Hepatobiliary Imaging

1. Hepatobiliary Imaging Beth Neilsen

2. Patient History • Ms. H is a 69-yo female who presents with a one week history of pain in the right upper quadrant that radiates to her right shoulder. She does not have a fever at the time of presentation, but reports she has felt “chills” at home for the past three days.

3. What radiological studies are available to evaluate problems in the right upper quadrant? • What are the recommendations about the appropriate use of these tests?

4. Ultrasound Findings in cholecystitis: • Thick gallbladder wall (greater than 3 mm) • Stones • Pericholecystic fluid • Sonographic Murphy's sign (tenderness over the gallbladder from the ultrasound transducer)

5. Ultrasound

6. Ultrasound Thickened gallbladder wall Fluid

7. CT

8. HIDA • How it is done: • The patient receives an intravenous injection of radioactive hydroxy iminodiacetic acid (HIDA). • The HIDA material is taken up by hepatocytes and excreted into the bile. •  In a healthy person, HIDA will pass through the bile ducts and into the cystic duct to enter the gallbladder.  • It will also pass into the common bile duct and enter the small intestine, from which it eventually makes its way out of the body in the stool. • After 30-60 minutes, the scan will show the flow of bile through the biliary tree including common bile duct, cystic duct, and gallbladder. • HIDA imaging is done by a nuclear scanner, which takes pictures of the patient's biliary tract over the course of about two hours. 

9. HIDA

10. HIDA • Indications: • Diagnosis of acute cholecystitis • Evaluation of extrahepatic biliary tract obstruction • Evaluation of post surgical biliary tract • Diagnosis of biliary atresia and other congenital anomalies of the biliary tract

11. ERCP • An endoscope is passed through the esophagus, stomach, and duodenum until it reaches the spot where the ducts of the biliary tree and pancreas open into the duodenum. • A small plastic tube through the scope, through which contrast is injected into the ducts to make them show up clearly on x rays. • If the exam shows a gallstone or narrowing of the ducts, the physician can insert instruments into the scope to remove or relieve the obstruction. Also, tissue samples (biopsy) can be taken for further testing.

12. ERCP

13. ERCP • Imaging: • Once considered the gold standard for diagnosis of choledocholithiasis, it is evolving into a predominantly therapeutic procedure as newer diagnostic imaging technologies emerge. • Gallstones: • Postoperative ERCP is both safe and reliable in clearing common bile duct stones. • A valuable therapeutic modality in choledocholithiasis with jaundice, dilated common bile duct, acute pancreatitis, or cholangitis. • Pancreatitis: • Useful only when biliary pancreatitis is suspected. In this case, early intervention with ERCP reduces morbidity and mortality. • Beneficial in selected patients with recurrent pancreatitis or pancreatic pseudocysts • Cancer: • Palliation of biliary obstruction in patients with pancreatic or biliary cancer when surgery is not elected. • Tissue sampling for patients with pancreatic or biliary cancer not undergoing surgery may be achieved by ERCP, but this is not always diagnostic. • ERCP is the best means to diagnose ampullary cancers.

14. Variant 1: No fever, normal WBC. Appropriateness Criteria Scale1 2 3 4 5 6 7 8 91 = Least appropriate 9 = Most appropriate

15. Variant 2: No fever, normal WBC, ultrasound shows only gallstones.

16. Variant 3: Fever, elevated WBC, positive Murphy sign.

17. Variant 4: Same as #1, but following normal gallbladder ultrasound.

18. Variant 5: Hospitalized patient with fever, elevated WBC, and positive Murphy sign.