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. Coronal and Axial images
PORTAL VEIN
Coronal and Axial images CT US

6. Transverse CT sections and corresponding US6

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

8. LATERAL 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.

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

10. Arteriography of the three main branches of the celiac artery: Common Hepatic Artery, Left Gastric Artery, and Splenic Artery
HEART
This selective arteriogram has a catheter extending in the aorta with the tip of the catheter in the origin of the Celiac artery. The three main branches of the celiac artery: the CHA, LGA, and SpA. The CHA divides into the PHA and gastroduodenal artery. The PHA divides into the LHA and RHA.
Celiac
Furuta T et al. Radiographics 2009;29:e37
©2009 by Radiological Society of North America

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

12. HEPATIC VEINS
Coronal scan

13. HEPATIC VEINS ENTERING IVCCT
ULTRASOUND

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

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

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

17. OPERATIVE CHOLANGIOGRAM
MR CHOLANGIOGRAM
COMMON BILE DUCT

18. POST CHOLECYSTECTOMY
GALLBLADDER
GALLBLADDER CALCULI

19. ENDOSCOPIC RETROGRADE Cholangio - Pancreatography
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.

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

23. RIGHT UPPER QUADRANT PAIN
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. ACUTE CHOLECYSTITIS
Sonography is preferred as the initial imaging test of choice, with supplemental scintigraphy in problematic cases.

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

28. Murphy’s Sign
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.

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

30. HEPATO - BILIARY SCINTIGRAM
NORMAL HIDA
Gall bladder
Obstructed cystic duct doesn’t
allow for filling of radionuclide
into the GB.
Absent Gall bladder
ABNORMAL HIDA

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

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 33

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

35. Note dilated bile ducts
*Note dilated bile ducts. (Low density branching structures anterior to portal veins)
Normal
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. 35

36. Endoscopic retrograde Cholangiopancreatography
Dilated CBD with calculi
Normal size CBD
Endoscopic retrograde
Cholangiopancreatography
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 PATIENTS39

40. GALLSTONE ILEUS
Small Bowel Obstruction at IC valve due to migration of gallstones that erode into duodenum from GB.
2002
1999

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

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

46. JAUNDICE 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 role
Mechanical biliary obstruction.

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

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

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. COMPLICATIONS OF PANCREATITIS
Pseudocyst
Pain
Infection
Hemorrhage- pseudoaneurysm
Pancreatic insufficiency
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. 61

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

63. Coronal scan *
SPLENOMEGLY
*Note dilated splenic vein

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

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 68

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

70. TRAUMA

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

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

73. F.A.S.T. SCAN Ultrasound survey for free peritoneal fluid
(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