Imaging of Bile Duct - Columbia Asia Workshop

IMAGING OF BILE DUCT DR.SUDHEER HEGDE CONSULTANT RADIOLOGIST DEPARTMENT OF RADIOLOGY COLUMBIA 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 - CT right 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

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 > 2mm

CBD > 6mm

Post Fatty Meal Sonography

CBD size increase of 2mm

Post Cholecystectomy

No compensatory dilatation of CBD

CBD > 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 CHOLANGIOGRAPHY visualisation 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.

Periampullary Carcinoma

Ca pancreas double duct sign

ALGORITHM for OBSTRUCTIVE JAUNDICE ULTRASOUND BILIARY DILATATION MASS+ MR (MRC, MRA) or CT (CTC + CTA) or MRC + CT + CTA STENT 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 adenocarcinoma encasing 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 STENT PLACEMENT 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

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 LEAKS Site 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 ILEUS Rigler’s triad - air in the biliary tree small bowel obstruction ectopic gall stone MIRIZZI SYNDROME

GALL STONE ILEUS