LAUSR

A 67-year old man was referred to our centre for recurrent acute cholangitis associated to fluctuant jaundice in the last 2 years. His medical history was positive for IBD for which the patient underwent a total proctocolectomy with ileostomy, GIST of the stomach surgically resected, type 2 diabetes mellitus and a renal vein thrombosis. Previous cholangitis was treated by repeated endoscopic stents positioning until the last hospitalization for a severe isolate obstructive jaundice, (total bilirubin 18–83 mg/dl). Spyglass allowed the direct examination of the bile duct with findings of mucinous, frond-like, floating projections suspected for biliary intraductal papillary mucinous neoplasm (B-IPMN). Biopsies were performed but results were inconclusive. After first-line radiological analysis (US), biliary drainage with ERCP has been performed (Fig. 1) with mucoid lumps at the common biliary confluence. In view of surgical intervention, hepatic-specific MRI has been accomplished with peculiar findings. MR cholangiography has presented diffuse biliary dilation particularly of left hepatic lobe (Fig. 2). MRI, in the hepato-biliary phase, showed no contrast signal in the dilated biliary tract. In particular, Fig. 2 highlights pathognomonic Bthread sign^ (dashed red line box) of B-IPMN represented by presence of hypointense striations within the extrahepatic bile duct. These radiological findings are always pathognomonic for B-IPMN. Due to its premalignant status, left hepatectomy has