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M-2 HEPATOBILIARY IMAGING

M-2 HEPATOBILIARY IMAGING. Liver Gallbladder And Bile Ducts Pancreas Spleen. 2014. HEPATIC ANATOMY. Catalano, O. A. et al. Radiographics 2008;28:359-378. GOALS. Review anatomy of hepato- biliary system. Correlate imaging with pathology.

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M-2 HEPATOBILIARY IMAGING

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  1. M-2HEPATOBILIARY IMAGING Liver Gallbladder And Bile Ducts Pancreas Spleen 2014

  2. HEPATIC ANATOMY Catalano, O. A. et al. Radiographics 2008;28:359-378

  3. GOALS • Review anatomy of hepato- biliary system. • Correlate imaging with pathology. • Discuss radiologic imaging options. • Choose treatment

  4. ANATOMY / PHYSIOLOGY Portal vein flow Hepatic arterial flow Hepatic vein flow Biliary drainage

  5. PORTAL BLOOD FLOW The Portal vein is formed by the juncture of the Splenic vein and the Superior Mesenteric vein. The Inferior Mesenteric vein usually joins the Splenic vein.

  6. PORTAL VEIN Coronal and Axial images CT US

  7. HEPATIC ARTERIAL FLOWLATERAL AORTOGRAM SHOWS ORIGIN OF CELIAC ARTERY AND THE SUPERIOR MESENTERIC ARTERY CELIAC The Celiac Artery splits into 3 branches: Supplies Diaphragmatic organs 1- Common Hepatic Artery. 2- Splenic Artery. 3- Lt. Gastric Artery. SMA

  8. THE COMMON HEPATIC ARTERY BECOMES THE PROPER HEPATIC ARTERY AFTER THE GASTRODUODENAL BRANCH DESCENDS. Proper hepatic * Celiac Gastroduodenal SMA * The Lt. gastric is small and out of the section on this image

  9. HEPATIC VEINS Coronal scan

  10. HEPATIC VEINS ENTERING IVC CT ULTRASOUND

  11. What is the presentation of hepatic vein thrombosis?

  12. WHAT IS THE PRESENTATION OF HEPATIC VEIN THROMBOSIS?(Budd Chiari syndrome) • Enlarged edematous liver • Painful-capsular pressure • Ascites-pressure effects • Hypercoagulable states- etiology • Elevated liver enzymes- infarction • Diagnosed with Hepatic Venography • Or CT

  13. NORMAL BILIARY ANATOMY ULTRASOUND GALLBLADDER COMMON BILE DUCT Silva, A. C. et al. Radiographics 2004;24:677-687

  14. NORMAL BILIARY ANATOMY MR CHOLANGIOGRAM (MRCP) Silva, A. C. et al. Radiographics 2004;24:677-687

  15. ENDOSCOPIC RETROGRADE Cholangio - Pancreatography ERCP MR cholangiogram shows signal from the bile and other fluids. ERCP has iodinated contrast injected with an endoscope with the canula in the distal common bile duct.

  16. OPERATIVE CHOLANGIOGRAM HEPATO-BILIARY SCAN - HIDA

  17. PANCREATIC ANATOMYCT SCAN

  18. Transverse CT sections and corresponding US CT US

  19. DARK GREEN EMESIS WOULD BE TYPICAL FOR GI OBSTRUCTION. • Pyloric stenosis • Duodenal atresia • Annular pancreas • Gallstone ileus

  20. ANNULAR PANCREASPANCREATIC EMBRYOLOGYMALROTATION AND FUSION

  21. WHO PRESENTS FOR IMAGING? • Right upper quadrant pain • Altered laboratory data • Staging of malignancy / infection • Physical exam findings • Abdominal trauma

  22. ACUTE RIGHT UPPER QUADRANT PAIN • Differential Diagnosis: • Acute Cholecystitis • PUD / Gastritis / Reflux • Acute Hepatitis • Pancreatitis

  23. RIGHT UPPER QUADRANT PAIN • Gallstone = cholelithiasis- 10% prevalence • Stone impaction and obstruction cystic duct • Pain with contraction after fatty meal 20-30 minutes • Adult 40+- female more common

  24. DIAGNOSIS ULTRASOUND • Cost / Availability • Fluid background is ideal for imaging • Helpful to assess for any associated biliary dilatation or inflammatory change

  25. CHOLELITHIASIS

  26. MURPHY’S SIGN A Sonographic Murphy’s sign is focal tenderness corresponding to the gallbladder. Along with other ultrasound evidence of inflammation (gallbladder wall thickening, pericholecystic fluid) it helps physicians separate Acute Cholecystitis from gallstones alone.

  27. CHOLECYSTITISWith diffuse wall thickening and edema. Ultrasound and CT demostration of edema in and around GB wall

  28. CHOLECYSTITIS QUESTION? Pain is often referred to other location with cholecystitis, Which is the correct answer? 1--Shoulder 2--Umbilicus 3--EG junction 4--Back

  29. IMAGING ALTERNATIVES • Nuclear medicine - HIDA • CT • X-ray • Cholangiography - MR or Endoscopic

  30. HEPATO - BILIARY SCINTIGRAM NORMAL HIDA Gall bladder Obstructed cystic duct doesn’t allow for filling of radionuclide into the GB. Absent Gall bladder ABNORMAL HIDA

  31. GALLSTONES 15-30% calcify

  32. COMPLICATIONS OF GALLSTONES Cystic duct obstruction Cholecystitis A Common bile duct obstruction Obstructive jaundice B Ascending cholangitis Pancreatic duct obstruction Pancreatitis C A B C

  33. ALTERED LABORATORY DATA • Bilirubin - jaundice • Amylase / lipase - pancreatitis

  34. QUESTION? HOW CAN A HEMOLYTIC ANEMIA (SICKLE CELL ANEMIA) GIVE AN ELEVATED DIRECT BILIRUBIN? 1--Hemolytic crisis 2--Transfusion Hepatitis 3--Choledocholithiasis 4--Hepatic infarction

  35. CBD Obstructed duct due to distal calculus PV Normal bile duct size Diameter < portal diameter Note dilated CBD with impacted calculus

  36. *Note dilated bile ducts. (Low density branching structures anterior to portal veins) Normal The Portal vein is opacified (white) from IV contrast administration. The biliary tree is of lower density and shows as a branching structure anterior to the portal vein.

  37. Dilated CBD with calculi Normal size CBD Endoscopic retrograde Cholangiopancreatography ERCP

  38. PANCREATITIS elevatedAMYLASE & LIPASE Biliary calculi-obstruction Alcohol- chemical toxicity

  39. ACUTE PANCREATITISEDEMATOUS There is diffuse edema in and adjacent tissues around the pancreas.

  40. A patient with diagnosis of pancreatitis who had developed a pseudocyst over past month Comes to the hospital with worsened pain and a blood pressure of 80/60. 1-Mesenteric arterial infarction 2-Portal vein thrombosis 3-Perforated ulcer 4-Leaking pseudoaneurysm

  41. Normal vasculature Pseudo aneurysm

  42. DRAINAGE OF PANCREATIC ABSCESS

  43. COMPLICATIONS OF PANCREATITIS • Pseudocyst • Pain • Infection • Hemorrhage- pseudoaneurysm • Pancreatic insufficiency Large retrogastric fluid collection is a pseudocyst related to pancreatic enzyme break down of tissue.

  44. SPECIAL CASES • Emphysematous cholecystitis • Acalculous cholecystitis • Gallstone ileus

  45. A 64-year-old man with insulin-dependent adult-onset diabetes mellitus seeks emergency medical treatment after 2 days of increasingly severe abdominal pain in the right upper quadrant that has spread over the entire abdomen and is associates with nausea, vomiting, fever and chills. On examination, he is alert and oriented but appears to be quite acutely distressed. Vital signs are temperature 39.4C (103F), pulse 140 beats per minute, and blood pressure 100/60mmHg. His sclerae are mildly icteric. His abdomen is diffusely tender with marked guarding in the right upper quadrant.

  46. EMPHYSEMATOUS CHOLECYSTITISDIABETIC PATIENTS - AIR IN WALL

  47. QUESTION? IN GALLSTONE ILEUS OBSTUCTION OF THE GI TRACT OCCURS COMMONLY IN THE: 1--Pyloric channel 2--Duodenal C loop 3--Ileocecal valve 4--Hepatic flexure

  48. GALLSTONE ILEUS Small Bowel Obstruction at IC valve due to migration of gallstones that erode into duodenum from GB. 2002 1999

  49. ACALCULOUS CHOLECYSTITISBILIARY STASIS - FASTING / ICU PATIENTS

  50. SAME PATIENT ABDOMEN SCAN DONE 2/25/08

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