Hepatic pseudolesion due to unrecognized obstruction of right posterior hepatic duct from cholecystectomy
Presentation
Evaluate indeterminate echogenic liver lesion in the right hepatic lobe seen on ultrasound (not shown). History of cholecystectomy 4 years prior.
Patient Data
Ill-defined hypoenhancement involving hepatic segments six and to a lesser extent hepatic segment seven. This is associated with dilation of the intrahepatic ducts draining the segments, which appear to lead to the cholecystectomy clips. No hyperenhancement on arterial and portal venous phases. No discrete mass.
Moderate dilation of the intrahepatic bile ducts draining hepatic segments six and seven with relative atrophy and T2 hyperintensity/heterogeneous hypoperfusion of the segments compared to the remainder of the liver.
The dilated segments of the posterior right hepatic duct leads to the susceptibility artifact associated with cholecystectomy clips. No other intrahepatic biliary ductal dilatation. The right anterior left intrahepatic ducts are patent. No intraluminal mass or abnormal enhancement is associated with this finding.
Case Discussion
Variant intrahepatic bile duct anatomy such as the right posterior hepatic duct draining the common hepatic duct or into the cystic duct are examples which can have increased risk of inadvertent clipping/occlusion at the time of cholecystectomy. The operative note was reviewed and no such anatomical variant was noted.
However, it is quite apparent that the dilated intrahepatic ducts draining segments six and seven (which is the right posterior hepatic duct) lead into cholecystectomy clips without evidence of mass. There is relative atrophy of hepatic segments six and seven. This makes chronic obstruction of these ducts due to inadvertent clipping at the time of cholecystectomy the most likely and logical explanation of these findings.
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