Catalano, O. A. et al. Radiographics 2008;28: HEPATIC VEINS
HEPATIC VEINS ENTERING IVC CT ULTRASOUND
Catalano, O. A. et al. Radiographics 2008;28: INTRA AND EXTRAHEPATIC BILIARY TREE
Silva, A. C. et al. Radiographics 2004;24: NORMAL BILIARY ANATOMY NORMAL HIDA SCAN
Silva, A. C. et al. Radiographics 2004;24: COMPARISON WITH MR 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 contrast injected with an endoscope with the canula in the distal common bile duct. ENDOSCOPIC RETROGRADE Cholangio - Pancreatography
WHO PRESENTS FOR IMAGING? Right upper quadrant pain Altered laboratory data Staging of malignancy / infection Physical exam findings Abdominal trauma
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
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
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.
JAUNDICE VIRAL 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
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.
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
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 ccs Not good for organ injury or bowel injury Peritoneal Lavage is outdated
HEPATIC / SPLENIC LACERATION Note rib fractures on x-ray
POST TRAUMATIC PANCREATITIS 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