HEPATOBILIARY IMAGING

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HEPATOBILIARY IMAGING

• LIVER
• GALLBLADDER AND BILE DUCTS
• PANCREAS
• SPLEEN

Dr. Francis Neuffer
1/2009
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GOALS

• REVIEW ANATOMY OF HEPATO-BILIARY SYSTEM
• CORRELATE IMAGING WITH PATHOLOGY
• DISCUSS RADIOLOGIC IMAGING OPTIONS

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ANATOMY
ESSENTIALS BILIARY DRAINAGE PORTAL BLOOD
FLOW
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BILIARY DRAINAGEPORTAL BLOOD FLOW
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PORTAL BLOOD FLOW
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CORONAL
CT
MRI
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Portal Vein
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PORTAL VEIN ANATOMY AXIAL CT
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CT
SPLENIC VEIN JOINS SMV TO FORM PORTAL VEIN
US
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HEPATIC VEINS
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HEPATIC VEINS ENTERING IVC
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AXIAL CT
HEPATIC VEIN
PORTAL VEIN
SPLENIC VEIN
GALLBLADDER
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HEPATIC VEINS
SCAN LEVEL
15A
SCAN LEVEL
STOMACH
SPLEEN
CT ABDOMEN
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PORTAL VEIN
IVC
SCAN LEVEL
CT ABDOMEN
RT. KDNEY
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PANCREAS
SPLENIC VEIN
SCAN LEVEL
CT ABDOMEN
RENAL VEIN
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GALLBLADDER
SCAN LEVEL
CT ABDOMEN
SMA
SMV
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LIVER
GALLBLADDER
HEPATIC VEIN
PANCREAS
BILE DUCT
PORTAL VEIN
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GALL BLADDER AND BILIARY TREE
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POST CHOLECYSTECTOMY
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GALL BLADDER
GALL BLADDER CALCULI
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HIDA SCAN
OPERATIVE CHOLANGIOGRAM
MR CHOLANGIOGRAM
COMMON BILE DUCT
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PANCREATIC ANATOMY
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MRCP
ERCP
PANCREATIC DUCT
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PANCREAS
CT
US
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WHO ARE THE PATIENTS ?
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WHO ARE THE PATIENTS ?

• RIGHT UPPER QUADRANT PAIN
• ALTERED LABORATORY DATA
• STAGING OF MALIGNANCY/INFECTION
• PHYSICAL EXAM
• ABDOMINAL TRAUMA
• INCIDENTAL FINDING

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WHAT IMAGING POSSIBILTIES?

• PLAIN X-RAY--- ERCP
• ULTRASOUND--- GB/CBD
• CT---PANCREAS
• NUCLEAR MEDICINE---HIDA
• MR----MRCP

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RIGHT UPPER QUADRANT PAIN

• GALLSTONE CHOLELITHIASIS
• COMMON - PREVALENCE 10
• PAIN WITH CONTRACTION AFTER EATING

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DIAGNOSIS

• ULTRASOUND
• COST / AVAILABILITY
• FLUID BACKGROUND IS IDEAL FOR IMAGING

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IMAGING ALTERNATIVES

• NUCLEAR MEDICINE - HIDA
• CT
• XRAY
• CHOLANGIOGRAPHY - MR OR ENDOSCOPIC

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GALLSTONES -15-30 calcify
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HEPATO-BILIARY SCINTIGRAM
NORMAL HIDA
OBSTRUCTED CYSTIC DUCT DOESNT ALLOW FOR FILLING
OF RADIONUCLIDE
ABNORMAL HIDA
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GALLSTONE
NORMAL GALLBLADDER
THICKENED EDEMATOUS GALLBLADDER WALL WITH
CHOLECYSTITIS ON CT
CHOLECYSTITIS
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CHOLECYSTITISWITH DIFFUSE WALL THICKENING AND
EDEMA
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CBD
OBSTRUCTED DUCT DUE TO DISTAL CALCULUS
PV
NORMAL BILE DUCT-SIZE DIAMETERlt PORTAL
DIAMETER
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LONGITUDINAL CBDDILATED DUCTNOTE DOPPLER
SIGNAL AND SIZE
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NOTE DILATED BILE DUCTS. (LOW DENSITY BRANCHING
STRUCTURES ANTERIOR TO PORTAL VEINS)
Normal
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DILATED BILIARY TREE
CT and ULTRASOUND
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Normal size cbd
DILATED CBD WITH CALCULI ENDOSCOPIC
RETROGRADE CHOLANGIOPANCREATOGRAPHY ERCP
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COMPLICATIONS

• CYSTIC DUCT OBSTRUCTION
• CHOLECYSTITIS
• COMMON BILE DUCT OBSTRUCTION
• OBSTRUCTIVE JAUNDICE
• PANCREATIC DUCT OBSTRUCTION
• PANCREATITIS

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PANCREATITIS CT AND USDIFFUSE EDEMA
BILIARY CALCULI - ALCOHOL TOXICITY
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RETROGASTRIC FLUID COLLECTION PSEUDOCYST
COMPLICATIONS

• PAIN
• INFECTION
• HEMORHAGE-PSEUDOANEURYSM

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SPECIAL CASES

• EMPHYSEMATOUS CHOLECYSTITIS
• ACALCULOUS CHOLECYSTITIS
• GALLSTONE ILLEUS

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EMPHYSEMATOUS CHOLECYTISDIABETIC PATIENTS - AIR
IN WALL
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ACALCULOUS CHOLECYSTITISBILIARY STASIS
FASTING/ICU PATIENTS
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GALLSTONE ILEUS SMALL BOWEL OBSTRUCTION AT IC
VALVE DUE TO MIGRATION OF GALLSTONES THAT ERODE
INTO DUODENUM FROM GB.
2002
1999
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ACUTE RUQ PAIN

• ACUTE CHOLECYSTITIS - MOST COMMON
• DIFFERENTIAL DIAGNOSIS
• PUD / GASTRITIS / REFLUX
• ACUTE HEPATITIS / PANCREATITIS
• RIGHT SIDED PNEUMONIA
• CHOLEDOCHOLITHIASIS
• LIVER ABSCESS

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RUQ PAINIMAGING EVALUATION

• ULTRASOUND 1ST
• CT / HIDA 2ND
• ERCP / MRCP - 3RD

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ULTRASOUND

• SENSITIVE AND SPECIFIC FOR DEMONSTRATING..
• GALLSTONES
• BILIARY DILATATION
• FEATURES OF INFLAMMATORY DISEASE

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ALTERED LABORATORY DATA

• BILIRUBIN OBSTRUCTIVE JAUNDICE
• AMYLASE-PANCREATITIS
• ALT / AST-LIVER DYSFUNCTION

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JAUNDICEBILIRUBIN

• ELEVATED BILIRUBIN DIRECT / CONJUGATED
• OBSTUCTION
• PAINLESS-CBD STONE / MALIGNANCY
• PAINFUL- HEPATITIS / CHOLECYSTITIS

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CHOLELITHIASIS AND OBSTRUCTED DUCT DUE TO DISTAL
CALCULUS
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PANCREATIC CANCEROBSTRUCTIVE JAUNDICE
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ELEVATED AMYLASEPANCREATITISEDEMA AND DILATED
PANCREATIC DUCT
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CHRONIC CALCIFIC PANCREATITIS
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HEPATIC DYSFUNCTIONALT / AST
NORMAL LIVER
FATTY INFILTRATION
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CIRRHOSIS
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VARICES
TREAT BY SHUNT OR EMBOLIZATION TO DECREASE PORTAL
PRESSURE
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METASTATIC DISEASE
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STAGINGMALIGNANCY / INFECTIONMESENTERIC BLOOD
FLOW SPREADS DISEASE TO LIVER
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COLON CANCER WITH METASTASIS
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APPENDICITIS
Normal
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APPENDICEAL ABSCESSHEPATIC ABSCESS
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PALPABLE FINDINGS

• ENLARGED LIVER
• ENLARGED SPLEEN
• ASCITES-DISTENTION

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CIRRHOTIC LIVER
PALPABLE LIVER
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PALPABLE GALLBLADDER
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ENLARGED PALPABLE SPLEEN
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SPLEEN
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Lucent fluid at tip of liver on ultrasound
Fluid on CT
Ascites displacing bowel medially on Xray
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TRAUMA
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Rib fractures
HEPATIC / SPLENIC LACERATION
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POST TRAUMATIC PANCREATITIS(SEAT-BELT INJURY)
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• F.A.S.T. SCAN
• (FOCUSED ASSESSMENT WITH SONOGRAPHY FOR TRAUMA)
• ULTRASOUND SURVEY FOR FREE PERITONEAL FLUID

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INCIDENTAL FINDING
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HEPATIC CYST
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HEMANGIOMA BENIGN HEPATIC LESION
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CHOLELITHIASIS INCIDENCE IS 10 OF GENERAL
POPULATION
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http//www.acr.org/SecondaryMainMenuCategories/qua
lity_safety/app_criteria/pdf.aspx
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http//www.med-ed.virginia.edu/courses/rad/
GI RADIOLOGY
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SUMMARY

• ANATOMY RELATIVE TO VASCULAR SUPPLY AND BILIARY
  DRAINAGE IS KEY.
• CLASSIC IMAGING FINDINGS OF HEPATO- BILARY
  DISEASE
• ACR APPROPRIATENESS CRITERIA IN DECISION MAKING
• WEB RESOURCES

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VARICES
TREAT BY EMBOLIZING OR SHUNT TO DECREASE PORTAL
PRESSURE
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SPLENORENAL SHUNT FOR PORTAL DECOMPRESSION
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TIPS SHUNT FOR PORTAL DECOMPRESSION
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