Imaging of Liver, Pancreas and Biliary . 56.pdfImaging of Liver, Pancreas and Biliary System ......

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Transcript of Imaging of Liver, Pancreas and Biliary . 56.pdfImaging of Liver, Pancreas and Biliary System ......

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    Imaging of Liver, Pancreas and Biliary System

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    (Topic module)




    3. 4.


    2. Plain film radiograph, ultrasonography, computed tomography magnetic resonance imaging

    3. portal hypertension

    1. 2. / 3.

    1. Multiple choice question (MCQ) Objective structured clinical examination (OSCE)


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    (Imaging of liver, pancreas and biliary system)

    Anatomy Imaging Modalities Common diseases

    Hepatomegaly Liver cirrhosis Portal hypertension Liver abscess Gallstone bile duct stone Biliary tract obstruction Acute cholecystits Acute chronic pancreatitis



    (size): 1-2 kg

    - Anteroposterior diameter: 10.0 - 12.5 cm - Transverse diameter: 20.0 - 25.5 cm - Superoinferior diameter: 15.0 17.5 cm

    (lobes of liver): , (right, left lobes) caudate lobe

    median fissure gall bladder fossa IVC ( 1A)

    caudate lobe ligamentum venosum ( 1B)


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    1 1A () median fissure 1B () caudated lobe (C) ligamentum venosum ()

    (hepatic vasculature)

    2 hepatic artery portal vein (bile ducts) ( 2)

    2 Hepatic artery portal vein Biliary system

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    - Hepatic artery: celiac artery right left hepatic arteries oxygen hepatic artery 25% hepatic blood flow

    - Portal vein: 75% hepatic blood flow portal vein splenic vein superior mesenteric vein ( 3A) portal vein porta hepatis right left portal veins hepatic arteries

    hepatic arteries portal veins hepatic lobules portal triad (mix) hepatic sinusoids sinusoids hepatic central veins hepatic veins (right, middle left hepatic veins) inferior vena cava right atrium

    Porta hepatis region: (hepatic root) (hepatic artery, main portal vein), (common hepatic duct) (primary lymphatic drainage)

    Portal system

    Portal vein ( 3B)

    1. Splenic vein: pancreas superior mesenteric vein (SMV) pancreatic neck portal vein splenic vein Short gastric vein Left gastroepiploic vein Pancreatic vein Inferior mesenteric vein left colic vein, sigmoid vein

    superior rectal vein 2. Superior mesenteric vein

    Pancreaticoduodenal vein Right gastroepiploic vein Ileocolic vein Right colic vein Middle colic vein

    3. Coronary vein gastric vein lessor curvature stomach stomach esophagus (esophageal vein) portal vein

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    retroperitoneal organ retroperitoneal fat pancreatic head, neck, body, tail uncinate process landmark ( 4)

    3A portal system SMV = superior mesenteric vein, IMV = inferior mesenteric vein

    3 B portal system 1 = IVC 2 = left gastric vein 3 = right gastric vein 4 = splenic vein 5 = left gastroepiploic vein 6 = right gastropiploic vein 7 = IMV 8 = left colic vein 9 = sigmoid vein 10 = Jejunal and ileal branches 11 = ileocolic vein 12 = right colic vein 13 = middle colic vein 14 = SMV 15 = Pancreatoduodenal vein 16 = Portal vein 17 = left hepatic vein 18 = right hepatic vein

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    4 - Pancreatic head: SMV - Pancreatic neck: SMV - Pancreatic body tail: SMV (left border of SMV) splenic vein - Uncinate process: SMV SMV = superior mesenteric vein

    (Pancreatic ductal system)

    Main pancreatic duct body tail duct of Wirsung duct of Santorini duct of Wirsung common bile duct 2nd part duodenum papilla major ( 5)

    duodenum distal common bile duct pancreatic duct smooth muscle fiber sphincter of Oddi 2nd part duodenum ampulla

    5 (Pancreatic ductal anatomy) MPD = main pancreatic duct: body tail S = duct of Santorini W = duct of Wirsung

    (Biliary system)

    Bile duct 2 (intrahepatic portion) (extrahepatic portion) ( 6A)

    - Intrahepatic bile ducts bifurcation common hepatic duct right left hepatic ducts 4 segmental ducts (right posterior,

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    right anterior, left medial left lateral ducts) portal veins hepatic arteries portal triads

    - Extrahepatic bile duct: right left hepatic ducts common hepatic duct porta hepatis (liver root) cystic duct common bile duct Common hepatic duct cystic duct insertion Common bile duct cystic duct insertion

    Distal common bile duct 1st part duodenum pancreatic head right lateral aspect pancreatic head pancreatic duct medial wall 2nd part duodenum


    Gallbladder cholecystokinin cystic duct pear shape 8-10 cm 2-3 cm 3 fundus, body neck ( 6B)

    - Fundus: gallbladder

    - Body: gallbladder fundus neck - Neck: gallbladder cystic duct

    6 (biliary system) (gallbladder) 6A () biliary system 6B () gallbladder

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    1. Plain film radiograph

    2. Ultrasonography (US) and Endoscopic ultrasonography (EUS)

    3. Computed tomography (CT) and CT angiography (CTA)

    4. Magnetic resonance imaging (MRI)

    6. Endoscopic retrograde cholangiopancreatography (ERCP)

    Plain film radiograph

    ( 7) supine upright views

    Organomegaly: hepatomegaly, splenomegaly Abnormal air: pneumoperitoneum, air solid organ ( liver abscess), air

    (emphysematous cholecystitis) Abnormal calcification: (gallstone); calcium (Porcelain

    gallbladder); calcium ( aortic aneurysm, splenic aneurysm); calcium parenchyma solid organ ( calcium pancreatic parenchyma chronic pancreatiits)

    foreign bodies

    (sensitivity) (specificity)


    (Imaging Modalities)

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    7 plain film of the abdomen 7A () normal plain film of the abdomen fat shadow; H = hepatic shadow, K = kidney shadow, S = splenic shadow, = psoas shadow, = properitoneal fat stripe 7B () diagram normal plain film of the abdomen

    Ultrasonography (US) Endoscopic ultrasonography (EUS)


    (ultrasonography) (probe transducer) (reflection) (refraction) probe

    : 2-12 MHz probe 2

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    (convex probe): 2-6 MHz

    (Linear probe): 7-12 MHz breast, thyroid gland, testis, carotid artery

    (convex probe)

    (ultrasound upper abdomen):

    (ultrasound lower abdomen):


    Ultrasound upper abdomen: 4-6

    Ultrasound lower abdomen:

    Right upper quadrant mass: liver mass, gallbladder mass Enlarged abdominal organ: hepatomegaly, splenomegaly

    Abnormal liver function test: fatty liver, cirrhosis

    Abdominal pain, abdominal distension: gallstone, acute cholecystitis, acute pancreatitis, chronic pancreatitis

    Jaundice, biliary obstruction: bile duct stone ( choledocholithiasis), pancreatic tumor

    Abnormal vascular structure: portal hypertension, portal vein thrombosis,

    abdominal aortic aneurysm

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    Abdominal trauma

    Search for metastatic disease: liver metastasis breast

    cancer, colorectal cancer

    Search for occult primary neoplasm:


    Guidance for biopsy or drainage procedure: US

    (biopsy) (drainage)


    abscess, liver tumor, gallstone, fatty liver


    (cystic mass)

    (solid mass)

    biliary obstruction



    distal common bile duct

    Endoscopic ultrasonography (EUS)

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    (bile duct) (pancreatic duct) bile duct pancreatic duct (CA pancreas periampullary tumor)

    Computed tomography (CT)

    CT scan CT scan (intravenous contrast media)

    CT: iodine based contrast media




    Mass: benign, malignant tumor, abscess, hematoma CT ultrasound

    Infiltrative disease cirrhosis, fatty liver Abdominal pain ultrasound: acute pancreatitis, acute

    cholecystitis, acute cholangitis Abnormal calcification: gallstone, bile duct stone Biliary tract obstruction:

    cholangiocarcinoma Abnormal vascular structure: portal hypertension, portal vein thrombosis,

    abdominal aortic aneurysm

    Abdominal trauma: liver trauma, splenic trauma

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    multidetector CT scan (single breath hold) scan CT scan

    (axial plane) CT scan coronal plane sagittal plane multiplanar imaging

    calcium gallstone calcium ( pigment stone)

    abnormal air pneumoperitoneum, air abscess ( liver abscess, splenic abscess)

    radiation gallstone bile duct stone calcium

    pure cholesterol stone

    Multiphase dynamic contrast-enhanced CT scan

    (intravenous contrast media) blood flow blood flow CT scan multiphase dynamic contrast-enhanced CT scan

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    dynamic contrast-enhanced CT scan

    2 system (dual blood supply) hepatic artery (25%) portal vein (75%) scan

    1. Non-contrast study:

    non-contrast study calcification, gallstone bile duct stone calcium, hemorrhage iron deposition non-contrast phase study

    2. Arterial phase study: scan CT 15-30 hepatic artery (diff