I recommend to use liver MRI with Gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA), which is a recently developed liver-specific MRI contrast agent with combined perfusion and hepatocyte-selective properties. This modality enables to find a small hepatic nodular lesion with 3mm in diameter !

the recommended MRI of the specialists may be completely supported, for distant (pulmonary) metastasis a high resolution CT of the thorax may be recommended. In cases with unclear exclusion of metastasis with the mentioned techniques, we also would consider a FDG PET

intrahepatic cholangios also have a high rate of smaller bilobar liver and peritoneal metastasis, neither MRI nor PET will identify those.

and additional 20% of unrecognised mets are detected by Laparoscopy and IOUS.

So would start with CT chest , MRI liver and PET.

keep in mind thaht not all cholangios are PET avid too.

if all clear then laparoscopy and IOUS

Sorry that there is no cost savings in this setting. it is an expensive diagnosis

I agree with Mr Ballal. Present available investigations including MRI and PET can fail to pick up peritoneal disease. Hence Laparoscopy is excellent. Diagnostic laparoscopy may be attempted under short GA / could be gass less as well / I have not tried it as an out of OT procedure (Ward / ICU) but dont see any reason why it cannot be attempted as such. Any takers??

IOUS is excellent but that is after opening up. Lap USG probes are available which could prove very useful

I agree with the algorithm: CT, MRI, PET, Lap+IOUS, if you really want to find them. But bear in mind that this algorithm would be extremely sensitive, but not very specific, since anything suspicious would have to be biopsied, and you would get many false positive results. Not to mention that this approach is very expensive.

I suggest total body CT scan then PET an MR if any doubt as to liver metastatic involment.

For liver lesions: Obviously it depends on how diagnosis of cholangiocarcinoma was made, but if first CT-chest/abdomen/liver were done. liver MRI with Gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA) would be preferred next step.

Laparoscopy and proceed

Histopathological analysis of biopsy sample might be helpful for the detection of perineural or portal invasion which can suggest early metastatic events.