Slide 2: This is a normal nuclear medicine biliary scan. Normal uptake is noted in the liver at 5 minutes consistent with normal hepatocellular function. The common bile duct is visualized at 15 minutes and the gall bladder is seen at 30 minutes. These findings rule out acute cholecystitis with an accuracy of approximately 98%.

Slide 3: This nuclear medicine study shows normal liver uptake at 5 minutes. The common duct is visualized at 15 minutes but no gallbladder is visualized after 60 minutes. This study is diagnostic for cystic

duct obstruction consistent with acute cholecystitis.

Slide 4: This nuclear medicine biliary scan shows normal liver uptake but no visualization of the common bile duct or the gall bladder at 60 minutes. This study is diagnostic of common duct obstruction.

Slide 5: The oral cholecystogram is seldom used currently but still may be helpful in diagnosing chronic cholecystitis in patients with clinical symptoms of chronic biliary colic in the absence of stones in the gallbladder on ultrasound. This study represents a normal oral cholecystogram with filling of the gall bladder. An abnormal study would fail to visualize the gall bladder on two successive days after the tablet has taken orally the evening before. An oral

cholecystogram may also demonstrate filling of the gallbladder with filling defects representive of stones.

Slide 6: This slide shows a transhepatic cholangiogram demonstrating common duct obstruction. A Chiba needle is introduced percutaneously into a bile duct by fleuroscopic guidance. The ductal system is then filled with contrast material. Notice the tapering obstruction of the distal common duct suggestive of malignancy in the head of the pancreas. The small marks on the common duct demonstrate the usual caliber.

Slide 7: An alternative to transhepatic cholangiogram for visualization of the common bile duct is endoscopic

retrograde cholangiopancreatography (ERCP). In this study, a side viewing endoscope is passed through the stomach and into the duodenum for visualization of the ampula of Vater. A catheter is now passed through the ampula and dye injected to fill both the pancreatic duct (PD) and the common duct (CD). This study shows the typical appearance of a stone obstructing the common duct. ERCP is a frequent study in the evaluation of chronic pancreatic disease.

Slide 8: This slide demonstrates normal CT anatomy at the abdomen at the level of the pancreas. Compare the subsequent slides demonstrating pancreatic disease to this normal anatomy.

Slide 9: This CT scan of the abdomen with contrast shows the typical appearance of acute pancreatitis. The pancreas is edematous with extrapancreatic extension. The use of contrast allows visualization of areas of "unenhancement" diagnostic of pancreatic necrosis. Such areas of unenhancement may be aspirated to determine the presence of infected pancreatic necrosis.

Slide 10: This chest x-ray was taken of a patient four days after admission for severe acute pancreatitis. Adult respiratory distress syndrome (ARDS) is demonstrated, a complication of acute pancreatitis.

Slide 11: This slide demonstrates another complication of acute pancreatitis, a pancreatic pseudocyst. This 6 cm pseudocyst is in the head of the pancreas and adherent to the posterior wall of the stomach. These are treated with either CT guided percutaneous drainage or surgical drainage of the pseudocyst into the stomach (internal drainage).

Slide 12: This abdominal CT scan represents a large cancer in the head of the pancreas. The gallbladder is markedly dilated secondary to common duct obstruction. Such a gallbladder would be palpable but not nontender on physical examination (Courvoisier's Law).

Slide 13: This CT scan of the abdomen shows significant intrahepatic bile duct dilatation secondary to obstruction. The cause of the obstruction in this patient was a large cancer in the head of the pancreas.

Slide 14: This CT scan of the abdomen demonstrates the typical appearance of a hepatoma or hepatocellular cancer.

Slide 16: This patient presented to the surgical service with spiking fevers and right upper

quadrant abdominal pain. The CT scan of the abdomen shows the typical appearance of a liver abscess.