bile leaks are a recognized complication of liver transplantation ( commonly due to hepatic arterial thrombosis / stenosis or inadequate surgical technique ) and may manifest as newly developing intra - abdominal free fluid or collections . however , the presence of fluid or collections is non - specific in the early postoperative period , as these may represent surgical trauma including hematomas or seromas . primovist ( gadoxetate disodium ; bayer - schering , berlin , germany ) is an intravenous magnetic resonance imaging ( mri ) contrast agent which demonstrates hepatocyte uptake and biliary excretion . in this case , we highlight the clinical utility of primovist - enhanced mri in demonstrating the presence and location of a postoperative bile leak following liver transplantation . a 35-year - old woman underwent orthotopic liver transplantation for autoimmune hepatitis - induced cirrhosis associated with secondary portal hypertension . her decompensated liver disease had been complicated by portal gastropathy , recurrent ascites with the development of spontaneous bacterial peritonitis , hydrothorax , and secondary bacterial empyema . liver transplantation was performed with standard venous reconstruction , single artery anastomoses , and biliary reconstruction via retrocolic roux - en - y hepaticojejunostomy . hepaticojejunostomy was preferred to primary duct - to - duct anastomosis due to perceived anastomotic tension at the time of surgery which prevented the latter technique . although postoperative recovery appeared to be rapid with early extubation , after transfer to the ward , large volume of bile - stained ascites was discovered from the surgical drains and the patient experienced increasing upper abdominal pain , a low - grade fever , and rising serum bilirubin levels . mri of the liver was performed according to our institution 's liver transplant protocol with dedicated hepatic artery angiography ( confirming normal postoperative hepatic arterial caliber and patency ) and standard magnetic resonance cholangiography ( mrc ) sequences to assess the biliary tree . at the discretion of the reporting radiologist , intravenous primovist ( 10 ml of 0.025 mmol / kg of body weight ) was administered as a contrast agent with delayed images obtained at 10 min and 45 min following injection . on pre - contrast imaging , a low t1 and high t2 signal fluid collection was present in the left perihepatic space indicating a biloma [ figure 1 ] . the biliary anastomosis was well identified between the common hepatic duct and the jejunal loop of the roux - en - y hepaticojejunostomy . following primovist administration , a high - grade bile leak was confirmed at the surgical anastomosis with extravasation of high t1 signal bile from the biliary tree , bypassing the jejunal loop , pooling within the perihepatic space biloma , left subphrenic space , and extending down the left paracolic gutter into the left side of the pelvis [ figures 2 and 3 ] . 35-year - old woman underwent orthotopic liver transplantation for autoimmune hepatitis - induced cirrhosis associated with secondary portal hypertension and was diagnosed with postoperative biliary anastomotic leakage . corresponding axial ( a ) t1-weighted and ( b ) t2-weighted sequences of the upper abdomen show left perihepatic fluid collection ( arrow ) with a low t1 signal and high t2 signal . 35-year - old woman underwent orthotopic liver transplantation for autoimmune hepatitis - induced cirrhosis associated with secondary portal hypertension and was diagnosed with postoperative biliary anastomotic leakage . axial t1 image 45 min post - primovist injection shows high t1 signal bile pooling ( arrow ) within the left perihepatic space . 35-year old woman underwent orthotopic liver transplantation for autoimmune hepatitis - induced cirrhosis associated with secondary portal hypertension and was diagnosed with postoperative biliary anastomotic leakage . coronal t1 mip image 45 min post - primovist injection shows high t1 signal bile pooling from biliary tree at the anastomotic site ( arrow ) and within the left perihepatic and subphrenic spaces . the patient was subsequently taken back to the operating room on the 10 postoperative day where a bile leak was surgically confirmed with disruption of the anterior wall of the anastomosis . the presence of a patent , normal caliber hepatic artery excluded hepatic arterial thrombosis or stenosis as an underlying etiology . abdominal washout and revision of the incidence of bile leak following orthotopic liver transplant has been reported to be between 5 and 10% . clinically , the diagnosis is suggested by the passage of bile through a surgical drain or abdominal scar along with fever , jaundice , and abdominal pain , but debate exists over the best imaging modality to make the diagnosis . endoscopic retrograde cholangiography ( erc ) is regarded as the gold standard , although this is an invasive test and not without inherent complications such as hemorrhage , pancreatitis , and infection . furthermore , erc was precluded in our case due to altered anatomy from the hepaticojejunostomy formation . non - invasive investigations such as ultrasound , computed tomography ( ct ) , and mri ( both with and without gadolinium contrast agents ) allow demonstration of indirect evidence of biliary leakage such as perihepatic collections , acute onset of free intraperitoneal fluid , and biliary dilatation , but they lack the specificity to adequately confirm the direct site of leakage . primovist - enhanced mr imaging is a powerful non - invasive tool for evaluating the biliary system . approximately 50% of the injected dose of primovist is taken up by the hepatocytes and excreted into the biliary system . this permits exquisite opacification of the bile ducts during the hepatospecific delayed phase ( approximately 10120 min post - injection ) . furthermore , the images may be displayed on a workstation using 3d - multiplanar reconstructions for optimal interrogation and problem solving . as we have shown , primovist - enhanced mr imaging provided good visualization of the biliary tree with demonstration of the exact site of bile leakage , and confirmed active extravasation into the peritoneum . these encouraging findings merit more detailed investigation through controlled studies involving larger numbers of patients . castellanos et al . , found that primovist had 100% accuracy in excluding a bile leak in 23 patients with clinical suspicion for a bile leak . in addition , it should be noted that while 10 min and 45 min delayed images may be sufficient to detect a high - grade bile leak , a longer delay time ( e.g. 6090 min ) may be necessary for excluding a low - grade leak . in conclusion , our case highlights the clinical potential of primovist - enhanced mr imaging as a diagnostic tool for excluding post - transplant bile leaks . as biliary related issues are a frequent complication of liver transplantation , and as mri is a rapid non - invasive test , we believe that primovist - enhanced mr imaging represents a highly promising technique available to radiologists that can be used as a substitute for more invasive methods to evaluate this complication .
we present a case of postoperative biliary anastomotic leakage demonstrated on intravenous contrast - enhanced mri performed with primovist ( gadoxetate disodium ) . 
 primovist has been widely used for its combined extracellular and hepatocyte - specific properties in the characterization of liver lesions . 
 another recognized , but less widely utilized property of primovist is its ability to provide morphologic and functional assessment of the biliary system . in our case , 
 primovist - enhanced mr imaging demonstrated the presence and location of an active biliary leakage which was associated with free spillage into the peritoneum .