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Variants and artifacts that may simulate pathology or potentially complicate hepatobiliary surgical procedures
Congenital anomalies of gallbladder (GB)
Anomalies of number, shape, or position
Most are of no clinical significance but may make surgery more difficult
Normal biliary anatomy
Left HD formed by segmental branches from segments II-IV
Right HD has 2 branches, including horizontally oriented anterior branch draining segments V and VIII and vertically oriented posterior branch draining segments VI and VII
Right and left HDs converge at porta hepatis to form common HD
Cystic duct usually joins common HD just below confluence of right and left hepatic ducts
Only central intrahepatic ducts seen normally (measuring ≤ 3 mm): Visualization of ↑ intrahepatic ducts concerning for dilated ducts or strictures
Most common biliary variants
Usually aberrant right posterior branch, which can drain into left HD ("crossover anomaly"), common hepatic duct, common bile duct, cystic duct, or GB
May complicate or preclude living donor right liver transplantation
May result in bile leak or stricture following cholecystectomy
Anomalous insertion of cystic duct
Must be recognized at cholecystectomy to avoid iatrogenic biliary injuries
Persistent postoperative dilation of bile ducts
Especially common in patients who had choledocholithiasis and dilated common duct prior to surgery
No need for additional evaluation in absence of clinical or laboratory signs of biliary obstruction
MRCP artifacts may simulate or obscure pathology
Reconstruction artifacts (with MIP reconstructions)
Respiratory motion artifacts
Partial volume effect
Overestimation of ductal narrowing
Susceptibility artifacts (e.g., surgical clips, coils)
Pulsatile vascular compression
Intraductal mimics of gallstones (gas, flow artifact)
Spasm of sphincter of Oddi
Normal biliary variants are common (42% of population)
No clinical significance unless surgery is planned
Risk of injury if surgeon is unaware (especially anomalies of cystic duct and right hepatic duct)
Pseudocalculi, strictures, and other MR artifacts are common in biliary tree, making familiarity with artifacts critical to avoid unnecessary intervention
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