M-2 HEPATOBILIARY IMAGING Liver Gallbladder And Bile Ducts Pancreas Spleen 2013.
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Transcript of 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
Proper hepatic
Gastroduodenal
Celiac
SMA
THE COMMON HEPATIC ARTERY BECOMES THE PROPER HEPATIC ARTERYAFTER THE GASTRODUODENAL BRANCH DESCENDS.
Arteriography of the three main branches of the celiac artery: Common Hepatic Artery, Left Gastric Artery, and Splenic Artery
Furuta T et al. Radiographics 2009;29:e37
©2009 by Radiological Society of North America
Celiac
HEART
ERCP
MR cholangiogram shows signal from the bile and other fluids. ERCP has iodinated contrastinjected 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
Differential Diagnosis:
Acute Cholecystitis/Cholelithiasis
PUD / Gastritis / Reflux
Acute hepatitis / Liver Abcess
Pancreatitis
Choledocholithiasis
ACUTE RIGHT UPPER QUADRANT PAIN
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
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
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
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.
GALLSTONE ILEUS Small Bowel Obstruction at IC valve due to migration of
gallstones that erode into duodenum from GB.
1999 2002
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.
JAUNDICEVIRAL 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
JAUNDICEBILIRUBIN
Painless Malignancy Chronic obstruction
Painful Hepatitis / liver edema Choledocholithiasis / acute obstruction
PALPABLE GALL BLADDER
A palpable gall bladder in an asymtomatic patient can be seen with pancreatic carcinoma due to distal obstruction (Courvoisier sign)
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.
PALPABLE LIVER-metastatic disease
A palpable enlarged liver edge is nonspecific but raises questions of mass or liver pathology.
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.
Interventional Radiology shunt
Hepatic vein - Portal vein
TIPSTransjugular Intrahepatic Portosystemic Shunt
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 400-500 ccs
Not good for organ injury or bowel injury
Peritoneal Lavage is outdated
POST TRAUMATICPANCREATITIS
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