European Journal of Radiology Extra 54 (2005) 103–105 Unusual sonographic appearance of a haemorrhagic biliary cyst Antonio Giacobbe a,* , Angelo Iacobellis a , Domenico Facciorusso a , Telemaco Federici a , Vito Piermanni a , Alessandra Mangia a , Grazia Niro a , Michele Armillotta b a Department of Gastroenterology, IRCCS “Casa Sollievo Della Sofferenza” Hospital San Giovanni Rotonda (FOGGIA), Italy b Department of Radiology, IRCCS “Casa Sollievo Della Sofferenza” Hospital, San Giovanni Rotondo (FOGGIA), Italy Received 21 March 2005; received in revised form 29 March 2005; accepted 1 April 2005 Abstract Diagnosis of simple biliary cyst is relatively easy when classic ultrasonographic features are preserved. Yet, not rarely, it may appear with atypical aspects making for a somewhat uncertain differential diagnosis with other cystic lesions. A case of intracystic haemorrhage with unusual sonographic features, closely mimicking biliary cystadenocarcinoma, is reported. Diagnostic imaging, which is useful in differentiating haemorrhagic biliary cyst from cystadenoma and cystadenocarcinoma, is also considered. © 2005 Elsevier Ireland Ltd. All rights reserved. Keywords: Haemorrhagic biliary cyst; Cystadenoma; Cystadenocarcinoma; Echogenic projections; Papillary digitations 1. Introduction Intracystic haemorrhage in simple biliary cysts may lead to polymorphous and sometimes, changeable images often giving rise to diagnostic uncertainty when evaluated with conventional imaging techniques. We report a case of haemorrhagic biliary cyst with an ultrasonographic aspect so unusual as to mimic very closely a cystadenocarcinoma. 2. Case report A 61-year-old woman was admitted to our hospital in September 2003 with a long history of epigastric pain ra- diating to the right hypochondrium and flank. She had not any medical disease predisposing to bleeding, nor history of trauma, nor assumption of aspirin or anticoagulants. Family history was negative for hepatic or renal cystic disease. On admission, general physical examination was negative. Hypochondriac organs were within limits, no masses being * Corresponding author at: Piazza Aldo Moro 6, 71014 San Marco in Lamis (FG), Italy. Tel.: +39 0882 831512; fax: +39 0882 831512. E-mail address: thoro@libero.it (A. Giacobbe). palpable. Serum chemistry tests were normal including the liver function tests and tumour markers levels. Echinococcus serologic tests were negative. Sonographic examination, using an ultrasound scanner (SSA 340 A, Toshiba Corporation, Japan) equipped with a 3.75-MHz transducer, showed a 10 cm-diameter round le- sion in the right hepatic lobe and in the medial segment of the left lobe. The internal echostructure was complex, char- acterized by large echogenic projections, originating from several distinct parts of the wall and ending in thin papillary digitations, resembling fern leafage, floating in the remain- ing fluid space. Sharp, smooth and thin borders without cal- cification and strong posterior wall echoes were observable (Fig. 1). This ultrasound aspect remained the same in further US examinations performed during a 3-week period before surgery. Colour Doppler sonography showed no blood flow in the echogenic projections. Subsequent CT scan and magnetic resonance imaging (MRI) displayed a cystic 11 cm-diameter lesion with thin and clear wall. The wall was regular, except for a 0.5 cm nodule on the inside and a small focus of calcification externally. Cystic contents appeared hypodense and slightly unhomogeneous, on unenhanced CT scan, and unhomogeneously hyperintense on both T1 (Fig. 2) and T2-weighted (Fig. 3) MRI sequences. 1571-4675/$ – see front matter © 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrex.2005.04.002