Objectives

- To briefly review the pathophysiology of biliary system related emergencies.

- To identify the imaging appearances of both usual and unusual emergent biliary conditions in distinct imaging modalities.

- To discuss differential diagnostic hypotheses in the depicted clinical scenarios.

Background

Emergent biliary conditions may occur with several clinical presentations, the most frequent being abdominal pain, fever, jaundice and/or elevated direct bilirubin and liver enzymes – the so-called cholestatic pattern. As various biliary conditions may present with similar clinical and laboratory features, imaging is frequently required to accurately achieve diagnosis.

Imaging findings OR Procedure findings

We present a wide range of emergent biliary conditions, including the most common but also several unusual presentations, using a multimodality imaging approach (ultrasound, CT, MRI, endoscopy, EUS and ERCP).

Cases are categorized in inflammatory, obstructive, fistulizing, vascular and iatrogenic, according to the main pathological mechanism involved.

When relevant, the main differential diagnoses are discussed along with their imaging features.

Conclusion

An adequate imaging workup plays a crucial role in the diagnosis and treatment referral of patients with biliary emergencies. Ultrasound and CT are the more frequently used modalities in the emergency setting, while MRI is used in selected cases to provide a more detailed characterization of the biliary system.

Recognition of the characteristic imaging findings of both common and uncommon biliary tract related pathologies is therefore a fundamental skill for the radiologist.