Modern imaging in the evaluation of hepatolithiasis

Hepatolithiasis is a primary disease of the biliary ducts, presenting with recurrent pyogenic cholangitis, complicated by parenchymal infection, obstructive cholangiopathy and subsequent parenchymal destruction. Cholangiocarcinoma is a rarer complication. Modern imaging aims at accurate delineation of biliary ducts and liver parenchyma. It directs planning of surgical or interventional treatment, and serves to guide these procedures. The characteristic features comprise varying combinations of ductal dilatation, intrahepatic/extrahepatic ductal stones, segmental ductal strictures and lobar/segmental atrophy; and in acute exacerbation parenchymal or ductal contrast enhancement, abscess and biliary obstruction. Ultrasonography is the preferred primary examination. Further imaging depends on the ultrasonography findings, the patient's symptomatology, the clinical problems and the intended mode of treatment. Contrast cholangiography is warranted preceding biliary intervention. Computed tomography evaluates ductal stones, extent of disease, acute parenchymal complications and prior to hepatic resection. Magnetic resonance imaging is less accessible, but obtains cross-sectional findings similar to computed tomography. It comprehensively evaluates the liver and portal venous system, for prognostic indication and contemplation of liver resection. For diagnostic purposes, magnetic resonance cholangiography promises to replace the more invasive contrast cholangiography. Therapeutic approaches tailored to the results of strategically applied imaging helps to improve the outcome of patients with hepatolithiasis.