Surgical Pathology & X-rays for M edical Students 2007 GIT-2 Liver & biliary system Pancreas ...

Surgical Pathology & X-raysSurgical Pathology & X-raysfor for

MMedical Studentsedical Students20072007

GITGIT-2-2Liver & biliary system

Pancreas

Spleen

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Gall bladder & Bile ducts

Gall stones

Gall bladder imaging

• US

• Oral cholecystography

• Plain X-ray

Types of gall stones

Complications of gall stones

Bile ducts imaging

• US

• CT

• ERCP

Biliary stones

Bile duct CA

• PTC

• ‘T’ tube cholangiography

• Operative cholangiography

• MRCP

Diagnostic patterns of biliary obstruction

Liver

Multiple lacerations

Cirrhosis

Hepatoma

Liver secondary

Liver infections

• Ascending cholangitis

• Liver abscess

• Hydatid cyst

Pancreas

Pancreatic carcinoma

Pseudo-pancreatic cyst

Spleen: Traumatic rupture

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Gall Gall bladderbladder

& &

Bile Bile ductsducts

INDEX

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Gall stonesGall stones(cholelithiasis)(cholelithiasis)

INDEX

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Real time sonographyReal time sonography. Oral cholecystography (OCG), Plain filmsCT and radionuclide studies

GALLBLADDER - GALLBLADDER - IMAGING TECHNIQUESIMAGING TECHNIQUES

INDEX

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LiverLiver

G.B.G.B.Hepatic ductHepatic duct

The gall bladder size and shape are regular with no stones inside. Normal diameter of the bile ducts

Normal US of Normal US of the liver, GB & the liver, GB &

bile ductsbile ducts

US:US: is the most common method used to examine

the morphology and pathology of the liver and GB.

It is the primary screening modality for gallbladder disease

INDEX

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US showing normal GB US showing normal GB

1-1- Distended in a fasting patient

2-2- Contracted in a postprandial patient

INDEX

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Solitary stone Gall Bladder with posterior acoustic shadowing

INDEX

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Solitary stone Gall BladderSolitary stone Gall Bladder

INDEX

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Abdominal Ultrasound: CholelithiasisAbdominal Ultrasound: Cholelithiasis

Multiple, discrete echogenic foci within the gallbladder with posterior acoustic shadowing. The foci were shown to move with change in patient position.

INDEX

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Two round, echogenic stones (arrows) with an acoustic shadow are seen in the normal-sized gallbladder

INDEX

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Real time sonography.

Oral cholecystography (OCG),Oral cholecystography (OCG), Plain filmsCT and radionuclide studies


INDEX

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Normal Oral Oral cholecystographycholecystography (OCG)

INDEX

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ORAL CHOLECYSTOGRAPHY (OCGOCG):

stones filling defects

INDEX

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Oral cholecystography

Multiple gall bladder stones

INDEX

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Real time sonography. Oral cholecystography (OCG),

Plain filmsPlain filmsCT and radionuclide studies


INDEX

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AP plain X-ray RT. AP plain X-ray RT. hypochondrium:hypochondrium:

Several, small, calcified stones can be seen in the area of the elongated gallbladder, which is probably totally filled with stones.

INDEX

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Plain X-ray Plain X-ray film of the film of the abdomen- abdomen- showing multiple calcified gallstones in the Rt. upper quadrant

INDEX

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Plain X-ray film of Plain X-ray film of the abdomen- the abdomen- showing multiple calcified faceted gallstones outlining the contours of the gallbladder in the Rt. upper quadrant

INDEX

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Plain X-ray- Porcelain gallbladderPlain X-ray- Porcelain gallbladder

Elliptical ring-like calcification in the RUQ which corresponds to the shape and location of the gallbladder, the characteristic appearance of porcelain gallbladder.

INDEX

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Porcelain gallbladderPorcelain gallbladder

A calcified gallbladder wall can be asymptomatic.

Gallstones are almost always present in cases of gallbladder calcification.

Considered a result of low-grade chronic inflammation.

Increased incidence of gallbladder carcinoma warrants prophylactic cholecystectomy

INDEX

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Real time sonography. Oral cholecystography (OCG), Plain films

CT and radionuclide studiesCT and radionuclide studies


INDEX

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GB mass GB mass withwith cancer head pancreas cancer head pancreas

GB massGB mass

Cancer head Cancer head pancreaspancreas

INDEX

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GB massGB mass

INDEX

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Types of gallstonesTypes of gallstones

1.Cholesterol stones (Often solitary)

2.Mixed stones (multiple, often faceted) [90% of gallstones]

3.Pigment stones (calcium bilirubinate)

INDEX

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Mixed stonesMixed stones

Mixed stones account to 80 – 90 % of gallstones

Mainly formed of cholesterol

10% of gallstones are radio-opaque

INDEX

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In the gall bladder:

Chronic cholecystitis

Acute cholecystitis

Gangrene, perforation

Empyema – Mucocele

Carcinoma

In the bile ducts:

Obstructive jaundice

Cholangitis

Acute pancreatitis

In the intestine:

Acute intestinal obstruction ( Gallstone ileus)

Effects & complications of gall stones:Effects & complications of gall stones:

INDEX

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Multiple mixed faceted GB stones with chronic calcular cholecystitis

Complications of gall stones in the gall bladdergall bladder

INDEX

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Gallstones (cholelithiasis)Gallstones (cholelithiasis)

Chronic calcular cholecystitisChronic calcular cholecystitis

INDEX

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Mixed Mixed GallstonesGallstones

Pigment Pigment GallstonesGallstones

INDEX

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Chronic cholescystitis with cholelithiasisNote the thickened gallbladder wall.

INDEX

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Autopsy specimen (of another patient)

SS: impacted stone

LL: liver

USUS:

Marked dilatation of the GB

Mucocele – Hydrops of GBMucocele – Hydrops of GB

INDEX

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Empyema of GBof GBThe GB is filled with bile stained pus & stones

The cystic duct is opened to show impacted stone

The GB wall is thick & fibrotic with congestion & erythema of the serosa (acute on top of chronic inflammation)

Inflamed omentum surrounds the inflamed GB

INDEX

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This tumor is uncommon but invariably associated with the presence of gallstones

Carcinoma of the gallbladderCarcinoma of the gallbladder

INDEX

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Obstructive jaundiceObstructive jaundice

More ERCP pictures will come later

Complications of gall stones in the bile ductsbile ducts

INDEX

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A gallstone obstructing the cystic duct and resulting in inflammation and compression of the common bile duct.

The symptoms and signs involve jaundice and pain.

The diagnosis and treatment involve ERCP

Mirizzi's SyndromeMirizzi's Syndrome

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ERCPERCP cholangiogram showing dilated CHD and intra-hepatic ducts with normal CBD and filling defect at cystic duct/CBD junction

More pictures for ERCP will come later

Mirizzi's SyndromeMirizzi's Syndrome

INDEX

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Pyogenic abscesses of the liver secondary to acute cholangitisExtension of the pyogenic process through the biliary tree

CholangitisCholangitis

INDEX

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Acute pancreatitis

INDEX

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70 y old female with known history of gallbladder stones

Vomiting & abdominal pain 2 days before admission

Plain X-ray showing mechanical small bowel obstruction, gall stone shadow & aerobilia

Gall stone ileusGall stone ileus

Complications of gall stones in the IntestineIntestine

INDEX

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Imaging of the Biliary Ducts.Imaging of the Biliary Ducts.

INDEX

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Non-invasive Non-invasive

screeningscreening for for suspected biliary suspected biliary ductal pathologyductal pathology

USUS

Direct opacification Direct opacification of the ductsof the ducts

PTC PTC

ERCPERCP

Postoperative T-Tube cholangiography

Intraoperative cholangiography

Intravenous cholangiography (IVC) is considered an outdated technique

Biliary scintigraphy, while very useful in the diagnosis of acute cholecystitis, has a limited role in the diagnosis of biliary ductal disease

CTCT

The initial imaging technique when biliary obstruction is suspected

Reserved for selected cases in which more information about levellevel and causecause of obstruction is needed

INDEX

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ULTRASOUND:ULTRASOUND:

INDEX

The common bile duct (3,8 mm) and the portal vein are of normal diameter. The intrahepatic bile ducts are also normal

Portal Portal veinvein

Common bile ductCommon bile duct

Normal Normal liverliver

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COMPUTED TOMOGRAPHY (CT)COMPUTED TOMOGRAPHY (CT)

CT is reserved for selected cases which are equivocal on sonography or in which more information about level and cause of obstruction is needed

Mass in the head of pancreas causing biliary obstruction &

huge BG dilatation

Small mass in the pancreas causing dilatation of the common bile duct (cbd)

& pancreatic duct (pd)

INDEX

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INDEX

ERCP:ERCP:EEndoscopic rretrograde ccholangioppancreatography

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Normal Normal ERCPERCP

Common bile ductCommon bile duct

Gall bladder

Common hepatic ductCommon hepatic duct

Rt. & Lt. hepatic ductsRt. & Lt. hepatic ducts

INDEX

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ERCP- ERCP- CholedocholithiasisCholedocholithiasis

Common duct stones

Dilated common bile duct to the level of the head of the pancreas.

In the dilated CBD is a radio-lucent stone (round, radiolucent filling defect) (arrow).

INDEX

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Endoscopic biliary sphincterotomy with stone removal

INDEX

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CBD stone extracted by Dormia basketCBD stone extracted by Dormia basket

Following sphincterotomy, the stone is extracted using a wire basket (Dormia Basket)

Common duct stones may also be identified on T-Tube cholangiography and operative cholangiography. The appearance is the same as on PTC or ERCP

INDEX

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ERCP:ERCP:

The contrast material fills the dilated intrahepatic and common bile duct, in which several filling defects (gallstones) are visible (arrows)

INDEX

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ERCPERCP

Stone CBDStone CBD

INDEX

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ERCPERCP

Stones CBDStones CBD

INDEX

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ERCPERCP

Stone CBDStone CBD

INDEX

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ERCPERCP

Stone CBDStone CBD

INDEX

Bismuth classification of Bismuth classification of hilar hilar CholangiocarcinomaCholangiocarcinoma

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ERCP- bile duct carcinomaERCP- bile duct carcinoma

A short segment constricting lesion with irregular margins was noted at the bifurcation of the common hepatic duct (arrow).

This high-grade constricting lesion at the hepatic duct is consistent with a primary bile duct bile duct carcinomacarcinoma, or Klatskin tumorKlatskin tumor.

INDEX

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Stent inserted endoscopically in CBD

The previous patient was inoperable.

A stent was inserted for palliative relief of jaundice.

INDEX

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Klatskin’s tumor: Bile duct carcinomaKlatskin’s tumor: Bile duct carcinoma

INDEX

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PTCPTC: PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY

INDEX

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Normal Normal PTCPTC

INDEX

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PTCPTC - stone lower CBD

INDEX

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PTC:PTC:

The contrast material administered through a Chiba needle (arrows) completely fills the intrahepatic bile ducts, extremely dilated because of an obstruction of the common bile duct.

INDEX

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T-TUBE CHOLANGIOGRAPHY:T-TUBE CHOLANGIOGRAPHY:

INDEX

Normal

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Normal T-tube cholangiography

Notice the free passage of contrast into the duodenum

INDEX

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Normal T-tube cholangiography

INDEX

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Radiologic extraction of retained common duct stone

The T-Tube cholangiogram

It shows a meniscoid filling defect in the distal common duct occluding flow. This represents a retained common duct stone.

The T-Tube was left in place to allow formation of a firm tract and the patient returned 5 weeks later (6 weeks after surgery) for radiologic extraction of the stone through the T-Tube tract. INDEX

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Stone engaged in the basket (curved arrow) and being removed from the duct via the T-Tube tract.

A post-procedure cholangiogram should be done to confirm that the duct is clear with no residual stone or fragments

Radiologic extraction of the stone through the T-Tube tractRadiologic extraction of the stone through the T-Tube tract

INDEX

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OPERATIVE CHOLANGIOGRAPHYOPERATIVE CHOLANGIOGRAPHYThe bile duct is opacified during operative cholangiography by inserting a needle or cannula directly into the cystic duct or CBD and injecting contrast material

This procedure is done at the time of cholecystectomy to assess for stones in the bile ducts to determine the need for common duct exploration

INDEX

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MRCPMRCP (normal)

(Magnetic resonance cholangio-panceriatography)

Advantages of MRCP:

Non invasive (avoids complications of diagnostic ERCP or PTC)

No sedation usually required

No iodinated intravenous contrast (avoids iodine anaphylaxis and contrast nephropathy)

Rapid scan time

No ionising radiation (safe in pregnancy and children)

Delineates ductal anatomy proximal to obstructions

Delineates anatomy post biliary-enteric anastomosis Define extraductal structures (useful in staging malignancy) INDEX

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MRCPMRCP

Normal anatomy

INDEX

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MRCPMRCP

showing 2 showing 2 CBD stones & CBD stones & dilated CBDdilated CBD

INDEX

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MRCPMRCP demonstrating a demonstrating a hilar cholangiocarcinomahilar cholangiocarcinoma. .

There is a stricture and obstruction at the hilum with intrahepatic There is a stricture and obstruction at the hilum with intrahepatic biliary dilatationbiliary dilatation

INDEX

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M.R. M.R. cholangiography cholangiography showingshowing

CHD injury with CHD injury with collectioncollection

INDEX

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DIAGNOSTIC PATTERNS DIAGNOSTIC PATTERNS of of

BILIARY OBSTRUCTIONBILIARY OBSTRUCTION

INDEX

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Types of BILIARY OBSTRUCTION.Types of BILIARY OBSTRUCTION.

1.1. Choledocholithiasis Choledocholithiasis (biliary duct stones)

One or more

intraluminal defects (round, faceted or lobulated) which produce varying degrees of biliary obstruction are seen. Occasionally stones are noted as small multiple free-floating defects in a non-dilated duct.

INDEX

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2.2. Pancreatic carcinoma Pancreatic carcinoma Complete or almost complete obstruction of the mid or distal common duct, usually over a long segment (3-4 cm) of the distal duct (intrapancreatic portion) is seen.

A "rat-tail" configuration is the typical appearance (red arrows);

however, a rounded end or short segment stenosis with more abrupt margins may be seen.

INDEX

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Adenocarcinoma of the pancreasTumors in the head of the pancreas tend to obstruct the bile duct

Duodenum: DUDU

Cancer head of pancreas: CHPCHP

INDEX

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3.3. Cholangiocarcinoma Cholangiocarcinoma The narrowing may occur at any level and typically presents as a short segmental stenosis. When the lesion is located at the bifurcation, it is referred to as a Klatskin tumor

Cholangiocarcinoma may be polypoid or diffusely infiltrating.

INDEX

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4. Benign strictureBenign stricture

There is a short segmental circumferential stricture in the mid-common duct in a patient with a previous cholecystectomy.

Most benign strictures are secondary to ductal injury during cholecystectomy. (iatrogenic)

INDEX

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5.5. Ampullary carcinoma Ampullary carcinoma

Focal obstruction of very distal CBD is noted.

A smooth constriction or an irregular polypoid mass growing into distal CBD may be seen.

INDEX

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6. Chronic pancreatitis Chronic pancreatitis causing stricturecausing stricture:

A long segment stricture of the intrapancreatic common duct is seen.

The stricture is more tapered than that seen in pancreatic carcinoma and does not usually completely obstruct. Calcifications in the pancreatic head help confirm the diagnosis.

8. Metastatic nodes to the porta Metastatic nodes to the porta hepatishepatis - Infiltration or encasement of the CHD, usually just below the bifurcation, is seen.

The obstruction tends to be short segmental, smooth, concentric and occurs in a patient with a clinical history of primary neoplasm elsewhere.

7. Sclerosing cholangitisSclerosing cholangitis There is a diffuse periductal

infiltrating lesion involving the intra- and extrahepatic ducts with beading, irregularity and segmental narrowing.

Other causes of biliary obstructionOther causes of biliary obstruction

INDEX

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Ascariasis worms causing obstructive jaundice

INDEX

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AscariasisWorms are seen extending through the common bile duct and major hepatic ducts

INDEX

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LiverLiver

INDEX

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•Massive abdominal blunt force injury often leads to liver injury, since it is the largest internal organ. Note the multiple lacerations seen here over the capsular surface of the liver.

•Crush injuries can damage abdominal organs causing lacerations or rupture with bleeding into the peritoneal cavity (hemoperitoneum) Peritoneal lavage can detect such bleeding

Multiple hepatic lacerations

INDEX

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Intraoperative photograph of the right hepatic lobe (In another patient)

Exploration should look for other injuries.Exploration should look for other injuries. In this patient, the missile traversed the liver and injured the right kidney, which required removal due to sever hemorrhage.

The hepatic injury, was successfully managed with debridement of non-viable parenchyma, ligation of arterial vessels on the raw surface, viable omental packing, and drainage.

Liver Liver injury due injury due to gun to gun shotshot

Free intraperitoneal fluid adjacent to the liver (black arrowheads) with laceration (curved arrow) to the anterior left lobe of liver.

Air (white arrowhead) is seen within muscle anterior to the liver injury (entry site)

INDEX

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Liver cirrhosisLiver cirrhosis

INDEX

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Portal venous systemPortal venous systemCP of portal CP of portal

hypertension with liver hypertension with liver cell failurecell failure

INDEX

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Esophageal varices as

seen in upper GI endoscopy

Caput MedusaePortal hypertension leads to expansion of collateral veins in the region of the

umbilicus

Splenomegaly on laparoscopy

What are the manifestations of

portal hypertension?

INDEX

© GIT 290Chronic alcoholism leads to fibrosis and regeneration of the hepatocytes in nodules. This firm, nodular appearance of the liver as seen here is called cirrhosis

Macro-nodular cirrhosis

INDEX

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Macro-nodular cirrhosis

INDEX

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Biliary cirrhosis

INDEX

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Liver cirrhosis Liver cirrhosis as seen during an operationas seen during an operation

Liver

Stomach

INDEX

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HepatomaHepatomaHepatocellular carcinoma .

A primary liver cancer that starts in the liver cells

INDEX

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Hepatocellular carcinoma (hepatoma)

(solitary large mass)

Note: cirrhosis; bulging,

pigmented hepatoma

INDEX

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CT scan with CT scan with intravenous contrastintravenous contrast

Multiple low density area suspicious of metastasis .

The commonest tumour in the liver is metastasis. The primary tumour may The primary tumour may commonly arise from the commonly arise from the lunglung, , breastbreast, , coloncolon, , stomachstomach and and pancreaspancreas.

Multiple liver Multiple liver metastasismetastasis

INDEX

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Numerous, mostly round-shaped hypodens lesions of different size are visible in both lobes of the liver.

Liver metastasisLiver metastasis

INDEX

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Liver Liver InfectionsInfections

Viral hepatitis

Ascending cholangitis

Pyogenic liver abscess

Amoebic live abscess

Hydatid liver disease

INDEX

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Ascending cholangitisAscending cholangitis

Pyogenic abscesses of the liver secondary to acute cholangitis

INDEX

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Chest radiograph demonstrating elevation of the right hemidiaphragm

Abdominal CT scan demonstrating a large abscess in the right hepatic lobe

Liver abscessLiver abscess

The clinical picture & lab investigations should ALWASYS be correlated to the US & CT findings

INDEX

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Amebic liver abscessAmebic liver abscess

Entameba histolytica

The ingested cyst reaches the intestine

The active trophozoite form in the colon can reach the liver via the portal blood (Extra-intestinal disease)

INDEX

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A 24-year-old male presented with 3 weeks history of fever, malaise, nausea, vomiting and right upper quadrant pain.

Bowels were regular with normal stools.

General examination: he was febrile (38oC)but vital signs were stable.

He was not anemic or jaundiced. Chest & heart examination was normal

Abdominal examination: right upper quadrant tenderness without rigidity or guarding.

No organomegaly, masses, or ascites and bowel sounds were normal

Investigations: CBC: raised WBC (13.200) and ESR (96 mm/hr). Liver functions showed elevated alkaline phosphatase (152 IU/L) and a low albumin (3.0 g/dL).

Amebic serology (Indirect Haemagglutination test) was positive

Abdominal US showed homogenous hypoechoic lesion with well-defined borders

Abdominal CT scan showed a well- demarcated abscess in the right lobe of liver

Diagnosis: Amebic liver abscess INDEX

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Clinical HistoryClinical History: 30 y old male with right upper quadrant pain and fever of 2 weeks duration

CTCT: Hypodense lesion within the posterior segment of the right lobe of the liver.

There is a peripheral region of increased density surrounding the hypodense lesionIf no wall is seen, the differential diagnosis would include: amebic liver abscess, pyogenic abscess, echinoccocal cyst, hematoma, or necrotic tumor.

If an enhancing wall is present (as in this case) the differential should be limited to inflammatory conditions Liver abscess that proved to be amebicLiver abscess that proved to be amebic

INDEX

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Pyogenic liver abscessPyogenic liver abscess

Usually in elderly, diabetics & immunosuppresed patients

Clinically, there is fever, malaise with upper Rt. quadrant discomfort

A multiloculated cystic mass is found on US & CT

Diagnosis is confirmed by guided aspiration. The aspirated material is sent to culture & sensitivity

Treatment is antibiotics & US guided aspiration

Blind percutanous aspiration may go through the pleural space & cause empyema

DD:DD: amebic liver abscess, pyogenic abscess, echinoccocal cyst, hematoma, or necrotic tumor or metastasis

The clinical picture & lab investigations should ALWASYS be correlated to the US & CT findings

INDEX

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Liver with a hydatid cyst containing fluid and daughter cysts.

Notice the thick connective tissue capsule

INDEX

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Hydatid CystHydatid Cyst

Echinococcus granulosusEchinococcus granulosus ( Tapeworm) infection of the liverHydatid cysts develop calcium in their wall which may be seen on a routine chest x-ray. INDEX

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US: US:

A septated, round, unechoic area, can be seen in the liver parenchyma

Hydatid CystHydatid Cyst

INDEX

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The pancreas is bisected along its longitudinal axis revealing a large adenocarcinoma (B) of the head. (A) is the tail of pancreas

Cancer head of pancreasCancer head of pancreas

INDEX

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High- grade stenosis of the lower biliary duct with a prestenotic dilatation of the CBD

ERCPERCP:

Cancer head pancreas CBD dilatation

Irregular high- grade stenosis

INDEX

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Cancer head Cancer head of pancreasof pancreas

Liver

Pancreas body

Cancer head

Kidney

IVC

Aorta

CT CT examinationexamination

INDEX

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Liver

Gall bladder (markedly dilated)

Cancer head

Kidney

IVC

Aorta

Patients with obstructive jaundice & Patients with obstructive jaundice & GB massGB mass – think of malignant obstruction – think of malignant obstruction

INDEX

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Notice the relation of the mass to the duodenum & inferior venacava

An irregular mass in the head of the pancreas

Cancer head Cancer head pancreaspancreas

INDEX

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Splenic lacerationsSplenic lacerations

Splenic rupture should be suspected after any trauma specially if associated with direct injury to the left upper quadrant. The possibility of injury increases if the spleen is diseased or enlarged.

The spleen is the most common organ to be injured in blunt abdominal trauma

INDEX

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A large crescentic, low-density fluid collection along the lateral aspect of the spleen.

Flattening of the normal splenic contour

CT abdomenCT abdomen

Traumatic sub-capsular hematoma

INDEX

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Traumatic rupture Traumatic rupture sspleen & Lt. pleen & Lt. kkidneyidney

Hematoma: HHSpleen: SS Kidney: KK

SS

KK

HH

HH

INDEX

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Pseudopanceriatic cyst & Splenic hematomaPseudopanceriatic cyst & Splenic hematoma

L: Liver

P: Pancreas

PS: Pseudopancreatic cyst

S: Spleen

H: Hematoma

INDEX

Surgical Pathology & X-rays for M edical Students 2007 GIT-2 Liver & biliary system Pancreas ...

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Transcript of Surgical Pathology & X-rays for M edical Students 2007 GIT-2 Liver & biliary system Pancreas ...