IMAGING OF BILE DUCT

DR.SUDHEER HEGDECONSULTANT RADIOLOGIST

DEPARTMENT OF RADIOLOGYCOLUMBIA ASIA HOSPITALS

Courtesy:Dr.Shalini Govil

NORMAL ANATOMY cross-sectional and cholangiographic

CAUSES OF LOWER BILIARY OBSTRUCTION

APPEARANCES ON DIFFERENT IMAGING MODALITIES

ALGORITHM FOR OBSTRUCTIVE JAUNDICE

BILIARY ANATOMY

IMAGING MODALITIES

• Ultrasound - transabdominal, EUS, intraductal•Cholangiography - invasive : ERCP / PTC

- non-invasive : MR Cholangiography CT Cholangiography

- minIP and maxIP

•Cross Sectional - spiral CT / MRI as part of MRC/CTC• Non-invasive biliary package – MRC with spiral CT• DSA • Biliary Scintigraphy

BILIARY ANATOMY - Cholangiogram

Ultrasound biliary tract

BILIARY ANATOMY - CTright hepatic duct

common hepatic duct / common duct at the hilum

BILIARY ANATOMY - CT

supra-pancreatic common duct in the lesser omentum

BILIARY ANATOMY - CT

BILIARY ANATOMY - CT

intra-pancreatic common duct

BILIARY ANATOMY - CT

intra-pancreatic common duct

MRCP

EUS – bile duct calculi

CAUSES OF LOWER BILIARY OBSTRUCTION

CLASSIFICATION BY LEVEL OF OBSTRUCTION

Intrapancreatic - choledocholithiasis, chronic pancreatitis, pancreatic carcinoma

Suprapancreatic – cholangiocarcinoma, metastatic adenopathy, choledochal cyst

Intraluminal – tumour – HCC/CC, blood, stone, worm, hydatid

ULTRASONOGRAPHY

• Signs of Biliary Dilatation:Parallel Channel sign – IHBD > 2mmCBD > 6mm

• Post Fatty Meal SonographyCBD size increase of 2mm

• Post CholecystectomyNo compensatory dilatation of CBDCBD > 10mm

CHOLANGIOGRAPHY

Invasive (ERCP / PTC) - High spatial resolution Possible therapeutic options Complication rate (2-3%)

Non-invasive CT Cholangiogram - with IV contrast (maxIP)

bilirubin > 2mg% - ineffective - without IV contrast (minIP)

MR Cholangiogram

MR CHOLANGIOGRAPHY Breath-hold (HASTE, RARE)Non-breath-hold (IRTSE)

Bile appears bright on heavily T2W images

Mapping of biliary tree proximal to obstruction

Contraindicated in presence of aneurysm clips,cardiac pacemakers.

MR CHOLANGIOGRAPHY

SENSITIVITY SPECIFICITY

Biliary Obstruction 91 – 100% 100%

Level of Obstruction 91 – 100% 100%

Choledocholithiasis 81 – 100% 85 – 100% (2mm)

MR CHOLANGIOGRAPHY

ERC MRC CTC

THERAPY + - -

SECTIONAL - + +IMAGING

ANGIOGRAM - + +

CT / MRI

• Extraductal information – mass, nodes, ascites, metastases, biliary cirrhosis, portal hypertension and varices

• CT / MR angiography – for tumour resectability: periampullary, pancreatic, GB and hilar carcinomas.

CTC

MRC

ERCP

MR/CT CHOLANGIOGRAPHYvisualisation of the proximal biliary tree involvement of CHD, confluence, RHD, LHD, second order ducts

SECTIONAL IMAGES nodes, liver metastases, ascites, peritoneal metastases, hilar vessel involvement

PANCREATIC / PERIAMPULLARY CARCINOMA

US – Double duct sign (CBD & PD dilated)

- Mass (+) - Ca Pancreas(95%) –US guided FNAC

- Mass (– )-Perimpullary Ca – ERC with Biopsy

Spiral CT - 80% accuracy(resectability)

Endoscopic US – local extent of disease.

PeriampullaryCarcinoma

PeriampullaryCarcinoma

Ca pancreas

double ductsign

ALGORITHM for OBSTRUCTIVE JAUNDICE

ULTRASOUND

BILIARY DILATATION

MASS+

MR (MRC, MRA)or

CT (CTC + CTA)or

MRC + CT + CTASTENT or SURGERY

? STRICTURE

? CALCULUS(intact bile duct)

(THERAPEUTIC) ERC

CALCULUS+MASS -

RESECTABILITY CRITERIA

Involvement of encasing the portal vein,distal superior mesenteric vein.

• Involvement of CBD and PD (both ducts)

• Unilateral vascular invasion with contralateral biliary involvement

• Metastases

Helical CT - 60% Accuracy

Pancreatic adenocarcinomaencasing the portal vein,distal superior mesenteric vein.

Intraluminal filling defect suggestive of a thrombus is seen in the superior mesenteric vein

THANK YOU

CHOLANGIOCARCINOMA Intraductal ultrasound

bile duct wall thickening - carcinoma vs inflammation

• semicircular, eccentric, asymmetric wall thickening

• notched outer margin

• rigid, papillary inner margin

• heterogeneous echoes

NON SURGICAL THERAPEUTIC DRAINAGE

• Low Obstruction – ERCP with Stent Placement

• Cholangitis – Drainage (Nasobiliary/PTBD)

PTBD with STENTPLACEMENT

ERC with STENT

DISTAL CHOLANGIOCARCINOMA

GB CARCINOMA

PRIMARY SCLEROSING CHOLANGITIS

US • extrahepatic and intrahepatic ductal wall thickening

CHOLANGIOGRAPHY• pruned tree appearance• multifocal strictures• pseudodiverticulae

PSC-like cholangitis – AIDS cholangitis

NON INVASIVE CHOLANGIOGRAM PREFERABLE

PRIMARY SCLEROSING CHOLANGITIS

HYDATID CYSTS

CHOLEDOCHAL CYST

US / NON INVASIVE CHOLANGIOGRAPHY

- Todani type

- abnormal pancreatico biliary junction

CHOLEDOCHAL CYST

CHOLEDOCHAL CYST

ABERRANT BILE DUCTS

non invasive cholangiogram – prior to laproscopic cholecystectomy

MRC HIGH DIAGNOSTIC CT C ACCURACY

MRC 0.5 T – SUBOPTIMAL VISUALISATION OF NORMAL CALIBER DUCTS

MRC

CTC

POST SURGICAL COMPLICATIONS

• Retained calculi – T tube Cholangiogram / ERCP

• Biliary leak

• Biliary stenosis/stricture

BILE LEAKSSite of Leak

T-Tube Cholangiogram

ERCP with sphincterotomy / Stent

Scintigram

Infected Biloma

US / CT – pigtail drainage

T – TUBE cholangiogram

BILE LEAKS

POST SURGICAL STRICTURE-BILIARY ENTERIC ANASTAMOSIS

-POST CHOLECYSTECTOMY

• US – biliary dilatation aerobilia

• MR / CT with Cholangiogram – level of obstruction

• HIDA Scan – assess patency

POST-SURGICAL STRICTURES

BISMUTH CLASSIFICATION

ERC

MRC

BISMUTH type 5 STRICTURE

ANASTAMOTIC STRICTURE

GALL STONE associated obstructions

GALL STONE ILEUSRigler’s triad - air in the biliary tree

small bowel obstructionectopic gall stone

MIRIZZI SYNDROME

GALL STONE ILEUS