RADIOLOGY OF HEPATOBILIARY SYSTREM , PANCREAS AND SOLEEN

For 4th year medical studentsBy: Dr.Idrees J. AhmedFIBMS Rediology lecturerCollege of medicineHawler Medical university

RADIOLOGY OF HEPATOBILIARY SYSTREM , PANCREAS AND SPLEEN

HEPATOBILIARY RADIOLOGICALANATOMY AND INVESTIGATION METHODSLECTURE ONETo be familiar with radiological anatomy and distinguish normal pictures

To be able to sort investigations according to indications and priorities LECTURE OBJECTIVERadiological anatomyMethods of investigationIndications , precautions and contraindicationPatient PreparationRadiological features of most common diseases referencesLecture overview

Liver :Variable size and shapeRt upper quadrantLobes and segmentsFalciform ligament ( contains lig. Teres ) Portal vein and portal triadsHepatic veins

Radiological anatomy of hepatobiliary system

LIVER ANATOMY

GALL BLADDER :( size , shape , location )2mm walls , 5x10 cmVariants :Phrygian cap , junctional fold , agenesis

INTRA AND EXTRAHEPATIC DUCTSRHD +LHD =CmDCmD+ CyD = CBD

Plain x-ray film , cholecystography( hystorical )UltrasoundCT scanMRI , MR cholangiopancreatographyERCP ( endoscopic retrograde cholangiopancreatography)

METHODS OF INVESTIGATION OF HEPATOBILIARY SYSTEM

Percutaneous transhepatic cholangiography ( PTC)Post-operative ( t-tube ) cholangiographyOperative cholangiographyAngiography ( diagnostic and therapeutic ) CTA , DSA and MRA Radionuclide imaging Methods of investigation of the hepatobiliary system ( cont.)

Main clinical Indications :Right upper quadrant painjaundiceClinically suspected liver lesion Abnormal lab testsStaging for malignant diseasesSuspected portal hypertension

ULTRASOUND OF LIVER AND GALL BLADDER

No contraindication

Preparation: Restrictuin to clear fluids for gall bladder study ( 6 8 hr )ULTRASOUND OF LIVER AND GALL BLADDER

ULTRASOUND MACHINE

ULTRASOUND OF LIVER AND GALL BLADDER

CT scanner

CT scan of liver and biliary tree

Clinical Indications:suspected liver lesionCharacterization of liver lesionStaging malignancyRt upper quadrant painTo facilitate placement of needles( biopsy, etc. ) Follow up after surgical or radiological intervention

CT SCAN OF LIVER AND BILIARY TREE

Contraindications :PregnancyAllergy to iodinated contrast media

Patient preparation: the patient fasted for at least 6 hr

Investigations to be continued next lectureCT SCAN OF LIVER AND BILIARY TREE ( CONT. )

Questions and discussion End of lecture oneOBJECTIVES :

Continuation of hepatobiliay investigations

Radiology of cystic liver lesionsLecture two

MRI LIVER

Indications :Lesion detection if US and CT not conclusiveLesion characterization after detection by US or CT

Contraindications :General contraindications to MRI( claustrophobia , implants , penetrating injuries , sensitivity to contrast media , early pregnancy )MRI scan of liver

2D or 3D T2 weighted , bile appears white

Indications :Investigation of obstructive jaundice

Biliary stone , colic

Suspected cholangitis , or chronic pancreatitis

Prior to ERCP/PTC

MRI scan of biliary tree (MRCP)

MRCP

Non-invasive

Relatively cheep

No radiation , No anesthesia

Less operator dependant

Ducts prox. to obstruction seen

Extraductal disease may be seen

Advantages of MRCP

Decreased resolution

Less sensitive to subtle ductal disease

Not theraputicDisadvantages of MRCP

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY( ERCP )Contrast-agent is injected through endoscope after cannulation of CBD

Indications :Diagnostic , in unsuitable or intolerant to MRCPManagement of bile duct stonesEvaluation of ampullary lesionsManagement of biliary stricturesChronic pancreatitisERCP

Contraindications :Upper GIT obstructionPrevious gastric surgery that prevents access to duodenumSever cardiac or respiratory distress

Complications :Pancreatitis 5%Duodenal perforationGastrointestinal bleeding ( ERCP ) cont.

FOCAL LIVER LESIONSarea of alteration of normal parenchymaCystic , solid or complex

Cysts : thin walls with clear fluid , benign

Complex : may be malignant

Solid : borders , outline Multiple : metastases ? Abscesses , hemangiomas , cirrhosis Liver lesions

hepatomegaly

generalized parenchyma changesFatty liverHepatitiscirrhosisDIFFUSE LIVER LESIONS

Rt lobe enlargement elevated Rt hemidiaph. splayed lower Rt ribs properitoneal fat bulge depressed hepatic flexture and Rt kidneyHEPATOMEGALY SIGNS

Lt lobe enlargement gastric fundus and posterior stomach displaced intra-abdominal oesophagus elongated pressure on lesser curveature of stomach

HEPATOMEGALY SIGNS

SIMPLE CYSTS

Common , congenital , may be multiple ( ADPCK disease )

LIVER CYSTS

SIMPLE LIVER CYSTS

may be indistinguishable from simple one

may be multiple or cyst inside cyst

wall layers on ultrasound

Calcification , no wall enhancement

signs of rupture

protein in its fluid

LIVERHYDATID CYSTS

LIVER HYDATID

HYDATID CYST LIVER

Summery

Discussion .

End of lecture twoRADIOLOGY OF LIVER AND BILIARY DISEASESLECTURE THREELIVER TUMORS

TRAUMA

INFECTION AND CIRRHOSIS

BILIARY DISEASESOVERVIEWMetastases:

More common

Often multiple , Peripheral , variable size

On ultrasound : appear dark ( hypoechoic ) , may be complex ,irregularly cystic , hyperechoic or not visible

ON CT SCAN : Dark , Contrast enhancement

LIVER NEOPLASMS

similar to secondary

usually solitary

PRIMARY LIVER CANCER

LIVER TUMOR

LIVER HEMANGIOMAS

Common 4-7% females 80% , incidental benign , vascular neoplasm

May bleed , biopsy avoided

Simulate neoplasm on ultrasound

On CT and MRI show centripetal enhancement

BENIGN LIVER TUMORS

LIVER HAEMANGIOMA

LIVER HEMANGIOMA

FNH : rare , hypervascular , iso to liver , central scar ( white on T2 ) , no malignant change

Adenoma : solit. , rare , malignant ( may) Other benign liver lesions

Like cysts , irregular thicker walls

Pus usually thicker than cyst fluid(water)

May calcify

Walls enhance , local edema

On imaging difficult to distinguish from a necrotic tumor ( clinical )Liver abscess

LIVER ABSCESS

Commonest fatal abdominal injury

Lacerations are most common parenchymal injury

Ass. With subcapsular hematoma

CT is best for hematoma detection and organ surveyLIVER TRAUMA

Liver trauma

Commonest cause for portal hypertension

Porto-systemic anastamases open to bypass liver ( eg. Lower esophagus )

Fibrosis of parenchyma , small liver ( coudate lobe preserved )

Large spleen , portal flow

Ascites and neoplasms

LIVER CIRRHOSIS

Liver cirrhosis

CHOLELITHIASIS :10-20% US population , 30% calcification

40-50% asymptpmatic

Surgery in symptomatic and diabetic

Cholesterol , pigment or ( most are ) mixed

Predisposition: obesity , diabeteis , cirrhosis , huperparathyroidismDISEASES OF THE BILIARY SYSTEM

Ultrasound featuresCan detect 2mm stone and largerBack shadow , mobility , wall-eacho-shadow triad ( contracted gb )Porcelain gall bladderEmphysematous cholecystitisGall bladder stones

Stone in bile ducts with jaundice and high grade obstruction ,ultrasound 75% sensitiveMIRIZZI syndrome CyD stone CBD obst.

CHOLEDOCHOLITHIASIS

CommonACUTE : calculus 95% , acalculus Distension , walls >5mm, free fluid, Murphys sign ( 90% specific , negative if gangrenous ) Acalculus : trauma , long fasting , DM , no stone ivisible , patient illCHRONIC: Thick smaller GB , stone 95% , STIFF

CHOLECYSTITIS

CHOLECYSTITIS

Infection of obstructed bile ducts ( E. coli )

Causes ( stone , stricture , drainage cath. , ampullary cancer )

Rad. Features :Duct dilatation, intrahepatic duct stone (pathognomonic )Segmental Hepatic atrophyLiver abscess , pancreatitis

CHOLANGITIS

CHOLANGITIS

Biliary cancers are 5th most common GI malignancy

Ass. With ( stone , porcelain GB , IBD , chronic cholecystitis )

Intraluminal soft tissue

Asymmetrically thickened GB wall No biliary dilatation

Invasion of liver and lymph nodes

GB canrcioma

Ca GB

RARE

Hilar : junction or RHD & LHD ( Klatskin) or peripheral from epithelium of intralobular ducts

Dilated intrahepatic normal extrahepatic ducts

Hilar mass , short annular constricting lesion

CHOLANGIOCARCINOMA

CHOLANGIOCARCINOMA

congenital dilatation of bile ducts

children or young adults

20-fold increased risk of malignancy

jaundice , abdominal pain , mass CHOLEDOCAL CYST

CHOLEDOCAL CYST

Summery

discussionRADIOLOGY OF PNACREAS AND SPLEENLECTUTE FOURRetroperitoneal , on posterior abdominal wall , L1 level

Head , neck , body and tail , 15 cm length

Duct (from tail to ampulla ) , 4mm on ERCP

PANCREAS

accessory duct ( santorini ) drains lower part of head

Grey on US and CT , whiter than liver on T1

Intense enhancement , Fat infiltration : common , normal , age

PANCREAS

RETROPERITONEUM

PANCREAS

Pancreatic injry :penetrating or blunt ( superficial , deep , duct involved ?)

Rad. Features : fragmentation , hematoma , non-enhancing regions , stranding

Complications: fistula , abscess , pancreatitis , pseudocystPANCREAS LESIONS

Pancreas injury

Acute mild edema, pain , vomiting , tenderness , not progress

Acute severe necrosis ,shock , renal failure , GI bleed

Chronic : alcohol , stone PANCREATITIS

US : hypoechoic due to edema , detect stone and follow up size of pseudocyst ( capsule )

CT : heterogeneous , focal necrosis 90% accurate , peripancreatic edema or fluid or even gas collectionPancreatitis , Rad. features

pancreatitis

CA. PANCREAS : 2\3 in head , CBD obst. , focal mass and deformity , duct dilatation , extrapancreatic and vascular extension

DDX regional LAP , focal pancreatitis , abscess , pseudocyst

PANCREATIC CANCER

Pancreas cancer

Lt upper quadrant , size of a fist , 12 x 7 x 4 cm in adult , along 9th rib , intraperitoneal

Accessory spleens at hilum ( 40% )

Wandering spl. Along pedicle

Poly and asplenia

SPLEEN

Splenomegaly

Trauma ( subcapsular or parenchymal hematoma , laceration , fragmentation , delayed rupture \rare )

Cyst , Tumor ( hemangioma , metastasis )infarctionSPLEEN LESIONS

Spleen lesions

Summery

discussion

Diagnostic imaging by Peter Armstrong 3rd editionAnatomy for diagnostic imaging 2nd edt. By Stephanie RyanPrimer of diagnostic radiology , 3rd edt.Text book of radiology and imaging by David sutton 7th edt.A guide to radiological procedures by Frances Aitchison 5th edt.

References

THANK YOU AND GOOD LUCK