Biliary System and Liver

1
Biliary System and Liver
1 23 2014
2
Liver

• Largest gland of body
• 2nd largest organ
• What is the 1st ?
• Skin
• How much does it weigh?
• Approx. 3 lbs

3

• Liver is only internal human organ capable of
  natural regeneration of lost tissue!
• as little as 25 of a liver can regenerate into a
  whole liver
• Not true regeneration!
• lobes removed do not regrow-
• function is restored, but not original form
  (aka compensatory growth)
• (in true regeneration, both original function and
  form are restored)

4
Falciform ligament divides liver into

• 2 major lobes
• Right lobe
• Left lobe
• 2 minor lobes
• Caudate lobe- part of right lobe -posterior
• Quadrate lobe - part of right lobe -inferior

5
Functions of liver

• Main function -formation of bile
• Maintain a proper level or glucose in blood
• Convert glucose to glycogen
• Produce urea
• Make certain amino acids
• Filter harmful substances from blood (alcohol)
• Store vitamins and minerals
• Produce 80 of cholesterol

6
What is unique about liver?
It has a dual blood supply! Receives both
oxygenated and deoxygenated blood (portal
system) 1. Hepatic artery- supplies liver
with oxygenated blood from abdominal aorta to
like any other part of body 2. Portal vein-
carries deoxygenated blood from digestive
organs to be modified and filtered by liver
blood then returns to heart (by hepatic veins)
and is circulated to rest of body
7
First Pass Effect Problem

• Many drugs taken orally are substantially
  metabolized by portal system of liver before
  reaching general circulation
• Known as first pass effect
• Thus certain drugs can only be taken via certain
  other routes!
• suppository
• intravenously
• intramuscularly
• aerosol inhalation
• sublingually
• Nitroglycerin cannot be swallowed - liver would
  inactivate medication -must be taken under tongue
  or transdermally

8
Biliary System
(Excretory system of liver)

• Consists basically of
• 1. gallbladder
• 2. bile ducts

9
Biliary Combining Forms

• chole relationship with bile (aka gall)
• bladder sac or bag serving as receptacle for a
  secretion
• cyst closed sac having distinct membrane and
  division with nearby tissue (May contain air,
  fluids, or semi-solid material)
• docho duct tube or passage way for conducting
  a substance
• angio - vessel
• graph- representation of a set of objects
• -iasis presence of
• -itis inflammation of

10
2 Primary Functions of Biliary System

• Aid in digestion- by controlling release of
  bile
• (Bile - greenish-yellow fluid produced in
  liver (consisting of waste products,
  cholesterol, and bile salts)
• (when excreted gives feces dark
  brown color)
• Drain waste products from liver into duodenum

11
Gall bladder

• Reservoir for bile from liver 2oz. capacity (50
  percent of bile is stored in gallbladder)
• Concentrates bile
• How much bile does it produce per day?
• 1-3 pints
• How does bile get into gallbladder?
• Sphincter of Oddi closes up, and bile is
  re-routed up into GB for temporary storage when
  not needed

12
When food containing fat enters digestive tract
the release of bile from the gallbladder is
stimulated by secretion of a hormone called
cholecystokinin
13
Transportation of bile sequence

• Liver secretes bile- into right and left hepatic
  ducts which join to become common hepatic duct
• which joins with cystic duct from gallbladder to
  become the
• common bile duct which joins with pancreatic
  duct to form a junction known as
• hepatopancreatic ampulla (or ampulla of vater
• Spincter of Oddi (or spincter of hepatopancreatic
  ampulla)controls emptying of bile into duodenum

14
Gallstones

• Hardened deposits of digestive fluid that can
  form in gallbladder
• Range in size from grain of sand to
• Can have one or hundreds!
• 1 in 10 people have gallstones (cant see if not
  calcified!)

15
Two types of gallstones

• 80 are cholesterol stones
• usually yellow-green and made primarily of
  hardened cholesterol
• 20 are pigment stones
• small, dark stones made of bilirubin

16
Risk Factors for Gallstones

• Female
• Age 60 or older
• American Indian or Mexican heritage
• Overweight or obese
• Pregnant
• Eating a high-fat, high-cholesterol, or low fiber
  diet
• Family history of gallstones
• Diabetes
• Losing weight very quickly
• Taking cholesterol-lowering medications
• Taking medications containing estrogen (such as
  hormone therapy drugs)

17
Complications from Gallbladder Stones

• Choledocholithiasis -
• presence of bile stones in ducts
• Cholecystitis -
• bile sac inflammation
• Pancreatitis
• Increased risk of gallbladder cancer (very rare)

18
Treatment for Gallstones

• Surgical removal of gallbladder -
• Cholecystectomy
• Use medicines to dissolve stones (isn't suitable
  for everyone -may take a very long time)
• Shock-wave lithotripsy ( high-energy sound waves)
  to break gallstones into tiny fragments, then
  dissolved by medicines

19
If your gallbladder is removed

• No longer a holding space to store bile
• Bile continuously runs out of liver, through the
  hepatic ducts, into common bile duct, and
  directly into small intestine
• When a high-fat meal is eaten - not enough bile
  available to digest it properly
• Can result in chronic diarrhea
• Small intestines ability to absorb essential
  fatty acids, vitamins and minerals is compromised
  without help of gallbladder

20
Pancreas

• Both an exocrine and endocrine gland!
• Endocrine- (Isle of Langerhans) produces glucagon
  and insulin to regulate sugar metabolism
• Exocrine- secretes digestive enzymes

Generally cannot be seen on radiographs
21
Radiological exams of Gallbladder (largely
replaced by Ultrsound, CT, MRI, nuclear medicine)

• Cholecystography
• Study of gallbladder
• Oral contrast is used
• Cholangiography
• Study of biliary ducts
• IV contrast is used
• (may be injected directly into ducts)

22
Indications for Biliary Tract Exam

• Cholelithiasis (gallstones) -bile calculi
  presence
• Cholecystitis (inflammation of
  gallbladder)-bile sac inflammation
• Check liver function
• Biliary neoplasia (tumor or mass in biliary
  system)
• Biliary stenosis (abnormal narrowing of ducts)
• Demonstrate concentrating/emptying ability of
  gallbladder

23
Contraindications for performing Biliary Tract
Exams
Allergy to contrast Pyloric obstruction (blockage
from stomach to duodenum) Severe
jaundice Malabsorption Liver dysfunction Hepatocel
lular disease- liver typically inflamed and shows
signs of injury
24
Patient Prep

• Fat-free meal evening before
• Oral contrast taken 2 to 3 hours after evening
  meal
• NPO after midnight until exam
• Avoid laxitaves less than 24 hours to avoid
  prevent voiding of contrast medium with fecal
  material
• Make sure patient can, will, and did follow
  instructions!
• Early morning appointment

25
Position of Gallbladder

• RUQ
• In hypersthenic pt.
• Superior and lateral
• In Asthenic
• Inferior and nearer to spine

26
ShieldingWhat 3 things must you consider?

• 1. Are gonads within 2 of primary x-ray field
  after proper collimation?
• 2. Are clinical objectives compromised?
• 3. Does pt have reasonable reproductive
  potential?

27
Gallbladder Exam(Cholecystography)

• Scout film will also demonstrate if contrast is
  visible in gallbladder
• Dr. may do fluoroscopic examination
• Post-fatty meal film may be obtained to
  demonstrate emptying ability of GB

28
PA Projection

• Patient prone- or upright facing wallboard
• Center 10x12 cassette at RUQ, level of the right
  elbow
• 70 - 80 kVp range
• Exposure made at end of full?
• expiration

29
PA Oblique Projection

• LAO position
• Pt rotated 15 - 40 degrees depending on body
  habitus
• CR at level of elbow, between spine and (R or L?)
  midaxillary line 10x12 cassette

30
Rt. Lateral Decubitus

• Demonstrates stones lighter than bile visible
  only by stratification
• CR
• Directed horizontally to level of gallbladder

31
Intravenous Cholangiography (IVC)

• Very rarely performed anymore
• Used when patients cannot tolerate oral contrast
• Generally done in supine, and RPO positions
• Films taken at timed intervals - up to about 40
  minutes after injection

32
Percutaneous Transhepatic Cholangiography(perform
ed preoperatively)

• (Percutaneous any medical procedure where access
  to inner organs or other tissue is done via
  needle-puncture of skin, rather than by scapel)
• Long needle (Chiba) is placed into bile ducts
• Contrast is injected under fluoro
• Biliary drainage or stone extraction may
  accompany this procedure

33
Cholangiography Intra-operative

• Performed during a cholecystectomy
• Examines patency of ducts during or after
  surgical removal of GB

34
T-Tube Cholangiography

• Post-operative (after cholecystectomy) procedure
  performed through T-tube left in common hepatic
  and common bile ducts (for drainage)
• To determine
• patency (openness) of biliary ducts after
  cholecystectomy
• status of Spincter of oddi
• presence of residual or undetected stones

35
3 Cholangiogram types compared
Intraoperative
Percutaneous
T-Tube
36
ERCP
Endoscopic Retrograde Cholangiopancreatography

• Used to diagnose biliary and pancreatic
  pathologic conditions
• when ducts are not dilated and ampulla is not
  obstructed
• Fiberoptic endoscope passed through mouth into
  duodenum under fluoroscopy
• Common bile duct is catheterized
• Contrast is injected