M-2
HEPATOBILIARY
IMAGING
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Liver
Gallbladder And Bile Ducts
Pancreas
Spleen
2014
HEPATIC ANATOMY
Catalano, O. A. et al. Radiographics 2008;28:359-378
GOALS
 Review anatomy of hepatobiliary system.
 Correlate imaging with
pathology.
 Discuss radiologic imaging
options.
 Choose treatment
ANATOMY / PHYSIOLOGY
Portal vein flow
Hepatic arterial flow
Hepatic vein flow
Biliary drainage
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.
PORTAL VEIN
CT
Coronal and Axial images
US
HEPATIC ARTERIAL FLOW
LATERAL AORTOGRAM SHOWS ORIGIN OF CELIAC
ARTERY AND THE SUPERIOR MESENTERIC ARTERY
CELIAC
SMA
The Celiac Artery splits into
3 branches: Supplies
Diaphragmatic organs
1- Common Hepatic Artery.
2- Splenic Artery.
3- Lt. Gastric Artery.
THE COMMON HEPATIC ARTERY BECOMES THE PROPER HEPATIC
ARTERY AFTER THE GASTRODUODENAL BRANCH DESCENDS.
Proper hepatic
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Celiac
Gastroduodenal
SMA
The Lt. gastric is small and out of the section on this image
HEPATIC VEINS
Coronal scan
HEPATIC VEINS ENTERING IVC
What is the presentation of
hepatic vein thrombosis?
WHAT IS THE PRESENTATION OF
HEPATIC VEIN THROMBOSIS?
(Budd Chiari syndrome)
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Enlarged edematous liver
Painful-capsular pressure
Ascites-pressure effects
Hypercoagulable states- etiology
Elevated liver enzymes- infarction
Diagnosed with Hepatic Venography
Or CT
NORMAL BILIARY ANATOMY
ULTRASOUND
GALLBLADDER
COMMON BILE DUCT
Silva, A. C. et al. Radiographics 2004;24:677-687
NORMAL BILIARY ANATOMY
MR CHOLANGIOGRAM (MRCP)
Silva, A. C. et al. Radiographics 2004;24:677-687
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.
OPERATIVE CHOLANGIOGRAM
HEPATO-BILIARY SCAN - HIDA
PANCREATIC ANATOMY
CT SCAN
Transverse CT sections and corresponding US
CT
US
DARK GREEN EMESIS WOULD BE
TYPICAL FOR GI OBSTRUCTION.
• Pyloric stenosis
• Duodenal atresia
• Annular pancreas
• Gallstone ileus
ANNULAR PANCREAS
PANCREATIC EMBRYOLOGY
MALROTATION AND FUSION
WHO PRESENTS FOR IMAGING?
 Right upper quadrant pain
 Altered laboratory data
 Staging of malignancy / infection
 Physical exam findings
 Abdominal trauma
ACUTE
RIGHT UPPER QUADRANT PAIN
Differential Diagnosis:
 Acute Cholecystitis
 PUD / Gastritis / Reflux
 Acute Hepatitis
 Pancreatitis
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
DIAGNOSIS
ULTRASOUND

Cost / Availability

Fluid background is ideal for imaging
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Helpful to assess for any associated
biliary dilatation or inflammatory change
CHOLELITHIASIS
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.
CHOLECYSTITIS
With diffuse wall thickening
and edema.
Ultrasound and CT demostration of edema in and around GB wall
QUESTION?
CHOLECYSTITIS
Pain is often referred to other location
with cholecystitis, Which is the correct
answer?
1--Shoulder
2--Umbilicus
3--EG junction
4--Back
IMAGING
ALTERNATIVES
 Nuclear medicine - HIDA
 CT
 X-ray
 Cholangiography - MR or Endoscopic
HEPATO - BILIARY
SCINTIGRAM
Gall bladder
Obstructed cystic duct doesn’t
allow for filling of radionuclide
into the GB.
Absent Gall bladder
GALLSTONES
15-30% calcify
COMPLICATIONS OF
GALLSTONES
• Cystic duct obstruction
Cholecystitis A
• Common bile duct obstruction
Obstructive jaundice B
Ascending cholangitis
A
• Pancreatic duct obstruction
Pancreatitis C
B
C
ALTERED LABORATORY DATA
 Bilirubin - jaundice
 Amylase / lipase - pancreatitis
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
CBD
Obstructed duct due
to distal calculus
PV
Normal bile duct size
Diameter < portal diameter
Note dilated CBD with impacted calculus
*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.
Dilated CBD with calculi
Normal size CBD
ERCP
Endoscopic retrograde
Cholangiopancreatography
PANCREATITIS
elevated
AMYLASE & LIPASE
Biliary calculi-obstruction
Alcohol- chemical toxicity
ACUTE PANCREATITIS
EDEMATOUS
There is diffuse edema in and adjacent tissues around the pancreas.
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
Normal vasculature
Pseudo aneurysm
DRAINAGE OF PANCREATIC ABSCESS
COMPLICATIONS OF PANCREATITIS
Pseudocyst
Pain
Infection
Hemorrhagepseudoaneurysm
Pancreatic insufficiency
Large retrogastric fluid collection is a pseudocyst related to pancreatic enzyme break
down of tissue.
SPECIAL CASES
 Emphysematous cholecystitis
 Acalculous cholecystitis
 Gallstone ileus
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.
EMPHYSEMATOUS CHOLECYSTITIS
DIABETIC PATIENTS - AIR IN WALL
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
GALLSTONE ILEUS
Small Bowel Obstruction at IC valve due to migration of
gallstones that erode into duodenum from GB.
1999
2002
ACALCULOUS CHOLECYSTITIS
BILIARY STASIS - FASTING / ICU PATIENTS
SAME PATIENT
ABDOMEN SCAN
DONE 2/25/08
CHOLECYSTOSTOMY
RUQ PAIN
IMAGING EVALUATION
 Ultrasound – 1st
 CT / HIDA – 2nd
JAUNDICE
VIRAL HEPATITIS
IMAGING- LIMITED VALUE
Acute – usually normal
helps to exclude obstruction
Chronic – increased malignancy risk
THE MOST COMMON CAUSES OF
OBSTRUCTIVE JAUNDICE
IN THE UNITED STATES
1--Neoplasms of the pancreas
2—Choledocholithiasis
3--Pancreatitis
4--Iatrogenic strictures of the biliary tree
JAUNDICE
BILIRUBIN
Painless
 Malignancy
 Chronic obstruction
Painful
 Hepatitis / liver edema
 Choledocholithiasis / acute obstruction
PANCREATIC CANCER
OBSTRUCTIVE JAUNDICE
PALPABLE
GALL BLADDER
A palpable gall bladder in an asymtomatic
patient can be seen with pancreatic
carcinoma due to distal obstruction
(Courvoisier sign)
SCLEROSING CHOLANGITIS
A 35 yo patient with history of
ulcerative colitis comes to see you
for pruritus. You notice
yellow sclera and mucous
membranes. His alkaline
phosphatase is elevated and the
MR cholangiogram reports
abnormal appearance with
multiple stenoses and focal dilated
segments appearing beaded.
25 yo with 2yr dx of ulcerative colitis was
managed well. Now he has increasing
pain and diarrhea.
• Physical examination of this thin, pale young man, who appears
acutely ill, reveals these vital signs: Temperature 37.8C (100F),
pulse 110 beats per minute, and blood pressure 120/70mmHg. The
lower abdomen is mildly and diffusely tender, but there is no
rebound tenderness and bowel sounds are active. Stool is grossly
bloody. Sigmoidoscopy, shows marked mucosal erythema and
friability; diffuse ulceration is present, and an exudate contains pus
and blood.
• Three hours after the Sigmoidoscopy the man’s abdominal pain
worsened markedly. Vital signs now are temperature 39.6C
(103.2F), pulse 130 beats per minute, and blood pressure 90/60
mmHg. On examination the abdomen is distended and diffusely
tender with rebound.
PSEUDOPOLYPS
with ulcerative colitis may progress
TOXIC MEGACOLON
STAGING
MALIGNANCY / INFECTION
Mesenteric blood flow
spreads disease to liver
GI malignancy often
spreads to liver as first
site of hematogenous
extention.
HEPATIC ABSCESS FROM
GI INFECTION
Mesenteric venous blood flow can spread infection to the liver.
PALPABLE PHYSICAL EXAM FINDINGS
 Enlarged liver
 Enlarged spleen
 Ascites - distention
PALPABLE LIVER-metastatic disease
A palpable enlarged liver edge is nonspecific
but raises questions of mass or liver pathology.
ENLARGED PALPABLE SPLEEN
Enlarged spleen raises issue of lymphoproliferative diseases or infection.
ENLARGED SPLEEN
ON
ULTRASOUND AND CT.
SPLEEN
*Note left kidney
SPLENOMEGALY WITH CIRRHOSIS
AND PORTAL HYPERTENSION
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SPLENOMEGALY
*Note dilated splenic vein
VARICES
Varices are at risk for hemorrhage. They can be treated by embolization at GI
endoscopy or vascular shunt of portal blood flow by surgery or radiology to
decrease portal pressure.
CIRRHOSIS
Portal hypertension
Here long standing cirrhosis has lead to a scarred shrunken liver. Portal hypertension
resulting leads to varices and redirection of blood flow into a recanalized umbilical vein.
Lucent fluid at tip of liver on ultrasound
Fluid on CT
Ascites displacing bowel medially on Xray
SAGITTAL ULTRASOUND
Small nodular echogenic liver shows cirrhotic change
SURGICAL PORTOCAVAL SHUNTS AS
THERAPY
FOR BLEEDING AND ASCITES
INTERVENTIONAL RADIOLOGY SHUNT
HEPATIC VEIN - PORTAL VEIN
TIPS
Transjugular Intrahepatic Portosystemic Shunt
TRAUMA
QUESTION?
IN ADDITION TO CARBON
TETRACLORIDE WHAT PAIN KILLER IS
ASSOCIATED WITH LIVER TOXICITY?
1--Aspirin - salicylic acid
2--Tylenol - acetaminophen
3--Advil - ibuprofen
4--Aleve - naproxen
TRAUMA
UNSTABLE—SURGERY
X-ray-- Chest/ Abd / Pelvis if possible
FAST SCAN-to look for peritoneal fluid
STABLE– CT SCANNING
F.A.S.T. SCAN
(Focused Assessment with Sonography for Trauma)
Ultrasound survey for free peritoneal fluid
F.A.S.T. SCAN
(Focused Assessment with Sonography for Trauma)
Ultrasound survey for free peritoneal fluid
Need 400-500 ccs
Not good for organ injury or bowel injury
HEPATIC / SPLENIC
LACERATION
Note rib fractures on x-ray
POST TRAUMATIC
PANCREATITIS
SEAT- BELT INJURY
There is diffuse edema and hemorrhage in adjacent tissues around the pancreas.
WHAT IMAGING POSSIBILITIES?
 ULTRASOUND---GB / CBD / LIVER
 Plain x-ray---ERCP
 CT---PANCREAS / LIVER
 Nuclear Medicine---HIDA
 MR---MRCP
These are the imaging modalities and important sites of assessment