Imaging of Bile Duct - Columbia Asia Workshop

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Transcript of Imaging of Bile Duct - Columbia Asia Workshop

  • 1. IMAGING OF BILE DUCT DR.SUDHEER HEGDE CONSULTANT RADIOLOGIST DEPARTMENT OF RADIOLOGY COLUMBIA ASIA HOSPITALS Courtesy : Dr.Shalini Govil

2. NORMAL ANATOMYcross-sectional and cholangiographic CAUSES OF LOWER BILIARY OBSTRUCTION APPEARANCES ON DIFFERENTIMAGING MODALITIES ALGORITHM FOROBSTRUCTIVE JAUNDICE 3. BILIARY ANATOMY 4. 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

5. BILIARY ANATOMY - Cholangiogram 6. Ultrasound biliary tract 7. BILIARY ANATOMY - CT right hepatic duct 8. common hepatic duct / common duct at the hilum BILIARY ANATOMY - CT 9. supra-pancreatic common duct in the lesser omentum BILIARY ANATOMY - CT 10. BILIARY ANATOMY - CT intra-pancreatic common duct 11. BILIARY ANATOMY - CT intra-pancreatic common duct 12. MRCP 13. EUS bile duct calculi 14. CAUSES OF LOWER BILIARY OBSTRUCTION CLASSIFICATION BY LEVELOF OBSTRUCTION Intrapancreatic - choledocholithiasis, chronic pancreatitis,pancreatic carcinoma Suprapancreatic cholangiocarcinoma, metastatic adenopathy,choledochal cyst Intraluminal tumour HCC/CC, blood, stone, worm, hydatid 15. ULTRASONOGRAPHY

  • Signs of Biliary Dilatation:
  • Parallel Channel sign IHBD > 2mm
  • CBD > 6mm
  • Post Fatty Meal Sonography
  • CBD size increase of 2mm
  • Post Cholecystectomy
  • No compensatory dilatation of CBD
  • CBD > 10mm

16. CHOLANGIOGRAPHY Invasive(ERCP / PTC) - High spatial resolution Possible therapeutic options Complication rate (2-3%) Non-invasiveCT Cholangiogram - with IV contrast (maxIP) bilirubin > 2mg% - ineffective - without IV contrast (minIP) MR Cholangiogram 17. 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. 18. MR CHOLANGIOGRAPHY SENSITIVITY SPECIFICITY Biliary Obstruction91 100% 100% Level of Obstruction91 100% 100% Choledocholithiasis81 100% 85 100% (2mm) 19. MR CHOLANGIOGRAPHY 20. ERC MRC CTC THERAPY + - - SECTIONAL - + + IMAGING ANGIOGRAM- + + 21. 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.

22. CTCMRC 23. ERCP 24. MR/CT CHOLANGIOGRAPHY visualisation of the proximal biliary treeinvolvement of CHD, confluence, RHD, LHD, second order ducts SECTIONAL IMAGES nodes, liver metastases, ascites,peritoneal metastases, hilar vessel involvement 25. PANCREATIC / PERIAMPULLARYCARCINOMA 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. 26. Periampullary Carcinoma 27. Periampullary Carcinoma 28. Ca pancreas double duct sign 29. ALGORITHM for OBSTRUCTIVEJAUNDICE ULTRASOUND BILIARY DILATATION MASS+ MR (MRC, MRA) or CT (CTC + CTA) or MRC + CT + CTA STENTorSURGERY ? STRICTURE ? CALCULUS (intact bile duct) (THERAPEUTIC) ERC CALCULUS+ MASS - 30. RESECTABILITY CRITERIA

  • Involvement ofencasing 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 31. Pancreatic adenocarcinoma encasing the portal vein, distal superior mesenteric vein.Intraluminal filling defect suggestiveof a thrombusis seen in the superior mesenteric vein 32. THANK YOU 33. CHOLANGIOCARCINOMA Intraductal ultrasound

  • bile duct wall thickening -carcinoma vs inflammation
  • semicircular, eccentric, asymmetric wall thickening
  • notched outer margin
  • rigid, papillary inner margin
  • heterogeneous echoes

34. NON SURGICALTHERAPEUTIC DRAINAGE

  • Low Obstruction
  • ERCP with Stent Placement
  • Cholangitis Drainage
  • (Nasobiliary/PTBD)

35. PTBD with STENT PLACEMENT ERC with STENT 36. DISTAL CHOLANGIOCARCINOMA 37. GB CARCINOMA 38. PRIMARY SCLEROSING CHOLANGITIS

  • US
  • extrahepatic and intrahepatic ductal wallthickening
  • CHOLANGIOGRAPHY
  • pruned tree appearance
  • multifocal strictures
  • pseudodiverticulae
  • PSC-like cholangitis AIDS cholangitis
  • NON INVASIVE CHOLANGIOGRAM PREFERABLE

39. PRIMARY SCLEROSING CHOLANGITIS 40. 41. HYDATID CYSTS 42. CHOLEDOCHAL CYST US / NON INVASIVE CHOLANGIOGRAPHY - Todani type- abnormal pancreatico biliary junction 43. CHOLEDOCHAL CYST 44. CHOLEDOCHAL CYST 45. ABERRANT BILE DUCTS non invasive cholangiogramprior to laproscopic cholecystectomy MRCHIGH DIAGNOSTIC CT CACCURACYMRC 0.5 T SUBOPTIMAL VISUALISATIONOF NORMAL CALIBER DUCTS 46. MRC CTC 47. POST SURGICALCOMPLICATIONS

  • Retained calculi T tube Cholangiogram / ERCP
  • Biliary leak
  • Biliary stenosis/stricture

48. 49. 50. BILE LEAKS Site of Leak T-Tube Cholangiogram ERCP with sphincterotomy / Stent Scintigram Infected Biloma US / CT pigtail drainage 51. T TUBE cholangiogram BILE LEAKS 52.

  • POST SURGICAL STRICTURE
  • BILIARY ENTERIC ANASTAMOSIS
  • POST CHOLECYSTECTOMY
  • US biliary dilatation
  • aerobilia
  • MR / CT with Cholangiogram
  • level of obstruction
  • HIDA Scan assess patency

53. POST-SURGICAL STRICTURES BISMUTH CLASSIFICATION 54. ERC MRC 55. BISMUTH type 5 STRICTURE ANASTAMOTIC STRICTURE 56. GALL STONEassociated obstructions GALL STONE ILEUS Riglers triad - air in the biliary tree small bowel obstruction ectopic gall stone MIRIZZI SYNDROME 57. GALL STONE ILEUS