For 4 th year medical students By: Dr.Idrees J. Ahmed FIBMS – Rediology lecturer College of...
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Transcript of For 4 th year medical students By: Dr.Idrees J. Ahmed FIBMS – Rediology lecturer College of...
For 4th year medical studentsBy: Dr.Idrees J. Ahmed
FIBMS – Rediology lecturerCollege of medicine
Hawler Medical university
RADIOLOGY OF HEPATOBILIARY SYSTREM , PANCREAS AND SPLEEN
HEPATOBILIARY RADIOLOGICALANATOMY
AND INVESTIGATION METHODS
LECTURE ONE
To be familiar with radiological anatomy and distinguish normal pictures
To be able to sort investigations according to indications and priorities
LECTURE OBJECTIVE
Radiological anatomy Methods of investigation Indications , precautions and
contraindication Patient Preparation Radiological features of most common
diseases references
Lecture overview
Liver :o Variable size and shapeo Rt upper quadranto Lobes and segmentso Falciform ligament ( contains lig. Teres ) o Portal vein and portal triadso Hepatic veins
Radiological anatomy of hepatobiliary system
LIVER ANATOMY
GALL BLADDER :( size , shape , location ) 2mm walls , 5x10 cm Variants :Phrygian cap , junctional fold ,
agenesis
INTRA AND EXTRAHEPATIC DUCTS RHD +LHD =CmD CmD+ CyD = CBD
1. Plain x-ray film , cholecystography( hystorical )
2. Ultrasound3. CT scan4. MRI , MR cholangiopancreatography5. ERCP ( endoscopic retrograde
cholangiopancreatography)
METHODS OF INVESTIGATION OF HEPATOBILIARY SYSTEM
1. Percutaneous transhepatic cholangiography ( PTC)
2. Post-operative ( t-tube ) cholangiography3. Operative cholangiography4. Angiography ( diagnostic and therapeutic )
CTA , DSA and MRA 5. Radionuclide imaging
Methods of investigation of the hepatobiliary system ( cont.)
Main clinical Indications :1. Right upper quadrant pain2. jaundice3. Clinically suspected liver lesion 4. Abnormal lab tests5. Staging for malignant diseases6. Suspected portal hypertension
ULTRASOUND OF LIVER AND GALL BLADDER
No contraindication
Preparation: Restrictuin to clear fluids for gall bladder study ( 6 – 8 hr )
ULTRASOUND OF LIVER AND GALL BLADDER
ULTRASOUND MACHINE
ULTRASOUND OF LIVER AND GALL BLADDER
CT scanner
CT scan of liver and biliary tree
Clinical Indications:1. suspected liver lesion2. Characterization of liver lesion3. Staging malignancy4. Rt upper quadrant pain5. To facilitate placement of needles( biopsy,
etc. ) 6. Follow up after surgical or radiological
intervention
CT SCAN OF LIVER AND BILIARY TREE
Contraindications :1. Pregnancy2. Allergy to iodinated contrast media
Patient preparation: the patient fasted for at least 6 hr
Investigations to be continued next lecture
CT SCAN OF LIVER AND BILIARY TREE ( CONT. )
Questions and discussion
End of lecture one
OBJECTIVES :
Continuation of hepatobiliay investigations
Radiology of cystic liver lesions
Lecture two
MRI LIVER
Indications :1. Lesion detection if US and CT not conclusive2. Lesion characterization after detection by
US or CT
Contraindications :General contraindications to
MRI( claustrophobia , implants , penetrating injuries , sensitivity to contrast media , early pregnancy )
MRI scan of liver
2D or 3D T2 weighted , bile appears white
Indications :1. Investigation of obstructive jaundice
2. Biliary stone , colic
3. Suspected cholangitis , or chronic pancreatitis
4. Prior to ERCP/PTC
MRI scan of biliary tree (MRCP)
MRCP
1. Non-invasive
2. Relatively cheep
3. No radiation , No anesthesia
4. Less operator dependant
5. Ducts prox. to obstruction seen
6. Extraductal disease may be seen
Advantages of MRCP
1. Decreased resolution
2. Less sensitive to subtle ductal disease
3. Not theraputic
Disadvantages of MRCP
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY( ERCP )
Contrast-agent is injected through endoscope after cannulation of CBD
Indications :1. Diagnostic , in unsuitable or intolerant to
MRCP2. Management of bile duct stones3. Evaluation of ampullary lesions4. Management of biliary strictures5. Chronic pancreatitis
ERCP
Contraindications :1. Upper GIT obstruction2. Previous gastric surgery that prevents
access to duodenum3. Sever cardiac or respiratory distress
Complications : Pancreatitis 5% Duodenal perforation Gastrointestinal bleeding
(ERCP ) cont.
FOCAL LIVER LESIONSarea of alteration of normal parenchymaCystic , solid or complex
Cysts : thin walls with clear fluid , benign
Complex : may be malignant
Solid : borders , outline Multiple : metastases ? Abscesses ,
hemangiomas , cirrhosis
Liver lesions
hepatomegaly
generalized parenchyma changes• Fatty liver• Hepatitis• cirrhosis
DIFFUSE LIVER LESIONS
Rt lobe enlargement elevated Rt hemidiaph. splayed lower Rt ribs properitoneal fat bulge depressed hepatic flexture and Rt kidney
HEPATOMEGALY SIGNS
Lt lobe enlargement gastric fundus and posterior stomach
displaced intra-abdominal oesophagus elongated pressure on lesser curveature of
stomach
HEPATOMEGALY SIGNS
SIMPLE CYSTS
Common , congenital , may be multiple ( ADPCK disease )
LIVER CYSTS
SIMPLE LIVER CYSTS
may be indistinguishable from simple one
may be multiple or cyst inside cyst
wall layers on ultrasound
Calcification , no wall enhancement
signs of rupture
protein in its fluid
LIVERHYDATID CYSTS
LIVER HYDATID
HYDATID CYST LIVER
Summery
Discussion .
End of lecture two
RADIOLOGY OF LIVER AND BILIARY DISEASES
LECTURE THREE
LIVER TUMORS
TRAUMA
INFECTION AND CIRRHOSIS
BILIARY DISEASES
OVERVIEW
Metastases:
More common
Often multiple , Peripheral , variable size
On ultrasound : appear dark ( hypoechoic ) , may be complex ,irregularly cystic , hyperechoic or not visible
ON CT SCAN : Dark , Contrast enhancement
LIVER NEOPLASMS
similar to secondary
usually solitary
PRIMARY LIVER CANCER
LIVER TUMOR
LIVER HEMANGIOMAS
Common 4-7% females 80% , incidental benign , vascular neoplasm
May bleed , biopsy avoided
Simulate neoplasm on ultrasound
On CT and MRI show centripetal enhancement
BENIGN LIVER TUMORS
LIVER HAEMANGIOMA
LIVER HEMANGIOMA
FNH : rare , hypervascular , iso to liver , central scar ( white on T2 ) , no malignant change
Adenoma : solit. , rare , malignant ( may)
Other benign liver lesions
Like cysts , irregular thicker walls
Pus usually thicker than cyst fluid(water)
May calcify
Walls enhance , local edema
On imaging difficult to distinguish from a necrotic tumor ( clinical )
Liver abscess
LIVER ABSCESS
Commonest fatal abdominal injury
Lacerations are most common parenchymal injury
Ass. With subcapsular hematoma
CT is best for hematoma detection and organ survey
LIVER TRAUMA
Liver trauma
Commonest cause for portal hypertension
Porto-systemic anastamases open to bypass liver ( eg. Lower esophagus )
Fibrosis of parenchyma , small liver ( coudate lobe preserved )
Large spleen , portal flow
Ascites and neoplasms
LIVER CIRRHOSIS
Liver cirrhosis
CHOLELITHIASIS : 10-20% US population , 30% calcification
40-50% asymptpmatic
Surgery in symptomatic and diabetic
Cholesterol , pigment or ( most are ) mixed
Predisposition: obesity , diabeteis , cirrhosis , huperparathyroidism
DISEASES OF THE BILIARY SYSTEM
Ultrasound featuresCan detect 2mm stone and largerBack shadow , mobility , wall-eacho-shadow
triad ( contracted gb )Porcelain gall bladderEmphysematous cholecystitis
Gall bladder stones
Stone in bile ducts with jaundice and high grade obstruction ,ultrasound 75% sensitive
MIRIZZI syndrome CyD stone CBD obst.
CHOLEDOCHOLITHIASIS
Common ACUTE : calculus 95% , acalculus Distension , walls >5mm, free fluid,
Murphy’s sign ( 90% specific , negative if gangrenous )
Acalculus : trauma , long fasting , DM , no
stone ivisible , patient ill CHRONIC: Thick smaller GB , stone 95% , STIFF
CHOLECYSTITIS
CHOLECYSTITIS
Infection of obstructed bile ducts ( E. coli )
Causes ( stone , stricture , drainage cath. , ampullary cancer )
Rad. Features : Duct dilatation, intrahepatic duct stone
(pathognomonic ) Segmental Hepatic atrophy Liver abscess , pancreatitis
CHOLANGITIS
CHOLANGITIS
Biliary cancers are 5th most common GI malignancy
Ass. With ( stone , porcelain GB , IBD , chronic cholecystitis )
Intraluminal soft tissue
Asymmetrically thickened GB wall No biliary dilatation
Invasion of liver and lymph nodes
GB canrcioma
Ca GB
RARE
Hilar : junction or RHD & LHD ( Klatskin) or peripheral from epithelium of intralobular
ducts
Dilated intrahepatic normal extrahepatic ducts
Hilar mass , short annular constricting lesion
CHOLANGIOCARCINOMA
CHOLANGIOCARCINOMA
congenital dilatation of bile ducts
children or young adults
20-fold increased risk of malignancy
jaundice , abdominal pain , mass
CHOLEDOCAL CYST
CHOLEDOCAL CYST
Summery
discussion
RADIOLOGY OF PNACREAS AND SPLEEN
LECTUTE FOUR
Retroperitoneal , on posterior abdominal wall , L1 level
Head , neck , body and tail , 15 cm length
Duct (from tail to ampulla ) , 4mm on ERCP
PANCREAS
accessory duct ( santorini ) drains lower part of head
Grey on US and CT , whiter than liver on T1
Intense enhancement , Fat infiltration : common , normal , age
PANCREAS
RETROPERITONEUM
PANCREAS
Pancreatic injry : penetrating or blunt ( superficial , deep ,
duct involved ?)
Rad. Features : fragmentation , hematoma , non-enhancing regions , stranding
Complications: fistula , abscess , pancreatitis , pseudocyst
PANCREAS LESIONS
Pancreas injury
Acute mild edema, pain , vomiting , tenderness , not progress
Acute severe necrosis ,shock , renal failure , GI bleed
Chronic : alcohol , stone
PANCREATITIS
US : hypoechoic due to edema , detect stone and follow up size of pseudocyst ( capsule )
CT : heterogeneous , focal necrosis 90% accurate , peripancreatic edema or fluid or even gas collection
Pancreatitis , Rad. features
pancreatitis
CA. PANCREAS : 2\3 in head , CBD obst. , focal mass and deformity , duct dilatation , extrapancreatic and vascular extension
DDX regional LAP , focal pancreatitis , abscess , pseudocyst
PANCREATIC CANCER
Pancreas cancer
Lt upper quadrant , size of a fist , 12 x 7 x 4 cm in adult , along 9th rib , intraperitoneal
Accessory spleens at hilum ( 40% )
Wandering spl. Along pedicle
Poly and asplenia
SPLEEN
Splenomegaly
Trauma ( subcapsular or parenchymal hematoma , laceration , fragmentation , delayed rupture \rare )
Cyst , Tumor ( hemangioma , metastasis )
infarction
SPLEEN LESIONS
Spleen lesions
Summery
discussion
Diagnostic imaging by Peter Armstrong 3rd edition
Anatomy for diagnostic imaging 2nd edt. By Stephanie Ryan
Primer of diagnostic radiology , 3rd edt. Text book of radiology and imaging by David
sutton 7th edt. A guide to radiological procedures by
Frances Aitchison 5th edt.
References
THANK YOU AND
GOOD LUCK