Surgical Pathology & X-rays for Medical Students 2007 GIT-2 Liver & biliary system Pancreas Spleen

Gall bladder & Bile ducts Gall stones Gall bladder imaging US Oral cholecystography Plain X-ray Types of gall stones Complications of gall stones Bile ducts imaging CT ERCP Biliary stones Bile duct CA PTC ‘T’ tube cholangiography Operative cholangiography MRCP Diagnostic patterns of biliary obstruction Liver Multiple lacerations Cirrhosis Hepatoma Liver secondary Liver infections Ascending cholangitis Liver abscess Hydatid cyst Pancreas Pancreatic carcinoma Pseudo-pancreatic cyst Spleen: Traumatic rupture © GIT 2

Gall bladder Bile ducts & Bile ducts © GIT 2 INDEX

Gall stones (cholelithiasis) © GIT 2 INDEX

Real time sonography. GALLBLADDER - IMAGING TECHNIQUES Oral cholecystography (OCG), Plain films CT and radionuclide studies © GIT 2 INDEX

Normal US of the liver, GB & bile ducts 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 Normal US of the liver, GB & bile ducts Liver G.B. Hepatic duct The gall bladder size and shape are regular with no stones inside. Normal diameter of the bile ducts © GIT 2 INDEX

1- Distended in a fasting patient US showing normal GB 1- Distended in a fasting patient 2- Contracted in a postprandial patient © GIT 2 INDEX

Solitary stone Gall Bladder with posterior acoustic shadowing © GIT 2 INDEX

Solitary stone Gall Bladder © GIT 2 INDEX

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. © GIT 2 INDEX

Two round, echogenic stones (arrows) with an acoustic shadow are seen in the normal-sized gallbladder © GIT 2 INDEX

Oral cholecystography (OCG), GALLBLADDER - IMAGING TECHNIQUES Real time sonography. Oral cholecystography (OCG), Plain films CT and radionuclide studies © GIT 2 INDEX

Normal Oral cholecystography (OCG) © GIT 2 INDEX

ORAL CHOLECYSTOGRAPHY (OCG): stones filling defects © GIT 2 INDEX

Oral cholecystography Multiple gall bladder stones © GIT 2 INDEX

Plain films GALLBLADDER - IMAGING TECHNIQUES Real time sonography. Oral cholecystography (OCG), Plain films CT and radionuclide studies © GIT 2 INDEX

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. © GIT 2 INDEX

Plain X-ray film of the abdomen- showing multiple calcified gallstones in the Rt. upper quadrant © GIT 2 INDEX

Plain X-ray film of the abdomen- showing multiple calcified faceted gallstones outlining the contours of the gallbladder in the Rt. upper quadrant © GIT 2 INDEX

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. © GIT 2 INDEX

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 © GIT 2 INDEX

GALLBLADDER - IMAGING TECHNIQUES Real time sonography. Oral cholecystography (OCG), Plain films CT and radionuclide studies © GIT 2 INDEX

GB mass with cancer head pancreas © GIT 2 INDEX

GB mass © GIT 2 INDEX

Types of gallstones Cholesterol stones (Often solitary) Mixed stones (multiple, often faceted) [90% of gallstones] Pigment stones (calcium bilirubinate) © GIT 2 INDEX

Mixed stones account to 80 – 90 % of gallstones Mainly formed of cholesterol 10% of gallstones are radio-opaque © GIT 2 INDEX

Effects & complications of gall stones: 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: © GIT 2 INDEX

Multiple mixed faceted GB stones with chronic calcular cholecystitis Complications of gall stones in the gall bladder Multiple mixed faceted GB stones with chronic calcular cholecystitis © GIT 2 INDEX

Chronic calcular cholecystitis Gallstones (cholelithiasis) © GIT 2 INDEX

Mixed Gallstones Pigment Gallstones © GIT 2 INDEX

Chronic cholescystitis with cholelithiasis Note the thickened gallbladder wall. © GIT 2 INDEX

Mucocele – Hydrops of GB US: Marked dilatation of the GB Autopsy specimen (of another patient) S: impacted stone L: liver © GIT 2 INDEX

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 Empyema of GB © GIT 2 INDEX

Carcinoma of the gallbladder This tumor is uncommon but invariably associated with the presence of gallstones © GIT 2 INDEX

More ERCP pictures will come later Complications of gall stones in the bile ducts Obstructive jaundice © GIT 2 More ERCP pictures will come later INDEX

Mirizzi's Syndrome 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 © GIT 2

More pictures for ERCP will come later Mirizzi's Syndrome 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 © GIT 2 INDEX

Cholangitis Pyogenic abscesses of the liver secondary to acute cholangitis Extension of the pyogenic process through the biliary tree © GIT 2 INDEX

Acute pancreatitis © GIT 2 INDEX

Complications of gall stones in the Intestine Gall stone ileus 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 © GIT 2 INDEX

Imaging of the Biliary Ducts. There are a number of techniques used to image the bile ducts. Ultrasound and CT are non-invasive methods used to screen patients with suspected biliary ductal pathology, particularly biliary obstruction. Direct opacification of the ducts by PTC or ERCP is done when more detailed information about ductal anatomy, obstruction, level of obstruction or etiology is needed. The ducts may also be directly opacified by postoperative T-Tube cholangiography or intraoperative cholangiography. Intravenous cholangiography (IVC) is considered an outdated technique, the usefulness of which was limited by contrast toxicity, high error rate and frequently inadequate visualization of the ducts. IVC has been largely replaced by CT, US, PTC and ERCP. Biliary scintigraphy, while very useful in the diagnosis of acute cholecystitis, has a limited role in the diagnosis of biliary ductal disease. ULTRASOUND: Sonography accurately demonstrates the caliber of the intra- and extrahepatic bile ducts and is considered the initial imaging technique when biliary obstruction is suspected. Intrahepatic ducts of normal caliber are not visible on US; however, the common hepatic duct (CHD) is almost always identifiable in the porta hepatis anterior to the portal vein. The more distal common bile duct (CBD) is less frequently visualized as it may be obscured by adjacent gas in the duodenum or colon. The normal diameter of the CHD is 4-6 mm or less. A CHD greater than 7 mm is considered abnormal, indicating either present or past biliary disease. Sonography is reported to be 90-97% accurate in detecting dilated ducts and diagnosing obstructive jaundice. The limitation of the technique is that bile duct caliber does not always correlate with the presence or absence of biliary obstruction. Some patients, e.g., sclerosing cholangitis, may have significant biliary obstruction without dilated ducts. COMPUTED TOMOGRAPHY: CT can demonstrate the caliber of intra- and extraheptic ducts as accurately as sonography. Because of the higher cost and need for IV contrast with CT, US is preferred as the initial screening evaluation for biliary ductal disease. CT is reserved for selected cases which are equivocal on sonography or in which more information about level and cause of obstruction is needed. Intrahepatic ducts of normal caliber are rarely visible on CT. Dilated ducts are usually readily demonstrated as low density tubular branching structures converging at the porta hepatis. IV contrast enhancement is necessary for accurate CT assessment of the biliary tree. The normal extrahepatic duct is visible on CT in most patients. Thin consecutive cuts show the CBD as a circular low density structure coursing from the porta through the head of the pancreas to the ampulla. In evaluating the bile ducts with CT, scanning should be done initially without oral and IV contrast, which may obscure calcified stones. Dynamic scanning technique following an IV bolus, and thin section (5 mm) cuts are helpful to evaluate the duct in the area of the porta hepatis and the pancreatic head. Imaging of the Biliary Ducts. © GIT 2 INDEX

Direct opacification of the ducts Non-invasive screening for suspected biliary ductal pathology US The initial imaging technique when biliary obstruction is suspected CT Reserved for selected cases in which more information about level and cause of obstruction is needed 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 © GIT 2 INDEX

ULTRASOUND: Normal liver Portal vein Common bile duct The common bile duct (3,8 mm) and the portal vein are of normal diameter. The intrahepatic bile ducts are also normal © GIT 2 INDEX

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) © GIT 2 INDEX

ERCP: Endoscopic retrograde cholangiopancreatography © GIT 2 INDEX

Normal ERCP Common bile duct Gall bladder Common hepatic duct Rt. & Lt. hepatic ducts © GIT 2 INDEX

Dilated common bile duct to the level of the head of the pancreas. 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). © GIT 2 INDEX

Endoscopic biliary sphincterotomy with stone removal © GIT 2 INDEX

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 © GIT 2 INDEX

ERCP: The contrast material fills the dilated intrahepatic and common bile duct, in which several filling defects (gallstones) are visible (arrows) © GIT 2 INDEX

ERCP Stone CBD © GIT 2 INDEX

ERCP Stones CBD © GIT 2 INDEX

ERCP Stone CBD © GIT 2 INDEX

ERCP Stone CBD © GIT 2 INDEX

Bismuth classification of hilar Cholangiocarcinoma

ERCP- bile duct carcinoma A short segment constricting lesion with irregular margins was noted at the bifurcation of the common hepatic duct (arrow). This high-grade constricting lesion at the hepatic duct is consistent with a primary bile duct carcinoma, or Klatskin tumor. © GIT 2 INDEX

Stent inserted endoscopically in CBD The previous patient was inoperable. A stent was inserted for palliative relief of jaundice. © GIT 2 INDEX

Klatskin’s tumor: Bile duct carcinoma © GIT 2 INDEX

PTC: PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY © GIT 2 INDEX

Normal PTC © GIT 2 INDEX

PTC - stone lower CBD © GIT 2 INDEX

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. © GIT 2 INDEX

T-TUBE CHOLANGIOGRAPHY: Normal © GIT 2 INDEX

Normal T-tube cholangiography Notice the free passage of contrast into the duodenum © GIT 2 INDEX

Normal T-tube cholangiography © GIT 2 INDEX

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. © GIT 2 INDEX

Radiologic extraction of the stone through the T-Tube tract 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 © GIT 2 INDEX

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 © GIT 2 INDEX

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) © GIT 2 INDEX

MRCP Normal anatomy © GIT 2 INDEX

showing 2 CBD stones & dilated CBD MRCP showing 2 CBD stones & dilated CBD © GIT 2 INDEX

MRCP demonstrating a hilar cholangiocarcinoma. There is a stricture and obstruction at the hilum with intrahepatic biliary dilatation © GIT 2 INDEX

M.R. cholangiography showing CHD injury with collection © GIT 2 INDEX

DIAGNOSTIC PATTERNS of BILIARY OBSTRUCTION Identification of the level of biliary obstruction is of great importance since the differential diagnosis and therapeutic implications are different for each level. A distal CBD obstruction may be amenable to surgical correction whereas a more proximal one may be inoperable or require a more complex intrahepatic anastomosis or percutaneous drainage. Knowing the level also helps determine whether an antegrade (PTC) or retrograde (ERCP) cholangiogram should be done. The differential diagnosis of the etiology of biliary obstruction is also related to the level. Obstructions at or proximal to the porta hepatis are, for all practical purposes, malignant and often better palliated with PBD. Obstruction of the mid-common duct may be due to benign or malignant disease. Intrapancreatic obstruction is usually secondary to pancreatic carcinoma or chronic pancreatitis. Ampullary obstruction may be due to a stone, tumor or ampullary stenosis. Calculi, sclerosing cholangitis, cholangiocarcinoma and metastases may occlude the ductal system at any site. The differential diagnosis of lesions causing obstruction at each level is outlined below: Level of Obstruction Differential Diagnosis 1. Intrahepatic/Bifurcation sclerosing cholangitis/ cholangiocarcinoma/ metastasis 2. Porta hepatis metastatic nodes/ cholangiocarcinoma/ gallbladder carcinoma/ sclerosing cholangitis 3. Mid-common duct/ benign stricture/ cholangiocarcinoma/ gallbladder carcinoma/ pancreatic Suprapancreatic carcinoma/ stone 4. Intrapancreatic pancreatic carcinoma/ chronic pancreatitis/ cholangiocarcinoma 5. Ampullary stone/ pancreatic carcinoma/ ampullary or duodenal carcinoma/ ampullary stenosis DIAGNOSTIC PATTERNS of BILIARY OBSTRUCTION © GIT 2 INDEX

Types of BILIARY OBSTRUCTION. 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. © GIT 2 INDEX

A "rat-tail" configuration is the typical appearance (red arrows); 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. © GIT 2 INDEX

Cancer head of pancreas: CHP Adenocarcinoma of the pancreas Tumors in the head of the pancreas tend to obstruct the bile duct Duodenum: DU Cancer head of pancreas: CHP © GIT 2 INDEX

Cholangiocarcinoma may be polypoid or diffusely infiltrating. 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. © GIT 2 INDEX

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) © GIT 2 INDEX

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. © GIT 2 INDEX

Other causes of biliary obstruction 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. 7. Sclerosing cholangitis There is a diffuse periductal infiltrating lesion involving the intra- and extrahepatic ducts with beading, irregularity and segmental narrowing. 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. © GIT 2 INDEX

Ascariasis worms causing obstructive jaundice © GIT 2 INDEX

Ascariasis Worms are seen extending through the common bile duct and major hepatic ducts © GIT 2 INDEX

Liver © GIT 2 INDEX

Multiple hepatic lacerations 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 © GIT 2 INDEX

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) Intraoperative photograph of the right hepatic lobe (In another patient) 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. © GIT 2 INDEX

Liver cirrhosis © GIT 2 INDEX

CP of portal hypertension with liver cell failure Portal venous system © GIT 2 INDEX

What are the manifestations of portal hypertension? Caput Medusae Portal hypertension leads to expansion of collateral veins in the region of the umbilicus Esophageal varices as seen in upper GI endoscopy Splenomegaly on laparoscopy INDEX © GIT 2

Macro-nodular cirrhosis 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 © GIT 2 INDEX

Macro-nodular cirrhosis © GIT 2 INDEX

© GIT 2 INDEX

Biliary cirrhosis © GIT 2 INDEX

Liver cirrhosis as seen during an operation Stomach © GIT 2 INDEX

Hepatoma Hepatocellular carcinoma. A primary liver cancer that starts in the liver cells © GIT 2 INDEX

Hepatocellular carcinoma (hepatoma) (solitary large mass) Note: cirrhosis; bulging, pigmented hepatoma © GIT 2 INDEX

Solitary hepatic nodule for D.D. © GIT 2 INDEX

Hepatoma © GIT 2 INDEX

Secondaries in the Liver © GIT 2 INDEX

Multiple liver secondaries © GIT 2 INDEX

CT scan with intravenous contrast Multiple liver metastasis CT scan with intravenous contrast Multiple low density area suspicious of metastasis. The commonest tumour in the liver is metastasis. The primary tumour may commonly arise from the lung, breast, colon, stomach and pancreas. © GIT 2 INDEX

Multiple liver metastasis © GIT 2 INDEX

Multiple liver metastasis © GIT 2 INDEX

Multiple liver metastasis © GIT 2 INDEX

Multiple liver metastasis © GIT 2 INDEX

Multiple liver metastasis © GIT 2 INDEX

Multiple liver metastasis © GIT 2 INDEX

Liver metastasis Numerous, mostly round-shaped hypodens lesions of different size are visible in both lobes of the liver. © GIT 2 INDEX

Liver Infections Ascending cholangitis Pyogenic liver abscess Viral hepatitis Ascending cholangitis Pyogenic liver abscess Amoebic live abscess Hydatid liver disease © GIT 2 INDEX

Ascending cholangitis Pyogenic abscesses of the liver secondary to acute cholangitis © GIT 2 INDEX

Chest radiograph demonstrating elevation of the right hemidiaphragm Liver abscess Chest radiograph demonstrating elevation of the right hemidiaphragm Abdominal CT scan demonstrating a large abscess in the right hepatic lobe The clinical picture & lab investigations should ALWASYS be correlated to the US & CT findings © GIT 2 INDEX

Amebic liver abscess The ingested cyst reaches the intestine The active trophozoite form in the colon can reach the liver via the portal blood (Extra-intestinal disease) Entameba histolytica © GIT 2 INDEX

Diagnosis: Amebic liver abscess 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 (38oC)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 © GIT 2 INDEX

Liver abscess that proved to be amebic Clinical History: 30 y old male with right upper quadrant pain and fever of 2 weeks duration 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 © GIT 2 INDEX

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: 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 © GIT 2 INDEX

Liver abscess (proved to be amebic) © GIT 2 INDEX

Liver abscess © GIT 2 INDEX

Hydatid Cyst of the liver © GIT 2 INDEX

Liver with a hydatid cyst containing fluid and daughter cysts. Notice the thick connective tissue capsule © GIT 2 INDEX

Hydatid Cyst Echinococcus granulosus ( Tapeworm) infection of the liver Hydatid cysts develop calcium in their wall which may be seen on a routine chest x-ray. © GIT 2 INDEX

Hydatid Cyst US: A septated, round, unechoic area, can be seen in the liver parenchyma © GIT 2 INDEX

CT: Multivesicular hydatid with multiple daughter cysts giving a septated appearance © GIT 2 INDEX

Pancreas © GIT 2 INDEX

Cancer head of pancreas The pancreas is bisected along its longitudinal axis revealing a large adenocarcinoma (B) of the head. (A) is the tail of pancreas © GIT 2 INDEX

Irregular high- grade stenosis ERCP: Cancer head pancreas CBD dilatation High- grade stenosis of the lower biliary duct with a prestenotic dilatation of the CBD Irregular high- grade stenosis © GIT 2 INDEX

Cancer head of pancreas CT examination Liver Pancreas body Cancer head Kidney IVC Aorta © GIT 2 INDEX

Gall bladder (markedly dilated) Patients with obstructive jaundice & GB mass – think of malignant obstruction Liver Gall bladder (markedly dilated) Cancer head Kidney IVC Aorta © GIT 2 INDEX

Cancer head pancreas An irregular mass in the head of the pancreas Notice the relation of the mass to the duodenum & inferior venacava © GIT 2 INDEX

Ba meal showing pancreatic pseudocyst compressing the stomach © GIT 2 INDEX

Acute hemorrhagic pancreatitis © GIT 2 INDEX

Spleen © GIT 2 INDEX

Splenic lacerations The spleen is the most common organ to be injured in blunt abdominal trauma 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. © GIT 2 INDEX

Traumatic sub-capsular hematoma CT abdomen Traumatic sub-capsular hematoma A large crescentic, low-density fluid collection along the lateral aspect of the spleen. Flattening of the normal splenic contour © GIT 2 INDEX

CT abdomen Splenic lacerations © GIT 2 INDEX

Traumatic rupture spleen & Lt. kidney H K Hematoma: H Spleen: S Kidney: K © GIT 2 INDEX

Pseudopanceriatic cyst & Splenic hematoma L: Liver P: Pancreas PS: Pseudopancreatic cyst S: Spleen H: Hematoma © GIT 2 INDEX