- Critical Review
- Open access
- Published:
CT and MR imaging of primary biliary cholangitis: a pictorial review
Insights into Imaging volume 14, Article number: 180 (2023)
Abstract
Primary biliary cholangitis (PBC) is a rare chronic autoimmune-mediated cholestatic liver disease involving medium and small bile ducts that can lead to liver fibrosis and cirrhosis. To date, the pathogenesis of PBC remains elusive, and there is currently no curative medical treatment. Computed tomography (CT) and magnetic resonance (MR) imaging, as common technical tools that allow non-invasive monitoring of liver tissue in vivo, play crucial roles in the diagnosis, staging, and prognosis prediction in PBC by enabling assessment of abnormalities in liver morphology and parenchyma, irregular configuration of bile ducts, lymphadenopathy, portal hypertension, and complications of cirrhosis. Moreover, CT and MRI can be used to monitor the disease progression after treatment of PBC (e.g. the onset of cirrhotic decompensation or HCC) to guide the clinical decisions for liver transplantation. With the optimization of imaging technology, magnetic resonance elastography (MRE) offers additional information on liver stiffness, allows for the identification of early cirrhosis in PBC and provides a basis for predicting prognosis. Gadoxetic acid-enhanced MRI enables the assessment of liver function in patients with PBC. The purpose of this review is to detail and illustrate the definition, pathological basis, and clinical importance of CT and MRI features of PBC to help radiologists and clinicians enhance their understanding of PBC.
Critical Relevance Statement
Characteristic CT and MR imaging manifestations of primary biliary cholangitis may reflect the course of the disease and provide information associated with histological grading and altered cellular function.
Key points
• Imaging has become highly useful for differentiating PBC from other diseases.
• Key pathological alterations of PBC can be captured by CT and MRI.
• Characteristic manifestations provide information associated with histological grade and cellular function.
• Despite this, the CT or MRI features of PBC are not specific.
Graphical Abstract
Introduction
Primary biliary cholangitis (PBC) is an uncommon, chronic, autoimmune-mediated cholestatic liver disease. It is characterized by progressive, nonsuppurative destruction of medium to small bile ducts [1]. Although some previous studies have indicated that the development of PBC involves an interaction of multiple factors, including environmental [2,3,4], genetic/epigenetic [5, 6], and immunological factors [7, 8], the exact origin (or origins) of PBC is still unknown. PBC usually affects middle-aged women and commonly presents as fatigue and pruritus. It can also be asymptomatic, with elevated serum alkaline phosphatase (ALP) or glutamyl transpeptidase (GGT) [9, 10]. The presence of antimitochondrial antibody (AMA) or other PBC-specific anti-nuclear antibodies is highly sensitive and specific for PBC in clinical settings. Ursodeoxycholic acid (UDCA) is recommended as the first-line treatment for PBC. For patients with an insufficient UDCA response, the use of second-line drugs such as obeticholic acid (OCA), fibrates, and budesonide has been shown to be effective in improving patient survival [11]. However, in the absence of proper treatment, there is a high probability of progression to liver fibrosis, leading to end-stage liver disease and a range of complications [12, 13].
In the past, imaging was primarily used for differentiating the disease from extrahepatic biliary obstructive disease. With the update of imaging technologies and the depth of relevant research, our understanding of the imaging manifestations of PBC has gradually improved, and several characteristic imaging features of PBC have been identified that can assist in the diagnosis, staging, outcome monitoring and disease prognosis of PBC. However, previous studies on the imaging of PBC were sporadically reported, lacking a summary, interpretation, and discussion of the clinical significance of the various imaging features of the disease, and did not provide sufficient guidance to radiologists and clinical researchers. The aim of this review is to describe the definition, pathological basis, and clinical importance of the computed tomography (CT) and magnetic resonance imaging (MRI) features of PBC and to summarize the application of the latest MRI techniques in PBC. In addition, the differentiation of PBC from other similar diseases is also briefly discussed.
Historical background
The designation of PBC, originally known as “primary biliary cirrhosis”, was prompted by the discovery that the formation of xanthoma or jaundice in PBC might be associated with biliary cirrhosis due to inflammatory destruction of small intrahepatic bile ducts [14]. Use of the above nomenclature continued for nearly a decade until it was found that not all patients with PBC develop cirrhosis and that patients have a relatively good prognosis (i.e., the median survival in fatal cases was up to 5.5 years and can exceed 10 years in asymptomatic patients), indicating that “primary biliary cirrhosis” might not accurately reflect the natural history of the disease [15]. It was not until 1965 that researchers discovered that the key serological indicator (i.e. AMA) was associated with the clinical subtype of PBC [16]. This important finding suggested the possibility of diagnosing PBC at an earlier pre-cirrhotic stage and eventually, in 2015, led to a change in the name to “primary biliary cholangitis” [17], which has remained in use to date.
Epidemiology
PBC is a disease in which female involvement is overwhelmingly dominant (the female-to-male incidence ratio is approximately 3.9–10:1) [1, 18,19,20]; however, the incidence in male patients has been gradually increasing (female-to-male ratio (3.9–6.2:1) in recent years [21,22,23,24,25]. According to statistics from the 2022 Asia–Pacific Society for the Study of the Liver (APASL) guidelines [11] and the latest meta-analysis, the estimated global incidence and prevalence of PBC are 17.6 and 146 per million, respectively, with North America being the highest, followed by Europe, and the lowest in the Asia–Pacific region. Notably, all three regions showed an upward trend in the incidence and prevalence of PBC, with North America showing the fastest growth in prevalence. In addition, the prevalence of PBC in the Asia–Pacific region has exceeded once deemed and is increasing rapidly. This may represent real growth, or it may be due to the improvement of awareness and ability regarding PBC and its treatment [26]. In addition, with the introduction of UDCA agents, the prognosis of PBC patients dramatically improved, even in those with insufficient response to UDCA [27, 28].
Histopathology and pathophysiology
The characteristics of PBC are variable and coexist in different stages of the disease, including florid duct lesions, portal tract inflammation, bile duct reduction, fibrosis, and cirrhosis [29] (Fig. 1). Florid duct lesions, defined as nonsuppurative destructive cholangitis, are distinctive in PBC. Parenchymal inflammatory necrosis may be seen but is usually mild. Bile duct reduction is the result of bile duct injury from persistent ductal and portal inflammation, with the smallest bile duct branches being the first to be involved. Portal and periportal collagen deposition finally leads to fibrosis and cirrhosis. However, the premature ductopenic variant, found in less than 10% of patients with PBC, is characterized by sudden and marked bile duct loss that is disproportionate to hepatic fibrosis.
In the multistep pathophysiological process of PBC, the presence of AMAs is key to the autoimmune destruction of biliary epithelial cells (BECs) [30]. The multilineage immune response, including AMAs, targets a specific family of mitochondrial enzymes within BEC, particularly the E2-subunit of the pyruvate dehydrogenase complex (PDC-E2). It also results in the cell death of BECs and eventually the loss of small and medium bile ducts with subsequent cholestasis and fibrosis [8, 30].
Diagnosis and staging
According to 2022 APASL guidelines, two of the following three conditions must be met to establish the diagnosis of PBC [11]: (1) chronic cholestasis with elevated ALP (other causes of cholestasis are excluded); (2) positive AMA or PBC-specific autoantibodies such as sp100 or gp210 if AMA is negative; and (3) liver biopsy suggesting nonsuppurative destructive cholangitis. However, the presence of atypical clinical phenotypes (e.g. AMA-negative disease) or variants of PBC (e.g. PBC with autoimmune hepatitis [AIH] features) increases the difficulty of diagnosing PBC clinically [11].
The conventional staging systems of PBC include the Ludwig [31] and Scheuer [32] staging systems (Electronic Supplementary Material Table 1), which have long been recommended in guidelines and widely used in PBC research [11]. Recently, some new approaches have been proposed for the staging of PBC. Nakanuma’s staging system showed the strongest prognostic value compared to previous methods, especially in predicting cirrhosis and its complications [33, 34]. Wendum’s staging system showed better correlations with biochemistry than conventional staging systems and exhibited substantial intraobserver and moderate interobserver reproducibility [35]. As mentioned above, liver biopsy is crucial in diagnosing antibody-negative PBC and in disease staging. However, biopsy is invasive and prone to sampling errors. Thus, there is an urgent need for non-invasive markers such as imaging, to provide a complementary role in the diagnosis and staging of PBC when biopsy is not feasible (e.g. when the patient is in poor general condition, in combination with hematological disorders, or unconscious) and in disease follow-up.
CT and MRI features of PBC
CT and MRI, with their advantages of non-invasive, multiparameter and multiplane imaging, enable visualization of the morphological and functional alterations associated with the development and progression of PBC [36]. The definition, pathological basis and clinical importance of the characteristic CT and MRI features of PBC are summarized in Table 1.
Abnormalities in liver morphology
Hepatomegaly
Hepatomegaly is defined as abnormal diffuse enlargement of the liver. Imaging diagnosis of hepatomegaly is mainly based on subjective evaluation supplemented by lineal craniocaudal measurement (e.g. craniocaudal diameter of the liver in midclavicular line of ≥ 15.5 cm) [37, 38]. However, unidimensional measurement cannot accurately reflect liver volume, and a consensus on the threshold of hepatomegaly is still lacking [49]. Hepatomegaly in PBCs is thought to be associated with diffuse intrahepatic cholestasis, hepatocyte edema, degeneration, and massive inflammatory cell infiltration [29]. Approximately 11–50% of patients with PBC present hepatomegaly, with the exact percentage tending to decrease with increasing stage of the disease [37, 38, 44, 50].
Liver surface nodularity
The liver margin in patients with PBC can be smooth or nodular (with nodules of < 3 cm) [39]. The configuration of the liver margin is correlated with the size of the underlying regenerative nodules. Gerald et al. [39] reported that 64% of patients with cirrhosis caused by PBC presented with nodular liver margins, and 36% presented with smooth liver margins. However, lobulated liver margins (with more than one nodule > 3 cm) are not seen in PBC. The presence of liver surface nodularity was correlated with advanced stages of the disease and can be used for differentiating stage I–II and stage III–IV fibrosis in PBC[38].
Liver lobe redistribution
Lobal redistribution in PBC might be correlated with altered segmental portal venous perfusion, although the exact mechanism is still not fully understood [40]. Segmental atrophy often appears when the disease progresses to late cirrhosis [44]. Atrophy is only seen in 36% of patients with cirrhosis caused by PBC (half with diffuse atrophy and half with segmental atrophy), which is different to that of viral-induced cirrhosis, and focal atrophy of the left medial segment and right anterior segment is uncommon [39]. Previous studies have reported that segmental hypertrophy was common in PBC patients with stage IV fibrosis [37] but less frequent in those with advanced cirrhosis [44]. In PBC-induced cirrhosis, segmental hypertrophy (most common in the left lateral segment and the caudate lobe) is found more frequently than diffuse hypertrophy (56% vs. 12%) [39, 43].
Abnormalities in liver parenchyma
Liver parenchyma heterogeneity
Lace-like or patchy density or signal abnormalities in the liver parenchyma can be seen in PBC, which can be visualized both on unenhanced and contrast-enhanced images. It may be associated with parenchymal necroinflammatory changes or fibrosis and perfusion changes secondary to the destruction of portal vein branches [1, 38]. The degree of heterogeneity on T2-weighted imaging (T2WI) was reported to be significantly correlated with the fibrosis stages of PBC but not with the portal inflammation grade [38, 41].
Periportal halo sign
The portal halo sign is defined as a rounded low signal intensity lesion centred on a portal vein branch with a diameter of 5 mm to 1 cm but no mass effect on both T1-weighted imaging (T1WI) and T2WI and without obvious enhancement (Fig. 2) [42]. This sign may be correlated with the deposition of fibrous tissue and parenchymal extinction around the portal triads. The portal halo sign is the most typical feature of PBC, although it may sometimes also be found in autoimmune hepatitis-PBC overlap [51]. This sign is observed only in patients with later stages of the disease (fibrosis stage II or greater), and the prevalence tends to increase with the increase in the fibrosis stage [37, 38, 52].
Periportal edema
Periportal edema is not unique to PBC and can be seen in all processes involving ductal hyperplasia, lymphatic dilatation, and inflammatory cell infiltration [43]. This sign has been depicted on MRI in previous studies, mainly presenting as periportal hyperintensity on T2WI [37, 38, 41] (Fig. 3a), but in fact, it can also be seen on CT, where it presents as periportal low density (Fig. 3b). A previous study reported that periportal hyperintensity on T2WI was most common in the early stages of PBC, with a prevalence of 80–100% [45]. As the disease progresses, this sign is less likely to be seen, which is probably because the inflammatory process is gradually replaced by the accumulation of fibrous tissue. However, a recent study demonstrated no significant correlation between periportal hyperintensity on T2WI and fibrosis stage [38]. In addition, Kovač et al. [37] found that approximately 66.7% of patients with PBC with stage IV fibrosis still presented periportal hyperintensity on T2WI, which may indicate that periportal inflammation persists throughout the disease.
Irregular configuration of the biliary ducts
Magnetic resonance cholangiopancreatography (MRCP) may be normal in most patients with PBC, especially in the early stages of the disease when fibrosis in the portal triads has not developed. As the disease progresses to cirrhosis, irregularity and pruning will occur in the intrahepatic bile ducts [43]. Typical bile duct manifestations of PSC, such as beaded dilatation of the intrahepatic and extrahepatic biliary tree, are not seen in PBC. Instead, PBC often presents with segmental small bile duct dilatation, stenosis or poor visualization, mostly with involvement of the intrahepatic secondary bile ducts (Fig. 4).
Lymphadenopathy
Lymphadenopathy, defined as the presence of more than two enlarged lymph nodes (≥ 1 cm on the short axis), is reported to occur in 62–88% of PBC patients [37, 38, 44]. Enlarged lymph nodes can be seen in the periportal space, gastrohepatic ligament, retroperitoneal space, paracardial space and mesentery [42]. Lymphadenopathy is probably caused by benign reactive hyperplasia and has no obvious correlation with the fibrosis stage or inflammation grade of PBC [38].
Portal hypertension
Common signs of portal hypertension in PBC include splenomegaly, portal vein dilatation, portal vein thrombosis, and portosystemic collaterals [43, 45]. Portal hypertension is common in PBC. However, unlike other chronic liver diseases, portal hypertension can occur in the early stages of PBC before cirrhosis has developed, indicating that portal hypertension is initially presinusoidal [53]. Previous studies have demonstrated that the development and severity of portal hypertension is associated with the histological grade and long-term prognosis of PBC, and changes in the portohepatic gradient can be used to identify responders to UDCA treatment [54, 55]. In addition, splenomegaly is thought to be the first sign that may be captured on imaging in non-hemorrhagic PBC [45]. This may be related to prolonged portal hypertension and possible immune disarrangement in PBC. Other signs, such as the occurrence of portosystemic collaterals, are more relevant to advanced stages of the disease [37].
Complications of cirrhosis
Patients with advanced PBC can develop all the common complications of cirrhosis, including ascites, spontaneous bacterial peritonitis, variceal bleeding, hepatic encephalopathy, hepatorenal syndrome, and HCC [11]. Among these complications, ascites, spontaneous peritonitis (e.g. peritoneal thickening and blurring of the abdominal fat planes), and hepatocellular carcinoma can be identified and diagnosed on CT and MRI and require the attention of radiologists. PBC with baseline cirrhosis is widely recognized as a strong predictor of worse long-term outcomes, and liver transplantation should be considered once symptoms fail to resolve [11]. Close monitoring of HCC should be emphasized during the follow-up of patients with PBC, especially for high-risk patients with PBC, such as males, patients with advanced-stage disease, and non-responders to UDCA [11]. A recent meta-analysis showed that the pooled HCC incidence in patients with PBC cirrhosis at baseline was 13.05 per 1000 person-years, which was significantly higher than that of PBC patients without cirrhosis (the pooled HCC incidence of 0.35 to 6.02 per 1000 person-years) [56]. Therefore, for PBC patients with comorbid cirrhosis, regular surveillance of imaging by using non-invasive criteria such as LI-RADS allows for earlier detection of HCC and improves patient prognosis [57].
Liver stiffness quantification
Liver stiffness obtained from ultrasound elastography (USE) has been recognized as a reliable alternative to liver biopsy and histologic diagnosis of fibrosis and cirrhosis [36].
Recently, sound touch elastography (STE) has been introduced to achieve ultra-wide beam tracking imaging. This technique allows all shear waves to be detected within a few hundred microseconds and rapidly calculated, and thus, the results are developed in real time as elastography maps (Fig. 5) [58]. In the study of Luo et al. [59], liver stiffness measurements obtained by STE showed good capability to evaluate liver fibrosis stages in patients with autoimmune liver disease and were superior to the aspartate aminotransferase (AST)-to-platelet ratio index (APRI), and fibrosis-4 (FIB-4) index. In addition, a few published studies [58, 60] indicated that STE performed similarly to other USE technologies, such as shear wave elastography (SWE) and vibration-controlled transient elastography (VCTE) in chronic liver disease (including PBC) differentiation.
Magnetic resonance elastography (MRE) is considered to have equal diagnostic value as ultrasound in providing liver stiffness values and even outperforms ultrasound in monitoring early fibrosis [46, 61]. In PBC, liver stiffness measured by MRE can be used to identify histologically advanced fibrosis and performs better than biochemical indicators. In addition, liver stiffness > 4.30 kPa on MRE was considered to be a risk factor for the development of cirrhotic decompensation in PBC patients treated with UDCA [62].
Impairment of hepatocyte function
Hepatobiliary contrast agents, i.e. gadoxetate disodium (Gd-BOPTA) and gadobenate dimeglumine (Gd-EOB-DTPA), are increasingly being used for MRI-based diagnosis of cirrhosis or HCC [63]. The results of Liu et al. [64] have shown that the biliary imaging derived from the hepatobiliary phase of Gd-BOPTA-enhanced MRI could be used as a valuable tool in the prediction of hepatic decompensation and insufficiency for cirrhotic patients. However, Gd-EOB-DTPA has a pharmacokinetic profile different from that of Gd-BOPTA. In cirrhotic patients, as reported, Gd-BOPTA-enhanced MRI yielded lower enhancement of the hepatic parenchyma and lower contrast of the portal vein than Gd-EOB-DTPA-enhanced MRI in the portal venous phase [65]. Given this, the hepatic parenchyma from the hepatobiliary phase with Gd-EOB-DTPA-enhanced MRI of cirrhotic patients demonstrates better compared to Gd-BOPTA-enhanced MRI [66].
Previous studies have revealed important differences in several quantitative parameters related to hepatic blood perfusion on Gd-EOB-DTPA-enhanced MRI between patients with PBC and healthy subjects [47]. In addition, the mean relative signal enhancement in the liver of PBC patients at 4, 20, and 50 min and the mean contrast-to-noise ratio of the common bile duct were significantly different compared with all post-hepatitic cirrhosis patients of the same Child‒Pugh classification. However, the ability of hepatobiliary phase imaging to differentiate different etiologies of liver cirrhosis (i.e. PBC or viral hepatitis) needs further investigation [48]. In addition, some new scoring methods derived from Gd-EOB-DTPA-enhanced MRI such as the functional liver imaging score (FLIS), may serve as a reference for future studies of PBC [67].
Overall, there are several pathological changes throughout the disease process of PBC that can be captured and monitored by imaging (Figs. 6, 7, and 8). In terms of the CT /MR imaging features, some are relatively unique to PBC, such as liver parenchyma heterogeneity, periportal halo sign, irregular configuration of the small to medium biliary ducts and lymphadenopathy. These features can be better demonstrated on MRI and deserve the attention of radiologists. Thus, they are essential for the early diagnosis of PBC and the timely implementation of clinical management for patients. As the disease progresses, patients with PBC may show signs of liver fibrosis and cirrhosis (i.e. abnormalities in liver morphology, portal hypertension, ascites, and spontaneous peritonitis). These features are more familiar to clinicians and can inform liver transplant decisions. Regarding radiological imaging techniques, CT and MRI have their own advantages and disadvantages for the diagnosis and assessment of PBC, as detailed in Table 2.
PBC-AIH variant
Approximately 10–20% of patients with PBC may exhibit clinical symptoms and histological features similar to those of AIH but lack some components of the classical diagnostic criteria in terms of pathology [68, 69]. This condition was formerly called “PBC-AIH overlap syndrome” and was replaced with “PBC-AIH variant”, since not all the patients concurrently present both diseases at the same time [69]. At present, the diagnosis of the PBC-AIH variant is challenging in clinical practice and there are no up-to-date consensus criteria to define it [29]. Liver biopsy is the gold standard for the diagnosis of the PBC-AIH variant and it is also recommended by most authoritative guidelines [1, 20, 69, 70]. Imaging techniques (primarily US) are currently used mainly in the grading of fibrosis in this variant, and their value in the diagnosis of this disease remains to be explored [36, 71, 72].
Differentiation of PBC from similar diseases
PBC should be differentiated primarily from intrahepatic cholestasis of other causes (e.g. PSC, IgG4-related sclerosing cholangiopathy, sarcoidosis, Langerhans cell histiocytosis (LCH), and secondary biliary cirrhosis) [11] Of these, the distinction between PBC, PSC, and IgG4-related sclerosing cholangiopathy is even more important (Table 3).
PSC is also a chronic immune-mediated inflammatory disease involving the bile ducts. However, it differs from PBC in several ways [73, 74]. First, PSC classically occurs in young people aged 30–40 years and is predominantly in males (the ratio of males to females is approximately 2:1). In addition, there is a close relationship between the development of PSC and human leukocyte antigen (HLA) antigens. Furthermore, the intestinal microbiome plays a key role in the initiation of immune responses in the biliary tree. Therefore, there is usually a high probability of diagnosis of irritable bowel disease, including Crohn’s disease and ulcerative colitis, in patients with PSC. On imaging, most PSC cases are observed to involve both the medium- to large-calibre intrahepatic and extrahepatic biliary systems, usually presenting as a branching-tree appearance with saccular dilatations and segmental strictures of the extrahepatic biliary ducts. Moreover, PSC may also involve the cystic duct, gallbladder, and pancreatic duct, which is a point of differentiation from PBC (Fig. 9) [75]. Unlike PBC, patients with PSC have a higher risk of developing cholangiocarcinoma regardless of the degree of fibrosis. About one-thirds of CCAs are detected within 1 year of the diagnosis of PSC. Besides, since 80% of PSC patients may have a combined inflammatory bowel disease, it is advisable to recommend a fusion of CA-199 and colonoscopy, in addition to MRI/MRCP, for the follow-up of PSC patients [76].
IgG4-related sclerosing cholangitis affects multiple organs and has imaging presentations that are more similar to PSC than PBC [77]. It often affects the distal or intrapancreatic segment of the common bile duct and hepatic bile duct and presents as isolated or continuous stricture or circumferential symmetrical bile duct wall thickening (Fig. 10) [75].
Sarcoidosis (granulomatous cholangitis-induced biliary ductopenia) presents with similar clinical symptoms to PBC. On imaging, intrahepatic granulomas present low signals on both T1WI and T2WI, like the “periportal halo sign” of PBC. However, granulomas usually present mild enhancement, which is different from the “periportal halo sign” [78].
LCH is a rare group of idiopathic disorders caused by the neoplastic proliferation of myeloid cells that infiltrate various tissues and organs [79]. Approximately 10 ~ 15% of cases of LCH involve the bile ducts, so sclerosing cholangitis (often presented as a confined intrahepatic mass, as well as dilated, partially mass-like dilatation of intrahepatic and extrahepatic bile ducts [80,81,82] can be used to differentiate LCH from PBC.
Secondary biliary cirrhosis is a form of cirrhosis caused by prolonged obstruction of the large bile duct. Cholelithiasis (Fig. 11) is the most common cause of biliary obstruction and often coexists with cholangitis [83]. Other conditions include carcinoma of the pancreatic head or biliary tree (Fig. 12), postsurgical duct stricture, compression of the bile ducts with enlarged lymph nodes, and biliary atresia (mostly in neonates). Imaging will help to diagnose the level, severity, and cause of biliary obstruction and detect signs of cirrhosis. Calculi can be hyperattenuating to hypoattenuating to bile on CT and manifest as signal voids on T2WI and MRCP. In other settings, stenosis of the lumen of the large bile duct, with or without proximal ductal dilatation, can be seen. Benign stenoses tend to present with smooth symmetrical luminal narrowing, while malignant stenoses often manifest as abrupt transitions without tapering [83].
Management and treatment monitoring of PBC
As PBC is highly associated with environmental factors, maintaining a healthy lifestyle can help slow the progression of the disease. Patients with PBC should be encouraged to quit smoking, stop drinking alcohol, and maintain an ideal body weight. Moreover, standardized UDCA therapy (13–15 mg/kg/day) should be implemented for all PBC patients. Nevertheless, up to 40% of patients with PBC have an insufficient biochemical response to UDCA and are at high risk of experiencing progression to liver failure or liver transplantation [84]. Hence, the long-term results of second-line drugs such as OCA, fibrates, and budesonide need further verification. It is also necessary to further explore the clinical, imaging and laboratory risk factors to provide individualized care with the available therapeutic agents. Finally, the role of imaging in the assessment of biochemical response after drug treatment for PBC and in the monitoring of disease progression needs to be further explored.
Conclusion
With the development of imaging technologies, some key pathological alterations in the development and progression of PBC can be captured by CT and MRI. These characteristic intra- and extrahepatic imaging manifestations may reflect the course of the disease and provide information associated with histological grading and altered cellular function. Despite this, the CT or MRI features of PBC are not specific, as many cholestatic liver diseases may present with similar features, and the clinical diagnosis of PBC still requires a combination of imaging, clinical, and laboratory findings.
Availability of data and materials
The figure and table are available from the corresponding author, Prof. Bin Song, upon reasonable request.
Abbreviations
- AIH:
-
Autoimmune hepatitis
- ALP:
-
Alkaline phosphatase
- AMA:
-
Antimitochondrial antibody
- APASL:
-
Asia-Pacific Society for the Study of the Liver
- APRI:
-
Aspartate aminotransferase to platelet ratio index
- AST:
-
Aspartate aminotransferase
- BECs:
-
Biliary epithelial cells
- CT:
-
Computed tomography
- FIB-4:
-
Fibrosis-4
- FLIS:
-
Functional liver imaging score
- Gd-BOPTA:
-
Gadoxetate disodium
- Gd-EOB-DTPA:
-
Gadobenate dimeglumine
- GGT:
-
Glutamyl transpeptidase
- HLA:
-
Human leukocyte antigen
- LCH:
-
Langerhans cell histiocytosis
- MR:
-
Magnetic resonance
- MRCP:
-
MR cholangiopancreatography
- MRE:
-
MR elastography
- MRI:
-
MR imaging
- OCA:
-
Obeticholic acid
- PBC:
-
Primary biliary cholangitis
- PDC-E2:
-
E2-subunit of the pyruvate dehydrogenase complex
- PSC:
-
Primary sclerosing cholangitis
- STE:
-
Sound touch elastography
- SWE:
-
Shear wave elastography
- T1WI:
-
T1-weighted imaging
- T2WI:
-
T2-weighted imaging
- UDCA:
-
Ursodeoxycholic acid
- USE:
-
Ultrasound elastography
- VCTE:
-
Vibration-controlled transient elastography
References
European Association for the Study of the Liver (2017) EASL clinical practice guidelines: the diagnosis and management of patients with primary biliary cholangitis. J Hepatol 67(1):145–172
Wijarnpreecha K, Werlang M, Panjawatanan P et al (2019) Association between smoking and risk of primary biliary cholangitis: a systematic review and meta-analysis. J Gastrointestin Liver Dis 28:197–203
Ala A, Stanca CM, Bu-Ghanim M et al (2006) Increased prevalence of primary biliary cirrhosis near superfund toxic waste sites. Hepatology 43:525–531
Prince MI, Ducker SJ, James OF (2010) Case-control studies of risk factors for primary biliary cirrhosis in two united kingdom populations. Gut 59:508–512
Gulamhusein AF, Juran BD, Lazaridis KN (2015) Genome-wide association studies in primary biliary cirrhosis. Semin Liver Dis 35:392–401
Cordell HJ, Fryett JJ, Ueno K et al (2021) An international genome-wide meta-analysis of primary biliary cholangitis: novel risk loci and candidate drugs. J Hepatol 75:572–581
Selmi C, Lleo A, Pasini S, Zuin M, Gershwin ME (2009) Innate immunity and primary biliary cirrhosis. Curr Mol Med 9:45–51
Hirschfield GM, Gershwin ME (2013) The immunobiology and pathophysiology of primary biliary cirrhosis. Annu Rev Pathol 8:303–330
Prince MI, Chetwynd A, Craig WL, Metcalf JV, James OF (2004) Asymptomatic primary biliary cirrhosis: clinical features, prognosis, and symptom progression in a large population based cohort. Gut 53:865–870
Murillo Perez CF, Goet JC (2018) Milder disease stage in patients with primary biliary cholangitis over a 44-year period: a changing natural history. Hepatology 67:1920–1930
You H, Ma X, Efe C et al (2022) APASL clinical practice guidance: the diagnosis and management of patients with primary biliary cholangitis. Hepatol Int 16:1–23
Carbone M, Mells GF, Pells G et al (2013) Sex and age are determinants of the clinical phenotype of primary biliary cirrhosis and response to ursodeoxycholic acid. Gastroenterology 144:560–569 e567; quiz e513–564
Trivedi PJ, Lammers WJ, van Buuren HR et al (2016) Stratification of hepatocellular carcinoma risk in primary biliary cirrhosis: a multicentre international study. Gut 65:321–329
Ahrens EH Jr, Kunkel HG (1949) The relationship between serum lipids and skin xanthomata in 18 patients with primary biliary cirrhosis. J Clin Investig 28:1565–1574
Sherlock S (1959) Primary billiary cirrhosis (chronic intrahepatic obstructive jaundice). Gastroenterology 37:574–586
Walker JG, Doniach D, Roitt IM, Sherlock S (1965) Serological tests in diagnosis of primary biliary cirrhosis. Lancet 1:827–831
Beuers U, Gershwin ME, Gish RG et al (2015) Changing nomenclature for pbc: from 'cirrhosis' to 'cholangitis'. Hepatology 62:1620–1622
Selmi C, Bowlus CL, Gershwin ME, Coppel RL (2011) Primary biliary cirrhosis. Lancet 377:1600–1609
Lindor KD, Bowlus CL, Boyer J, Levy C, Mayo M (2019) Primary biliary cholangitis: 2018 practice guidance from the American Association for the Study of Liver Diseases. Hepatology 69:394–419
Hirschfield GM, Dyson JK, Alexander GJM et al (2018) The British Society of Gastroenterology/UK-PBC primary biliary cholangitis treatment and management guidelines. Gut 67:1568–1594
Kim KA, Ki M, Choi HY, Kim BH, Jang ES, Jeong SH (2016) Population-based epidemiology of primary biliary cirrhosis in South Korea. Aliment Pharmacol Ther 43:154–162
Tanaka A, Mori M, Matsumoto K, Ohira H, Tazuma S, Takikawa H (2019) Increase trend in the prevalence and male-to-female ratio of primary biliary cholangitis, autoimmune hepatitis, and primary sclerosing cholangitis in Japan. Hepatol Res 49:881–889
Cheung KS, Seto WK, Fung J, Lai CL, Yuen MF (2017) Epidemiology and natural history of primary biliary cholangitis in the Chinese: a territory-based study in Hong Kong between 2000 and 2015. Clin Transl Gastroenterol 8:e116
Chen S, Duan W, Li M et al (2019) Prognosis of 732 ursodeoxycholic acid-treated patients with primary biliary cholangitis: a single center follow-up study from China. J Gastroenterol Hepatol 34:1236–1241
Lin CY, Cheng YT, Chang ML, Chien RN (2019) The extrahepatic events of Asian patients with primary biliary cholangitis: a 30-year cohort study. Sci Rep 9:7577
Lleo A, Colapietro F (2018) Changes in the epidemiology of primary biliary cholangitis. Clin Liver Dis 22:429–441
Corpechot C, Chazouillères O, Poupon R (2011) Early primary biliary cirrhosis: Biochemical response to treatment and prediction of long-term outcome. J Hepatol 55:1361–1367
Harms MH, van Buuren HR, Corpechot C et al (2019) Ursodeoxycholic acid therapy and liver transplant-free survival in patients with primary biliary cholangitis. J Hepatol 71:357–365
Sarcognato S, Sacchi D, Grillo F et al (2021) Autoimmune biliary diseases: primary biliary cholangitis and primary sclerosing cholangitis. Pathologica 113:170–184
Leung KK, Deeb M, Hirschfield GM (2020) Review article: pathophysiology and management of primary biliary cholangitis. Aliment Pharmacol Ther 52:1150–1164
Ludwig J, Dickson ER, McDonald GS (1978) Staging of chronic nonsuppurative destructive cholangitis (syndrome of primary biliary cirrhosis). Virchows Archiv. A, Pathol Anat Histol 379:103–112
Scheuer PJ (1983) Primary biliary cirrhosis: diagnosis, pathology and pathogenesis. Postgrad Med J 59(Suppl 4):106–115
Nakanuma Y, Zen Y, Harada K et al (2010) Application of a new histological staging and grading system for primary biliary cirrhosis to liver biopsy specimens: Interobserver agreement. Pathol Int 60:167–174
Kakuda Y, Harada K, Sawada-Kitamura S et al (2013) Evaluation of a new histologic staging and grading system for primary biliary cirrhosis in comparison with classical systems. Hum Pathol 44:1107–1117
Wendum D, Boëlle PY, Bedossa P et al (2015) Primary biliary cirrhosis: proposal for a new simple histological scoring system. Liver Int 35:652–659
Morgan MA, Sundaram KM (2023) Primary biliary cholangitis: review for radiologists. Abdom Radiol (NY) 48:127–135
Kovač JD, Ješić R, Stanisavljević D et al (2012) Integrative role of MRI in the evaluation of primary biliary cirrhosis. Eur Radiol 22:688–694
Idilman IS, Venkatesh SH, Eaton JE et al (2020) Magnetic resonance imaging features in 283 patients with primary biliary cholangitis. Eur Radiol 30:5139–5148
Dodd GD 3rd, Baron RL, Oliver JH 3rd, Federle MP (1999) Spectrum of imaging findings of the liver in end-stage cirrhosis: part i, gross morphology and diffuse abnormalities. AJR Am J Roentgenol 173:1031–1036
Ito K, Mitchell DG, Gabata T (2000) Enlargement of hilar periportal space: a sign of early cirrhosis at MR imaging. J Magn Reson Imaging 11:136–140
Meng Y, Liang Y, Liu M (2015) The value of MRI in the diagnosis of primary biliary cirrhosis and assessment of liver fibrosis. PLoS One 10:e0120110
Wenzel JS, Donohoe A, Ford KL 3rd, Glastad K, Watkins D, Molmenti E (2001) Primary biliary cirrhosis: MR imaging findings and description of MR imaging periportal halo sign. AJR Am J Roentgenol 176:885–889
Haliloglu N, Erden A, Erden I (2009) Primary biliary cirrhosis: Evaluation with t2-weighted MR imaging and MR cholangiopancreatography. Eur J Radiol 69:523–527
Blachar A, Federle MP, Brancatelli G (2001) Primary biliary cirrhosis: clinical, pathologic, and helical ct findings in 53 patients. Radiology 220:329–336
Kobayashi S, Matsui O, Gabata T et al (2005) Mri findings of primary biliary cirrhosis: correlation with Scheuer histologic staging. Abdom Imaging 30:71–76
Guglielmo FF, Venkatesh SK, Mitchell DG (2019) Liver MR elastography technique and image interpretation: pearls and pitfalls. Radiographics 39:1983–2002
Nilsson H, Blomqvist L, Douglas L, Nordell A, Jonas E (2010) Assessment of liver function in primary biliary cirrhosis using Gd-EOB-DTPA-enhanced liver MRI. HPB (Oxford) 12:567–576
Han D, Liu J, Jin E, He W (2019) Liver assessment using Gd-EOB-DTPA-enhanced magnetic resonance imaging in primary biliary cholangitis patients. Jpn J Radiol 37:412–419
Perez AA, Noe-Kim V, Lubner MG et al (2022) Deep learning ct-based quantitative visualization tool for liver volume estimation: defining normal and hepatomegaly. Radiology 302:336–342
Kaplan MM, Gershwin ME (2005) Primary biliary cirrhosis. N Engl J Med 353:1261–1273
Malik N, Venkatesh SK (2017) Imaging of autoimmune hepatitis and overlap syndromes. Abdom Radiol (NY) 42:19–27
Takeyama Y, Tsuchiya N, Kunimoto H et al (2015) Gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging as a useful detection method for advanced primary biliary cirrhosis. Hepatol Res 45:E108–114
Navasa M, Parés A, Bruguera M, Caballería J, Bosch J, Rodés J (1987) Portal hypertension in primary biliary cirrhosis. Relationship with histological features. J Hepatol 5:292–298
Huet PM, Vincent C, Deslaurier J et al (2008) Portal hypertension and primary biliary cirrhosis: effect of long-term ursodeoxycholic acid treatment. Gastroenterology 135:1552–1560
Burghart L, Halilbasic E, Schwabl P et al (2022) Distinct prognostic value of different portal hypertension-associated features in patients with primary biliary cholangitis. J Gastroenterol 57:99–110
Natarajan Y, Tansel A, Patel P et al (2021) Incidence of hepatocellular carcinoma in primary biliary cholangitis: a systematic review and meta-analysis. Dig Dis Sci 66:2439–2451
Chernyak V, Fowler KJ, Kamaya A, Kielar AZ, Elsayes KM, Bashir MR (2018) Liver imaging reporting and data system (li-rads) version 2018: imaging of hepatocellular carcinoma in at-risk patients. Radiology 289:816–830
Gatos I, Drazinos P, Yarmenitis S, Theotokas I, Zoumpoulis PS (2020) Comparison of sound touch elastography, shear wave elastography and vibration-controlled transient elastography in chronic liver disease assessment using liver biopsy as the “reference standard.” Ultrasound Med Biol 46:959–971
Yang L, Ling W, He D et al (2021) Shear wave-based sound touch elastography in liver fibrosis assessment for patients with autoimmune liver diseases. Quant Imaging Med Surg 11:1532–1542
Gatos I, Yarmenitis S, Theotokas I et al (2022) Comparison of visual transient elastography, vibration controlled transient elastography, shear wave elastography and sound touch elastography in chronic liver disease assessment using liver biopsy as “gold standard.” Eur J Radiol 157:110557
Guo Y, Parthasarathy S, Goyal P, McCarthy RJ, Larson AC, Miller FH (2015) Magnetic resonance elastography and acoustic radiation force impulse for staging hepatic fibrosis: a meta-analysis. Abdom Imaging 40:818–834
Osman KT, Maselli DB, Idilman IS et al (2021) Liver stiffness measured by either magnetic resonance or transient elastography is associated with liver fibrosis and is an independent predictor of outcomes among patients with primary biliary cholangitis. J Clin Gastroenterol 55:449–457
Renzulli M, Biselli M, Brocchi S et al (2018) New hallmark of hepatocellular carcinoma, early hepatocellular carcinoma and high-grade dysplastic nodules on Gd-EOB-DTPA MRI in patients with cirrhosis: a new diagnostic algorithm. Gut 67:1674–1682
Liu C, Sun Y, Yang Y et al (2021) Gadobenate dimeglumine-enhanced biliary imaging from the hepatobiliary phase can predict progression in patients with liver cirrhosis. Eur Radiol 31:5840–5850
Vernuccio F, Cannella R, Gozzo C et al (2020) Hepatic enhancement in cirrhosis in the portal venous phase: what are the differences between gadoxetate disodium and gadobenate dimeglumine? Abdom Radiol (NY) 45:2409–2417
KhouriChalouhi C, Vernuccio F, Rini F et al (2019) Hepatobiliary phase in cirrhotic patients with different model for end-stage liver disease score: Comparison of the performance of gadoxetic acid to gadobenate dimeglumine. Eur Radiol 29:3090–3099
Bastati N, Beer L, Mandorfer M et al (2020) Does the functional liver imaging score derived from gadoxetic acid-enhanced MRI predict outcomes in chronic liver disease? Radiology 294:98–107
Dalekos GN, Gatselis NK (2019) Variant and specific forms of autoimmune cholestatic liver diseases. Arch Immunol Ther Exp 67:197–211
Boberg KM, Chapman RW, Hirschfield GM, Lohse AW, Manns MP, Schrumpf E (2011) Overlap syndromes: The International Autoimmune Hepatitis Group (IAIHG) position statement on a controversial issue. J Hepatol 54:374–385
Dalekos GN, Koskinas J, Papatheodoridis GV (2019) Hellenic association for the study of the liver clinical practice guidelines: autoimmune hepatitis. Ann Gastroenterol 32:1–23
Goertz RS, GaBmann L, Strobel D et al (2019) Acoustic radiation force impulse (ARFI) elastography in autoimmune and cholestatic liver diseases. Ann Hepatol 18:23–29
Sun LL, Dong G, Wang B, Zheng Q, Wang S, Zhang RF (2016) Real-time shear wave elastrography and apri index for evaluating autoimmune hepatitis fibrosis. J Biol Regul Homeost Agents 30:1019–1021
Dyson JK, Beuers U, Jones DEJ, Lohse AW, Hudson M (2018) Primary sclerosing cholangitis. Lancet 391:2547–2559
Karlsen TH, Franke A, Melum E et al (2010) Genome-wide association analysis in primary sclerosing cholangitis. Gastroenterology 138:1102–1111
Khoshpouri P, Habibabadi RR, Hazhirkarzar B, Ameli S, Ghadimi M, Ghasabeh MA (2019) Imaging features of primary sclerosing cholangitis: from diagnosis to liver transplant follow-up. Radiographics 39:1938–1964
Venkatesh SK, Welle CL, Miller FH et al (2022) Reporting standards for primary sclerosing cholangitis using MRI and MR cholangiopancreatography: guidelines from MR Working Group of the International Primary Sclerosing Cholangitis Study Group. Eur Radiol 32:923–937
Martínez-de-Alegría A, Baleato-González S, García-Figueiras R et al (2015) Igg4-related disease from head to toe. Radiographics 35:2007–2025
Guidry C, Fricke RG, Ram R, Pandey T, Jambhekar K (2016) Imaging of sarcoidosis: a contemporary review. Radiol Clin North Am 54:519–534
Lampert F (1998) Langerhans cell histiocytosis. Historical perspectives. Hematol/Oncol Clin North Am 12:213–219
Murakami M, Onishi S, Ohya Y et al (2020) Langerhans cell histiocytosis confined to extrahepatic bile duct causing sclerosing cholangitis in child: a case report. Surg Case Rep 6:137
Aldarwish S, Schafmayer C, Erbersdobler A, Hinz S (2022) An extremely rare cause of an obstructive jaundice in adults: limited Langerhans cell histiocytosis of the extrahepatic bile duct. Visc Med 38:295–299
Consing M, Lee HE, Jess H, Vahidi S (2022) Solitary involvement of the liver: a rare manifestation of Langerhans cell histiocytosis. Am J Case Rep 23:e937628
O’Connor OJ, O’Neill S, Maher MM (2011) Imaging of biliary tract disease. AJR Am J Roentgenol 197:W551–558
Corpechot C, Abenavoli L, Rabahi N et al (2008) Biochemical response to ursodeoxycholic acid and long-term prognosis in primary biliary cirrhosis. Hepatology 48:871–877
Funding
This work was funded by the Science and Technology Support Program of Sichuan Province (No. 2023NSFSC1617).
Author information
Authors and Affiliations
Contributions
Study concept and design: YZ and TYZ. Data acquisition: YZ, TYZ, ZXH. Data analysis and interpretation: YZ and TYZ. Writing and editing of the manuscript: YZ and TYZ. Study supervision: ZXH, BS.
Corresponding author
Ethics declarations
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
Bin Song is a Deputy Editor of Insights into Imaging. He has not taken part in the review or selection process of this article.
All remaining authors disclose no conflict of interest relevant to this work.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Supplementary Information
Additional file 1: Supplementary Table 1.
The conventional staging systems of primary biliary cholangitis.
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
About this article
Cite this article
Zhang, Y., Zheng, T., Huang, Z. et al. CT and MR imaging of primary biliary cholangitis: a pictorial review. Insights Imaging 14, 180 (2023). https://doi.org/10.1186/s13244-023-01517-3
Received:
Accepted:
Published:
DOI: https://doi.org/10.1186/s13244-023-01517-3