M-2 HEPATOBILIARY IMAGING  Liver  Gallbladder And Bile Ducts...

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M-2 HEPATOBILIARY IMAGING Liver Gallbladder And Bile Ducts Pancreas Spleen 2013 Slide 2 GOALS Review anatomy of hepato- biliary system. Correlate imaging with pathology. Discuss radiologic imaging options. Choose treatment Slide 3 ANATOMY / PHYSIOLOGY Portal vein flow Hepatic arterial flow Hepatic vein flow Biliary drainage Slide 4 PORTAL BLOOD FLOW CT Slide 5 PORTAL VEIN Coronal and Axial images CT US Slide 6 CT US Transverse CT sections and corresponding US Slide 7 Catalano, O. A. et al. Radiographics 2008;28:359-378 HEPATIC ARTERIES Slide 8 LATERAL AORTOGRAM AND CT SHOW ORIGINS OF CELIAC ARTERY AND SMA SMA Celiac SMA Slide 9 Proper hepatic Gastroduodenal Celiac SMA THE COMMON HEPATIC ARTERY BECOMES THE PROPER HEPATIC ARTERYAFTER THE GASTRODUODENAL BRANCH DESCENDS. Slide 10 Arteriography of the three main branches of the celiac artery : Common Hepatic Artery, Left Gastric Artery, and Splenic Artery Furuta T et al. Radiographics 2009;29:e37 2009 by Radiological Society of North America Celiac HEART Slide 11 Catalano, O. A. et al. Radiographics 2008;28:359-378 HEPATIC VEINS Slide 12 Coronal scan Slide 13 HEPATIC VEINS ENTERING IVC CT ULTRASOUND Slide 14 Catalano, O. A. et al. Radiographics 2008;28:359-378 INTRA AND EXTRAHEPATIC BILIARY TREE Slide 15 Silva, A. C. et al. Radiographics 2004;24:677-687 NORMAL BILIARY ANATOMY NORMAL HIDA SCAN Slide 16 Silva, A. C. et al. Radiographics 2004;24:677-687 COMPARISON WITH MR CHOLANGIOGRAM (MRCP) Slide 17 MR CHOLANGIOGRAM OPERATIVE CHOLANGIOGRAM COMMON BILE DUCT Slide 18 GALLBLADDER POST CHOLECYSTECTOMY GALLBLADDER CALCULI Slide 19 ERCP MR cholangiogram shows signal from the bile and other fluids. ERCP has iodinated contrast injected with an endoscope with the canula in the distal common bile duct. ENDOSCOPIC RETROGRADE Cholangio - Pancreatography Slide 20 PANCREATIC ANATOMY Slide 21 WHO PRESENTS FOR IMAGING? Right upper quadrant pain Altered laboratory data Staging of malignancy / infection Physical exam findings Abdominal trauma Slide 22 Differential Diagnosis: Acute Cholecystitis/Cholelithiasis PUD / Gastritis / Reflux Acute hepatitis / Liver Abcess Pancreatitis Choledocholithiasis ACUTE RIGHT UPPER QUADRANT PAIN Slide 23 Gallstone = cholelithiasis Common - prevalence 10% Pain with contraction after eating Slide 24 DIAGNOSIS ULTRASOUND Cost / Availability Fluid background is ideal for imaging Helpful to assess for any associated biliary dilatation or inflammatory change Slide 25 CHOLELITHIASIS Slide 26 Sonography is preferred as the initial imaging test of choice, with supplemental scintigraphy in problematic cases. ACUTE CHOLECYSTITIS Slide 27 CHOLECYSTITIS With diffuse wall thickening and edema. Ultrasound and CT demostration of edema in and around GB wall Slide 28 A Sonographic Murphys sign is focal tenderness corresponding to the gallbladder. Along with other ultrasound evidence of inflammation (gallbladder wall thickening, pericholecystic fluid) it helps physicians separate Acute Cholecystitis from gallstones alone. Murphys Sign Slide 29 IMAGING ALTERNATIVES Nuclear medicine - HIDA CT X-ray Cholangiography - MR or Endoscopic Slide 30 NORMAL HIDA ABNORMAL HIDA Obstructed cystic duct doesnt allow for filling of radionuclide into the GB. HEPATO - BILIARY SCINTIGRAM Gall bladder Absent Gall bladder Slide 31 NORMAL GALLBLADDER GALLSTONE CHOLECYSTITIS Thickened edematous gallbladder wall with cholecystitis on CT Slide 32 GALLSTONES 15-30% calcify Slide 33 COMPLICATIONS OF GALLSTONES Cystic duct obstruction Cholecystitis A Common bile duct obstruction Obstructive jaundice B Ascending cholangitis Pancreatic duct obstruction Pancreatitis C A B C Slide 34 Normal bile duct size Diameter < portal diameter Obstructed duct due to distal calculus PV CBD Note dilated CBD with impacted calculus Slide 35 Normal *Note dilated bile ducts. (Low density branching structures anterior to portal veins) The Portal vein is opacified (white) from IV contrast administration. The biliary tree is of lower density and shows as a branching structure anterior to the portal vein. Slide 36 Endoscopic retrograde Cholangiopancreatography Normal size CBD Dilated CBD with calculi ERCP Slide 37 SPECIAL CASES Emphysematous cholecystitis Acalculous cholecystitis Gallstone ileus Slide 38 EMPHYSEMATOUS CHOLECYSTITIS DIABETIC PATIENTS - AIR IN WALL Slide 39 ACALCULOUS CHOLECYSTITIS BILIARY STASIS - FASTING / ICU PATIENTS Slide 40 GALLSTONE ILEUS Small Bowel Obstruction at IC valve due to migration of gallstones that erode into duodenum from GB. 1999 2002 Slide 41 ABDOMEN SCAN DONE 2/12/08 Slide 42 SAME PATIENT ABDOMEN SCAN DONE 2/25/08 Slide 43 CHOLECYSTOSTOMY SKIN MARKERS NEEDLE POSITION DRAIN PRESENTATION PLACEMENT Slide 44 Ultrasound 1st CT / HIDA 2nd ERCP / MRCP-- 3rd RUQ PAIN IMAGING EVALUATION Slide 45 ALTERED LABORATORY DATA +-PAIN Bilirubin - jaundice Amylase - pancreatitis Slide 46 JAUNDICE Jaundice is a clinical finding, not a single disease entity. Two distinct categories: Intrahepatic biliary stasis (hepatocellular jaundice) -imaging plays little useful role Mechanical biliary obstruction. Slide 47 JAUNDICE VIRAL HEPATITIS IMAGING- LIMITED VALUE Acute usually normal helps to exclude obstruction Chronic increased malignancy risk Slide 48 Neoplasms of the pancreas Choledocholithiasis Pancreatitis Iatrogenic strictures of the biliary tree THE MOST COMMON CAUSES OF OBSTRUCTIVE JAUNDICE IN THE UNITED STATES Slide 49 JAUNDICE BILIRUBIN Painless Malignancy Chronic obstruction Painful Hepatitis / liver edema Choledocholithiasis / acute obstruction Slide 50 PANCREATIC CANCER OBSTRUCTIVE JAUNDICE Slide 51 PALPABLE GALL BLADDER A palpable gall bladder in an asymtomatic patient can be seen with pancreatic carcinoma due to distal obstruction (Courvoisier sign) Slide 52 PANCREATITIS elevated AMYLASE & LIPASE Biliary calculi-obstruction Alcohol- chemical toxicity Slide 53 Pseudocyst Pain Infection Hemorrhage- pseudoaneurysm Pancreatic insufficiency COMPLICATIONS OF PANCREATITIS Large retrogastric fluid collection is a pseudocyst related to pancreatic enzyme break down of tissue. Slide 54 PANCREATIC ABSCESS Slide 55 DRAINAGE OF PANCREATIC ABSCESS Slide 56 STAGING MALIGNANCY / INFECTION Mesenteric blood flow spreads disease to liver Slide 57 GI malignancy often spreads to liver as first site of hematogenous extention. Slide 58 HEPATIC ABSCESS FROM GI INFECTION Mesenteric venous blood flow can spread infection to the liver. Slide 59 PALPABLE PHYSICAL EXAM FINDINGS Enlarged liver Enlarged spleen Ascites - distention Slide 60 PALPABLE LIVER-metastatic disease A palpable enlarged liver edge is nonspecific but raises questions of mass or liver pathology. Slide 61 ENLARGED PALPABLE SPLEEN Enlarged spleen raises issue of lymphoproliferative diseases or infection. Slide 62 SPLEEN ENLARGED SPLEEN ON ULTRASOUND AND CT. *Note left kidney Slide 63 Coronal scan SPLENOMEGLY *Note dilated splenic vein * Slide 64 Ascites displacing bowel medially on Xray Lucent fluid at tip of liver on ultrasound Fluid on CT Slide 65 Sagittal Ultrasound Small nodular echogenic liver shows cirrhotic change Slide 66 CIRRHOSIS Portal hypertension Here long standing cirrhosis has lead to a scarred shrunken liver. Portal hypertension resulting leads to varices and redirection of blood flow into a recanalized umbilical vein. Slide 67 VARICES Varices are at risk for hemorhage. They can be treated by embolization at GI endoscopy or vascular shunt of portal blood flow by Surgery or Radiology to decrease portal pressure. Slide 68 Surgical Portocaval shunts as therapy Side to side Splenorenal Slide 69 Interventional Radiology shunt Hepatic vein - Portal vein TIPS Transjugular Intrahepatic Portosystemic Shunt Slide 70 TRAUMA Slide 71 UNSTABLESURGERY X-ray-- Chest/ Abd / Pelvis if possible FAST SCAN-- to look for peritoneal fluid STABLE CT SCANNING TRAUMA Slide 72 F.A.S.T. SCAN (Focused Assessment with Sonography for Trauma) Ultrasound survey for free peritoneal fluid Slide 73 F.A.S.T. SCAN (Focused Assessment with Sonography for Trauma) Ultrasound survey for free peritoneal fluid Need 400-500 ccs Not good for organ injury or bowel injury Peritoneal Lavage is outdated Slide 74 HEPATIC / SPLENIC LACERATION Note rib fractures on x-ray Slide 75 POST TRAUMATIC PANCREATITIS SEAT- BELT INJURY There is diffuse edema and hemorhage in adjacent tissues around the pancreas. Slide 76 WHAT IMAGING POSSIBILITIES? ULTRASOUND---GB / CBD / LIVER Plain x-ray---ERCP CT---PANCREAS / LIVER Nuclear Medicine---HIDA MR --- MRCP These are the imaging modalities and important sites of assessment Slide 77