regurgitation, there is reverse flow in the hepatic veins.
In cirrhosis, there is loss of the triphasic pattern since the encased
hepatic vein is less compliant. The hepatic artery has a high

Figure 6 Ultrasound is sensitive in detecting solid from cystic lesions, but

not in characterizing them. This lesion is hypoechoic compared to the rest
of the liver. It was thought to be due to focal fatty sparing, but needed
magnetic resonance imaging to confirm its nature and avoid the patient
any unnecessary biopsy.

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Figure 7 The flow in the normal portal vein is monophasic. Colour Doppler
with the cursor placed in the middle of the portal vein.

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Arterial phase: the blood supply of the liver is via the hepatic
artery (25%) and the portal vein (75%). Most tumours have
a predominantly arterial supply.
Imaging the liver 20 seconds after the start of the injection of
contrast is ideal for detecting most lesions. It is a very short phase
because iodinated contrast diffuses rapidly from the intravascular compartment into the extravascular space. Highly vascular
lesions are highlighted against a background of unenhanced
normal liver parenchyma. Such lesions will become isodense if
scanned later during the equilibrium phase, and may be missed.
Portal venous phase: this the commonest phase scan performed
for the evaluation of the liver. It is performed with a delay of
50e70 seconds after contrast injection. There is maximum
enhancement of the liver parenchyma. Many liver metastases are
supplied primarily by the hepatic artery and may therefore
appear as hypodense compared with the normal surrounding
liver parenchyma during this phase (Figure 8).

Figure 8 Multiple metastases (*) become more conspicuous compared to

the normal liver parenchyma in the portal venous phases, where they
appear as lower attenuation.

Delayed phase: delayed imaging, usually obtained 10e20

minutes after injection of contrast, is rarely used; it may be useful
in detecting intrahepatic cholangiocarcinoma and metastases.
Retention of contrast may be seen in cholangiocarcinoma,
fibrous tumours or scar tissue.

Computed tomography (CT)

Advances such as helical CT and multi-detector CT (MDCT) have
enabled rapid image acquisition, improved spatial resolution and
the ability to image the liver and biliary tree in multiple phases of
contrast enhancement in a more precise manner. Advances in
post-processing images have allowed the acquisition of 3D
images of the hepatic vasculature (CT angiography), which is
important in mapping the vascular anatomy and tumour volume.
Intravenous iodinated contrast, routinely used for CT, increases
the relative attenuation difference between focal lesions and
vessels from the normal hepatic parenchyma, making them more
conspicuous. Enhancement of the liver is dependent on the phase
of contrast delivery during which scanning occurs. It also helps to
characterize focal lesions based on the enhancement pattern
during the various phases of contrast circulation in the liver. When
performed properly, CT will suffice for most clinical indications.
The various phases used are:

General uses of CT: CT is useful for assessing the overall background of the liver as well as giving an overview of the
remainder of the abdominal contents. Multiphase MDCT is an
effective method for detecting liver tumours and characterizing
focal lesions.
The main indication for CT in biliary disease is for the diagnosis
and staging of GB carcinoma and in the evaluation of complications of cholecystitis, such as perforation and pericholecystic
abscess. It is also used in identifying the cause of biliary
obstruction, such as periampullary pancreatic tumours and nodal
masses at the porta hepatis (Figure 9). Often, it will differentiate
benign from malignant causes of obstruction and provides guidance for biopsy and radiological staging of biliary tumours.
Despite the immense usefulness of CT in modern medical
practice there are some limitations that should be borne in mind.
First, its high radiation dose, especially in MDCT with multiphase

Unenhanced: unenhanced CT is not done routinely unless haemorrhage or calcification is suspected within liver lesions.

Figure 9 Dilated common bile duct (**) on US. The cause on US was unknown. On CT, there is intrahepatic bile duct dilatation (*). The dilated ducts on CT
are of lower density compared to the adjacent intrahepatic branches of the portal vein, which contain contrasts within them. CT was useful in identifying
the cause of the obstruction in this patient as being due to malignancy of the pancreatic head (not shown).

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scanning; second, its low sensitivity for detecting and characterizing lesions smaller than 1 cm; and third, iodinated contrast is
contraindicated in those with history of previous anaphylaxis
and should be used with extreme caution in patients with renal
impairment.

in CT. It diffuses out of the intravascular space into the liver

parenchyma, so rapid imaging is required to exploit differences
between the lesion and the surrounding liver parenchyma. In an
analogous manner to multiphase MDCT, imaging is obtained in
several timed phases. This dynamic contrast enhancement
pattern is useful in the characterization of many focal hepatic
lesions, including haemangiomas, hypervascular metastases,
HCC, focal nodular hyperplasia and adenomas.
Liver-specific agents, such as mangafadipir trisodium (taken
up by hepatocytes) and ferrumoxides (taken up by Kupffer cells),
demonstrate selective uptake in the liver and are used primarily
for lesion detection.8 Other agents that combine the effect of
gadolinium but are excreted primarily via the biliary tree are also
available and are used for characterization of focal lesions.
Fat suppression techniques are useful in detecting cellular fat;
they can differentiate pseudolesions, such as focal fatty infiltration and focal fat sparing, from pathological liver lesions. The use
of 3D gradient recall echo (GRE) sequences has improved MRI by
providing a dynamic, contrast-enhanced thin-section images
with fat saturation and high signal-to-noise ratio. The advantages
of 3D techniques over 2D dynamic imaging are the ability to
reformat in any plane, and high-quality thin-section imaging with
no gaps. In addition the data can be used to generate MR of the
vasculature (MR angiography).
Magnetic resonance cholangiopancreatography (MRCP) is
a non-invasive investigation that involves no contrast. It uses
heavily weighted T2 sequences to delineate the ductal system. It
involves acquiring thin-slice images, usually in a single breath
hold with reduced motion artefact, although more modern
machines are using respiratory gating sequences.
The diagnostic accuracy of MRCP is comparable to that of ERCP
in the evaluation of bile duct stones, malignant biliary obstruction
and anatomic variants, as well as the visualization of the pancreatic

Magnetic resonance imaging (MRI)

In many centres, MRI is the modality of choice for investigating
complex hepatobiliary disease. The development of rapid
acquisition techniques and tissue-specific contrast agents, the
lack of ionizing radiation and the ability to produce non-invasive
cholangiograms make it an ideal investigation. It is very useful in
investigating focal liver lesions, the biliary tree, intrinsic biliary
lesions, and to a lesser extent, extrinsic lesions. Its disadvantages
include cost, limited availability and the usual general contraindications to MRI imaging.
MRI is used to diagnose and characterize diffuse and focal liver
disease, and obviates the need for invasive procedures such as
biopsy. Biopsies should be avoided if at all possible, especially if
tumour is suspected, due to the risk of seeding along the needle track.
Most focal hepatic lesions can be reliably characterized with MRI.
MRI is also useful for mapping of tumours before treatment.
Various sequences are used; these usually include dynamic
gadolinium imaging, with images acquired at different time
points after contrast administration. Contrast enhancement
patterns can be specific to focal lesions and a knowledge of
which contrast agent has been injected is vital as there is an
increasing portfolio of agents, several of which are liver-specific,
and their actions are different (Table 1).
Various contrast agents are used in MRI imaging of the liver.7
Gadolinium is the most commonly used agent. It has an excellent
distribution and behaves in a similar fashion to iodinated agents

MRI characteristics of focal liver lesions

Benign hypodense/hypoenhancing lesions
Hepatic cysts
Regenerating/dysplastic nodules e cirrhosis
Lipoma
Bile duct hamartoma
Malignant hypodense/hypoenhancing lesions
Hypovascular metastases (e.g. colon, lung, prostate, stomach)
Lymphoma
Arterial hyperdense/hyperenhancing lesions
Benign e hepatic adenoma
Malignant e HCC, hypervascular metastases (e.g. thyroid,
melanoma, breast, carcinoid)
Hypervascular lesion with central scar e FNH, fibrolamellar HCC
Delayed enhancement
Haemangiomas, cholangiocarcinoma
Other patterns of enhancement
Ring enhancement e abscess, pseudocysts,
post-radiofrequency ablation
Peripheral washout e metastases (e.g. carcinoid, breast)
Figure 10 Magnetic resonance cholangiopancreatography (MRCP) in
coronal plane. Note the dilated CBD and hepatic ducts. The obstruction
was due to a low CBD stone which appeared as a filling defect (arrow).
CBD stone on MRCP.

FNH, focal nodular hyperplasia; HCC, hepatocellular carcinoma.

Table 1

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mimic filling defects. It is very important to review all of the images

in both the axial and coronal planes to avoid these pitfalls.12
Diffusion-weighted MRI is a form of MRI in which benign
lesions can be delineated from malignant ones. Malignant lesions,
such as HCC and metastases, have a low apparent diffusion coefficient (ADC), whereas benign lesions have a high ADC. This
modality is also used to differentiate liver abscess from cystic and
necrotic tumours. Abscesses are markedly hyperintense whereas
cystic or necrotic tumours are hypointense on MRI-DWI.13
Direct cholangiography
This involves two techniques, percutaneous transhepatic cholangiography (PTC) and ERCP. These are fluoroscopic techniques
in which the biliary tree is opacified directly using iodinated
contrast. Normally, antibiotics are given before the procedure to
prevent sepsis, and any coagulopathy corrected.
These techniques are most useful when intervention (stent
placement, drainages, biopsy or brushings) is needed. They have
over a 95% success rate in determining the site of obstruction
and more than a 90% success rate in determining its cause.
Direct cholangiography is also of use in assessment of biliary
leaks and biliary fistulas.
In PTC, the biliary system is punctured peripherally using
a fine needle (Chiba-22G), under US and/or fluoroscopic guidance with contrast being injected to opacify the ducts. PTC is
uniformly successful in experienced hands where the ducts are
dilated and allows therapeutic measures (e.g. stent placement,
biopsy, stone extraction) to be undertaken (Figure 11).
In ERCP, the biliary tree is accessed distally in a retrograde
fashion via an endoscope. It allows visualization and biopsy of the
ampulla, and therapeutic manoeuvres such as sphincterotomy,
stone extraction and stenting. The pancreatic duct is also assessed.
The choice of PTC versus ERCP depends on several factors.
ERCP is impossible in the presence of previous biliary-enteric
bypass surgery. In our institution, ERCP is the method of
choice in cases of low biliary obstruction, whereas PTC is
preferred in cases where obstruction is higher than the common
hepatic duct, or where ERCP has failed.14
However, the choice of PTC versus ERCP also depends on the
planned therapeutic procedure; if CBD stones are suspected,

Figure 11 Percutaneous transhepatic cholangiography demonstrating

dilated proximal CBD and intrahepatic ducts (thin arrows). The lack of
contrast in the mid-CBD was due to a stricture (thick arrow). Such
a shouldered stricture is usually due to a malignant stricture.

duct.9 MRCP is more sensitive than US and CT for imaging CBD

stones, and is especially accurate when these are symptomatic10,11
(Figure 10). Stones (as small as 2 mm) are seen as wellcircumscribed, low signal-intensity filling defects in the biliary tract.
MRCP has obvious advantages over direct cholangiography: no contrast is injected, and there is no radiation and no
risk of the complications associated with ERCP, such as
pancreatitis, perforation or sepsis. There is also no requirement for sedation or post-sedation recovery. ERCP should be
reserved for those cases where a therapeutic option is
required at the same sitting.
The disadvantages of MRCP are that gas, blood or abnormalities
within the duct can simulate stones, and signal loss can result from
surgical clips. Bright signal from fluid collections within the
abdomen, ascites or oedema may also interfere with the signal
from biliary fluid. Flow artefacts from adjacent vessels can also

Figure 12 This patient had undergone previous radiofrequency ablation (RFA) for this malignant liver lesion. On the follow-up CT scan (a), it was not easy
to determine whether the low-density lesion (*) was due to residual disease or post-RFA changes. PET-CT was used as a problem-solving tool. The fused
images from PET-CT (b) show that this lesion was highly metabolically active () compared with the surrounding liver and therefore confirmed that it was
due to residual disease activity rather than pure post-RFA changes.

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ERCP with sphincterotomy and endoscopic stone extraction may

be the procedure of choice. ERCP is also preferred in a nondilated biliary duct system, low CBD strictures, or where the
primary suspected pathology is in the pancreas and opacification
of the pancreatic duct is needed for the diagnosis.
Complication rates of direct cholangiography are 1e2% and
include sepsis, biliary peritonitis, bleeding, inadvertent damage
to adjacent organs and pancreatitis.
Nuclear medicine
Radionuclide imaging of the biliary tree is a useful technique that
can demonstrate both anatomy and function. In cholescintigraphy, the patient is injected with technetium 99 (radioisotope)
labelled hydroxy iminodiacetic acid (99m Tc-HIDA). The tracer is
taken up by the liver and excreted in the bile. In acute cholecystitis,
the main finding is prompt biliary excretion of the tracer without
demonstration of the GB. This method is very sensitive and
specific for the diagnosis of acute cholecystitis. Despite this, this
test is not commonly used for diagnosing acute cholecystitis. False
positives occur in patients with abnormal bile flow due to liver
disease, or a prolonged fast with a distended sludge-filled GB.
Positron emission tomography-CT (PET-CT)
This relatively modern method of imaging has an important role in
the evaluation of metastatic disease. Most malignant lesions have
a higher metabolic activity than the surrounding tissues because
they have a greater uptake of glucose, labelled as 18F-fluoro-2deoxy D glucose (FDG) (Figure 12). This allows the identification of malignant tumour foci.15 PET is highly sensitive and can
look at the entire body. The disadvantages are the cost, limited
availability and limited sensitivity for lesions less than 1 cm in
diameter. False positives occur in areas of increased metabolism,
due to inflammation or infection. PET-CT combines the advantages of CT with the functional ability of PET by fusing the images.
This helps to localize the areas of abnormality accurately.
A

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1 Ralls PW, Colletti PM, Lapin SA, et al. Real-time sonography in suspected acute cholecystitis. Prospective evaluation of primary and
secondary signs. Radiology 1985 June; 155: 767e71.

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