Biliary SystemBiliary System Bile, required for the digestion of food, is excreted by the Bile, required for the digestion of food, is excreted by the

liver into passages that carry bile toward the hepatic liver into passages that carry bile toward the hepatic duct, which joins with the cystic duct (carrying bile to and duct, which joins with the cystic duct (carrying bile to and from the gallbladder) to form the common bile duct, from the gallbladder) to form the common bile duct, which opens into the intestine.which opens into the intestine.

GallbladderGallbladder

The gallbladder functions as a resevoir for bile produced The gallbladder functions as a resevoir for bile produced by the liver. It is by the liver. It is 7-10cm long7-10cm long, , 3cm wide3cm wide at its broadest at its broadest

measure, and has a capacity of measure, and has a capacity of 30-50ml30-50ml..

The gallbladder is divided into 3regions : The gallbladder is divided into 3regions :

fundus, body, and neck. fundus, body, and neck.

Bile produced by the left and right portions of the liver travel through the right and left Bile produced by the left and right portions of the liver travel through the right and left hepatic ducts (hepatic ducts (1-2mm in diameter1-2mm in diameter). These two ducts join to form the ). These two ducts join to form the common hepatic common hepatic ductduct..

The union of the The union of the common hepatic ductcommon hepatic duct and and cystic ductcystic duct forms the forms the common bile duct common bile duct ((up up to 6mm in diameter. Diameter increase 0.5-1mm per decade).to 6mm in diameter. Diameter increase 0.5-1mm per decade).

The The common bile ductcommon bile duct passes posterior to the first portion of the duodenum. It then passes posterior to the first portion of the duodenum. It then descends via a groove on the superolateral portion of the posterior head of the descends via a groove on the superolateral portion of the posterior head of the

pancreas, sometimes traveling through the pancreas head.pancreas, sometimes traveling through the pancreas head. At the head of the pancreas, the At the head of the pancreas, the common bile ductcommon bile duct meets the meets the pancreatic ductpancreatic duct, and they , and they exit into the second part of the duodenum, forming the hepatopancreatic ampulla (or exit into the second part of the duodenum, forming the hepatopancreatic ampulla (or

ampulla of Vater).ampulla of Vater).

((Imaging ModalitiesImaging Modalities))

Indirect Imaging:Indirect Imaging: Indirect imaging involves non-Indirect imaging involves non-

invasive radiologic techniques invasive radiologic techniques including:including:

US,US, plain film,plain film, CT,CT, (MRCP)(MRCP) Oral ,IV CholecystographyOral ,IV Cholecystography Nuclear IDA scan Nuclear IDA scan

(Cholescintigraphy)(Cholescintigraphy)

Direct Imaging:Direct Imaging:   involves invasive radiologic involves invasive radiologic

procedures, which include:procedures, which include: ERCPERCP Operative and T-tube Operative and T-tube

cholangiogramcholangiogram PTCPTC

Plain RadiographyPlain RadiographyTo detect either stones, calcification or gas in the biliary system.To detect either stones, calcification or gas in the biliary system.

Emphysematous cholecystitisEmphysematous cholecystitis Porcelain GBPorcelain GB

UltrasoundUltrasound

Is the first and the most commonly obtained method of examination Is the first and the most commonly obtained method of examination in patients with RUQ pains, abnormal LFTs, or suspected liver in patients with RUQ pains, abnormal LFTs, or suspected liver masses.masses.

Is a noninvasive and excellent screening tool. Is a noninvasive and excellent screening tool.

Used to evaluate the presence of bile duct obstruction and Used to evaluate the presence of bile duct obstruction and

gallstones as well as to distinguish a solid lesion from a cystic one.gallstones as well as to distinguish a solid lesion from a cystic one. The patient should be NPO (nothing-by-mouth) for imaging the The patient should be NPO (nothing-by-mouth) for imaging the biliary tract with ultrasound. Fasting distends the gallbladder and biliary tract with ultrasound. Fasting distends the gallbladder and bile ducts and reduces bowel gas that may obscure visualization of bile ducts and reduces bowel gas that may obscure visualization of portions of the gallbladder. Food may increase the thickness of the portions of the gallbladder. Food may increase the thickness of the gallbladder wall imitating pathological wall thickening. Four hours is gallbladder wall imitating pathological wall thickening. Four hours is sufficient fasting for small children, and 6-8 hours for age 12 to sufficient fasting for small children, and 6-8 hours for age 12 to adult. They should be told not to smoke during the fasting period adult. They should be told not to smoke during the fasting period since smoking causes the bile ducts to contract. since smoking causes the bile ducts to contract.

Technique of examTechnique of exam Begin the exam with the patient in the supine position . Begin the exam with the patient in the supine position . The patient can be moved to the left posterior The patient can be moved to the left posterior

oblique ,left decubitus or even upright position. oblique ,left decubitus or even upright position.   

Obtain full length of gallbladder from the portal vein to Obtain full length of gallbladder from the portal vein to fundus fundus (7-10cm)(7-10cm) and transverse images and transverse images (3cm)(3cm) at at representative levels.  Measure GB wall thickness (representative levels.  Measure GB wall thickness (up to up to 3mm3mm) perpendicular to wall.Document any stones or ) perpendicular to wall.Document any stones or biliary dilatation.biliary dilatation.

If stones are seen, evaluate if they are mobile or impacted.  If stones are seen, evaluate if they are mobile or impacted.  Move the patient into upright or lateral decubitus positions to Move the patient into upright or lateral decubitus positions to demonstrate stone mobility. demonstrate stone mobility.

Rolling stone signRolling stone sign - movement of gallstones with GB with - movement of gallstones with GB with

position changeposition change

Note the change of position of the stones from (near the Note the change of position of the stones from (near the neck of GB )to its fundus when he changed his position neck of GB )to its fundus when he changed his position from supine to decubitus positionfrom supine to decubitus position

Obtain full length of common bile duct (CBD) or Obtain full length of common bile duct (CBD) or as much as possible, and measure CBD as much as possible, and measure CBD diameter(N up to diameter(N up to 6mm6mm till the age of 60 then it till the age of 60 then it increases 1mm each year).increases 1mm each year).

Acquire longitudinal and transverse views of Acquire longitudinal and transverse views of pancreatic head.pancreatic head.

Endoscopic UltrasonographyEndoscopic UltrasonographyEUS uses ultrasound probes carried on endoscopes, EUS uses ultrasound probes carried on endoscopes, so that ultrasound images can be obtained from inside so that ultrasound images can be obtained from inside the gastrointestinal tract.the gastrointestinal tract.Using ultrasound imaging from inside the body helps Using ultrasound imaging from inside the body helps prevent the artifacts that can occur when imaging prevent the artifacts that can occur when imaging through the abdominal and chest wall. Degradation of through the abdominal and chest wall. Degradation of the image by bone, fat, and bowel gas can be avoided. the image by bone, fat, and bowel gas can be avoided. In addition, higher frequencies of ultrasound can be In addition, higher frequencies of ultrasound can be used. The higher the frequency the shorter the used. The higher the frequency the shorter the penetration depth, but because EUS places the penetration depth, but because EUS places the ultrasound probe by endoscopy very close to the area ultrasound probe by endoscopy very close to the area to be examined, the smaller imaging area is not a to be examined, the smaller imaging area is not a problemproblem

Note the stone(red arrow)causing strong Note the stone(red arrow)causing strong acoustic shadowing (yellow arrow) is seen acoustic shadowing (yellow arrow) is seen within the dilated CBDwithin the dilated CBD

Note the stone within the dilated CBDNote the stone within the dilated CBD

Computed Tomography )CT(Computed Tomography )CT(

While CT is not the imaging modality of choice for visualizing While CT is not the imaging modality of choice for visualizing the biliary tree directly it is useful in diagnosing liver, the biliary tree directly it is useful in diagnosing liver, gallbladder, and pancreatic disease.gallbladder, and pancreatic disease.

CT can identify pathological dilation of the intra&extrahepatic CT can identify pathological dilation of the intra&extrahepatic bile ducts it also can help in identification of the cause of bile ducts it also can help in identification of the cause of obstruction as it can detect pancreatic cancer with 100% obstruction as it can detect pancreatic cancer with 100% accuracy , The sensitivity for identifying bile duct stones is accuracy , The sensitivity for identifying bile duct stones is low; however, in a few cases a stone in the bile ducts can be low; however, in a few cases a stone in the bile ducts can be identified. identified.

CT also can identify gallstones, cholecystitis &GB cancerCT also can identify gallstones, cholecystitis &GB cancer

Note the dilatation of the biliary radicals at the first image ,can you identify Note the dilatation of the biliary radicals at the first image ,can you identify the cause at the second image (cancer head of pancreas)the cause at the second image (cancer head of pancreas)

Common bile duct stone & GB stonesCommon bile duct stone & GB stones

Spiral CT cholangiographySpiral CT cholangiography 3-D CTC as a non-invasive and sensitive technique for the diagnosis of biliary diseases 3-D CTC as a non-invasive and sensitive technique for the diagnosis of biliary diseases

with high diagnostic accuracy will greatly increase the detection rate of biliary diseaseswith high diagnostic accuracy will greatly increase the detection rate of biliary diseases ..

One hundred milliliters of One hundred milliliters of cholangiographic contrast materialcholangiographic contrast material iotroxate iotroxate meglumine (Biliscopin) is infused IV over a period of 30 min, and helical meglumine (Biliscopin) is infused IV over a period of 30 min, and helical CT cholangiography was performed 30 min later. After rolling the patient CT cholangiography was performed 30 min later. After rolling the patient to mix bile and contrast material in the gallbladder to mix bile and contrast material in the gallbladder Multi-slice helical CTMulti-slice helical CT, using scanning mode HQ, 120 kV, 270-280 mA, , using scanning mode HQ, 120 kV, 270-280 mA, 0.8 s/r, pitch 3, with table incrementation rate of 11.25 mm/s. The scope 0.8 s/r, pitch 3, with table incrementation rate of 11.25 mm/s. The scope of scanning covered the whole biliary tree. 5 mm in thickness at 5 mm of scanning covered the whole biliary tree. 5 mm in thickness at 5 mm intervals was used, followed by an overlapping reconstruction of 3.75 intervals was used, followed by an overlapping reconstruction of 3.75 mm in thickness at 2.0 mm intervals, or 3.75 mm in thickness at 3.75 mm mm in thickness at 2.0 mm intervals, or 3.75 mm in thickness at 3.75 mm intervals, followed by an overlapping reconstruction of 2.5 mm in intervals, followed by an overlapping reconstruction of 2.5 mm in thickness at 1.0 mm intervals. Among the three-phase enhancement thickness at 1.0 mm intervals. Among the three-phase enhancement scanning, the portal phase was selected for a reconstruction of 3.75 mm scanning, the portal phase was selected for a reconstruction of 3.75 mm in thickness at 2.0 mm intervals.in thickness at 2.0 mm intervals. All imaging data were sent to the All imaging data were sent to the workstationworkstation .Based on actual .Based on actual requirements, maximum density projection (MIP), minimum density requirements, maximum density projection (MIP), minimum density projection (MinP), surface shaded display (SDD), CT virtual endoscopy projection (MinP), surface shaded display (SDD), CT virtual endoscopy (CTVE) (CTVE)

Technique of CT cholangiographyTechnique of CT cholangiography

Magnetic resonance Magnetic resonance cholangiopancreatography )MRCP(cholangiopancreatography )MRCP(

MRCP is a non-invasive technique that delineates the pancreatic and MRCP is a non-invasive technique that delineates the pancreatic and biliary ductal systems, while providing projectional and cross sectional biliary ductal systems, while providing projectional and cross sectional images of the ducts.  MRCP does not require administration of IV contrast images of the ducts.  MRCP does not require administration of IV contrast material; it is based on material; it is based on T2-weighted imagesT2-weighted images, which depict , which depict static fluidstatic fluid (including bile and pancreatic secretions), with a higher signal intensity.  (including bile and pancreatic secretions), with a higher signal intensity.  MRCP also avoids the invasive complications of ERCP.  With the recent MRCP also avoids the invasive complications of ERCP.  With the recent improvements in MRCP, it is superceding ERCP for many of its diagnostic improvements in MRCP, it is superceding ERCP for many of its diagnostic indications.   MRCP is inferior to ERCP in several respects however.  The indications.   MRCP is inferior to ERCP in several respects however.  The spatial resolution of MRCP is lower than that of ERCP.  Furthermore, spatial resolution of MRCP is lower than that of ERCP.  Furthermore, ascites or fluid collections in the upper abdomen can interfere with the ascites or fluid collections in the upper abdomen can interfere with the

visualization of the pancreatic and biliary ducts.visualization of the pancreatic and biliary ducts.   

Technique of MRCPTechnique of MRCP

MRCP images are taken in axial, coronal, and 3-D MRCP images are taken in axial, coronal, and 3-D formats providing imaging referencing in multiple planes. formats providing imaging referencing in multiple planes. It is important that the entire gallbladder, biliary ducts, It is important that the entire gallbladder, biliary ducts, and pancreas are included in the axial, coronal, and 3-D and pancreas are included in the axial, coronal, and 3-D images. Two techniques are combined for imaging the images. Two techniques are combined for imaging the biliary tract: multisection thin-slice and single-slice thick-biliary tract: multisection thin-slice and single-slice thick-slab MRCP. Studies show that these techniques should slab MRCP. Studies show that these techniques should be combined in the imaging protocol to get the most out be combined in the imaging protocol to get the most out of the unenhanced and enhanced MR scan. of the unenhanced and enhanced MR scan. Intravenously administered fentanyl before MRCP has Intravenously administered fentanyl before MRCP has been shown to improve the qualitative and quantitative been shown to improve the qualitative and quantitative visualization of the biliary tree. The reason for both visualization of the biliary tree. The reason for both techniques is that single-shot thin-slice imaging is techniques is that single-shot thin-slice imaging is superior to multisection thin slice for bile duct imaging. superior to multisection thin slice for bile duct imaging.

Oral CholecystographyOral CholecystographyThe oral cholecystogram (OCG) is a purely The oral cholecystogram (OCG) is a purely historical historical examination that studied the opacification of the gallbladder. This examination that studied the opacification of the gallbladder. This study was once the diagnostic standard for imaging the gallbladder study was once the diagnostic standard for imaging the gallbladder before ultrasound and CT reached the current level of image before ultrasound and CT reached the current level of image quality. The basic process involved the patient not eating any fatty quality. The basic process involved the patient not eating any fatty foods, or being N.P.O (nothing by mouth) about 6 hours before foods, or being N.P.O (nothing by mouth) about 6 hours before ingesting oral contrast media. This was in the form of tablets (brand ingesting oral contrast media. This was in the form of tablets (brand name-Telopaque), that when dissolved the media is absorbed into name-Telopaque), that when dissolved the media is absorbed into

liver and secreted in bileliver and secreted in bile

Nuclear IDA scan Nuclear IDA scan )Cholescintigraphy()Cholescintigraphy(

It uses the radioisotope It uses the radioisotope imino diacetic acid (IDAimino diacetic acid (IDA)) to image part of the to image part of the biliary system. In the past the IDA scan has been called the HIDA biliary system. In the past the IDA scan has been called the HIDA scan. The most common reason for physicians requesting this scan scan. The most common reason for physicians requesting this scan is to evaluate the: is to evaluate the:

1-functioning of the cystic duct in case of suspected cholecystitis1-functioning of the cystic duct in case of suspected cholecystitis 2-can also detect biliary obstruction,2-can also detect biliary obstruction, 3- bile leak, 3- bile leak, 4- Atresia. 4- Atresia.

The IDA scan is a dynamic scan that assesses function of the The IDA scan is a dynamic scan that assesses function of the gallbladder and cystic duct patency. gallbladder and cystic duct patency. Technetium-99m-IDATechnetium-99m-IDA agents agents such as Choletec or Hepatolite are administered intravenously. such as Choletec or Hepatolite are administered intravenously. These agents are bilirubin analogues having the same biliary uptake These agents are bilirubin analogues having the same biliary uptake as bilirubin used to make bile, but are not conjugated to bilirubin. as bilirubin used to make bile, but are not conjugated to bilirubin. Then they are secreted into the biliary tract allowing them to be taken Then they are secreted into the biliary tract allowing them to be taken up by the liver and secreted into the biliary tract and concentrated in up by the liver and secreted into the biliary tract and concentrated in the normal functioning gallbladder. When the biliary tract is the normal functioning gallbladder. When the biliary tract is functioning properly the entire bilirubin pathway from filling of the functioning properly the entire bilirubin pathway from filling of the gallbladder to passage into the common bile duct and duodenum gallbladder to passage into the common bile duct and duodenum should be visualized. should be visualized.

Endoscopic Retrograde Endoscopic Retrograde Cholangiopancreatography )ERCP(Cholangiopancreatography )ERCP(

ERCP is a combined endoscopic and radiographic procedure that ERCP is a combined endoscopic and radiographic procedure that images the biliary and pancreatic ducts.  ERCP is performed with a images the biliary and pancreatic ducts.  ERCP is performed with a side-viewing duodenoscope which has an instrumentation channel that side-viewing duodenoscope which has an instrumentation channel that allows for the insertion of the cannulation catheter into the major or allows for the insertion of the cannulation catheter into the major or minor duodenal papilla.  A water-soluble contrast agent (60 % iodine) is minor duodenal papilla.  A water-soluble contrast agent (60 % iodine) is injected into the ductal system using fluoroscopy for imaging.  It is injected into the ductal system using fluoroscopy for imaging.  It is important to obtain adequate ductal filling without over-distending the important to obtain adequate ductal filling without over-distending the system.  (During interventional procedures, a guide-wire can be inserted system.  (During interventional procedures, a guide-wire can be inserted through the cannulation catheter, for subsequent insertion of additional through the cannulation catheter, for subsequent insertion of additional instruments like papillotomes, drainage devices, cytology brush, etc.)  instruments like papillotomes, drainage devices, cytology brush, etc.)  Althought ERCP is an important diagnostic tool in the evaluation of Althought ERCP is an important diagnostic tool in the evaluation of patients with suspected biliary and pancreatic disorders, MRCP is patients with suspected biliary and pancreatic disorders, MRCP is

superceding ERCP for some of its indications.superceding ERCP for some of its indications.

ERCP Indications ERCP Indications >Biliary disease>Biliary disease--Jaundice--Jaundice--Cholestasis--Cholestasis--Cholangitis--Cholangitis--Choledocholithiasis/gallstones--Choledocholithiasis/gallstones--Tumors--Tumors--Primary biliary sclerosis--Primary biliary sclerosis

>Pancreatic Disease>Pancreatic Disease--Acute gallstone pancreatitis--Acute gallstone pancreatitis--Recurrent acute pancreatitis--Recurrent acute pancreatitis--Chronic pancreatitis--Chronic pancreatitis--Pancreatic pseudocyst, abcess--Pancreatic pseudocyst, abcess--Pancreatic tumors>Pre- and/or post-op duct eval--Pancreatic tumors>Pre- and/or post-op duct eval>Evaluation post liver transplant>Evaluation post liver transplant>Sphincter of Oddi manometry>Sphincter of Oddi manometry>Unexplained upper abdominal pain>Unexplained upper abdominal pain

>Therapeutic interventions>Therapeutic interventions--Biopsy/cytology--Biopsy/cytology--Sphincterotomy--Sphincterotomy--Stone extraction--Stone extraction--Lithotripsy--Lithotripsy--Stent placement--Stent placement--Balloon dilation of strictures--Balloon dilation of strictures--Pseudocyst drainage--Pseudocyst drainage--Irradiation--Irradiation

ERCP complicationsERCP complications ComplicationComplication

1.1. Pancreatitis Pancreatitis

2.2. Cholangitis Cholangitis

3.3. Infection Infection

4.4. Perforation Perforation

5.5. Significant Significant bleeding bleeding

Mechanism/commentMechanism/comment1.1. Secondary to over-distention of Secondary to over-distention of

pancreatic ducts with contrast pancreatic ducts with contrast extravisation into parenhymal extravisation into parenhymal tissue, tissue,

2.2. Antibiotics are initiated if biliary Antibiotics are initiated if biliary obstruction is present and obstruction is present and cannot be relieved.  Most cannot be relieved.  Most common organisms include common organisms include GNR (E. coli, Klebsiella) GNR (E. coli, Klebsiella)

3.3. Bacteremia, pseudocyst, and Bacteremia, pseudocyst, and

abcess formationabcess formation 4.4. Sphincterotomy, ampulla in Sphincterotomy, ampulla in

duodenal diverticulumduodenal diverticulum

5.5. Sphincterotomy Sphincterotomy

PostOperative Cholangiography PostOperative Cholangiography )T-tube Cholangiogram()T-tube Cholangiogram(

Postoperative t-tube cholangiography is performed to exclude a Postoperative t-tube cholangiography is performed to exclude a retained bile duct calculus or to assess for any surgical retained bile duct calculus or to assess for any surgical complications such as a bile duct leak before removal of the t-tube. complications such as a bile duct leak before removal of the t-tube.

The study is usually performed 7-10 days after surgeryThe study is usually performed 7-10 days after surgery..

Percutaneous Transhepatic Percutaneous Transhepatic Cholangiography )PTC(Cholangiography )PTC(

This is another radiographic study that is purely historical This is another radiographic study that is purely historical and is not done in modern radiographic imaging. It was and is not done in modern radiographic imaging. It was both a diagnostic procedure in cases of suspected both a diagnostic procedure in cases of suspected obstructive jaundice, and obstructive jaundice, and therapeutictherapeutic in that dilated bile in that dilated bile ducts could be drained during the procedure. ducts could be drained during the procedure. Occasionally a stone could be removed by this procedure Occasionally a stone could be removed by this procedure eliminating the risk of open surgical intervention. Today eliminating the risk of open surgical intervention. Today there are many other invasive procedures with lower risk there are many other invasive procedures with lower risk than PTC. This study was a type of invasive than PTC. This study was a type of invasive cholangiography that involved direct puncture of the cholangiography that involved direct puncture of the biliary ducts. A fine needle was passed from the skin biliary ducts. A fine needle was passed from the skin surface through the liver into a biliary duct. Risk of the surface through the liver into a biliary duct. Risk of the procedure included possible puncture of the lung, procedure included possible puncture of the lung, bleeding from the liver and vascular injury. This was not bleeding from the liver and vascular injury. This was not an easy procedure to perform so benefit of the procedure an easy procedure to perform so benefit of the procedure had to far outweigh its risk before it was performed. had to far outweigh its risk before it was performed.

Developmental anomalies&Normal Developmental anomalies&Normal variantsvariants

Gallbladder ectopiaGallbladder ectopia. . Intrahepatic gallbladder Intrahepatic gallbladder (GB) demonstrated on (GB) demonstrated on CT scan CT scan

Gallbladder ectopiaGallbladder ectopia. . Situs inversus with left-Situs inversus with left-

sided gallbladdersided gallbladder

The phrygian cap The phrygian cap

Double gall bladderDouble gall bladder

Choledochal cystCholedochal cyst Type I Type I

Caroli's diseaseCaroli's disease

Anatomic variants in the Anatomic variants in the cystic ductcystic duct