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HEPATOBILIARY IMAGING

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HEPATOBILIARY IMAGING – PowerPoint PPT presentation

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Title: HEPATOBILIARY IMAGING


1
HEPATOBILIARY IMAGING
  • LIVER
  • GALLBLADDER AND BILE DUCTS
  • PANCREAS
  • SPLEEN

Dr. Francis Neuffer
1/2008
2
GOALS
  • Review anatomy of hepato-biliary system
  • Correlate imaging with pathology
  • Discuss strengths and weaknesses of specific
    radiologic exams
  • Discuss imaging algorithms of clinical
    Hepato-biliary disease
  • Review web resources for radiologic education and
    decision making

3
OBJECTIVES
  • Identify classic imaging findings of
    Hepato-Bilary disease
  • Distinguish anatomy relative to vascular supply
    and biliary drainage
  • Employ ACR appropriateness criteria and web
    tutorials in decision making
  • Apply solutions to clinical problems based on
    understanding of imaging technology

4
ANATOMY REVIEW
5
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6
Portal Vein
7
NORMAL PORTAL VEIN ANATOMY
8
CT ANGIOGRAM
Hepatic Veins
Portal Vein
9
PORTAL CONFLUENCE JUNCTURE OF SMV AND SPLENIC
VEIN
CT
US
10
LIVER
GALLBLADDER
PANCREAS
BILE DUCT
11
LIVER
SCAN LEVEL
15A
HEPATIC VEINS
SCAN LEVEL
SPLEEN
CT ABDOMEN
15
12
PORTAL VEIN
STOMACH
FOOD
SCAN LEVEL
CT ABDOMEN
RT. KIDNEY
20
13
1-AORTA 2-CELIAC ARTERY 3-IVC 4-PORTAL VEIN
4
2
3
1
SCAN LEVEL
23
RT. KIDNEY
LT. KIDNEY
23
14
1-SMA 2-SPLENIC VEIN
PANCREAS
2
1
2
SCAN LEVEL
CT ABDOMEN
BENIGN GRANULOMA IN SPLEEN
25
15
GASTRIC ANTRUM AND DUODENUM
GALLBLADDER
PANCREAS
SCAN LEVEL
CT ABDOMEN
SMA
SMV
16
GALL BLADDER AND BILIARY TREE.
17
POST CHOLECYSTECTOMY
5
1
4
GALL BLADDER
COMMON BILE DUCT
18
HIDA SCAN
OPERATIVE CHOLANGIOGRAM
MR CHOLANGIOGRAM
19
PANCREATIC ANATOMY
20
UPPER GI
MR CHOLANGIOGRAM
21
Pancreatic duct
22
PANCREAS
CT
US
23
WHO ARE THE PATIENTS ?
24
WHO ARE THE PATIENTS ?
  • Right upper quadrant pain
  • Altered laboratory data
  • Staging of malignancy/infection
  • Physical exam
  • Abdominal trauma
  • Incidental finding

25
WHAT IMAGING POSSIBILTIES?
  • Plain x-ray
  • Ultrasound
  • CT
  • Nuclear Medicine
  • MR

26
RIGHT UPPER QUADRANT PAIN
  • Gallstone cholelithiasis
  • Common - prevalence 10
  • Pain with contraction after eating

27
COMPLICATIONS
  • Cystic duct obstruction
  • Cholecystitis
  • Common bile duct obstruction
  • Obstructive jaundice
  • Pancreatic duct obstruction
  • Pancreatitis

28
DIAGNOSIS
  • ULTRASOUND
  • Cost / Availability
  • Fluid background is ideal for imaging

29
IMAGING ALTERNATIVES
  • Nuclear medicine - HIDA
  • CT
  • Xray
  • Cholangiography - MR or endoscopic

30
GALLSTONES -15-30 calcify
31
Hepato-biliary scintigram
NORMAL HIDA
Obstructed cystic duct doesnt allow for filling
of radionuclide
ABNORMAL HIDA
32
GALLSTONE
NORMAL GALLBLADDER
Thickened edematous gallbladder wall with
cholecystitis on CT
CHOLECYSTITIS
33
CHOLECYSTITISWith diffuse wall thickening and
edema
34
Normal bile duct Obstructed duct due to
distil calculus
35
Longitudinal CBDdilated ductnote Doppler
signal in vessels
36
Note dilated bile ducts. (Low density branching
structures anterior to portal veins)
Normal
37
DILATED BILIARY TREE
CT and ULTRASOUND
38
Normal size cbd
Dilated CBD with calculi Endoscopic
retrograde Cholangiopancreatography ERCP
39
PANCREATITIS CT AND USDiffuse edema
40
Pancreatitis Biliary calculiAlcohol toxicity
41
RETROGASTRIC FLUID COLLECTION PSEUDOCYST
COMPLICATIONS
Pain Infection Hemorhage-pseudoaneurysm
42
Chronic calcific pancreatitis
43
SPECIAL CASES
  • Emphysematous cholecystitis
  • Acalculous cholecystitis
  • Gallstone illeus

44
EMPHYSEMATOUS CHOLECYTISDIABETIC PATIENTS -AIR
IN WALL
45
ACALCULOUS CHOLECYSTITISBILIARY STASIS-
FASTING/ICU PATIENTS
46
GALLSTONE ILLEUS Small Bowel Obstruction at IC
valve due to migration of gallstones
2002
1999
47
ACUTE RUQ PAIN
  • Acute Cholecystitis - most common
  • Differential Diagnosis
  • PUD/Gastritis/Reflux
  • Acute hepatitis/Pancreatitis
  • Right sided pneumonia
  • Choledocholithiasis
  • Liver abscess

48
RUQ PAINIMAGING EVALUATION
  • Ultrasound 1st
  • CT/HIDA 2nd
  • ERCP/MRCP 3rd

49
ULTRASOUND
  • Sensitive and specific for demonstrating..
  • Gallstones
  • Biliary dilatation
  • Features of inflammatory disease

50
ALTERED LABORATORY DATA
  • Bilirubin
  • Amylase
  • SGOT/SGPT

51
JAUNDICEbilirubin
  • Elevated bilirubin -direct/conjugated
  • Obstuction
  • Painless-cbd stone/ malignancy
  • Painful- hepatitis/cholecystitis

52
Cholelithiasis and obstructed duct due to distil
calculus
53
PANCREATIC CANCERobstructive jaundice
54
ELEVATED AMYLASEpancreatitisedema and dilated
pancreatic duct
55
HEPATIC DYSFUNCTIONSGOT/SGPT
Normal liver
Fatty infiltration
56
CIRRHOSIS
57
METASTATIC DISEASE
58
STAGINGMALIGNANCY / INFECTION
59
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60
APPENDICITIS ANDHEPATIC ABSCESS
61
PALPABLE FINDINGS
  • Enlarged liver
  • Enlarged spleen
  • Ascites-distention

62
CIRRHOTIC LIVER
PALPABLE LIVER
63
PALPABLE GALLBLADDER
64
Enlarged palpable spleen
65
SPLEEN
66
Lucent fluid at tip of liver on ultrasound
Fluid on CT
Ascites displacing bowel medially on Xray
67
TRAUMA
68
HEPATIC/SPLENIC LACERATION
69
POST TRAUMATICPANCREATITISSEAT-BELT INJURY
70
  • F.A.S.T. SCAN
  • (Focused Assessment with Sonography for Trauma)
  • Ultrasound survey for free peritoneal fluid

71
INCIDENTAL FINDING
72
HEPATIC CYST
73
HEMANGIOMA BENIGN HEPATIC LESION
74
CHOLELITHIASIS Incidence is 10 of general
population
75
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76
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77
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78
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79
SUMMARY
  • Anatomy relative to vascular supply and biliary
    drainage
  • Classic imaging findings of Hepato-Bilary
    disease
  • ACR appropriateness criteria in decision making
  • Solutions to clinical problems based on
    understanding of imaging technology
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