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For 4th year medical studentsBy: Dr.Idrees J. Ahmed
FIBMS – Rediology lecturerCollege of medicine
Hawler Medical university
RADIOLOGY OF HEPATOBILIARY SYSTREM , PANCREAS AND SPLEEN
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HEPATOBILIARY RADIOLOGICALANATOMY
AND INVESTIGATION METHODS
LECTURE ONE
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To be familiar with radiological anatomy and distinguish normal pictures
To be able to sort investigations according to indications and priorities
LECTURE OBJECTIVE
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Radiological anatomy Methods of investigation Indications , precautions and
contraindication Patient Preparation Radiological features of most common
diseases references
Lecture overview
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Liver :o Variable size and shapeo Rt upper quadranto Lobes and segmentso Falciform ligament ( contains lig. Teres ) o Portal vein and portal triadso Hepatic veins
Radiological anatomy of hepatobiliary system
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LIVER ANATOMY
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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
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1. Plain x-ray film , cholecystography( hystorical )
2. Ultrasound3. CT scan4. MRI , MR cholangiopancreatography5. ERCP ( endoscopic retrograde
cholangiopancreatography)
METHODS OF INVESTIGATION OF HEPATOBILIARY SYSTEM
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1. Percutaneous transhepatic cholangiography ( PTC)
2. Post-operative ( t-tube ) cholangiography3. Operative cholangiography4. Angiography ( diagnostic and therapeutic )
CTA , DSA and MRA 5. Radionuclide imaging
Methods of investigation of the hepatobiliary system ( cont.)
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Main clinical Indications :1. Right upper quadrant pain2. jaundice3. Clinically suspected liver lesion 4. Abnormal lab tests5. Staging for malignant diseases6. Suspected portal hypertension
ULTRASOUND OF LIVER AND GALL BLADDER
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No contraindication
Preparation: Restrictuin to clear fluids for gall bladder study ( 6 – 8 hr )
ULTRASOUND OF LIVER AND GALL BLADDER
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ULTRASOUND MACHINE
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ULTRASOUND OF LIVER AND GALL BLADDER
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CT scanner
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CT scan of liver and biliary tree
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Clinical Indications:1. suspected liver lesion2. Characterization of liver lesion3. Staging malignancy4. Rt upper quadrant pain5. To facilitate placement of needles( biopsy,
etc. ) 6. Follow up after surgical or radiological
intervention
CT SCAN OF LIVER AND BILIARY TREE
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Contraindications :1. Pregnancy2. Allergy to iodinated contrast media
Patient preparation: the patient fasted for at least 6 hr
Investigations to be continued next lecture
CT SCAN OF LIVER AND BILIARY TREE ( CONT. )
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Questions and discussion
End of lecture one
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OBJECTIVES :
Continuation of hepatobiliay investigations
Radiology of cystic liver lesions
Lecture two
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MRI LIVER
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Indications :1. Lesion detection if US and CT not conclusive2. Lesion characterization after detection by
US or CT
Contraindications :General contraindications to
MRI( claustrophobia , implants , penetrating injuries , sensitivity to contrast media , early pregnancy )
MRI scan of liver
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2D or 3D T2 weighted , bile appears white
Indications :1. Investigation of obstructive jaundice
2. Biliary stone , colic
3. Suspected cholangitis , or chronic pancreatitis
4. Prior to ERCP/PTC
MRI scan of biliary tree (MRCP)
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MRCP
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1. Non-invasive
2. Relatively cheep
3. No radiation , No anesthesia
4. Less operator dependant
5. Ducts prox. to obstruction seen
6. Extraductal disease may be seen
Advantages of MRCP
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1. Decreased resolution
2. Less sensitive to subtle ductal disease
3. Not theraputic
Disadvantages of MRCP
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ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY(
ERCP )
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Contrast-agent is injected through endoscope after cannulation of CBD
Indications :1. Diagnostic , in unsuitable or intolerant to
MRCP2. Management of bile duct stones3. Evaluation of ampullary lesions4. Management of biliary strictures5. Chronic pancreatitis
ERCP
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Contraindications :1. Upper GIT obstruction2. Previous gastric surgery that prevents
access to duodenum3. Sever cardiac or respiratory distress
Complications : Pancreatitis 5% Duodenal perforation Gastrointestinal bleeding
(ERCP ) cont.
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FOCAL LIVER LESIONSarea of alteration of normal parenchymaCystic , solid or complex
Cysts : thin walls with clear fluid , benign
Complex : may be malignant
Solid : borders , outline Multiple : metastases ? Abscesses ,
hemangiomas , cirrhosis
Liver lesions
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hepatomegaly
generalized parenchyma changes• Fatty liver• Hepatitis• cirrhosis
DIFFUSE LIVER LESIONS
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Rt lobe enlargement elevated Rt hemidiaph. splayed lower Rt ribs properitoneal fat bulge depressed hepatic flexture and Rt kidney
HEPATOMEGALY SIGNS
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Lt lobe enlargement gastric fundus and posterior stomach
displaced intra-abdominal oesophagus elongated pressure on lesser curveature of
stomach
HEPATOMEGALY SIGNS
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SIMPLE CYSTS
Common , congenital , may be multiple ( ADPCK disease )
LIVER CYSTS
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SIMPLE LIVER CYSTS
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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
LIVERHYDATID CYSTS
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LIVER HYDATID
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HYDATID CYST LIVER
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Summery
Discussion .
End of lecture two
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RADIOLOGY OF LIVER AND BILIARY DISEASES
LECTURE THREE
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LIVER TUMORS
TRAUMA
INFECTION AND CIRRHOSIS
BILIARY DISEASES
OVERVIEW
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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
LIVER NEOPLASMS
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similar to secondary
usually solitary
PRIMARY LIVER CANCER
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LIVER TUMOR
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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
BENIGN LIVER TUMORS
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LIVER HAEMANGIOMA
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LIVER HEMANGIOMA
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FNH : rare , hypervascular , iso to liver , central scar ( white on T2 ) , no malignant change
Adenoma : solit. , rare , malignant ( may)
Other benign liver lesions
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Like cysts , irregular thicker walls
Pus usually thicker than cyst fluid(water)
May calcify
Walls enhance , local edema
On imaging difficult to distinguish from a necrotic tumor ( clinical )
Liver abscess
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LIVER ABSCESS
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Commonest fatal abdominal injury
Lacerations are most common parenchymal injury
Ass. With subcapsular hematoma
CT is best for hematoma detection and organ survey
LIVER TRAUMA
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Liver trauma
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Commonest cause for portal hypertension
Porto-systemic anastamases open to bypass liver ( eg. Lower esophagus )
Fibrosis of parenchyma , small liver ( coudate lobe preserved )
Large spleen , portal flow
Ascites and neoplasms
LIVER CIRRHOSIS
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Liver cirrhosis
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CHOLELITHIASIS : 10-20% US population , 30% calcification
40-50% asymptpmatic
Surgery in symptomatic and diabetic
Cholesterol , pigment or ( most are ) mixed
Predisposition: obesity , diabeteis , cirrhosis , huperparathyroidism
DISEASES OF THE BILIARY SYSTEM
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Ultrasound featuresCan detect 2mm stone and largerBack shadow , mobility , wall-eacho-shadow
triad ( contracted gb )Porcelain gall bladderEmphysematous cholecystitis
Gall bladder stones
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Stone in bile ducts with jaundice and high grade obstruction ,ultrasound 75% sensitive
MIRIZZI syndrome CyD stone CBD obst.
CHOLEDOCHOLITHIASIS
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Common ACUTE : calculus 95% , acalculus Distension , walls >5mm, free fluid,
Murphy’s sign ( 90% specific , negative if gangrenous )
Acalculus : trauma , long fasting , DM , no
stone ivisible , patient ill CHRONIC: Thick smaller GB , stone 95% , STIFF
CHOLECYSTITIS
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CHOLECYSTITIS
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Infection of obstructed bile ducts ( E. coli )
Causes ( stone , stricture , drainage cath. , ampullary cancer )
Rad. Features : Duct dilatation, intrahepatic duct stone
(pathognomonic ) Segmental Hepatic atrophy Liver abscess , pancreatitis
CHOLANGITIS
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CHOLANGITIS
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Biliary cancers are 5th most common GI malignancy
Ass. With ( stone , porcelain GB , IBD , chronic cholecystitis )
Intraluminal soft tissue
Asymmetrically thickened GB wall No biliary dilatation
Invasion of liver and lymph nodes
GB canrcioma
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Ca GB
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RARE
Hilar : junction or RHD & LHD ( Klatskin) or peripheral from epithelium of intralobular
ducts
Dilated intrahepatic normal extrahepatic ducts
Hilar mass , short annular constricting lesion
CHOLANGIOCARCINOMA
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CHOLANGIOCARCINOMA
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congenital dilatation of bile ducts
children or young adults
20-fold increased risk of malignancy
jaundice , abdominal pain , mass
CHOLEDOCAL CYST
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CHOLEDOCAL CYST
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Summery
discussion
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RADIOLOGY OF PNACREAS AND SPLEEN
LECTUTE FOUR
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Retroperitoneal , on posterior abdominal wall , L1 level
Head , neck , body and tail , 15 cm length
Duct (from tail to ampulla ) , 4mm on ERCP
PANCREAS
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accessory duct ( santorini ) drains lower part of head
Grey on US and CT , whiter than liver on T1
Intense enhancement , Fat infiltration : common , normal , age
PANCREAS
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RETROPERITONEUM
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PANCREAS
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Pancreatic injry : penetrating or blunt ( superficial , deep ,
duct involved ?)
Rad. Features : fragmentation , hematoma , non-enhancing regions , stranding
Complications: fistula , abscess , pancreatitis , pseudocyst
PANCREAS LESIONS
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Pancreas injury
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Acute mild edema, pain , vomiting , tenderness , not progress
Acute severe necrosis ,shock , renal failure , GI bleed
Chronic : alcohol , stone
PANCREATITIS
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US : hypoechoic due to edema , detect stone and follow up size of pseudocyst ( capsule )
CT : heterogeneous , focal necrosis 90% accurate , peripancreatic edema or fluid or even gas collection
Pancreatitis , Rad. features
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pancreatitis
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CA. PANCREAS : 2\3 in head , CBD obst. , focal mass and deformity , duct dilatation , extrapancreatic and vascular extension
DDX regional LAP , focal pancreatitis , abscess , pseudocyst
PANCREATIC CANCER
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Pancreas cancer
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Lt upper quadrant , size of a fist , 12 x 7 x 4 cm in adult , along 9th rib , intraperitoneal
Accessory spleens at hilum ( 40% )
Wandering spl. Along pedicle
Poly and asplenia
SPLEEN
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Splenomegaly
Trauma ( subcapsular or parenchymal hematoma , laceration , fragmentation , delayed rupture \rare )
Cyst , Tumor ( hemangioma , metastasis )
infarction
SPLEEN LESIONS
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Spleen lesions
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Summery
discussion
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Diagnostic imaging by Peter Armstrong 3rd edition
Anatomy for diagnostic imaging 2nd edt. By Stephanie Ryan
Primer of diagnostic radiology , 3rd edt. Text book of radiology and imaging by David
sutton 7th edt. A guide to radiological procedures by
Frances Aitchison 5th edt.
References
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THANK YOU AND
GOOD LUCK