Imaging approach to Pancreas, Gallbladder and Bile duct anomalies and anatomical variants A Reinders...

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  • Imaging approach to Pancreas, Gallbladder and Bile duct anomalies and anatomical variants A Reinders Department of Radiology March 2012
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  • Introduction Embryology & normal anatomy Pancreas Bile ducts Gallbladder Cystic duct Liver vascular anatomy* Congenital variants Imaging approach Report
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  • Embryology Primitive Foregut & midgut Hepatic Diverticulum Gallbladder Ventral pancreatic outpoutching Dorsal pancreatic Outpoutching Bile duct Hepatic ducts 4 th Week of Fetal life
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  • Figure 1a. Drawings illustrate the normal embryologic development of the pancreas and biliary tree. Mortel K J et al. Radiographics 2006;26:715-731 2006 by Radiological Society of North America
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  • Embryology Pancreas Dorsal pancreatic outpoutching Dorsal pancreas Posterior pancreatic ductal system Ventral pancreatic outpouching Extrahepatic BD Intrahepatic BD Ventral pancreas 7 th Week of Fetal life
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  • Figure 1c. Drawings illustrate the normal embryologic development of the pancreas and biliary tree. Mortel K J et al. Radiographics 2006;26:715-731 2006 by Radiological Society of North America
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  • Figure 1d. Drawings illustrate the normal embryologic development of the pancreas and biliary tree. Mortel K J et al. Radiographics 2006;26:715-731 2006 by Radiological Society of North America
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  • Congenital Variants Pancreas Annular pancreas Hypoplasia/aplasia of the pancreas Ducts Rudimentary duct of Santorini Dominant duct of Santorini Ansa Pancreatica Pancreas Divisum Ectopic pancreas
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  • Annular Pancreas Rare = 1:2000 Incomplete rotation of ventral anlage Segment of pancreas encircling 2 nd part of duodenum Obstruction 10% Extramural Ventral pancreatic duct Encircles duodenum and joins MPD Intramural Pancreatic tissue intermingled with muscle fibres Small ducts drains directly into duodenum
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  • Leccos theory Baldwins theory Lee NK, Kim S, Jeon TY et al. Complications of congenital and developmental abnormalities of the gastrointestinal tract in adolescents and adults: Evaluation with multimodality imaging. Radiographics 2010;30:1489-1507
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  • Annular Pancreas Lee NK, Kim S, Jeon TY et al. Complications of congenital and developmental abnormalities of the gastrointestinal tract in adolescents and adults: Evaluation with multimodality imaging. Radiographics 2010;30:1489-1507 Annular pancreas in a 55-year-old man with repeated episodes of vomiting. Contrast-enhanced CT image shows pancreatic tissue (arrows) completely encircling the descending portion of the duodenum (*).
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  • Annular Pancreas Mortele KJ, Rocha TC, Streeter JL et al. Multimodality Imaging of Pancreatic and Biliary Congenital Anomalies. Radiographics 2006; 26:715-731
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  • Hypoplasia/Agenesis of Pancreas Hypoplasia Absence of ventral/dorsal anlage Dorsal hypoplasia more common NB to rule out pancreatic carcinoma with upstream atrophy of gland Degrees of hypoplasia with varying degrees of abscence of neck, body and tail, MDP and duct of Santorini Agenesis Total agenesis is rare = incompatible with life Associated with other GIT malformations Polysplenia GB aplasia
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  • Ductal Anatomy Two major duct Wirschung Main = 1.5 3.5 mm diameter 20 30 side branches Meets with CBD to pass through SOO 8 Y (75%) or V (20%) configuration 10 15 mm long U type (5%) Santorini Drains anterior and superior portion of head Normal narrowing at level of junction between MPD and W No proximal dilatation of duct Minor duodenal papilla +/- 27 different ductal configurations
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  • Figure 3a. Normal pancreatic ductal anatomy. Mortel K J et al. Radiographics 2006;26:715-731 2006 by Radiological Society of North America
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  • Ductal variants Rudimentary duct of Santorini (30%) Duct of Wirsung as manor drainage route still Dominant duct of Santorini (1%) Major drainage route Ansa Pancreatica Duct of Santorini forms a sigmoid curve as it courses to duct of Wirschung
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  • Figure 6b. Variant pancreatic ductal anatomy Ansa Pancreatica Mortel K J et al. Radiographics 2006;26:715-731 2006 by Radiological Society of North America
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  • Sphincter of Oddi 3 separate smooth muscle layers Surrounds MPD and CBD before AOV Anomalous junctions Fusion of MPD and CBD outside duodenal wall = Long common channel (>15mm) Reflux Pancreatitis Cholangitis Cyst Choledocal web
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  • Figure 3d. Normal pancreatic ductal anatomy. Mortel K J et al. Radiographics 2006;26:715-731 2006 by Radiological Society of North America
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  • Figure 10a. Abnormal common channel. Mortel K J et al. Radiographics 2006;26:715-731 2006 by Radiological Society of North America
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  • Figure 10b. ERCP: Abnormal common channel with CBD web in child Mortel K J et al. Radiographics 2006;26:715-731 2006 by Radiological Society of North America
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  • Pancreas Divisum Common 4 10% Ventral and dorsal ducts DONT fuse Wirschung (ventral) = atretic & short Santorini (dorsal) = Larger in caliber Focal dilatation of terminal portion Santorinicele Cause obstruction at minor papillae of duodenum
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  • Figure 6a. Variant pancreatic ductal anatomy - Santorinicele Mortel K J et al. Radiographics 2006;26:715-731 2006 by Radiological Society of North America
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  • Mortele KJ, Rocha TC, Streeter JL et al. Multimodality Imaging of Pancreatic and Biliary Congenital Anomalies. Radiographics 2006; 26:715-731
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  • Ectopic pancreas Incidence 0,6 13% 0,5 2 cm in largest dimensions Usually asx rarely become malignant In submucosa (50%) Stomach (26 - 38%) Duodenum (28 36%) Jejenum (16%) Meckels diverticulum
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  • Biliary System Liver segments Cuinaud classification Main hepatic ducts Cystic duct Choledochal cyst Todanis classification Gallbladder
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  • Biliary System Intrahepatic bile ducts (IBD) run parallel to portal supply RHD Right posterior duct = I, VI & VII (horizontal) 7 Super and Inferior Right anterior duct = V & VIII (vertical) Superior and inferior LHD Draining II, III and IV Lateral and medial Superior and inferior CHD 58 % of people
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  • Images available from URL: http://www.pkdiet.com/pages/pld/pldresection.htm
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  • Figure 5. Normal biliary anatomy. Mortel K J et al. Radiographics 2006;26:715-731 2006 by Radiological Society of North America
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  • Biliary System Right posterior duct (RHD) Drain into LHD before confluence with RAD 13 19% Will not pass RAD posterior but drains directly into it 12% Tripple confluence 11% Drains into CHD Left
  • Biliary System Choledochal cysts Rare Biliary tree dilatation > Female 4:1 Abdominal pain Jaundice Right upper quadrant mass Children 2 38%
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  • Todani Classification Images available from URL: http://radiopaedia.org/encyclopaedia/quizzes/all/8097
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  • Figure 16b. Todani Type 1 Choledochal cysts. Mortel K J et al. Radiographics 2006;26:715-731 2006 by Radiological Society of North America
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  • Figure 16d. Todani Type 2 Choledochal cysts. Mortel K J et al. Radiographics 2006;26:715-731 2006 by Radiological Society of North America
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  • Figure 16f. Todani Type 3 Choledochal cyst Mortel K J et al. Radiographics 2006;26:715-731 2006 by Radiological Society of North America
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  • Figure 17b. (a, b) Drawing (a) and coronal MR cholangiopancreatogram (b) show type IV choledochal cysts. Mortel K J et al. Radiographics 2006;26:715-731 2006 by Radiological Society of North America
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  • Figure 17d. (a, b) Drawing (a) and Endoscopic Retrograde Cholangiopancreatogram (b) show type IV choledochal cysts. Mortel K J et al. Radiographics 2006;26:715-731 2006 by Radiological Society of North America
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  • Carolis Disease Imaging Central dot sign Dilagted IHD with contrast enhancement of the portal branches Todani classifications Type 5 If large IBD affected = Carolis disease If small interlobular bile ducts also affected = Congenital hepatic fibrosis Carolis Syndrome
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  • Gallbladder Adjacent to inferior surface of liver Plane of interlobar fissure Different positions Under left lobe Situs inversus Intrahepatic Subcapsular along ant-inf surface of right lobe of liver Transverse Retroperitoneal Congenital Acquired
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  • Gallbladder GB displacement/rotation Hepatic lobe abnormalities Aplasia Hypoplasia Associated with Cystic Fibrosis Hypertrophy Agenesis DuplicationRare
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  • Gallbladder Phrygian cap Ancient Greek headgear Asx folding of GB fundus Junctional fold Usually posterior wall Septa MultiseptateStatis and stone Honeycombed appearanceformation Extension of Spiral valves of Heister Other Duplication/Triplication, Bifid gallbladder Diverticulum
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  • Gallbladder Meilstrup JW. Hopper KD. Thieme GA. Imaging of gallbladder variants. AJR 1991;157:1205-1208
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  • Liver Arterial Proper hepatic artery (CHA from Coeliac trunk) Right, middel and left hepatic artery (55%) Porto-venous Porta hepatis (SMV and SV) Right Post and anterior Left portal vein Venous = IVC Right Segment 6 & 7 Middle Segments 4,5 & 8 LeftCommon trunk (60%) Segments 2 & 3
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  • Arterial and Venous anatomy Onofrio AC, Anandkumar HS, Raul NU et al. Vascular and biliary variants in the liver: Implications for liver surgery. Radiographics 2008; 28:359-378
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  • Porto-venous anatomy Onofrio AC, Anandkumar HS, Raul NU et al. Vascular and biliary variants in the liver: Implications for liver surgery. Radiographics 2008; 28:359-378
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  • Arterial Variants Onofrio AC, Anandkumar HS, Raul NU et al. Vascular and biliary variants in the liver: Implications for liver surgery. Radiographics 2008; 28:359-378
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  • Arterial Variants Onofrio AC, Anandkumar HS, Raul NU et al. Vascular and biliary variants in the liver: Implications for liver surgery. Radiographics 2008; 28:359-378
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  • Venous Variants Tributary veins Drain segments in addition to hepatic veins Eg. Segment 8 into MHV (9%) NB for surgical incision (Cantlie line) Accessory inferior right hepatic vein Drains directly into IVC (47%) NB: Nr of acc veins Size and distance from main hepatic venous drainage site along IVC Surgical difficulty if >40 mm
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  • Venous Variant Onofrio AC, Anandkumar HS, Raul NU et al. Vascular and biliary variants in the liver: Implications for liver surgery. Radiographics 2008; 28:359-378
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  • Portal Vein Variants Gallego C. Velasco M. Marcuello P et al. Congenital and Acquired anomalies of the portal venous system. Radiographics 2002;22:141-159
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  • Portal Vein Variants Variants common (20%) Trifurcation (7 10%) RPPV from MPV (5 6%) RAPV from LPV (3 4%) Cantlie line Hypovascular surgical line transplantations 1cm to right of MHV Between IVC and gallbladder fossa
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  • Imaging No surprises Radiologist/Surgeon Pre operative planning Liver transplant/resection/cholecystectomy Whipples procedures Intra arterial chemotherapy (HAIP) Asymptomatic Several options Helical CT Cholangiography, MR Cholangiography ERCP, PC Cholangiography Oral Cholangiography, Scintigraphy Best? Kapoor V, Peterson MS, Baron RL. Intrahepatic biliary anatomy of living adult donors: Correlation of Mangafodipir Trisodium enhanced MR Cholangiography and intraoperative cholangiography. AJR Nov 2002; 179(5):1281-1286
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  • Report Technique used Sequences and contrast material Puncture site Normal anatomy If not where does what implant? Classifications and measurements Distinguish from pathological processes
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  • Bibliography 1. Lee NK, Kim S, Jeon TY et al. Complications of congenital and developmental abnormalities of the gastrointestinal tract in adolescents and adults: Evaluation with multimodality imaging. Radiographics 2010;30:1489-1507 2. Mortele KJ, Rocha TC, Streeter JL et al. Multimodality Imaging of Pancreatic and Biliary Congenital Anomalies. Radiographics 2006; 26:715-731 3. Rizzo RJ, Szucs RA, Turner MA. Congenital abnormalities of the pancreas and biliary tree in adults. Radiographics 1995;15:49-68 4. Onofrio AC, Anandkumar HS, Raul NU et al. Vascular and biliary variants in the liver: Implications for liver surgery. Radiographics 2008; 28:359-378 5. Turner MA, Fulcher AS. The Cystic Duct: Normal Anatomy and Disease Processes. Radiographics 2001;21:3-22 6. Kapoor V, Peterson MS, Baron RL. Intrahepatic biliary anatomy of living adult donors: Correlation of Mangafodipir Trisodium enhanced MR Cholangiography and intraoperative cholangiography. AJR Nov 2002; 179(5):1281-1286 7. Applied Radiological anatomy. Butler P, Mitchell AWM, Ellis H Editors. Cambridge University Press. United Kingdom. 2008. Chapter 9. Embryology of the gastrointestinal tract and its adenxae. p185-186 8. Radiology Review Manual. 6 th Edition. Danhert Wolfgang. Lippincott Williams & Wilkins. Philadelphia. 2007. p687 - 690 9. Primer of Diagnostic Imaging. 4 th Edtion. Weissleder R, Wittenberg J, Mukesh GH, Chen J. Mosby Elsevier. 2007. p227-228 10. Meilstrup JW. Hopper KD. Thieme GA. Imaging of gallbladder variants. AJR 1991;157:1205-1208 11. Gallego C. Velasco M. Marcuello P et al. Congenital and Acquired anomalies of the portal venous system. Radiographics 2002;22:141-159