IMAGING OF BILE DUCT
DR.SUDHEER HEGDECONSULTANT RADIOLOGIST
DEPARTMENT OF RADIOLOGYCOLUMBIA ASIA HOSPITALS
Courtesy:Dr.Shalini Govil
NORMAL ANATOMY cross-sectional and cholangiographic
CAUSES OF LOWER BILIARY OBSTRUCTION
APPEARANCES ON DIFFERENT IMAGING MODALITIES
ALGORITHM FOR OBSTRUCTIVE JAUNDICE
BILIARY ANATOMY
IMAGING MODALITIES
• Ultrasound - transabdominal, EUS, intraductal•Cholangiography - invasive : ERCP / PTC
- non-invasive : MR Cholangiography CT Cholangiography
- minIP and maxIP
•Cross Sectional - spiral CT / MRI as part of MRC/CTC• Non-invasive biliary package – MRC with spiral CT• DSA • Biliary Scintigraphy
BILIARY ANATOMY - Cholangiogram
Ultrasound biliary tract
BILIARY ANATOMY - CTright hepatic duct
common hepatic duct / common duct at the hilum
BILIARY ANATOMY - CT
supra-pancreatic common duct in the lesser omentum
BILIARY ANATOMY - CT
BILIARY ANATOMY - CT
intra-pancreatic common duct
BILIARY ANATOMY - CT
intra-pancreatic common duct
MRCP
EUS – bile duct calculi
CAUSES OF LOWER BILIARY OBSTRUCTION
CLASSIFICATION BY LEVEL OF OBSTRUCTION
Intrapancreatic - choledocholithiasis, chronic pancreatitis, pancreatic carcinoma
Suprapancreatic – cholangiocarcinoma, metastatic adenopathy, choledochal cyst
Intraluminal – tumour – HCC/CC, blood, stone, worm, hydatid
ULTRASONOGRAPHY
• Signs of Biliary Dilatation:Parallel Channel sign – IHBD > 2mmCBD > 6mm
• Post Fatty Meal SonographyCBD size increase of 2mm
• Post CholecystectomyNo compensatory dilatation of CBDCBD > 10mm
CHOLANGIOGRAPHY
Invasive (ERCP / PTC) - High spatial resolution Possible therapeutic options Complication rate (2-3%)
Non-invasive CT Cholangiogram - with IV contrast (maxIP)
bilirubin > 2mg% - ineffective - without IV contrast (minIP)
MR Cholangiogram
MR CHOLANGIOGRAPHY Breath-hold (HASTE, RARE)Non-breath-hold (IRTSE)
Bile appears bright on heavily T2W images
Mapping of biliary tree proximal to obstruction
Contraindicated in presence of aneurysm clips,cardiac pacemakers.
MR CHOLANGIOGRAPHY
SENSITIVITY SPECIFICITY
Biliary Obstruction 91 – 100% 100%
Level of Obstruction 91 – 100% 100%
Choledocholithiasis 81 – 100% 85 – 100% (2mm)
MR CHOLANGIOGRAPHY
ERC MRC CTC
THERAPY + - -
SECTIONAL - + +IMAGING
ANGIOGRAM - + +
CT / MRI
• Extraductal information – mass, nodes, ascites, metastases, biliary cirrhosis, portal hypertension and varices
• CT / MR angiography – for tumour resectability: periampullary, pancreatic, GB and hilar carcinomas.
CTC
MRC
ERCP
MR/CT CHOLANGIOGRAPHYvisualisation of the proximal biliary tree involvement of CHD, confluence, RHD, LHD, second order ducts
SECTIONAL IMAGES nodes, liver metastases, ascites, peritoneal metastases, hilar vessel involvement
PANCREATIC / PERIAMPULLARY CARCINOMA
US – Double duct sign (CBD & PD dilated)
- Mass (+) - Ca Pancreas(95%) –US guided FNAC
- Mass (– )-Perimpullary Ca – ERC with Biopsy
Spiral CT - 80% accuracy(resectability)
Endoscopic US – local extent of disease.
PeriampullaryCarcinoma
PeriampullaryCarcinoma
Ca pancreas
double ductsign
ALGORITHM for OBSTRUCTIVE JAUNDICE
ULTRASOUND
BILIARY DILATATION
MASS+
MR (MRC, MRA)or
CT (CTC + CTA)or
MRC + CT + CTASTENT or SURGERY
? STRICTURE
? CALCULUS(intact bile duct)
(THERAPEUTIC) ERC
CALCULUS+MASS -
RESECTABILITY CRITERIA
Involvement of encasing the portal vein,distal superior mesenteric vein.
• Involvement of CBD and PD (both ducts)
• Unilateral vascular invasion with contralateral biliary involvement
• Metastases
Helical CT - 60% Accuracy
Pancreatic adenocarcinomaencasing the portal vein,distal superior mesenteric vein.
Intraluminal filling defect suggestive of a thrombus is seen in the superior mesenteric vein
THANK YOU
CHOLANGIOCARCINOMA Intraductal ultrasound
bile duct wall thickening - carcinoma vs inflammation
• semicircular, eccentric, asymmetric wall thickening
• notched outer margin
• rigid, papillary inner margin
• heterogeneous echoes
NON SURGICAL THERAPEUTIC DRAINAGE
• Low Obstruction – ERCP with Stent Placement
• Cholangitis – Drainage (Nasobiliary/PTBD)
PTBD with STENTPLACEMENT
ERC with STENT
DISTAL CHOLANGIOCARCINOMA
GB CARCINOMA
PRIMARY SCLEROSING CHOLANGITIS
US • extrahepatic and intrahepatic ductal wall thickening
CHOLANGIOGRAPHY• pruned tree appearance• multifocal strictures• pseudodiverticulae
PSC-like cholangitis – AIDS cholangitis
NON INVASIVE CHOLANGIOGRAM PREFERABLE
PRIMARY SCLEROSING CHOLANGITIS
HYDATID CYSTS
CHOLEDOCHAL CYST
US / NON INVASIVE CHOLANGIOGRAPHY
- Todani type
- abnormal pancreatico biliary junction
CHOLEDOCHAL CYST
CHOLEDOCHAL CYST
ABERRANT BILE DUCTS
non invasive cholangiogram – prior to laproscopic cholecystectomy
MRC HIGH DIAGNOSTIC CT C ACCURACY
MRC 0.5 T – SUBOPTIMAL VISUALISATION OF NORMAL CALIBER DUCTS
MRC
CTC
POST SURGICAL COMPLICATIONS
• Retained calculi – T tube Cholangiogram / ERCP
• Biliary leak
• Biliary stenosis/stricture
BILE LEAKSSite of Leak
T-Tube Cholangiogram
ERCP with sphincterotomy / Stent
Scintigram
Infected Biloma
US / CT – pigtail drainage
T – TUBE cholangiogram
BILE LEAKS
POST SURGICAL STRICTURE-BILIARY ENTERIC ANASTAMOSIS
-POST CHOLECYSTECTOMY
• US – biliary dilatation aerobilia
• MR / CT with Cholangiogram – level of obstruction
• HIDA Scan – assess patency
POST-SURGICAL STRICTURES
BISMUTH CLASSIFICATION
ERC
MRC
BISMUTH type 5 STRICTURE
ANASTAMOTIC STRICTURE
GALL STONE associated obstructions
GALL STONE ILEUSRigler’s triad - air in the biliary tree
small bowel obstructionectopic gall stone
MIRIZZI SYNDROME
GALL STONE ILEUS