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

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Presentation on theme: "M-2 HEPATOBILIARY IMAGING  Liver  Gallbladder And Bile Ducts  Pancreas  Spleen 2013."— Presentation transcript:

1 M-2 HEPATOBILIARY IMAGING  Liver  Gallbladder And Bile Ducts  Pancreas  Spleen 2013

2 GOALS  Review anatomy of hepato- biliary system.  Correlate imaging with pathology.  Discuss radiologic imaging options.  Choose treatment

3 ANATOMY / PHYSIOLOGY Portal vein flow Hepatic arterial flow Hepatic vein flow Biliary drainage

4 PORTAL BLOOD FLOW CT

5 PORTAL VEIN Coronal and Axial images CT US

6 CT US Transverse CT sections and corresponding US

7 Catalano, O. A. et al. Radiographics 2008;28: HEPATIC ARTERIES

8 LATERAL AORTOGRAM AND CT SHOW ORIGINS OF CELIAC ARTERY AND SMA SMA Celiac SMA

9 Proper hepatic Gastroduodenal Celiac SMA THE COMMON HEPATIC ARTERY BECOMES THE PROPER HEPATIC ARTERYAFTER THE GASTRODUODENAL BRANCH DESCENDS.

10 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

11 Catalano, O. A. et al. Radiographics 2008;28: HEPATIC VEINS

12 Coronal scan

13 HEPATIC VEINS ENTERING IVC CT ULTRASOUND

14 Catalano, O. A. et al. Radiographics 2008;28: INTRA AND EXTRAHEPATIC BILIARY TREE

15 Silva, A. C. et al. Radiographics 2004;24: NORMAL BILIARY ANATOMY NORMAL HIDA SCAN

16 Silva, A. C. et al. Radiographics 2004;24: COMPARISON WITH MR CHOLANGIOGRAM (MRCP)

17 MR CHOLANGIOGRAM OPERATIVE CHOLANGIOGRAM COMMON BILE DUCT

18 GALLBLADDER POST CHOLECYSTECTOMY GALLBLADDER CALCULI

19 ERCP MR cholangiogram shows signal from the bile and other fluids. ERCP has iodinated contrast injected with an endoscope with the canula in the distal common bile duct. ENDOSCOPIC RETROGRADE Cholangio - Pancreatography

20 PANCREATIC ANATOMY

21 WHO PRESENTS FOR IMAGING?  Right upper quadrant pain  Altered laboratory data  Staging of malignancy / infection  Physical exam findings  Abdominal trauma

22 Differential Diagnosis:  Acute Cholecystitis/Cholelithiasis  PUD / Gastritis / Reflux  Acute hepatitis / Liver Abcess  Pancreatitis  Choledocholithiasis ACUTE RIGHT UPPER QUADRANT PAIN

23  Gallstone = cholelithiasis  Common - prevalence 10%  Pain with contraction after eating

24 DIAGNOSIS ULTRASOUND  Cost / Availability  Fluid background is ideal for imaging  Helpful to assess for any associated biliary dilatation or inflammatory change

25 CHOLELITHIASIS

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

27 CHOLECYSTITIS With diffuse wall thickening and edema. Ultrasound and CT demostration of edema in and around GB wall

28 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

29 IMAGING ALTERNATIVES  Nuclear medicine - HIDA  CT  X-ray  Cholangiography - MR or Endoscopic

30 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

31 NORMAL GALLBLADDER GALLSTONE CHOLECYSTITIS Thickened edematous gallbladder wall with cholecystitis on CT

32 GALLSTONES 15-30% calcify

33 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

34 Normal bile duct size Diameter < portal diameter Obstructed duct due to distal calculus PV CBD Note dilated CBD with impacted calculus

35 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.

36 Endoscopic retrograde Cholangiopancreatography Normal size CBD Dilated CBD with calculi ERCP

37 SPECIAL CASES  Emphysematous cholecystitis  Acalculous cholecystitis  Gallstone ileus

38 EMPHYSEMATOUS CHOLECYSTITIS DIABETIC PATIENTS - AIR IN WALL

39 ACALCULOUS CHOLECYSTITIS BILIARY STASIS - FASTING / ICU PATIENTS

40 GALLSTONE ILEUS Small Bowel Obstruction at IC valve due to migration of gallstones that erode into duodenum from GB

41 ABDOMEN SCAN DONE 2/12/08

42 SAME PATIENT ABDOMEN SCAN DONE 2/25/08

43  CHOLECYSTOSTOMY SKIN MARKERS NEEDLE POSITION DRAIN PRESENTATION PLACEMENT

44  Ultrasound – 1st  CT / HIDA – 2nd  ERCP / MRCP-- 3rd RUQ PAIN IMAGING EVALUATION

45 ALTERED LABORATORY DATA +-PAIN  Bilirubin - jaundice  Amylase - pancreatitis

46 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.

47 JAUNDICE VIRAL HEPATITIS IMAGING- LIMITED VALUE Acute – usually normal helps to exclude obstruction Chronic – increased malignancy risk

48 Neoplasms of the pancreas Choledocholithiasis Pancreatitis Iatrogenic strictures of the biliary tree THE MOST COMMON CAUSES OF OBSTRUCTIVE JAUNDICE IN THE UNITED STATES

49 JAUNDICE BILIRUBIN Painless  Malignancy  Chronic obstruction Painful  Hepatitis / liver edema  Choledocholithiasis / acute obstruction

50 PANCREATIC CANCER OBSTRUCTIVE JAUNDICE

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

52 PANCREATITIS elevated AMYLASE & LIPASE Biliary calculi-obstruction Alcohol- chemical toxicity

53  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.

54 PANCREATIC ABSCESS

55 DRAINAGE OF PANCREATIC ABSCESS

56 STAGING MALIGNANCY / INFECTION Mesenteric blood flow spreads disease to liver

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

58 HEPATIC ABSCESS FROM GI INFECTION Mesenteric venous blood flow can spread infection to the liver.

59 PALPABLE PHYSICAL EXAM FINDINGS  Enlarged liver  Enlarged spleen  Ascites - distention

60 PALPABLE LIVER-metastatic disease A palpable enlarged liver edge is nonspecific but raises questions of mass or liver pathology.

61 ENLARGED PALPABLE SPLEEN Enlarged spleen raises issue of lymphoproliferative diseases or infection.

62 SPLEEN ENLARGED SPLEEN ON ULTRASOUND AND CT. *Note left kidney

63 Coronal scan SPLENOMEGLY *Note dilated splenic vein *

64 Ascites displacing bowel medially on Xray Lucent fluid at tip of liver on ultrasound Fluid on CT

65 Sagittal Ultrasound Small nodular echogenic liver shows cirrhotic change

66 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.

67 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.

68 Surgical Portocaval shunts as therapy Side to side Splenorenal

69 Interventional Radiology shunt Hepatic vein - Portal vein TIPS Transjugular Intrahepatic Portosystemic Shunt

70 TRAUMA

71 UNSTABLE—SURGERY X-ray-- Chest/ Abd / Pelvis if possible FAST SCAN-- to look for peritoneal fluid STABLE – CT SCANNING TRAUMA

72 F.A.S.T. SCAN (Focused Assessment with Sonography for Trauma) Ultrasound survey for free peritoneal fluid

73 F.A.S.T. SCAN (Focused Assessment with Sonography for Trauma) Ultrasound survey for free peritoneal fluid Need ccs Not good for organ injury or bowel injury Peritoneal Lavage is outdated

74 HEPATIC / SPLENIC LACERATION Note rib fractures on x-ray

75 POST TRAUMATIC PANCREATITIS SEAT- BELT INJURY There is diffuse edema and hemorhage in adjacent tissues around the pancreas.

76 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

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