Download - M-2 HEPATOBILIARY IMAGING Liver Gallbladder And Bile Ducts Pancreas Spleen 2013.

M-2HEPATOBILIARY

IMAGING

Liver Gallbladder And Bile Ducts Pancreas Spleen

2013

GOALS

Review anatomy of hepatobiliary system.

Correlate imaging with pathology.

Discuss radiologic imaging options.

Choose treatment

ANATOMY / PHYSIOLOGY

Portal vein flow

Hepatic arterial flow

Hepatic vein flow

Biliary drainage

PORTAL BLOOD FLOW

CT

PORTAL VEIN

Coronal and Axial imagesCT

US

CT

US

Transverse CT sections and corresponding US

Catalano, O. A. et al. Radiographics 2008;28:359-378

HEPATIC ARTERIES

LATERAL AORTOGRAM AND CT SHOW ORIGINS OF

CELIAC ARTERY AND SMA

SMA

Celiac

Celiac

SMA

Proper hepatic

Gastroduodenal

Celiac

SMA

THE COMMON HEPATIC ARTERY BECOMES THE PROPER HEPATIC ARTERYAFTER THE GASTRODUODENAL BRANCH DESCENDS.

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


HEPATIC VEINS

HEPATIC VEINSCoronal scan

HEPATIC VEINS ENTERING IVC CT

ULTRASOUND


INTRA AND EXTRAHEPATIC BILIARY TREE

Silva, A. C. et al. Radiographics 2004;24:677-687

NORMAL BILIARY ANATOMY

NORMAL HIDA SCAN

Silva, A. C. et al. Radiographics 2004;24:677-687

COMPARISON WITHMR CHOLANGIOGRAM (MRCP)

MR CHOLANGIOGRAM

OPERATIVE CHOLANGIOGRAM

COMMON BILE DUCT

GALLBLADDER

POST CHOLECYSTECTOMY

GALLBLADDER CALCULI

ERCP

MR cholangiogram shows signal from the bile and other fluids. ERCP has iodinated contrastinjected with an endoscope with the canula in the distal common bile duct.

ENDOSCOPIC RETROGRADE

Cholangio - Pancreatography

PANCREATIC ANATOMY

WHO PRESENTS FOR IMAGING?

Right upper quadrant pain

Altered laboratory data

Staging of malignancy / infection

Physical exam findings

Abdominal trauma

Differential Diagnosis:

Acute Cholecystitis/Cholelithiasis

PUD / Gastritis / Reflux

Acute hepatitis / Liver Abcess

Pancreatitis

Choledocholithiasis

ACUTE RIGHT UPPER QUADRANT PAIN

RIGHT UPPER QUADRANT PAIN

Gallstone = cholelithiasis

Common - prevalence 10%

Pain with contraction after eating

DIAGNOSIS

ULTRASOUND

Cost / Availability

Fluid background is ideal for imaging

Helpful to assess for any associated biliary dilatation or inflammatory change

CHOLELITHIASIS

Sonography is preferred as the initial imaging test of choice, with supplemental scintigraphy in problematic cases.

ACUTE CHOLECYSTITIS

CHOLECYSTITIS

With diffuse wall thickening and edema.

Ultrasound and CT demostration of edema in and around GB wall

A Sonographic Murphy’s 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.

Murphy’s Sign

IMAGING ALTERNATIVES

Nuclear medicine - HIDA

CT

X-ray

Cholangiography - MR or Endoscopic

NORMAL HIDA

ABNORMAL HIDA

Obstructed cystic duct doesn’t allow for filling of radionuclide into the GB.

HEPATO - BILIARY

SCINTIGRAM

Gall bladder

Absent Gall bladder

NORMAL GALLBLADDER

GALLSTONE

CHOLECYSTITIS

Thickened edematous gallbladder wall with cholecystitis on CT

GALLSTONES 15-30% calcify

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

Normal bile duct size

Diameter < portal diameter

Obstructed duct due to distal calculus

PV

CBD

Note dilated CBD with impacted calculus

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.

Endoscopic retrograde

Cholangiopancreatography

Normal size CBD

Dilated CBD with calculi

ERCP

SPECIAL CASES

Emphysematous cholecystitis

Acalculous cholecystitis

Gallstone ileus

EMPHYSEMATOUS CHOLECYSTITISDIABETIC PATIENTS - AIR IN WALL

ACALCULOUS CHOLECYSTITISBILIARY STASIS - FASTING / ICU PATIENTS

GALLSTONE ILEUS Small Bowel Obstruction at IC valve due to migration of

gallstones that erode into duodenum from GB.

1999 2002

ABDOMEN SCANDONE 2/12/08

SAME PATIENTABDOMEN SCAN

DONE 2/25/08

CHOLECYSTOSTOMYSKIN MARKERS

NEEDLE

POSITION

DRAIN PRESENTATION

PLACEMENT

Ultrasound – 1st

CT / HIDA – 2nd

ERCP / MRCP-- 3rd

RUQ PAINIMAGING EVALUATION

ALTERED LABORATORY DATA+-PAIN

Bilirubin - jaundice

Amylase - pancreatitis

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.

JAUNDICEVIRAL HEPATITIS

IMAGING- LIMITED VALUE

Acute – usually normal

helps to exclude obstruction

Chronic – increased malignancy risk

Neoplasms of the pancreas

Choledocholithiasis

Pancreatitis

Iatrogenic strictures of the biliary tree

THE MOST COMMON CAUSES OF OBSTRUCTIVE JAUNDICE

IN THE UNITED STATES

JAUNDICEBILIRUBIN

Painless Malignancy Chronic obstruction

Painful Hepatitis / liver edema Choledocholithiasis / acute obstruction

PANCREATIC CANCEROBSTRUCTIVE JAUNDICE

PALPABLE GALL BLADDER

A palpable gall bladder in an asymtomatic patient can be seen with pancreatic carcinoma due to distal obstruction (Courvoisier sign)

PANCREATITIS elevated

AMYLASE & LIPASE

Biliary calculi-obstruction Alcohol- chemical toxicity

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.

PANCREATIC ABSCESS

DRAINAGE OF PANCREATIC ABSCESS

STAGINGMALIGNANCY / INFECTION

Mesenteric blood flow spreads disease to liver

GI malignancy often spreads to liver as first site of hematogenous extention.

HEPATIC ABSCESS FROM GI INFECTION

Mesenteric venous blood flow can spread infection to the liver.

PALPABLE PHYSICAL EXAM FINDINGS

Enlarged liver

Enlarged spleen

Ascites - distention

PALPABLE LIVER-metastatic disease

A palpable enlarged liver edge is nonspecific but raises questions of mass or liver pathology.

ENLARGED PALPABLE SPLEEN

Enlarged spleen raises issue of lymphoproliferative diseases or infection.

SPLEEN

ENLARGED SPLEEN ON

ULTRASOUND AND CT.

*Note left kidney

Coronal scan

SPLENOMEGLY

*Note dilated splenic vein

*

Ascites displacing bowel medially on Xray

Lucent fluid at tip of liver on ultrasound

Fluid on CT

Sagittal Ultrasound

Small nodular echogenic liver shows cirrhotic change

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.

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.

Surgical Portocaval shunts as therapy

Side to side

Splenorenal

Interventional Radiology shunt

Hepatic vein - Portal vein

TIPSTransjugular Intrahepatic Portosystemic Shunt

TRAUMA

UNSTABLE—SURGERY

X-ray-- Chest/ Abd / Pelvis if possible

FAST SCAN-- to look for peritoneal fluid

STABLE– CT SCANNING

TRAUMA

F.A.S.T. SCAN(Focused Assessment with Sonography for Trauma)

Ultrasound survey for free peritoneal fluid

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

HEPATIC / SPLENIC

LACERATION

Note rib fractures on x-ray

POST TRAUMATICPANCREATITIS

SEAT- BELT INJURY

There is diffuse edema and hemorhage in adjacent tissues around the pancreas.

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