Answer for BIR CoW 23 Aug 2026
Portal biliopathy
Findings
Liver measure 14.4 cm showing irregular surface with relative left lobe atrophy and caudate lobe hypertrophy. Spleen appears enlarged measuring 18.3cm, Splenic index- 1350cc. Evidence of multiple T2 hypointense calculi noted in common bile duct, common hepatic duct and right posterior sectoral duct largest measuring 1.5 x 1.3 cm in common hepatic duct. Cavernous transformation of portal vein noted. Multiple dilated tortuous peripancreatic and periportal collaterals noted causing extrinsic compression over the distal common bile duct with dilatation of common hepatic duct and bilobar intrahepatic biliary radicles. Splenic vein not visualised and replaced by multiple tortuous splenorenal, omental and splenic hilar collaterals. Gallbladder not visualised.- Status post cholecystectomy.
Discussion
Definition Portal biliopathy refers to biliary ductal and gallbladder abnormalities occurring secondary to long-standing extrahepatic portal vein obstruction (EHPVO) with portal cavernoma. The biliary changes are caused by extrinsic compression from peribiliary venous collaterals and ischemic injury to the bile ducts. Radiological Findings Irregular strictures with alternating dilatation of the intrahepatic and extrahepatic bile ducts. Smooth narrowing and displacement of the common bile duct due to collateral veins. Gallbladder varices and biliary calculi may be seen in chronic cases. Ultrasound with Doppler demonstrates portal vein thrombosis and cavernous transformation. MRCP is the preferred non-invasive investigation for evaluating biliary abnormalities. Contrast-enhanced CT/MRI depicts the portal cavernoma and peribiliary collateral veins. ERCP is reserved mainly for therapeutic intervention. Pseudocholangiocarcinoma Sign The pseudocholangiocarcinoma sign is the appearance of a smooth stricture of the common hepatic duct or common bile duct caused by compression from enlarged peribiliary venous collaterals, mimicking cholangiocarcinoma on cholangiography. The presence of a portal cavernoma, venous collaterals, and the absence of an enhancing biliary mass help differentiate this benign condition from malignancy. Clinical Significance Most patients are asymptomatic. Symptomatic cases present with obstructive jaundice, recurrent cholangitis, or biliary stones. Recognition of portal biliopathy and the pseudocholangiocarcinoma sign is important to avoid misdiagnosis and unnecessary surgery.
REFERENCES
Dhiman R. K., Behera A., et al. Portal biliopathy. Gut. 2007;56(7):1001–1008. Chandra R., et al. Portal biliopathy: Radiological features and imaging approach. Abdominal Radiology / standard radiology reviews.
Findings
Liver measure 14.4 cm showing irregular surface with relative left lobe atrophy and caudate lobe hypertrophy. Spleen appears enlarged measuring 18.3cm, Splenic index- 1350cc. Evidence of multiple T2 hypointense calculi noted in common bile duct, common hepatic duct and right posterior sectoral duct largest measuring 1.5 x 1.3 cm in common hepatic duct. Cavernous transformation of portal vein noted. Multiple dilated tortuous peripancreatic and periportal collaterals noted causing extrinsic compression over the distal common bile duct with dilatation of common hepatic duct and bilobar intrahepatic biliary radicles. Splenic vein not visualised and replaced by multiple tortuous splenorenal, omental and splenic hilar collaterals. Gallbladder not visualised.- Status post cholecystectomy.
Discussion
Definition Portal biliopathy refers to biliary ductal and gallbladder abnormalities occurring secondary to long-standing extrahepatic portal vein obstruction (EHPVO) with portal cavernoma. The biliary changes are caused by extrinsic compression from peribiliary venous collaterals and ischemic injury to the bile ducts. Radiological Findings Irregular strictures with alternating dilatation of the intrahepatic and extrahepatic bile ducts. Smooth narrowing and displacement of the common bile duct due to collateral veins. Gallbladder varices and biliary calculi may be seen in chronic cases. Ultrasound with Doppler demonstrates portal vein thrombosis and cavernous transformation. MRCP is the preferred non-invasive investigation for evaluating biliary abnormalities. Contrast-enhanced CT/MRI depicts the portal cavernoma and peribiliary collateral veins. ERCP is reserved mainly for therapeutic intervention. Pseudocholangiocarcinoma Sign The pseudocholangiocarcinoma sign is the appearance of a smooth stricture of the common hepatic duct or common bile duct caused by compression from enlarged peribiliary venous collaterals, mimicking cholangiocarcinoma on cholangiography. The presence of a portal cavernoma, venous collaterals, and the absence of an enhancing biliary mass help differentiate this benign condition from malignancy. Clinical Significance Most patients are asymptomatic. Symptomatic cases present with obstructive jaundice, recurrent cholangitis, or biliary stones. Recognition of portal biliopathy and the pseudocholangiocarcinoma sign is important to avoid misdiagnosis and unnecessary surgery.
REFERENCES
Dhiman R. K., Behera A., et al. Portal biliopathy. Gut. 2007;56(7):1001–1008. Chandra R., et al. Portal biliopathy: Radiological features and imaging approach. Abdominal Radiology / standard radiology reviews.
Note:
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!