RADIOLOGY OF HEPATOBILIARY SYSTREM , PANCREAS AND SPLEEN

1. RADIOLOGY OF HEPATOBILIARY SYSTREM , PANCREAS AND SPLEEN For 4th year medical students By: Dr.Idrees J. Ahmed FIBMS – Rediology lecturer College of medicine Hawler Medical university

2. LECTURE ONE HEPATOBILIARY RADIOLOGICALANATOMY AND INVESTIGATION METHODS

3. LECTURE OBJECTIVE • To be familiar with radiological anatomy and distinguish normal pictures • To be able to sort investigations according to indications and priorities

4. Lecture overview • Radiological anatomy • Methods of investigation • Indications , precautions and contraindication • Patient Preparation • Radiological features of most common diseases • references

5. Radiological anatomy of hepatobiliary system • Liver : • Variable size and shape • Rt upper quadrant • Lobes and segments • Falciform ligament ( contains lig. Teres ) • Portal vein and portal triads • Hepatic veins

6. LIVER ANATOMY

8. GALL BLADDER : ( size , shape , location ) • 2mm walls , 5x10 cm • Variants :Phrygian cap , junctional fold , agenesis INTRA AND EXTRAHEPATIC DUCTS • RHD +LHD=CmD • CmD+ CyD = CBD

10. METHODS OF INVESTIGATION OF HEPATOBILIARY SYSTEM • Plain x-ray film , cholecystography( hystorical ) • Ultrasound • CT scan • MRI , MR cholangiopancreatography • ERCP ( endoscopic retrograde cholangiopancreatography)

11. Methods of investigation of the hepatobiliary system ( cont.) • Percutaneoustranshepaticcholangiography ( PTC) • Post-operative ( t-tube ) cholangiography • Operative cholangiography • Angiography ( diagnostic and therapeutic ) CTA , DSA and MRA • Radionuclide imaging

12. ULTRASOUND OF LIVER AND GALL BLADDER • Main clinical Indications : • Right upper quadrant pain • jaundice • Clinically suspected liver lesion • Abnormal lab tests • Staging for malignant diseases • Suspected portal hypertension

13. ULTRASOUND OF LIVER AND GALL BLADDER • No contraindication • Preparation: Restrictuin to clear fluids for gall bladder study ( 6 – 8 hr )

14. ULTRASOUND MACHINE

15. ULTRASOUND OF LIVER AND GALL BLADDER

16. CT scanner

17. CT scan of liver and biliary tree

18. CT SCAN OF LIVER AND BILIARY TREE • Clinical Indications: • suspected liver lesion • Characterization of liver lesion • Staging malignancy • Rt upper quadrant pain • To facilitate placement of needles( biopsy, etc. ) • Follow up after surgical or radiological intervention

19. CT SCAN OF LIVER AND BILIARY TREE ( CONT. ) • Contraindications : • Pregnancy • Allergy to iodinated contrast media • Patient preparation: the patient fasted for at least 6 hr • Investigations to be continued next lecture

20. End of lecture one • Questions and discussion

22. Lecture two • OBJECTIVES : • Continuation of hepatobiliay investigations • Radiology of cystic liver lesions

23. MRI LIVER

24. MRI scan of liver • Indications : • Lesion detection if US and CT not conclusive • Lesion characterization after detection by US or CT • Contraindications : General contraindications to MRI( claustrophobia , implants , penetrating injuries , sensitivity to contrast media , early pregnancy )

25. MRI scan of biliary tree (MRCP) • 2D or 3D T2 weighted , bile appears white • Indications : • Investigation of obstructive jaundice • Biliary stone , colic • Suspected cholangitis , or chronic pancreatitis • Prior to ERCP/PTC

26. MRCP

27. Advantages of MRCP • Non-invasive • Relatively cheep • No radiation , No anesthesia • Less operator dependant • Ducts prox. to obstruction seen • Extraductal disease may be seen

28. Disadvantages of MRCP • Decreased resolution • Less sensitive to subtle ductal disease • Not theraputic

29. ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY( ERCP )

30. ERCP • Contrast-agent is injected through endoscope after cannulation of CBD • Indications : • Diagnostic , in unsuitable or intolerant to MRCP • Management of bile duct stones • Evaluation of ampullary lesions • Management of biliary strictures • Chronic pancreatitis

31. ( ERCP ) cont. • Contraindications : • Upper GIT obstruction • Previous gastric surgery that prevents access to duodenum • Sever cardiac or respiratory distress • Complications : • Pancreatitis 5% • Duodenal perforation • Gastrointestinal bleeding

32. Liver lesions • FOCAL LIVER LESIONS area of alteration of normal parenchyma Cystic , solid or complex Cysts : thin walls with clear fluid , benign Complex : may be malignant Solid : borders , outline Multiple : metastases ? Abscesses , hemangiomas , cirrhosis

33. DIFFUSE LIVER LESIONS • hepatomegaly • generalized parenchyma changes • Fatty liver • Hepatitis • cirrhosis

34. HEPATOMEGALY SIGNS Rt lobe enlargement • elevated Rthemidiaph. • splayed lower Rt ribs • properitoneal fat bulge • depressed hepatic flexture and Rt kidney

35. HEPATOMEGALY SIGNS • Lt lobe enlargement gastric fundus and posterior stomach displaced intra-abdominal oesophagus elongated pressure on lesser curveature of stomach

36. LIVER CYSTS SIMPLE CYSTS Common , congenital , may be multiple ( ADPCK disease )

37. SIMPLE LIVER CYSTS

38. LIVERHYDATID CYSTS • may be indistinguishable from simple one • may be multiple or cyst inside cyst • wall layers on ultrasound • Calcification , no wall enhancement • signs of rupture • protein in its fluid

39. LIVER HYDATID

40. HYDATID CYST LIVER

41. End of lecture two • Summery • Discussion .

43. LECTURE THREE RADIOLOGY OF LIVER AND BILIARY DISEASES

44. OVERVIEW • LIVER TUMORS • TRAUMA • INFECTION AND CIRRHOSIS • BILIARY DISEASES

45. LIVER NEOPLASMS Metastases: • More common • Often multiple , Peripheral , variable size • On ultrasound : appear dark ( hypoechoic ) , may be complex ,irregularly cystic , hyperechoic or not visible • ON CT SCAN : Dark , Contrast enhancement

46. PRIMARY LIVER CANCER • similar to secondary • usually solitary

47. LIVER TUMOR

48. BENIGN LIVER TUMORS LIVER HEMANGIOMAS • Common 4-7% females 80% , incidental benign , vascular neoplasm • May bleed , biopsy avoided • Simulate neoplasm on ultrasound • On CT and MRI show centripetal enhancement

49. LIVER HAEMANGIOMA

50. LIVER HEMANGIOMA