7HEPATIC ARTERIESCatalano, O. A. et al. Radiographics 2008;28:
8LATERAL AORTOGRAM AND CT SHOW ORIGINS OF CELIAC ARTERY AND SMA Arterial blood flow to the liver is via the Celiac Artery which extends from the anterior surface of the aorta and splits into 3 branches.
9THE COMMON HEPATIC ARTERY BECOMES THE PROPER HEPATIC ARTERYAFTER THE GASTRODUODENAL BRANCH DESCENDS. CeliacGastroduodenalSMA
19ENDOSCOPIC RETROGRADE Cholangio - Pancreatography ERCPMR 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.
26ACUTE CHOLECYSTITISSonography is preferred as the initial imaging test of choice, with supplemental scintigraphy in problematic cases.
27CHOLECYSTITIS With diffuse wall thickening and edema. Ultrasound and CT demostration of edema in and around GB wall
28Murphy’s SignA 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.
29IMAGING ALTERNATIVES Nuclear medicine - HIDA CT X-ray Cholangiography - MR or Endoscopic
30HEPATO - BILIARY SCINTIGRAM NORMAL HIDAGall bladderObstructed cystic duct doesn’tallow for filling of radionuclideinto the GB.Absent Gall bladderABNORMAL HIDA
31GALLSTONE NORMAL GALLBLADDER CHOLECYSTITIS Thickened edematous gallbladderwall with cholecystitis on CTCHOLECYSTITIS
33COMPLICATIONS OF GALLSTONES Cystic duct obstructionCholecystitis ACommon bile duct obstructionObstructive jaundice BAscending cholangitisPancreatic duct obstructionPancreatitis CABC33
34Obstructed duct due to distal calculus PV CBD Normal bile duct size Diameter < portal diameterNote dilated CBD with impacted calculus
35Note dilated bile ducts *Note dilated bile ducts. (Low density branching structures anterior to portal veins)NormalThe 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.35
36Endoscopic retrograde Cholangiopancreatography Dilated CBD with calculiNormal size CBDEndoscopic retrogradeCholangiopancreatographyERCP
45ALTERED LABORATORY DATA +-PAIN Bilirubin - jaundiceAmylase - pancreatitis
46JAUNDICE Jaundice is a clinical finding, not a single disease entity. Jaundice is a clinical finding, not a single disease entity.Two distinct categories:Intrahepatic biliary stasis (hepatocellular jaundice) -imaging plays little useful roleMechanical biliary obstruction.
47JAUNDICE VIRAL HEPATITIS IMAGING- LIMITED VALUEAcute – usually normalhelps to exclude obstructionChronic – increased malignancy risk
48THE MOST COMMON CAUSES OF OBSTRUCTIVE JAUNDICEIN THE UNITED STATESNeoplasms of the pancreasCholedocholithiasisPancreatitisIatrogenic strictures of the biliary tree
51PALPABLE GALL BLADDERA palpable gall bladder in an asymtomatic patient can be seen with pancreatic carcinoma due to distal obstruction(Courvoisier sign)
52PANCREATITIS elevated AMYLASE & LIPASE Biliary calculi-obstructionAlcohol- chemical toxicity
53COMPLICATIONS OF PANCREATITIS PseudocystPainInfectionHemorrhage- pseudoaneurysmPancreatic insufficiencyLarge retrogastric fluid collection is a pseudocyst related to pancreatic enzyme break down of tissue.
66CIRRHOSIS 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.
67VARICESVarices 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.
68Surgical Portocaval shunts as therapy Side to sideSplenorenal68
71TRAUMA UNSTABLE—SURGERY STABLE– CT SCANNING X-ray-- Chest/ Abd / Pelvis if possibleFAST SCAN--to look for peritoneal fluidSTABLE– CT SCANNING
72F.A.S.T. SCAN Ultrasound survey for free peritoneal fluid (Focused Assessment with Sonography for Trauma)Ultrasound survey for free peritoneal fluid
73F.A.S.T. SCAN Ultrasound survey for free peritoneal fluid (Focused Assessment with Sonography for Trauma)Ultrasound survey for free peritoneal fluidNeed ccsNot good for organ injury or bowel injuryPeritoneal Lavage is outdated
74HEPATIC / SPLENIC LACERATION Note rib fractures on x-ray
75POST TRAUMATIC PANCREATITIS SEAT- BELT INJURY There is diffuse edema and hemorhage in adjacent tissues around the pancreas.
76WHAT IMAGING POSSIBILITIES? ULTRASOUND---GB / CBD / LIVERPlain x-ray---ERCPCT---PANCREAS / LIVERNuclear Medicine---HIDAMR---MRCPThese are the imaging modalities and important sites of assessment