Biliary System and LiverBiliary System and Liver

8/21/2015

LiverLiver

LaLargest gland of body rgest gland of body –(any organ –(any organ that secrets enzymes is a gland - all that secrets enzymes is a gland - all glands are organs)glands are organs)

2nd largest organ-2nd largest organ-(group specialized (group specialized tissues performing specific function or tissues performing specific function or function)function)

What is the 1What is the 1st st ??SkinSkin

How much does it weigh?How much does it weigh?Approx. 3 lbsApprox. 3 lbs

Liver is only internal human organ capable Liver is only internal human organ capable of natural regeneration of lost tissue!of natural regeneration of lost tissue!

as little as 25% of a liver can regenerate into a as little as 25% of a liver can regenerate into a whole liverwhole liver

Not true regeneration!Not true regeneration!lobes removed do not regrow- lobes removed do not regrow-

function is restored, but not original form function is restored, but not original form (aka: compensatory growth)(aka: compensatory growth)

(in (in true regeneration, both original function true regeneration, both original function and form are restoredand form are restored))

Fatty liverFatty liverNormal liverNormal liver

Cirrhosis

Cirrhosis can occur in non-drinkers

2 major lobes:2 major lobes:Right lobeRight lobeLeft lobeLeft lobe

2 minor lobes:2 minor lobes: Caudate lobe- Caudate lobe- part of part of

right lobe -right lobe -posteriorposterior Quadrate lobeQuadrate lobe - - part part

of right lobeof right lobe -inferior -inferior

Falciform ligament divides liver into:

Functions of liverFunctions of liver

Main function Main function -formation of bile-formation of bile

Not on midterm or finalNot on midterm or final: :

(Filter harmful substances from blood (alcohol)(Filter harmful substances from blood (alcohol)

Maintain a proper level of glucose in bloodMaintain a proper level of glucose in blood

Convert glucose to glycogenConvert glucose to glycogen

Produce ureaProduce urea

Make certain amino acids Make certain amino acids

Store vitamins and mineralsStore vitamins and minerals

Produce 80% of cholesterol )Produce 80% of cholesterol )

It has a dual It has a dual bloodblood supply! supply!

1. 1. From From Hepatic artery-Hepatic artery-

Liver gets Liver gets oxygenated blood oxygenated blood fromfrom abdominal aorta to like any other part of bodyabdominal aorta to like any other part of body

2. 2. From From Portal vein- Portal vein- (Portal system)(Portal system)

Liver receives Liver receives deoxygenated blood deoxygenated blood from digestivefrom digestive organs organs (stomach, spleen, intestinal tract, gall bladder and pancreas(stomach, spleen, intestinal tract, gall bladder and pancreas) ) Modifies and filters itModifies and filters it

Sends it back by Sends it back by hepatic veinshepatic veins to heart where it is to heart where it is circulated to rest of bodycirculated to rest of body

What is unique about What is unique about liver?liver?

Big Problem!Big Problem!

Many drugs taken Many drugs taken orallyorally are substantially metabolized by are substantially metabolized by portal system portal system of liver before reaching general of liver before reaching general circulation!circulation!

Known as “Known as “First Pass EffectFirst Pass Effect””

Thus Thus certaincertain drugs can only be taken via certain other drugs can only be taken via certain other routes!routes!

1. Sublingual1. Sublingual

Example: Nitroglycerin cannot be swallowed - liver would inactivate Example: Nitroglycerin cannot be swallowed - liver would inactivate medication -must be taken under tongue or transdermally (patch) medication -must be taken under tongue or transdermally (patch)

Alternate ways to take meds Alternate ways to take meds (cont’d)(cont’d)

2. Intravenously2. Intravenously

3. Intramuscularly3. Intramuscularly

4. Aerosol inhaler4. Aerosol inhaler

5. Suppository5. Suppository

What is the Biliary System?What is the Biliary System?

Consists basically of :Consists basically of :

1. 1. gallbladder gallbladder

2. 2. bile ductsbile ducts

The Excretory system of liver!

Biliary Combining FormsBiliary Combining Forms

cholechole – relationship with – relationship with bile (aka: gall)bile (aka: gall)

bladderbladder – – sac or bag, serving as receptacle for a sac or bag, serving as receptacle for a secretionsecretion

cystcyst – – closed sac having distinct membrane and division with closed sac having distinct membrane and division with nearby tissuenearby tissue

docho docho – duct – tube or passage way for – duct – tube or passage way for conducting a substanceconducting a substance

angio angio – vessel– vessel

graph- graph- representation of a set of objects representation of a set of objects

--iasisiasis – presence of– presence of

--itisitis – inflammation of– inflammation of

What is Bile?What is Bile?

Greenish-yellow fluid produced in liver Greenish-yellow fluid produced in liver

(consists of waste products, cholesterol, and bile salts)(consists of waste products, cholesterol, and bile salts) (when excreted gives feces dark (when excreted gives feces dark brownbrown color) color)

2 Primary Functions of Biliary System:

Aids in digestion- by controlling release of bile

Drains waste products from liver into duodenum

Gall bladderGall bladder

Reservoir for bile from Reservoir for bile from liverliver – 2oz. capacity (50 percent – 2oz. capacity (50 percent of bile is stored in gallbladder)of bile is stored in gallbladder)

How does bile get into How does bile get into gallbladdergallbladder??

Sphincter of Oddi Sphincter of Oddi closes up, and bile closes up, and bile is re-routed up into is re-routed up into GB for temporary GB for temporary storage when not storage when not neededneeded

How much bile does liver How much bile does liver produce per day?produce per day?

1-3 pints 1-3 pints

Transportation of bile sequenceTransportation of bile sequence

LiverLiver secretes bile-secretes bile- into into

right right andand left hepatic ducts left hepatic ducts join to become join to become commoncommon hepatic ducthepatic duct

whichwhich joins with joins with cystic duct cystic duct from gallbladder to become from gallbladder to become the:the:

common bile duct common bile duct whichwhich joins joins with with pancreatic duct pancreatic duct to form a to form a junction known as:junction known as:

hepatopancreatic ampullhepatopancreatic ampulla a (or (or ampulla of vaterampulla of vater

Spincter of Oddi Spincter of Oddi (or spincter of (or spincter of hepatopancreatic ampulla)hepatopancreatic ampulla)controlscontrols emptying of bile into emptying of bile into duodenumduodenum

GallstonesGallstones

Hardened deposits of digestive fluid that Hardened deposits of digestive fluid that can form in gallbladdercan form in gallbladder

Range in size from grain of sand to a golf Range in size from grain of sand to a golf ballball

Can have one or hundreds!Can have one or hundreds!

1 in 10 people have gallstones 1 in 10 people have gallstones (can’t see if not (can’t see if not calcified!)calcified!)

Two types of gallstonesTwo types of gallstones

80% are 80% are cholesterol cholesterol stonesstones: :

usually yellow-green usually yellow-green and made primarily and made primarily of hardened of hardened cholesterolcholesterol

20% are pigment 20% are pigment stonesstones: : small, dark stones small, dark stones made of bilirubinmade of bilirubin

Risk Factors for GallstonesRisk Factors for Gallstones

Female Female Age 60 or older Age 60 or older American Indian or Mexican heritageAmerican Indian or Mexican heritage Overweight or obese Overweight or obese Pregnant Pregnant Eating a high-fat, high-cholesterol, or low fiber Eating a high-fat, high-cholesterol, or low fiber

diet diet Family history of gallstones Family history of gallstones Diabetes Diabetes Losing weight very quickly Losing weight very quickly Taking cholesterol-lowering medications Taking cholesterol-lowering medications Taking medications containing estrogen Taking medications containing estrogen (such as (such as

hormone therapy drugs)hormone therapy drugs)

Complications from Gallbladder Stones!Complications from Gallbladder Stones!

Choledocholithiasis -presence of bile stones in ducts

Cholecystitis - bile sac

inflammation

Pancreatitis Can cause

increased risk of gallbladder cancer (very rare)

Treatment for GallstonesTreatment for Gallstones

Use medicines to dissolve stones Use medicines to dissolve stones (isn't (isn't suitable for everyone -may take a very long suitable for everyone -may take a very long time) time)

Shock-wave lithotripsy Shock-wave lithotripsy - high-energy sound - high-energy sound waves break gallstones into tiny fragments, then waves break gallstones into tiny fragments, then dissolve by medicinesdissolve by medicines

CholecystectomyCholecystectomy - Surgical removal of - Surgical removal of gallbladder gallbladder

If your gallbladder is removed…If your gallbladder is removed…

No longer have a holding space to store bile!No longer have a holding space to store bile!

Most animal species don’t even have one!Most animal species don’t even have one!

Bile continuously runs out of liver, through hepatic ducts, into common Bile continuously runs out of liver, through hepatic ducts, into common bile duct, and directly into small intestinebile duct, and directly into small intestine

When a high-fat meal is eaten - not enough bile available to digest it When a high-fat meal is eaten - not enough bile available to digest it properly –properly –(may resolve in time)(may resolve in time)

Small intestine’s ability to absorb essential fatty acids, vitamins and Small intestine’s ability to absorb essential fatty acids, vitamins and minerals is compromisedminerals is compromised

Can result in chronic diarrheaCan result in chronic diarrhea

Release of bile from gallbladder is stimulated by secretion of hormone:

“cholecystokinin”

When food containing fat enters digestive tract…

PancreasPancreas

Both an exocrine and Both an exocrine and endocrine gland!endocrine gland!

EndocrineEndocrine- - (Isle of (Isle of Langerhans)Langerhans) produces produces glucagon and insulin glucagon and insulin to to regulate sugar regulate sugar metabolismmetabolism

ExocrineExocrine- secretes - secretes digestive enzymesdigestive enzymes

Generally cannot be seen on radiographs

Radiologic Exams of Biliary Radiologic Exams of Biliary SystemSystem

(largely replaced by Ultrasound, CT, MRI, nuclear medicine)

CholecystographyCholecystography

Study of gallbladderStudy of gallbladder

Oral contrast is usedOral contrast is used

CholangiographyCholangiographyStudy of biliary ductsStudy of biliary ducts

IV contrast is usedIV contrast is used

2 Basic Types of Radiological Exams of Biliary System

IndicationsIndications forfor Biliary Tract ExamBiliary Tract Exam

CholelithiasisCholelithiasis (gallstones) -bile calculi presence(gallstones) -bile calculi presence

CholecystitisCholecystitis (inflammation of gallbladder)-bile sac (inflammation of gallbladder)-bile sac inflammationinflammation

Check liver functionCheck liver function

Biliary neoplasia Biliary neoplasia (tumor or mass in biliary system)(tumor or mass in biliary system)

Biliary stenosis Biliary stenosis (abnormal narrowing of ducts)(abnormal narrowing of ducts)

Demonstrate concentrating/emptying ability of Demonstrate concentrating/emptying ability of gallbladdergallbladder

Patient PrepPatient Prep

FatFat-free meal evening before -free meal evening before (don’t want GB to empty)(don’t want GB to empty)

Oral contrast taken 2 to 3 hours after evening meal Oral contrast taken 2 to 3 hours after evening meal to be absorbed by GBto be absorbed by GB

NPO after midnight until examNPO after midnight until exam

No laxatives less than 24 hours before exam to avoid No laxatives less than 24 hours before exam to avoid prevent voiding of contrast medium!prevent voiding of contrast medium!

Early morning appointmentEarly morning appointment

Position of GallbladderPosition of Gallbladder RUQRUQ In In hyperhypersthenic pt.sthenic pt.

Superior and lateralSuperior and lateral In In AAsthenicsthenic

Inferior and nearer to spineInferior and nearer to spine

Shielding ReviewShielding Review

What 3 things must you consider?What 3 things must you consider?

1. Are gonads within 1. Are gonads within 2”2” of primary x-ray of primary x-ray field after proper collimation? field after proper collimation?

2. Are clinical objectives compromised?2. Are clinical objectives compromised?

3. Does pt have reasonable reproductive 3. Does pt have reasonable reproductive potential?potential?

CholecystogramCholecystogram (Gallbladder Exam)

Scout film Scout film (the one time you (the one time you shouldshould see gall bladder in image if see gall bladder in image if pt prepped properly)pt prepped properly)

PA, RAO, R DecubPA, RAO, R Decub

Dr. may do fluoroscopic examination

Post-fatty meal image may Post-fatty meal image may be obtained to be obtained to demonstrate emptying demonstrate emptying ability of GBability of GB

PA ProjectionPA Projection

Patient prone- or upright facing wallboard

Center 10x12 cassette at RUQ, level of the right elbow

70 - 80 kVp range

Exposure made at end of full

expiration

PA PA ObliqueOblique Projection Projection

LAO positionLAO position

Pt rotated 15 - 40 Pt rotated 15 - 40 degrees depending degrees depending on body habituson body habitus

CR at level of elbow, CR at level of elbow, between spine and between spine and R R midaxillary line midaxillary line

10x12 cassette10x12 cassette

Rt. Lateral DecubitusRt. Lateral Decubitus

Demonstrates stones Demonstrates stones lighter than bile lighter than bile visible only by visible only by stratificationstratification

CR:CR:Directed horizontally Directed horizontally

to level of to level of gallbladdergallbladder

Intravenous Cholangiography Intravenous Cholangiography (IVC)(IVC)

((Very rarely performed anymore)Very rarely performed anymore)

Radiologic procedure to:Radiologic procedure to:look at look at bile ducts bile ducts coming from livercoming from liver

locate any locate any gallstonesgallstones passed into the bile ducts passed into the bile ducts

identify other causes of identify other causes of obstruction of flow of bileobstruction of flow of bile

Used when pts can’t tolerate oral contrastUsed when pts can’t tolerate oral contrast

Iodine-containing dye is injected intravenously (or Iodine-containing dye is injected intravenously (or directly) to outline ducts and gallstonesdirectly) to outline ducts and gallstones

3 types we’ll talk about:3 types we’ll talk about:

Percutaneous Transhepatic CholangiographyPercutaneous Transhepatic Cholangiography(performed (performed prepreoperatively)operatively)

Performed when ductal system Performed when ductal system shown to be obstructed by CT shown to be obstructed by CT or Ultrasoundor Ultrasound

Contrast is injected directly into Contrast is injected directly into bile ducts using long needle bile ducts using long needle (chiba)) through abdominal (chiba)) through abdominal wall and liver under fluorowall and liver under fluoro

Decision is made to drain biliary Decision is made to drain biliary ducts, extract stones, or ducts, extract stones, or possibly leave catheter in for possibly leave catheter in for long telong term drainagerm drainage

(Percutaneous: any medical procedure where access to inner organs or other tissue is done via needle-puncture of skin, rather than by scapel)

CholangiographyCholangiography Intra-operativeIntra-operative

Obtained Obtained duringduring a a cholecystectomycholecystectomy

Examines patency of Examines patency of ducts and ducts and functionality of functionality of Spincter of Odi during Spincter of Odi during or after surgical or after surgical removal of GBremoval of GB

T-Tube CholangiographyT-Tube Cholangiography

Post-operativePost-operative (after (after cholecystectomy) procedure cholecystectomy) procedure performed through T-tube performed through T-tube left in common hepatic and left in common hepatic and common bile ducts (for common bile ducts (for drainage)drainage)

To determine:To determine: patency (openness) of patency (openness) of

biliary ducts after biliary ducts after cholecystectomycholecystectomy

status of Spincter of oddistatus of Spincter of oddi

presence of residual or presence of residual or

undetected stonesundetected stones

Intraoperative (during)

Percutaneous (before surgery)

3 Cholangiogram types compared

T-Tube (post)

ERCPERCP

Used to diagnose biliary and Used to diagnose biliary and pancreatic pathologic conditionspancreatic pathologic conditions

whenwhen ducts are ducts are notnot dilated and dilated and ampulla is ampulla is notnot obstructed obstructed

Fiberoptic endoscope passed Fiberoptic endoscope passed through mouth into duodenum through mouth into duodenum under fluoroscopyunder fluoroscopy

Common bile duct is catheterizedCommon bile duct is catheterized

Contrast is injectedContrast is injected

Stones can be removed at same Stones can be removed at same timetime

Endoscopic Retrograde Endoscopic Retrograde CholangiopancreatographyCholangiopancreatography