IMAGING IN HEPATOBILLIARY

SYSTEM

HEPATOBILLIARY SYSTEMHEPATOBILLIARY SYSTEM Many techniques are available.Many techniques are available. There is a preferred imaging technique There is a preferred imaging technique

for each potential hepatobilliary for each potential hepatobilliary abnormality.abnormality.

Careful history and physical Careful history and physical examination.examination.

Followed by appropriate clinical and Followed by appropriate clinical and laboratory tests. laboratory tests.

HEPATOBILLIARY SYSTEMHEPATOBILLIARY SYSTEM

The imaging techniques are used to The imaging techniques are used to confirm or exclude a suspected confirm or exclude a suspected diagnosis.diagnosis.

IMAGING TECHNIQUESIMAGING TECHNIQUES        Plain abdominal radiograph.Plain abdominal radiograph.               Oral cholecystogram (O.C.G).Oral cholecystogram (O.C.G).               Intravenous cholangiogram (I.V.C).Intravenous cholangiogram (I.V.C).               Percutaneous transhepatic cholangiogram.Percutaneous transhepatic cholangiogram.               Endoscopic retrograde cholangiopanceatogram Endoscopic retrograde cholangiopanceatogram               T tube cholangiogram.T tube cholangiogram.               Ultrasound.Ultrasound.               Computed tomography (C.T Scan).Computed tomography (C.T Scan).               Magnetic resonance imaging (M.R.I).Magnetic resonance imaging (M.R.I).               Scintigraphy.Scintigraphy.

PLAIN ABDOMINAL PLAIN ABDOMINAL RADIOGRAPH:RADIOGRAPH:

No primary use. However can show No primary use. However can show

Radio-opaque gall stones (10-20%)Radio-opaque gall stones (10-20%) Biliary AirBiliary Air -- Prior common duct surgeryPrior common duct surgery

-Biliary fistula-Biliary fistula -Recent passage of stone-Recent passage of stone Liver enlargementLiver enlargement Calcification in the liver and gall bladder wall.Calcification in the liver and gall bladder wall.

ORAL ORAL CHOLECYSTOGRAMCHOLECYSTOGRAM

Now almost replaced by ultrasound.Now almost replaced by ultrasound. Used for the diagnosis of chronic Used for the diagnosis of chronic

cholecystitis, Gall stones, Cholesterosischolecystitis, Gall stones, Cholesterosis It works best if bilirubin level is less than 5 It works best if bilirubin level is less than 5

mg/dl.mg/dl. Should not be performed in cases of renal Should not be performed in cases of renal

failurefailure

INTRAVENOUS INTRAVENOUS CHOLANGIOGRAM (IVC)CHOLANGIOGRAM (IVC)

Rarely done now-a-daysRarely done now-a-days Still can be used in evaluation of CBD Still can be used in evaluation of CBD

stones after cholecytectomy when stones after cholecytectomy when sonography is indeterminate.sonography is indeterminate.

Useless if bilirubin level is above 2.0 mg/dl.Useless if bilirubin level is above 2.0 mg/dl. Biliscopin is the contrastBiliscopin is the contrast TechniqueTechnique

  

ULTRASOUNDULTRASOUND The best imaging modality for hepatobiliary The best imaging modality for hepatobiliary

tract.tract. Non invasive, cheep and reliable.Non invasive, cheep and reliable. Does not depend on GB function.Does not depend on GB function. No ionising radiation. Safe in Pregnancy & No ionising radiation. Safe in Pregnancy &

children.children. Can show size, shape and masses of liver, Can show size, shape and masses of liver,

status of parenchyma.status of parenchyma. Shows detail of biliary tract and gall bladder.Shows detail of biliary tract and gall bladder.

C.T. SCANC.T. SCAN

Not a primary investigation. Stones are clearly seen. Useful in complicated cases, such as

complicated cholecystitis, gall bladder carcinoma.

NUCLEAR MEDICINENUCLEAR MEDICINE Limited role in gall bladder Imaging. Used primarily for diagnosis of acute

cholecystitis,because it is highly sensitive for detection of cystic duct obstruction.

NUCLEAR MEDICINENUCLEAR MEDICINE

I/V administration of 99mTc-IDA.I/V administration of 99mTc-IDA. Tracer Uptake by liver-out lining CBD- Tracer Uptake by liver-out lining CBD-

filling gall bladder- goes in to small gut.filling gall bladder- goes in to small gut. Absence of activity in GB suggest Absence of activity in GB suggest

cystic duct obstruction- acute cystic duct obstruction- acute cholecystitis.cholecystitis.

T-TUBE T-TUBE CHOLANGIOGRAMCHOLANGIOGRAM

Done 7-10 days following Done 7-10 days following cholecystectomy to see the biliary cholecystectomy to see the biliary tract.tract.

  PERCUTANEOUS TRANSHEPATIC PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAM (PTC)CHOLANGIOGRAM (PTC)

Done in obstructive jaundice to see the Done in obstructive jaundice to see the cause and level of obstructioncause and level of obstruction..

E.R.C.PE.R.C.P Endoscopic retrograde Endoscopic retrograde

cholangiopancreatogram.cholangiopancreatogram. Diagnostic as well as therapeutic.Diagnostic as well as therapeutic.

INTRA OPERETIVE CHOLANGIOGRAM

Done to see the status of billiary tree during surgery.

SOME INTRESTING SOME INTRESTING CASESCASES

Case: 1Case: 1

44 years old women with vague 44 years old women with vague right upper quadrent pain right upper quadrent pain aggrevated by taking meal.aggrevated by taking meal.

Case: 2Case: 2 49 years old woman with RUQ pain,49 years old woman with RUQ pain, Fever,Fever, Nausea & vomiting.Nausea & vomiting. Markedly tender in right Markedly tender in right

hypochondrium.hypochondrium. Elevated WBC count.Elevated WBC count.

CASE:3CASE:3 54 old women.54 old women. Chronic abdominal pain.Chronic abdominal pain. Episode of jaundice & upper Episode of jaundice & upper

abdominal pain 18 m0nths ago which abdominal pain 18 m0nths ago which was spontaneously resolved.was spontaneously resolved.

No previous history of surgery.No previous history of surgery.

CASE: 4CASE: 4

42 years old male.42 years old male. Intermittent RUQ pain.Intermittent RUQ pain. Mild jaundice & 102 temperature.Mild jaundice & 102 temperature. Elevated bilirubin & alkaline Elevated bilirubin & alkaline

phosphatase.phosphatase.

Biliary Duct Biliary Duct Obstruction:Obstruction:

Diagnostic Patterns.Diagnostic Patterns.

Radiological Radiological extraction of extraction of

retained bile duct retained bile duct stones after surgery.stones after surgery.