Intrahepatic biliary calculi

76 yo M with abdominal pain. Routine CT shows multiple central intrahepatic "lesions", with biliary dilatation and pneumobilia. Cholangiocarcinoma was suspected. 

On spectral analysis, the intrahepatic "lesions" show no uptake of iodine, high density on virtual non-contrast images, and are consistent with intrahepatic calculi.

The calculi are confirmed on MRI (T2W coronal image shown). Patient had history of choledochojejunostomy, and multiple biliary procedures in past. Further workup deferred as patient was leaving the country.

Coronal conventional CT with central liver "lesions" (yellow arrows). Note pneumobilia.

Iodine map shows no iodine uptake in these "lesions"

Virtual non-contrast shows high density consistent with stones.

T2W coronal MRI confirms calculi, which are without signal (black)