For 4th year medical studentsBy: Dr.Idrees J. Ahmed

FIBMS – Rediology lecturerCollege of medicine

Hawler Medical university

RADIOLOGY OF HEPATOBILIARY SYSTREM , PANCREAS AND SPLEEN

HEPATOBILIARY RADIOLOGICALANATOMY

AND INVESTIGATION METHODS

LECTURE ONE

To be familiar with radiological anatomy and distinguish normal pictures

To be able to sort investigations according to indications and priorities

LECTURE OBJECTIVE

Radiological anatomy Methods of investigation Indications , precautions and

contraindication Patient Preparation Radiological features of most common

diseases references

Lecture overview

Liver :o Variable size and shapeo Rt upper quadranto Lobes and segmentso Falciform ligament ( contains lig. Teres ) o Portal vein and portal triadso Hepatic veins

Radiological anatomy of hepatobiliary system

LIVER ANATOMY

GALL BLADDER :( size , shape , location ) 2mm walls , 5x10 cm Variants :Phrygian cap , junctional fold ,

agenesis

INTRA AND EXTRAHEPATIC DUCTS RHD +LHD =CmD CmD+ CyD = CBD

1. Plain x-ray film , cholecystography( hystorical )

2. Ultrasound3. CT scan4. MRI , MR cholangiopancreatography5. ERCP ( endoscopic retrograde

cholangiopancreatography)

METHODS OF INVESTIGATION OF HEPATOBILIARY SYSTEM

1. Percutaneous transhepatic cholangiography ( PTC)

2. Post-operative ( t-tube ) cholangiography3. Operative cholangiography4. Angiography ( diagnostic and therapeutic )

CTA , DSA and MRA 5. Radionuclide imaging

Methods of investigation of the hepatobiliary system ( cont.)

Main clinical Indications :1. Right upper quadrant pain2. jaundice3. Clinically suspected liver lesion 4. Abnormal lab tests5. Staging for malignant diseases6. Suspected portal hypertension

ULTRASOUND OF LIVER AND GALL BLADDER

No contraindication

Preparation: Restrictuin to clear fluids for gall bladder study ( 6 – 8 hr )

ULTRASOUND OF LIVER AND GALL BLADDER

ULTRASOUND MACHINE

ULTRASOUND OF LIVER AND GALL BLADDER

CT scanner

CT scan of liver and biliary tree

Clinical Indications:1. suspected liver lesion2. Characterization of liver lesion3. Staging malignancy4. Rt upper quadrant pain5. To facilitate placement of needles( biopsy,

etc. ) 6. Follow up after surgical or radiological

intervention

CT SCAN OF LIVER AND BILIARY TREE

Contraindications :1. Pregnancy2. Allergy to iodinated contrast media

Patient preparation: the patient fasted for at least 6 hr

Investigations to be continued next lecture

CT SCAN OF LIVER AND BILIARY TREE ( CONT. )

Questions and discussion

End of lecture one

OBJECTIVES :

Continuation of hepatobiliay investigations

Radiology of cystic liver lesions

Lecture two

MRI LIVER

Indications :1. Lesion detection if US and CT not conclusive2. Lesion characterization after detection by

US or CT

Contraindications :General contraindications to

MRI( claustrophobia , implants , penetrating injuries , sensitivity to contrast media , early pregnancy )

MRI scan of liver

2D or 3D T2 weighted , bile appears white

Indications :1. Investigation of obstructive jaundice

2. Biliary stone , colic

3. Suspected cholangitis , or chronic pancreatitis

4. Prior to ERCP/PTC

MRI scan of biliary tree (MRCP)

MRCP

1. Non-invasive

2. Relatively cheep

3. No radiation , No anesthesia

4. Less operator dependant

5. Ducts prox. to obstruction seen

6. Extraductal disease may be seen

Advantages of MRCP

1. Decreased resolution

2. Less sensitive to subtle ductal disease

3. Not theraputic

Disadvantages of MRCP

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY(

ERCP )

Contrast-agent is injected through endoscope after cannulation of CBD

Indications :1. Diagnostic , in unsuitable or intolerant to

MRCP2. Management of bile duct stones3. Evaluation of ampullary lesions4. Management of biliary strictures5. Chronic pancreatitis

ERCP

Contraindications :1. Upper GIT obstruction2. Previous gastric surgery that prevents

access to duodenum3. Sever cardiac or respiratory distress

Complications : Pancreatitis 5% Duodenal perforation Gastrointestinal bleeding

(ERCP ) cont.

FOCAL LIVER LESIONSarea of alteration of normal parenchymaCystic , solid or complex

Cysts : thin walls with clear fluid , benign

Complex : may be malignant

Solid : borders , outline Multiple : metastases ? Abscesses ,

hemangiomas , cirrhosis

Liver lesions

hepatomegaly

generalized parenchyma changes• Fatty liver• Hepatitis• cirrhosis

DIFFUSE LIVER LESIONS

Rt lobe enlargement elevated Rt hemidiaph. splayed lower Rt ribs properitoneal fat bulge depressed hepatic flexture and Rt kidney

HEPATOMEGALY SIGNS

Lt lobe enlargement gastric fundus and posterior stomach

displaced intra-abdominal oesophagus elongated pressure on lesser curveature of

stomach

HEPATOMEGALY SIGNS

SIMPLE CYSTS

Common , congenital , may be multiple ( ADPCK disease )

LIVER CYSTS

SIMPLE LIVER CYSTS

may be indistinguishable from simple one

may be multiple or cyst inside cyst

wall layers on ultrasound

Calcification , no wall enhancement

signs of rupture

protein in its fluid

LIVERHYDATID CYSTS

LIVER HYDATID

HYDATID CYST LIVER

Summery

Discussion .

End of lecture two

RADIOLOGY OF LIVER AND BILIARY DISEASES

LECTURE THREE

LIVER TUMORS

TRAUMA

INFECTION AND CIRRHOSIS

BILIARY DISEASES

OVERVIEW

Metastases:

More common

Often multiple , Peripheral , variable size

On ultrasound : appear dark ( hypoechoic ) , may be complex ,irregularly cystic , hyperechoic or not visible

ON CT SCAN : Dark , Contrast enhancement

LIVER NEOPLASMS

similar to secondary

usually solitary

PRIMARY LIVER CANCER

LIVER TUMOR

LIVER HEMANGIOMAS

Common 4-7% females 80% , incidental benign , vascular neoplasm

May bleed , biopsy avoided

Simulate neoplasm on ultrasound

On CT and MRI show centripetal enhancement

BENIGN LIVER TUMORS

LIVER HAEMANGIOMA

LIVER HEMANGIOMA

FNH : rare , hypervascular , iso to liver , central scar ( white on T2 ) , no malignant change

Adenoma : solit. , rare , malignant ( may)

Other benign liver lesions

Like cysts , irregular thicker walls

Pus usually thicker than cyst fluid(water)

May calcify

Walls enhance , local edema

On imaging difficult to distinguish from a necrotic tumor ( clinical )

Liver abscess

LIVER ABSCESS

Commonest fatal abdominal injury

Lacerations are most common parenchymal injury

Ass. With subcapsular hematoma

CT is best for hematoma detection and organ survey

LIVER TRAUMA

Liver trauma

Commonest cause for portal hypertension

Porto-systemic anastamases open to bypass liver ( eg. Lower esophagus )

Fibrosis of parenchyma , small liver ( coudate lobe preserved )

Large spleen , portal flow

Ascites and neoplasms

LIVER CIRRHOSIS

Liver cirrhosis

CHOLELITHIASIS : 10-20% US population , 30% calcification

40-50% asymptpmatic

Surgery in symptomatic and diabetic

Cholesterol , pigment or ( most are ) mixed

Predisposition: obesity , diabeteis , cirrhosis , huperparathyroidism

DISEASES OF THE BILIARY SYSTEM

Ultrasound featuresCan detect 2mm stone and largerBack shadow , mobility , wall-eacho-shadow

triad ( contracted gb )Porcelain gall bladderEmphysematous cholecystitis

Gall bladder stones

Stone in bile ducts with jaundice and high grade obstruction ,ultrasound 75% sensitive

MIRIZZI syndrome CyD stone CBD obst.

CHOLEDOCHOLITHIASIS

Common ACUTE : calculus 95% , acalculus Distension , walls >5mm, free fluid,

Murphy’s sign ( 90% specific , negative if gangrenous )

Acalculus : trauma , long fasting , DM , no

stone ivisible , patient ill CHRONIC: Thick smaller GB , stone 95% , STIFF

CHOLECYSTITIS

CHOLECYSTITIS

Infection of obstructed bile ducts ( E. coli )

Causes ( stone , stricture , drainage cath. , ampullary cancer )

Rad. Features : Duct dilatation, intrahepatic duct stone

(pathognomonic ) Segmental Hepatic atrophy Liver abscess , pancreatitis

CHOLANGITIS

CHOLANGITIS

Biliary cancers are 5th most common GI malignancy

Ass. With ( stone , porcelain GB , IBD , chronic cholecystitis )

Intraluminal soft tissue

Asymmetrically thickened GB wall No biliary dilatation

Invasion of liver and lymph nodes

GB canrcioma

Ca GB

RARE

Hilar : junction or RHD & LHD ( Klatskin) or peripheral from epithelium of intralobular

ducts

Dilated intrahepatic normal extrahepatic ducts

Hilar mass , short annular constricting lesion

CHOLANGIOCARCINOMA

CHOLANGIOCARCINOMA

congenital dilatation of bile ducts

children or young adults

20-fold increased risk of malignancy

jaundice , abdominal pain , mass

CHOLEDOCAL CYST

CHOLEDOCAL CYST

Summery

discussion

RADIOLOGY OF PNACREAS AND SPLEEN

LECTUTE FOUR

Retroperitoneal , on posterior abdominal wall , L1 level

Head , neck , body and tail , 15 cm length

Duct (from tail to ampulla ) , 4mm on ERCP

PANCREAS

accessory duct ( santorini ) drains lower part of head

Grey on US and CT , whiter than liver on T1

Intense enhancement , Fat infiltration : common , normal , age

PANCREAS

RETROPERITONEUM

PANCREAS

Pancreatic injry : penetrating or blunt ( superficial , deep ,

duct involved ?)

Rad. Features : fragmentation , hematoma , non-enhancing regions , stranding

Complications: fistula , abscess , pancreatitis , pseudocyst

PANCREAS LESIONS

Pancreas injury

Acute mild edema, pain , vomiting , tenderness , not progress

Acute severe necrosis ,shock , renal failure , GI bleed

Chronic : alcohol , stone

PANCREATITIS

US : hypoechoic due to edema , detect stone and follow up size of pseudocyst ( capsule )

CT : heterogeneous , focal necrosis 90% accurate , peripancreatic edema or fluid or even gas collection

Pancreatitis , Rad. features

pancreatitis

CA. PANCREAS : 2\3 in head , CBD obst. , focal mass and deformity , duct dilatation , extrapancreatic and vascular extension

DDX regional LAP , focal pancreatitis , abscess , pseudocyst

PANCREATIC CANCER

Pancreas cancer

Lt upper quadrant , size of a fist , 12 x 7 x 4 cm in adult , along 9th rib , intraperitoneal

Accessory spleens at hilum ( 40% )

Wandering spl. Along pedicle

Poly and asplenia

SPLEEN

Splenomegaly

Trauma ( subcapsular or parenchymal hematoma , laceration , fragmentation , delayed rupture \rare )

Cyst , Tumor ( hemangioma , metastasis )

infarction

SPLEEN LESIONS

Spleen lesions

Summery

discussion

Diagnostic imaging by Peter Armstrong 3rd edition

Anatomy for diagnostic imaging 2nd edt. By Stephanie Ryan

Primer of diagnostic radiology , 3rd edt. Text book of radiology and imaging by David

sutton 7th edt. A guide to radiological procedures by

Frances Aitchison 5th edt.

References

THANK YOU AND

GOOD LUCK