Imaging approach to Pancreas, Gallbladder and Bile duct
anomalies and anatomical variants A Reinders Department of
Radiology March 2012
Slide 2
Introduction Embryology & normal anatomy Pancreas Bile
ducts Gallbladder Cystic duct Liver vascular anatomy* Congenital
variants Imaging approach Report
Slide 3
Embryology Primitive Foregut & midgut Hepatic Diverticulum
Gallbladder Ventral pancreatic outpoutching Dorsal pancreatic
Outpoutching Bile duct Hepatic ducts 4 th Week of Fetal life
Slide 4
Figure 1a. Drawings illustrate the normal embryologic
development of the pancreas and biliary tree. Mortel K J et al.
Radiographics 2006;26:715-731 2006 by Radiological Society of North
America
Slide 5
Embryology Pancreas Dorsal pancreatic outpoutching Dorsal
pancreas Posterior pancreatic ductal system Ventral pancreatic
outpouching Extrahepatic BD Intrahepatic BD Ventral pancreas 7 th
Week of Fetal life
Slide 6
Figure 1c. Drawings illustrate the normal embryologic
development of the pancreas and biliary tree. Mortel K J et al.
Radiographics 2006;26:715-731 2006 by Radiological Society of North
America
Slide 7
Figure 1d. Drawings illustrate the normal embryologic
development of the pancreas and biliary tree. Mortel K J et al.
Radiographics 2006;26:715-731 2006 by Radiological Society of North
America
Slide 8
Congenital Variants Pancreas Annular pancreas
Hypoplasia/aplasia of the pancreas Ducts Rudimentary duct of
Santorini Dominant duct of Santorini Ansa Pancreatica Pancreas
Divisum Ectopic pancreas
Slide 9
Annular Pancreas Rare = 1:2000 Incomplete rotation of ventral
anlage Segment of pancreas encircling 2 nd part of duodenum
Obstruction 10% Extramural Ventral pancreatic duct Encircles
duodenum and joins MPD Intramural Pancreatic tissue intermingled
with muscle fibres Small ducts drains directly into duodenum
Slide 10
Leccos theory Baldwins theory Lee NK, Kim S, Jeon TY et al.
Complications of congenital and developmental abnormalities of the
gastrointestinal tract in adolescents and adults: Evaluation with
multimodality imaging. Radiographics 2010;30:1489-1507
Slide 11
Annular Pancreas Lee NK, Kim S, Jeon TY et al. Complications of
congenital and developmental abnormalities of the gastrointestinal
tract in adolescents and adults: Evaluation with multimodality
imaging. Radiographics 2010;30:1489-1507 Annular pancreas in a
55-year-old man with repeated episodes of vomiting.
Contrast-enhanced CT image shows pancreatic tissue (arrows)
completely encircling the descending portion of the duodenum
(*).
Slide 12
Annular Pancreas Mortele KJ, Rocha TC, Streeter JL et al.
Multimodality Imaging of Pancreatic and Biliary Congenital
Anomalies. Radiographics 2006; 26:715-731
Slide 13
Hypoplasia/Agenesis of Pancreas Hypoplasia Absence of
ventral/dorsal anlage Dorsal hypoplasia more common NB to rule out
pancreatic carcinoma with upstream atrophy of gland Degrees of
hypoplasia with varying degrees of abscence of neck, body and tail,
MDP and duct of Santorini Agenesis Total agenesis is rare =
incompatible with life Associated with other GIT malformations
Polysplenia GB aplasia
Slide 14
Ductal Anatomy Two major duct Wirschung Main = 1.5 3.5 mm
diameter 20 30 side branches Meets with CBD to pass through SOO 8 Y
(75%) or V (20%) configuration 10 15 mm long U type (5%) Santorini
Drains anterior and superior portion of head Normal narrowing at
level of junction between MPD and W No proximal dilatation of duct
Minor duodenal papilla +/- 27 different ductal configurations
Slide 15
Figure 3a. Normal pancreatic ductal anatomy. Mortel K J et al.
Radiographics 2006;26:715-731 2006 by Radiological Society of North
America
Slide 16
Ductal variants Rudimentary duct of Santorini (30%) Duct of
Wirsung as manor drainage route still Dominant duct of Santorini
(1%) Major drainage route Ansa Pancreatica Duct of Santorini forms
a sigmoid curve as it courses to duct of Wirschung
Slide 17
Figure 6b. Variant pancreatic ductal anatomy Ansa Pancreatica
Mortel K J et al. Radiographics 2006;26:715-731 2006 by
Radiological Society of North America
Slide 18
Sphincter of Oddi 3 separate smooth muscle layers Surrounds MPD
and CBD before AOV Anomalous junctions Fusion of MPD and CBD
outside duodenal wall = Long common channel (>15mm) Reflux
Pancreatitis Cholangitis Cyst Choledocal web
Slide 19
Figure 3d. Normal pancreatic ductal anatomy. Mortel K J et al.
Radiographics 2006;26:715-731 2006 by Radiological Society of North
America
Slide 20
Figure 10a. Abnormal common channel. Mortel K J et al.
Radiographics 2006;26:715-731 2006 by Radiological Society of North
America
Slide 21
Figure 10b. ERCP: Abnormal common channel with CBD web in child
Mortel K J et al. Radiographics 2006;26:715-731 2006 by
Radiological Society of North America
Slide 22
Pancreas Divisum Common 4 10% Ventral and dorsal ducts DONT
fuse Wirschung (ventral) = atretic & short Santorini (dorsal) =
Larger in caliber Focal dilatation of terminal portion
Santorinicele Cause obstruction at minor papillae of duodenum
Slide 23
Figure 6a. Variant pancreatic ductal anatomy - Santorinicele
Mortel K J et al. Radiographics 2006;26:715-731 2006 by
Radiological Society of North America
Slide 24
Mortele KJ, Rocha TC, Streeter JL et al. Multimodality Imaging
of Pancreatic and Biliary Congenital Anomalies. Radiographics 2006;
26:715-731
Slide 25
Ectopic pancreas Incidence 0,6 13% 0,5 2 cm in largest
dimensions Usually asx rarely become malignant In submucosa (50%)
Stomach (26 - 38%) Duodenum (28 36%) Jejenum (16%) Meckels
diverticulum
Slide 26
Biliary System Liver segments Cuinaud classification Main
hepatic ducts Cystic duct Choledochal cyst Todanis classification
Gallbladder
Slide 27
Biliary System Intrahepatic bile ducts (IBD) run parallel to
portal supply RHD Right posterior duct = I, VI & VII
(horizontal) 7 Super and Inferior Right anterior duct = V &
VIII (vertical) Superior and inferior LHD Draining II, III and IV
Lateral and medial Superior and inferior CHD 58 % of people
Slide 28
Images available from URL:
http://www.pkdiet.com/pages/pld/pldresection.htm
Slide 29
Figure 5. Normal biliary anatomy. Mortel K J et al.
Radiographics 2006;26:715-731 2006 by Radiological Society of North
America
Slide 30
Biliary System Right posterior duct (RHD) Drain into LHD before
confluence with RAD 13 19% Will not pass RAD posterior but drains
directly into it 12% Tripple confluence 11% Drains into CHD
Left
Biliary System Choledochal cysts Rare Biliary tree dilatation
> Female 4:1 Abdominal pain Jaundice Right upper quadrant mass
Children 2 38%
Slide 37
Todani Classification Images available from URL:
http://radiopaedia.org/encyclopaedia/quizzes/all/8097
Slide 38
Figure 16b. Todani Type 1 Choledochal cysts. Mortel K J et al.
Radiographics 2006;26:715-731 2006 by Radiological Society of North
America
Slide 39
Figure 16d. Todani Type 2 Choledochal cysts. Mortel K J et al.
Radiographics 2006;26:715-731 2006 by Radiological Society of North
America
Slide 40
Figure 16f. Todani Type 3 Choledochal cyst Mortel K J et al.
Radiographics 2006;26:715-731 2006 by Radiological Society of North
America
Slide 41
Figure 17b. (a, b) Drawing (a) and coronal MR
cholangiopancreatogram (b) show type IV choledochal cysts. Mortel K
J et al. Radiographics 2006;26:715-731 2006 by Radiological Society
of North America
Slide 42
Figure 17d. (a, b) Drawing (a) and Endoscopic Retrograde
Cholangiopancreatogram (b) show type IV choledochal cysts. Mortel K
J et al. Radiographics 2006;26:715-731 2006 by Radiological Society
of North America
Slide 43
Carolis Disease Imaging Central dot sign Dilagted IHD with
contrast enhancement of the portal branches Todani classifications
Type 5 If large IBD affected = Carolis disease If small
interlobular bile ducts also affected = Congenital hepatic fibrosis
Carolis Syndrome
Slide 44
Gallbladder Adjacent to inferior surface of liver Plane of
interlobar fissure Different positions Under left lobe Situs
inversus Intrahepatic Subcapsular along ant-inf surface of right
lobe of liver Transverse Retroperitoneal Congenital Acquired
Gallbladder Phrygian cap Ancient Greek headgear Asx folding of
GB fundus Junctional fold Usually posterior wall Septa
MultiseptateStatis and stone Honeycombed appearanceformation
Extension of Spiral valves of Heister Other
Duplication/Triplication, Bifid gallbladder Diverticulum
Liver Arterial Proper hepatic artery (CHA from Coeliac trunk)
Right, middel and left hepatic artery (55%) Porto-venous Porta
hepatis (SMV and SV) Right Post and anterior Left portal vein
Venous = IVC Right Segment 6 & 7 Middle Segments 4,5 & 8
LeftCommon trunk (60%) Segments 2 & 3
Slide 50
Arterial and Venous anatomy Onofrio AC, Anandkumar HS, Raul NU
et al. Vascular and biliary variants in the liver: Implications for
liver surgery. Radiographics 2008; 28:359-378
Slide 51
Porto-venous anatomy Onofrio AC, Anandkumar HS, Raul NU et al.
Vascular and biliary variants in the liver: Implications for liver
surgery. Radiographics 2008; 28:359-378
Slide 52
Arterial Variants Onofrio AC, Anandkumar HS, Raul NU et al.
Vascular and biliary variants in the liver: Implications for liver
surgery. Radiographics 2008; 28:359-378
Slide 53
Arterial Variants Onofrio AC, Anandkumar HS, Raul NU et al.
Vascular and biliary variants in the liver: Implications for liver
surgery. Radiographics 2008; 28:359-378
Slide 54
Venous Variants Tributary veins Drain segments in addition to
hepatic veins Eg. Segment 8 into MHV (9%) NB for surgical incision
(Cantlie line) Accessory inferior right hepatic vein Drains
directly into IVC (47%) NB: Nr of acc veins Size and distance from
main hepatic venous drainage site along IVC Surgical difficulty if
>40 mm
Slide 55
Venous Variant Onofrio AC, Anandkumar HS, Raul NU et al.
Vascular and biliary variants in the liver: Implications for liver
surgery. Radiographics 2008; 28:359-378
Slide 56
Portal Vein Variants Gallego C. Velasco M. Marcuello P et al.
Congenital and Acquired anomalies of the portal venous system.
Radiographics 2002;22:141-159
Slide 57
Portal Vein Variants Variants common (20%) Trifurcation (7 10%)
RPPV from MPV (5 6%) RAPV from LPV (3 4%) Cantlie line Hypovascular
surgical line transplantations 1cm to right of MHV Between IVC and
gallbladder fossa
Slide 58
Imaging No surprises Radiologist/Surgeon Pre operative planning
Liver transplant/resection/cholecystectomy Whipples procedures
Intra arterial chemotherapy (HAIP) Asymptomatic Several options
Helical CT Cholangiography, MR Cholangiography ERCP, PC
Cholangiography Oral Cholangiography, Scintigraphy Best? Kapoor V,
Peterson MS, Baron RL. Intrahepatic biliary anatomy of living adult
donors: Correlation of Mangafodipir Trisodium enhanced MR
Cholangiography and intraoperative cholangiography. AJR Nov 2002;
179(5):1281-1286
Slide 59
Report Technique used Sequences and contrast material Puncture
site Normal anatomy If not where does what implant? Classifications
and measurements Distinguish from pathological processes
Slide 60
Bibliography 1. Lee NK, Kim S, Jeon TY et al. Complications of
congenital and developmental abnormalities of the gastrointestinal
tract in adolescents and adults: Evaluation with multimodality
imaging. Radiographics 2010;30:1489-1507 2. Mortele KJ, Rocha TC,
Streeter JL et al. Multimodality Imaging of Pancreatic and Biliary
Congenital Anomalies. Radiographics 2006; 26:715-731 3. Rizzo RJ,
Szucs RA, Turner MA. Congenital abnormalities of the pancreas and
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Anandkumar HS, Raul NU et al. Vascular and biliary variants in the
liver: Implications for liver surgery. Radiographics 2008;
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Anatomy and Disease Processes. Radiographics 2001;21:3-22 6. Kapoor
V, Peterson MS, Baron RL. Intrahepatic biliary anatomy of living
adult donors: Correlation of Mangafodipir Trisodium enhanced MR
Cholangiography and intraoperative cholangiography. AJR Nov 2002;
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Danhert Wolfgang. Lippincott Williams & Wilkins. Philadelphia.
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