The Mercedes Benz Sign on Magnetic Resonance Cholangiopancreatography
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IMAGES IN SURGERY
The Mercedes Benz Sign on Magnetic Resonance Cholangiopancreatography Raghav Yelamanchi 1
&
Himanshu Agrawal 1 & Nikhil Gupta 1 & C K Durga 1
Received: 20 July 2020 / Accepted: 9 October 2020 # Association of Surgeons of India 2020
Abstract A 28-year-old lady has presented to the surgical emergency with jaundice and pain in the right upper abdomen for 4 days. Ultrasound features were suggestive of gallstones with a dilated common bile duct (CBD). On magnetic resonance cholangiopancreatography (MRCP), there was a gallstone of size 2.5 cm obstructing the CBD with a characteristic hyperintense core with triradiate pattern—the Mercedes Benz sign. Keywords Mercedes Benz sign . Seagull sign . Gallstones . Common bile duct obstruction . Magnetic resonance cholangiopancreatography
Case Summary
Discussion
A 28-year-old lady has presented to the surgical emergency with jaundice and pain in the right hypochondrium for 4 days. On examination, there was tenderness and guarding in the right hypochondrium. Blood investigations were suggestive of a severe obstructive pattern of jaundice. Ultrasound abdomen was suggestive of gallbladder stones with a dilated common bile duct (CBD) of size 1.5 cm. On magnetic resonance cholangiopancreatography (MRCP), there was a stone of size 2.5 cm obstructing the CBD with a characteristic hyperintense core with triradiate pattern— the Mercedes Benz sign (Fig. 1). Open cholecystectomy with CBD exploration and choledochoduodenostomy was performed. The patient had an uneventful recovery in the post-operative period.
The Mercedes Benz sign also known as seagull sign refers to the typical triradiate pattern seen on imaging performed for diagnosing gallstones. About 50% of gallstones have fissures in the inner two-third which are filled predominantly by fluid or nitrogen gas [1]. These fissures form due to unequal contraction of the mantle and core of the gallstone. This is a rare sign visible on X-ray and computerized tomography (CT) of the abdomen when sections are studied along the longitudinal axis of the calculus [2]. This sign should not be confused with the Mercedes Benz sign in other organs (Table 1). The above case is unique with respect to the visualization of the Mercedes Benz sign on MRCP. On MRCP T2-weighted image, gallstones appear as low signal or signal void-filling defects in a background of hyperintense bile [3]. The appearance of hyperintense triradiate pattern in the gallstone can be hypothesized due to diffusion of bile into the fissures of gallstone under increased bile duct pressure as in this case due to complete bile duct obstruction. Hence, even though this sign is rare, it could be used for diagnosing gallstones on MRCP apart from X-ray and CT.
* Raghav Yelamanchi [email protected] 1
Department of Surgery, Ward 17, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi Pin-110001, India
Indian J Surg
Compliance with Ethical Standards Conflict of Interest The authors declare that they have no co
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