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

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

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

PORTAL BLOOD FLOW CT

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

Transverse CT sections and corresponding US 6

HEPATIC ARTERIES Catalano, O. A. et al. Radiographics 2008;28:359-378

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.

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

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

HEPATIC VEINS Catalano, O. A. et al. Radiographics 2008;28:359-378

HEPATIC VEINS Coronal scan

HEPATIC VEINS ENTERING IVC CT ULTRASOUND

INTRA AND EXTRAHEPATIC BILIARY TREE Catalano, O. A. et al. Radiographics 2008;28:359-378

NORMAL BILIARY ANATOMY NORMAL HIDA SCAN Silva, A. C. et al. Radiographics 2004;24:677-687

MR CHOLANGIOGRAM (MRCP) COMPARISON WITH MR CHOLANGIOGRAM (MRCP) Silva, A. C. et al. Radiographics 2004;24:677-687

OPERATIVE CHOLANGIOGRAM MR CHOLANGIOGRAM COMMON BILE DUCT

POST CHOLECYSTECTOMY GALLBLADDER GALLBLADDER CALCULI

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.

PANCREATIC ANATOMY

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

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

RIGHT UPPER QUADRANT PAIN 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

CHOLELITHIASIS

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

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

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.

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

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

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

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 33

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

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

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

SPECIAL CASES Emphysematous cholecystitis Acalculous cholecystitis Gallstone ileus

EMPHYSEMATOUS CHOLECYSTITIS DIABETIC PATIENTS - AIR IN WALL

ACALCULOUS CHOLECYSTITIS BILIARY STASIS - FASTING / ICU PATIENTS 39

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

ABDOMEN SCAN DONE 2/12/08

SAME PATIENT ABDOMEN SCAN DONE 2/25/08

CHOLECYSTOSTOMY SKIN MARKERS NEEDLE POSITION DRAIN PRESENTATION PLACEMENT

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

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

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.

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

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

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

PANCREATIC CANCER OBSTRUCTIVE JAUNDICE

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

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

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.

PANCREATIC ABSCESS

DRAINAGE OF PANCREATIC ABSCESS

STAGING MALIGNANCY / INFECTION Mesenteric blood flow spreads disease to liver

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

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

PALPABLE PHYSICAL EXAM FINDINGS Enlarged liver Enlarged spleen Ascites - distention

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

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

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

Coronal scan * SPLENOMEGLY *Note dilated splenic vein

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

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 68

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

TRAUMA

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

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

F.A.S.T. SCAN Ultrasound survey for free peritoneal fluid (Focused Assessment with Sonography for Trauma) Ultrasound survey for free peritoneal fluid Need 400-500 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