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Surgical Pathology & X-rays for M edical Students 2007 GIT-2 Liver & biliary system Pancreas Spleen
© GIT 2 2 Gall bladder & Bile ducts Gall bladder & Bile ducts Gall stones Gall stones Gall bladder imaging US Oral cholecystography Plain X-ray Types of gall stones Types of gall stones Complications of gall stones Complications of gall stones Bile ducts imaging Bile ducts imaging US CT ERCP Biliary stones Biliary stones Bile duct CABile duct CA PTC ‘T’ tube cholangiography Operative cholangiography MRCP Diagnostic patterns of biliary obstruction Diagnostic patterns of biliary obstruction Liver Liver Multiple lacerations Multiple lacerations Cirrhosis Cirrhosis Hepatoma Hepatoma Liver secondary Liver secondary Liver infections Liver infections Ascending cholangitis Liver abscess Hydatid cyst Pancreas Pancreas Pancreatic carcinoma Pancreatic carcinoma Pseudo-pancreatic cyst Pseudo-pancreatic cyst Spleen : Traumatic rupture Spleen : Traumatic rupture
© GIT 2 3 Gall bladder & Bile ducts INDEX
© GIT 2 4 Gall stones (cholelithiasis) INDEX
© GIT 2 5 Real time sonography Real time sonography. Oral cholecystography (OCG), Plain films CT and radionuclide studies GALLBLADDER - IMAGING TECHNIQUES INDEX
© GIT 2 6 Liver G.B. Hepatic duct The gall bladder size and shape are regular with no stones inside. Normal diameter of the bile ducts Normal US of the liver, GB & bile ducts US: US: is the most common method used to examine the morphology and pathology of the liver and GB. It is the primary screening modality for gallbladder disease INDEX
© GIT 2 7 US showing normal GB 1- 1- Distended in a fasting patient 2- 2- Contracted in a postprandial patient INDEX
© GIT 2 8 Solitary stone Gall Bladder with posterior acoustic shadowing INDEX
© GIT 2 9 Solitary stone Gall Bladder INDEX
© GIT 2 10 Abdominal Ultrasound: Cholelithiasis Multiple, discrete echogenic foci within the gallbladder with posterior acoustic shadowing. The foci were shown to move with change in patient position. INDEX
© GIT 2 11 Two round, echogenic stones (arrows) with an acoustic shadow are seen in the normal-sized gallbladder INDEX
© GIT 2 12 Real time sonography. Oral cholecystography (OCG), Plain films CT and radionuclide studies GALLBLADDER - IMAGING TECHNIQUES INDEX
© GIT 2 13 Oral cholecystography Normal Oral cholecystography (OCG) INDEX
© GIT 2 14 OCG ORAL CHOLECYSTOGRAPHY (OCG): stones filling defects INDEX
© GIT 2 15 Oral cholecystography Multiple gall bladder stones INDEX
© GIT 2 16 Real time sonography. Oral cholecystography (OCG), Plain films CT and radionuclide studies GALLBLADDER - IMAGING TECHNIQUES INDEX
© GIT 2 17 AP plain X-ray RT. hypochondrium: Several, small, calcified stones can be seen in the area of the elongated gallbladder, which is probably totally filled with stones. INDEX
© GIT 2 18 Plain X-ray film of the abdomen- Plain X-ray film of the abdomen- showing multiple calcified gallstones in the Rt. upper quadrant INDEX
© GIT 2 19 Plain X-ray film of the abdomen- Plain X-ray film of the abdomen- showing multiple calcified faceted gallstones outlining the contours of the gallbladder in the Rt. upper quadrant INDEX
© GIT 2 20 Plain X-ray- Porcelain gallbladder Elliptical ring-like calcification in the RUQ which corresponds to the shape and location of the gallbladder, the characteristic appearance of porcelain gallbladder. INDEX
© GIT 2 21 Porcelain gallbladder A calcified gallbladder wall can be asymptomatic. Gallstones are almost always present in cases of gallbladder calcification. Considered a result of low-grade chronic inflammation. Increased incidence of gallbladder carcinoma warrants prophylactic cholecystectomy INDEX
© GIT 2 22 Real time sonography. Oral cholecystography (OCG), Plain films CT and radionuclide studies GALLBLADDER - IMAGING TECHNIQUES INDEX
© GIT 2 23 GB mass with cancer head pancreas GB mass Cancer head pancreas INDEX
© GIT 2 24 GB mass INDEX
© GIT 2 25 Types of gallstones 1.Cholesterol stones (Often solitary) 2.Mixed stones (multiple, often faceted) [90% of gallstones] 3.Pigment stones (calcium bilirubinate) INDEX
© GIT 2 26 Mixed stones Mixed stones account to 80 – 90 % of gallstones Mainly formed of cholesterol 10% of gallstones are radio-opaque INDEX
© GIT 2 27 In the gall bladder: Chronic cholecystitis Acute cholecystitis Gangrene, perforation Empyema – Mucocele Carcinoma In the bile ducts: Obstructive jaundice Cholangitis Acute pancreatitis In the intestine: Acute intestinal obstruction ( Gallstone ileus) Effects & complications of gall stones: INDEX
© GIT 2 28 Multiple mixed faceted GB stones with chronic calcular cholecystitis gall bladder Complications of gall stones in the gall bladder INDEX
© GIT 2 29 Gallstones (cholelithiasis) Chronic calcular cholecystitis INDEX
© GIT 2 30 Mixed Gallstones Pigment Gallstones INDEX
© GIT 2 31 Chronic cholescystitis with cholelithiasis Note the thickened gallbladder wall. INDEX
© GIT 2 32 Autopsy specimen (of another patient) S S: impacted stone L L: liver US US: Marked dilatation of the GB Mucocele – Hydrops of GB INDEX
© GIT 2 33 of GB Empyema of GB The GB is filled with bile stained pus & stones The cystic duct is opened to show impacted stone The GB wall is thick & fibrotic with congestion & erythema of the serosa (acute on top of chronic inflammation) Inflamed omentum surrounds the inflamed GB INDEX
© GIT 2 34 This tumor is uncommon but invariably associated with the presence of gallstones Carcinoma of the gallbladder INDEX
© GIT 2 35 Obstructive jaundice More ERCP pictures will come later bile ducts Complications of gall stones in the bile ducts INDEX
© GIT 2 36 A gallstone obstructing the cystic duct and resulting in inflammation and compression of the common bile duct. The symptoms and signs involve jaundice and pain. The diagnosis and treatment involve ERCP Mirizzi's Syndrome
© GIT 2 37 ERCP ERCP cholangiogram showing dilated CHD and intra-hepatic ducts with normal CBD and filling defect at cystic duct/CBD junction More pictures for ERCP will come later Mirizzi's Syndrome INDEX
© GIT 2 38 Pyogenic abscesses of the liver secondary to acute cholangitis Extension of the pyogenic process through the biliary tree Cholangitis INDEX
© GIT 2 39 Acute pancreatitis INDEX
© GIT 2 40 70 y old female with known history of gallbladder stones Vomiting & abdominal pain 2 days before admission Plain X-ray showing mechanical small bowel obstruction, gall stone shadow & aerobilia Gall stone ileus Intestine Complications of gall stones in the Intestine INDEX
© GIT 2 41 Imaging of the Biliary Ducts. INDEX
© GIT 2 42 Non-invasive screening for suspected biliary ductal pathology US Direct opacification of the ducts PTC ERCP Postoperative T-Tube cholangiography Intraoperative cholangiography Intravenous cholangiography (IVC) is considered an outdated technique Biliary scintigraphy, while very useful in the diagnosis of acute cholecystitis, has a limited role in the diagnosis of biliary ductal disease CT The initial imaging technique when biliary obstruction is suspected level cause Reserved for selected cases in which more information about level and cause of obstruction is needed INDEX
© GIT 2 43 ULTRASOUND: INDEX The common bile duct (3,8 mm) and the portal vein are of normal diameter. The intrahepatic bile ducts are also normal Portal vein Common bile duct Normal liver
© GIT 2 44 COMPUTED TOMOGRAPHY (CT) CT is reserved for selected cases which are equivocal on sonography or in which more information about level and cause of obstruction is needed Mass in the head of pancreas causing biliary obstruction & huge BG dilatation Small mass in the pancreas causing dilatation of the common bile duct (cbd) & pancreatic duct (pd) INDEX
© GIT 2 45 INDEXERCP: Er cp Endoscopic retrograde cholangiopancreatography
© GIT 2 46 Normal ERCP Common bile duct Gall bladder Common hepatic duct Rt. & Lt. hepatic ducts INDEX
© GIT 2 47 ERCP- Choledocholithiasis Common duct stones Dilated common bile duct to the level of the head of the pancreas. In the dilated CBD is a radio-lucent stone (round, radiolucent filling defect) (arrow). INDEX
© GIT 2 48 Endoscopic biliary sphincterotomy with stone removal INDEX
© GIT 2 49 CBD stone extracted by Dormia basket Following sphincterotomy, the stone is extracted using a wire basket (Dormia Basket) Common duct stones may also be identified on T-Tube cholangiography and operative cholangiography. The appearance is the same as on PTC or ERCP INDEX
© GIT 2 50 ERCP: The contrast material fills the dilated intrahepatic and common bile duct, in which several filling defects (gallstones) are visible (arrows) INDEX
© GIT 2 51 ERCP Stone CBD INDEX
© GIT 2 52 ERCP Stones CBD INDEX
© GIT 2 53 ERCP Stone CBD INDEX
© GIT 2 54 ERCP Stone CBD INDEX
Bismuth classification of hilar Cholangiocarcinoma
© GIT 2 56 ERCP- bile duct carcinoma A short segment constricting lesion with irregular margins was noted at the bifurcation of the common hepatic duct (arrow). bile duct carcinoma Klatskin tumor This high-grade constricting lesion at the hepatic duct is consistent with a primary bile duct carcinoma, or Klatskin tumor. INDEX
© GIT 2 57 Stent inserted endoscopically in CBD The previous patient was inoperable. A stent was inserted for palliative relief of jaundice. INDEX
© GIT 2 58 Klatskin’s tumor: Bile duct carcinoma INDEX
© GIT 2 59 PTC PTC : PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY INDEX
© GIT 2 60 Normal PTC INDEX
© GIT 2 61 PTC PTC - stone lower CBD INDEX
© GIT 2 62 PTC: The contrast material administered through a Chiba needle (arrows) completely fills the intrahepatic bile ducts, extremely dilated because of an obstruction of the common bile duct. INDEX
© GIT 2 63 T-TUBE CHOLANGIOGRAPHY: INDEX Normal
© GIT 2 64 Normal T-tube cholangiography Notice the free passage of contrast into the duodenum INDEX
© GIT 2 65 Normal T-tube cholangiography INDEX
© GIT 2 66 Radiologic extraction of retained common duct stone The T-Tube cholangiogram It shows a meniscoid filling defect in the distal common duct occluding flow. This represents a retained common duct stone. The T-Tube was left in place to allow formation of a firm tract and the patient returned 5 weeks later (6 weeks after surgery) for radiologic extraction of the stone through the T- Tube tract. INDEX
© GIT 2 67 Stone engaged in the basket (curved arrow) and being removed from the duct via the T- Tube tract. A post-procedure cholangiogram should be done to confirm that the duct is clear with no residual stone or fragments Radiologic extraction of the stone through the T-Tube tract INDEX
© GIT 2 68 OPERATIVE CHOLANGIOGRAPHY The bile duct is opacified during operative cholangiography by inserting a needle or cannula directly into the cystic duct or CBD and injecting contrast material This procedure is done at the time of cholecystectomy to assess for stones in the bile ducts to determine the need for common duct exploration INDEX
© GIT 2 69 MRCP MRCP (normal) (Magnetic resonance cholangio- panceriatography) Advantages of MRCP: Non invasive (avoids complications of diagnostic ERCP or PTC) No sedation usually required No iodinated intravenous contrast (avoids iodine anaphylaxis and contrast nephropathy) Rapid scan time No ionising radiation (safe in pregnancy and children) Delineates ductal anatomy proximal to obstructions Delineates anatomy post biliary-enteric anastomosis Define extraductal structures (useful in staging malignancy) INDEX
© GIT 2 70 MRCP Normal anatomy INDEX
© GIT 2 71 MRCP showing 2 CBD stones & dilated CBD INDEX
© GIT 2 72 MRCP demonstrating a hilar cholangiocarcinoma. There is a stricture and obstruction at the hilum with intrahepatic biliary dilatation INDEX
© GIT 2 73 M.R. cholangiography showing CHD injury with collection INDEX
© GIT 2 74 DIAGNOSTIC PATTERNS of BILIARY OBSTRUCTION INDEX
© GIT 2 75 Types of BILIARY OBSTRUCTION. 1. Choledocholithiasis 1. Choledocholithiasis (biliary duct stones) One or more intraluminal defects (round, faceted or lobulated) which produce varying degrees of biliary obstruction are seen. Occasionally stones are noted as small multiple free-floating defects in a non-dilated duct. INDEX
© GIT 2 76 2. Pancreatic carcinoma 2. Pancreatic carcinoma Complete or almost complete obstruction of the mid or distal common duct, usually over a long segment (3-4 cm) of the distal duct (intrapancreatic portion) is seen. A "rat-tail" configuration is the typical appearance (red arrows); however, a rounded end or short segment stenosis with more abrupt margins may be seen. INDEX
© GIT 2 77 Adenocarcinoma of the pancreas Tumors in the head of the pancreas tend to obstruct the bile duct DU Duodenum: DU CHP Cancer head of pancreas: CHP INDEX
© GIT 2 78 3. Cholangiocarcinoma 3. Cholangiocarcinoma The narrowing may occur at any level and typically presents as a short segmental stenosis. When the lesion is located at the bifurcation, it is referred to as a Klatskin tumor Cholangiocarcinoma may be polypoid or diffusely infiltrating. INDEX
© GIT 2 79 Benign stricture 4. Benign stricture There is a short segmental circumferential stricture in the mid-common duct in a patient with a previous cholecystectomy. Most benign strictures are secondary to ductal injury during cholecystectomy. (iatrogenic) INDEX
© GIT 2 80 5. Ampullary carcinoma Focal obstruction of very distal CBD is noted. A smooth constriction or an irregular polypoid mass growing into distal CBD may be seen. INDEX
© GIT 2 81 Chronic pancreatitis causing stricture 6. Chronic pancreatitis causing stricture: A long segment stricture of the intrapancreatic common duct is seen. The stricture is more tapered than that seen in pancreatic carcinoma and does not usually completely obstruct. Calcifications in the pancreatic head help confirm the diagnosis. Metastatic nodes to the porta hepatis 8. Metastatic nodes to the porta hepatis - Infiltration or encasement of the CHD, usually just below the bifurcation, is seen. The obstruction tends to be short segmental, smooth, concentric and occurs in a patient with a clinical history of primary neoplasm elsewhere. Sclerosing cholangitis 7. Sclerosing cholangitis There is a diffuse periductal infiltrating lesion involving the intra- and extrahepatic ducts with beading, irregularity and segmental narrowing. Other causes of biliary obstruction INDEX
© GIT 2 82 Ascariasis worms causing obstructive jaundice INDEX
© GIT 2 83 Ascariasis Worms are seen extending through the common bile duct and major hepatic ducts INDEX
© GIT 2 84 Liver INDEX
© GIT 2 85 Massive abdominal blunt force injury often leads to liver injury, since it is the largest internal organ. Note the multiple lacerations seen here over the capsular surface of the liver. Crush injuries can damage abdominal organs causing lacerations or rupture with bleeding into the peritoneal cavity (hemoperitoneum) Peritoneal lavage can detect such bleeding Multiple hepatic lacerations INDEX
© GIT 2 86 Intraoperative photograph of the right hepatic lobe (In another patient) Exploration should look for other injuries. Exploration should look for other injuries. In this patient, the missile traversed the liver and injured the right kidney, which required removal due to sever hemorrhage. The hepatic injury, was successfully managed with debridement of non-viable parenchyma, ligation of arterial vessels on the raw surface, viable omental packing, and drainage. Liver injury due to gun shot Free intraperitoneal fluid adjacent to the liver (black arrowheads) with laceration (curved arrow) to the anterior left lobe of liver. Air (white arrowhead) is seen within muscle anterior to the liver injury (entry site) INDEX
© GIT 2 87 Liver cirrhosis INDEX
© GIT 2 88 Portal venous system CP of portal hypertension with liver cell failure INDEX
© GIT 2 89 Esophageal varices as seen in upper GI endoscopy Caput Medusae Portal hypertension leads to expansion of collateral veins in the region of the umbilicus Splenomegaly on laparoscopy What are the manifestations of portal hypertension? INDEX
© GIT 2 90 Chronic alcoholism leads to fibrosis and regeneration of the hepatocytes in nodules. This firm, nodular appearance of the liver as seen here is called cirrhosis Macro-nodular cirrhosis INDEX
© GIT 2 91 Macro-nodular cirrhosis INDEX
© GIT 2 92 INDEX
© GIT 2 93 Biliary cirrhosis INDEX
© GIT 2 94 Liver cirrhosis as seen during an operation Liver Stomach INDEX
© GIT 2 95 Hepatoma Hepatocellular carcinoma. A primary liver cancer that starts in the liver cells INDEX
© GIT 2 96 Hepatocellular carcinoma (hepatoma) (solitary large mass) Note: cirrhosis; bulging, pigmented hepatoma INDEX
© GIT 2 97 Solitary hepatic nodule for D.D. INDEX
© GIT 2 98 Hepatoma INDEX
© GIT 2 99 Secondaries in the Liver INDEX
© GIT 2 100 Multiple liver secondaries INDEX
© GIT 2 101 CT scan with intravenous contrast Multiple low density area suspicious of metastasis. The primary tumour may commonly arise from the lung, breast, colon, stomach and pancreas The commonest tumour in the liver is metastasis. The primary tumour may commonly arise from the lung, breast, colon, stomach and pancreas. Multiple liver metastasis INDEX
© GIT 2 102 Multiple liver metastasis INDEX
© GIT 2 103 Multiple liver metastasis INDEX
© GIT 2 104 Multiple liver metastasis INDEX
© GIT 2 105 Multiple liver metastasis INDEX
© GIT 2 106 Multiple liver metastasis INDEX
© GIT 2 107 Multiple liver metastasis INDEX
© GIT 2 108 Numerous, mostly round-shaped hypodens lesions of different size are visible in both lobes of the liver. Liver metastasis INDEX
© GIT 2 109 Liver Infections Viral hepatitis Ascending cholangitis Pyogenic liver abscess Amoebic live abscess Hydatid liver disease INDEX
© GIT 2 110 Ascending cholangitis Pyogenic abscesses of the liver secondary to acute cholangitis INDEX
© GIT 2 111 Chest radiograph demonstrating elevation of the right hemidiaphragm Abdominal CT scan demonstrating a large abscess in the right hepatic lobe Liver abscess The clinical picture & lab investigations should ALWASYS be correlated to the US & CT findings INDEX
© GIT 2 112 Amebic liver abscess Entameba histolytica The ingested cyst reaches the intestine The active trophozoite form in the colon can reach the liver via the portal blood (Extra- intestinal disease) INDEX
© GIT 2 113 A 24-year-old male presented with 3 weeks history of fever, malaise, nausea, vomiting and right upper quadrant pain. Bowels were regular with normal stools. General examination: he was febrile (38 o C)but vital signs were stable. He was not anemic or jaundiced. Chest & heart examination was normal Abdominal examination: right upper quadrant tenderness without rigidity or guarding. No organomegaly, masses, or ascites and bowel sounds were normal Investigations: CBC: raised WBC (13.200) and ESR (96 mm/hr). Liver functions showed elevated alkaline phosphatase (152 IU/L) and a low albumin (3.0 g/dL). Amebic serology (Indirect Haemagglutination test) was positive Abdominal US showed homogenous hypoechoic lesion with well-defined borders Abdominal CT scan showed a well- demarcated abscess in the right lobe of liver Diagnosis: Amebic liver abscess INDEX
© GIT 2 114 Clinical History Clinical History: 30 y old male with right upper quadrant pain and fever of 2 weeks duration CT CT: Hypodense lesion within the posterior segment of the right lobe of the liver. There is a peripheral region of increased density surrounding the hypodense lesion If no wall is seen, the differential diagnosis would include: amebic liver abscess, pyogenic abscess, echinoccocal cyst, hematoma, or necrotic tumor. If an enhancing wall is present (as in this case) the differential should be limited to inflammatory conditions Liver abscess that proved to be amebic INDEX
© GIT 2 115 Pyogenic liver abscess Usually in elderly, diabetics & immunosuppresed patients Clinically, there is fever, malaise with upper Rt. quadrant discomfort A multiloculated cystic mass is found on US & CT Diagnosis is confirmed by guided aspiration. The aspirated material is sent to culture & sensitivity Treatment is antibiotics & US guided aspiration Blind percutanous aspiration may go through the pleural space & cause empyema DD: DD: amebic liver abscess, pyogenic abscess, echinoccocal cyst, hematoma, or necrotic tumor or metastasis The clinical picture & lab investigations should ALWASYS be correlated to the US & CT findings INDEX
© GIT 2 116 Liver abscess Liver abscess (proved to be amebic) INDEX
© GIT 2 117 Liver abscess INDEX
© GIT 2 118 Hydatid Cyst of the liver INDEX
© GIT 2 119 Liver with a hydatid cyst containing fluid and daughter cysts. Notice the thick connective tissue capsule INDEX
© GIT 2 120 Hydatid Cyst Echinococcus granulosus Echinococcus granulosus ( Tapeworm) infection of the liver Hydatid cysts develop calcium in their wall which may be seen on a routine chest x-ray. INDEX
© GIT 2 121 US: A septated, round, unechoic area, can be seen in the liver parenchyma Hydatid Cyst INDEX
© GIT 2 122 CT: hydatid Multivesicular hydatid with multiple daughter cysts giving a septated appearance INDEX
© GIT 2 123 Pancreas INDEX
© GIT 2 124 The pancreas is bisected along its longitudinal axis revealing a large adenocarcinoma (B) of the head. (A) is the tail of pancreas Cancer head of pancreas INDEX
© GIT 2 125 High- grade stenosis of the lower biliary duct with a prestenotic dilatation of the CBD ERCP ERCP: Cancer head pancreas CBD dilatation Irregular high- grade stenosis INDEX
© GIT 2 126 Cancer head of pancreas Liver Pancreas body Cancer head Kidney IVC Aorta CT examination INDEX
© GIT 2 127 Liver Gall bladder (markedly dilated) Cancer head Kidney IVC Aorta Patients with obstructive jaundice & GB mass – think of malignant obstruction INDEX
© GIT 2 128 Notice the relation of the mass to the duodenum & inferior venacava An irregular mass in the head of the pancreas Cancer head pancreas INDEX
© GIT 2 129 Ba meal showing pancreatic pseudocyst compressing the stomach INDEX
© GIT 2 130 Acute hemorrhagic pancreatitis INDEX
© GIT 2 131 Spleen INDEX
© GIT 2 132 Splenic lacerations Splenic rupture should be suspected after any trauma specially if associated with direct injury to the left upper quadrant. The possibility of injury increases if the spleen is diseased or enlarged. The spleen is the most common organ to be injured in blunt abdominal trauma INDEX
© GIT 2 133 A large crescentic, low-density fluid collection along the lateral aspect of the spleen. Flattening of the normal splenic contour CT abdomen Traumatic sub-capsular hematoma INDEX
© GIT 2 134 Splenic lacerations CT abdomen INDEX
© GIT 2 135 Traumatic rupture s pleen & Lt. k idney H Hematoma: H S Spleen: S K Kidney: K S K HH INDEX
© GIT 2 136 Pseudopanceriatic cyst & Splenic hematoma L: Liver P: Pancreas PS: Pseudopancreatic cyst S: Spleen H: Hematoma INDEX
Diagnostic studies Blood Tests Imaging Modalities Reference: Schwartz’s Principles of Surgery 8 th Edition.
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