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Imaging of the patient with obstructive jaundice

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Imaging of the patient with obstructive jaundice Arye Blachar MD Department of Radiology Tel Aviv Sourasky Medical Center Introduction Cholestasis: Clinical and ... – PowerPoint PPT presentation

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Title: Imaging of the patient with obstructive jaundice


1
Imaging of the patient with obstructive jaundice
  • Arye Blachar MD
  • Department of Radiology
  • Tel Aviv Sourasky Medical Center

2
Introduction
  • Cholestasis Clinical and biochemical syndrome,
    results when bile flow is impaired.
  • Impairment of bile flow- hepatic cell bile
    canaliculus ? ampula of vater
  • Intra hepatic hepatitis, drug toxicity,
    alcoholic liver disease, PBC, PSC, metastatic
    carcinoma, CholangioCA, etc
  • Extra hepatic Pancreatic tumor, ampulary tumor,
    CholangioCA, biliary stone disease, pancreatitis,
    pancreatic pseudocyst, PD stricture

3
Extra-hepatic cholestasis
Pancreatic tumor
  • Malignant tumor arising from epithelium of
    exocrine pancreas
  • 5th leading cause of death
  • Risk smoking, diabetes, chr. Pancreatitis, high
    fat diet
  • Mean age 55 yrs, peak 7th decade, mf-21
  • Presentation head jaundice, pain, weight loss
    body tail weight loss. Mets to liver

4
Extra-hepatic cholestasis
Pancreatic tumor - location
  • Head 60-70- causes jaundice
  • Body 20
  • Tail 10
  • Diffuse involvement 5-10
  • Average diameter 2.5-3.0 cm
  • Average diameter 5.0-7.0 cm

5
Extra-hepatic cholestasis
Pancreatic tumor imaging
  • Helping the General Surgeon
  • Is there a pancreatic tumor?
  • What is the tumor type?
  • Is the tumor resectable?
  • Are there any significant anatomical variants?

6
Extra-hepatic cholestasis
Pancreatic tumor Imaging - Technique
  • Pure water or milk 4
  • Non-ionic contrast 120- 150cc at 4-5cc/sec
  • Thin slices
  • Arterial phase 25sec after the start of inj.
  • Pancreatic phase 40-50sec after start of inj.
  • Liver phase 70sec after the start of inj.

7
Extra-hepatic cholestasis
Pancreatic tumor Imaging - Technique
  • Multi plannar reformats, 3D imaging and review on
    a workstation are very helpful
  • Improved tumor conspicuity
  • Improved depiction of PD and CBD
  • Better delineation of vascular anatomy
  • Raptopoulos et al, Radiology 1998 207317-324
  • Nino Murcia et al, AJR 2001 176689-693
  • Prokesch et al, Radiology 2002 225759-765

8
Extra-hepatic cholestasis
Pancreatic tumor - Tumor Detection
  • Focal enlargement of the gland
  • Hypodense mass on enhanced CT
  • Secondary signs
  • Mass effect or convex contour abnormality
  • Atrophic distal pancreatic parenchyma
  • Dilatation of CBD and MPD in the absence of
    obstructive calculus (interupted duct sign)

9
Extra-hepatic cholestasis
Pancreatic tumor - Unresectability
  • Vascular invasion
  • Invasion of adjacent organs
  • Stomach, spleen, left adrenal, mesentery
  • Distal metastasis
  • Liver (30), regional LN, omentum, ascites (10),
    lungs, pleura, bone

10
Extra-hepatic cholestasis
Pancreatic tumor - Unresectability vascular
invasion
  • Involvement of SMA, Celiac, SMV, PV or SV
    (isolated focal SV or PV?)
  • Axial images CT grading of circumferential
    tumor-vessel contiguity (gt50)
    sen-84, spec-98 Lu et al AJR 1997
    1681439-1443
  • MPR/3D/CTA images Evaluate change in vessel
    caliber or occlusion
  • Raptopoulos et al AJR 1997 168971-977
  • Prokesch et al, Radiology 2002 225759-765

11
Extra-hepatic cholestasis
Pancreatic tumor Unresectability- Mets
  • Hepatic Metastases
  • Hypovascular best seen on PVP
  • Sensitivity for detection of mets gt1cm 90
  • Overall sensitivity for mets- 75
  • Even small lt5mm mets may be detected
  • LN mets- CT not accurate
  • gt10mm sensitivity 14, specificity 85 PPV
    17 Roche ET AL, AJR 2003180475-480

12
Extra-hepatic cholestasis
Pancreatic tumor - Imaging - How good are we?
  • Accuracy of tumor detection 80-91 using older
    dynamic scanners. Accuracy with MDCT 95-96.
    Overall CT staging accuracy 90
  • PPV for surgical unresectability 89-100 but PPV
    for resectability up to 80
  • Poor performance in detecting small hepatic
    metastases, small peritoneal implants, LN
    mets in normal size LN

13
Pancreatic cancer staging PET CT
  • PET not yet widely used for pancreatic cancer
    staging, though promising results are being
    reported.
  • FDG-PET is a very useful tool in diagnosing
    pancreatic cancer. FDG-PET may be also used as an
    adjunct for determining the treatment modality of
    pancreatic cancer and evaluating tumor response
    to therapy .
  • J Clin Gastroenterol. 2006 Nov-Dec40(10)923-9

14
Pancreatic cancer staging PET CT
  • PET not yet widely used for pancreatic cancer
    staging, though promising results are being
    reported.
  • FDG-PET is a very useful tool in diagnosing
    pancreatic cancer. FDG-PET may be also used as an
    adjunct for determining the treatment modality of
    pancreatic cancer and evaluating tumor response
    to therapy .
  • J Clin Gastroenterol. 2006 Nov-Dec40(10)923-9

15
Extra-hepatic cholestasis
Ampulary tumor
  • Malignant epithelial tumor , ampula of vater
  • Presents with jaundice, weight loss. Abd or back
    pain
  • Age mean 65 yrs, no sex predeliction
  • Prognosis depends on nodeal status and
    differentiation of tu, better than panc ca
  • 5 yrs- 38 if resected
  • Treatment Whipple if pos.

16
Extra-hepatic cholestasis
Ampulary tumor
  • Imaging
  • Lobulated soft tissue mass at ampula
  • Double duct sign
  • CT Hypodense mass , distention of du helpful

17
Extra-hepatic cholestasis
Cholangiocarcinoma
  • Cholangio-cellular carcinoma, arises from the
    IHBD or EHBD epithelium
  • 2ND most common primary hep tumor
  • Types
  • Intra-hepatic- peripheral (exophytic, polypoid,
    infiltrative)
  • Intra-hepatic central or hilar
  • Extra hepatic originates from CBD as stricture or
    mass

18
Extra-hepatic cholestasis
Cholangiocarcinoma
  • Age 6-7th decade, MF-32
  • Risk biliary lithiasis, clonorchiasis, rec.
    pyogenic infections, PSC, IBD, caroli disease,
    choledochal cyst, thorotrast exposure, BD
    papilomatosis,alfa-1 anti-tripsin
  • Presentation by location,jaundice, weight loss,
    abd pain, palpable mass
  • Treat surgical resection (lt20), radiation,
    chemo, stenting
  • Prognosis poor extra(1.6 5yrs), intra (30)

19
Extra-hepatic cholestasis
Cholangiocarcinoma
  • US dilated BD, mass hyperechogenic(75)
  • CT hypodense mass, IHBD dilatation, rim
    enhancement with prog central patchy enhancement,
    persistent enhancement on delayed scan

20
Extra-hepatic cholestasis
Gallstone disease
  • 15-20 of the population
  • Passage of gallstones through biliary system
    causes -----gt
  • Biliary colic
  • Acute cholecystitis
  • Choledocholithiasis
  • Cholecystoenteric fistula

21
Extra-hepatic cholestasis
Gallstone disease- Cholelithiasis
  • Incidence increases with age
  • Risk factors female, fat, forty, fair, fertile -
    5F
  • Obesity, rapid weight-loss, genetic
    predisposition, diabetes mellitus, cirrhosis,
    pregnancy, biliary tract infection, Crohns
    disease, sickle cell anemia
  • Cholesterol (80), Ca bilirubinate (20)
  • RUQ pain in 10-25 of pts. (10 years)
  • Imaging US (EUS), MRI (MRCP), ERCP, CT,

22
Biliary tree imaging modalities ERCP, MRCP,PTC
  • CT and US are excellent for dilated ducts but not
    for assessing the entire tree.
  • ERCP contrast media is placed endoscopically
    through the biliary tree.

23
Biliary tree imaging modalities ERCP, MRCP, PTC
  • MRCP specific MR sequence is employed to
    demonstrate the biliary tree.
  • No IV contrast and definitely no biliary
    cannulation involved.

24
Biliary tree imaging modalities ERCP, MRCP, PTC
  • PTC direct cannulation of the biliary tree, and
    iodinated contrast injection.
  • Advantageous over MRCP for showing distal, small
    duct pathology and walls irregularity.

25
PTC
  • Percutaneous access to
  • the biliary tree, through the
  • CBD, if possible, and into
  • the duodenum.
  • Downsides
  • External drainage
  • Procedural risks
  • Coagulopathy
  • ascites

26
Biliary stone disease - summary
  • US is the modality of choice for demonstrating
    gallstones.
  • US is the very good for demonstrating biliary
    ducts.
  • CT will show biliary ducts, less reliable for
    filling defects. Good for neoplastic disease.
  • MRCP is the non invasive study
  • ERCP is invasive but potentially therapeutic.
  • PTC even more invasive, when ERCP is limited.

27
Extra-hepatic cholestasis Cholelithiasis
  • Sensitivity 90-95
  • Variable SI
  • Water/lipids contents
  • Elevated SI on T2 in center (? 50)
  • Elevated SI on T1 (? 90) Co, Fe, Mg (pigmented
    gallstones Ca Bilirrubinate)
  • Ukaji M et al. Eur J Radiol 2002 Jan41(1)49-56

28
Choledocholithiasis
  • Asymptomatic
  • Symptoms calculi in distal CBD (90)
  • CBD stones
  • 15 pts. with gallstones
  • 15 pts. with acute cholecystitis
  • Diagnosis pre laparoscopic cholecystectomy
  • ERCP
  • Stones in only 27-50 of pts with clinical
    suspicion

29
Choledocholithiasis MR
  • Normal CBD
  • 98 of the pts
  • Foci of low SI surrounded by bright bile
    (T2-WI)
  • Stones ? 2 mm
  • CBD stones
  • Sensitivity 85-100
  • Specificity 90-99
  • Accuracy 89-97
  • PPV 77-93
  • NPV 94-100
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