Radiological investigation of billiary tact 01
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The name biliary tract is used to refer to all of the ducts, structures and organs involved in the production, storage and secretion of bile. Bile canaliculi >> Canals of Hering >> intrahepatic bile ductule (in portal tracts / triads) >> interlobular bile ducts >> left and right hepatic ducts >> These merge to form the common hepatic duct This exits the liver and joins with the cystic duct from gall bladder Together these form the common bile duct which joins the pancreatic duct These pass through the ampulla of Vater and enter the duodenum
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Radiological investigation of billiary tact 01
- 1. Radiological Investigation of Billiary Tact-01 Presenter Miss Kajal Jha BSC.MIT-016 BPKIHS,Dharan Moderator Mr. Mukesh Kr Jha Senior Demonstator BPKIHS,Dharan
- 2. As a whole.
- 3. Biliary tract consists of: liver, gall bladder and bile ducts
- 4. TREE? The biliary tract is often referred to as a tree because it begins with many small branches which end in the common bile duct, someatimes referred to as the trunk of the biliary tree
- 5. The name biliary tract is used to refer to all of the ducts, structures and organs involved in the production, storage and secretion of bile.
- 6. The tract is as follows: Bile canaliculi >> Canals of Hering >> intrahepatic bile ductule (in portal tracts / triads) >> interlobular bile ducts >> left and right hepatic ducts >> These merge to form the common hepatic duct This exits the liver and joins with the cystic duct from gall bladder Together these form the common bile duct which joins the pancreatic duct These pass through the ampulla of Vater and enter the duodenum
- 7. LIVER
- 9. Gall Bladder
- 11. Methods of imaging the hepatobiliary system 1. Plain film 2. Ultrasound (US): a. Transcutaneous b. Intraoperative c. Endoscopic. 3. CT including: a. Routine ‘staging’ (portal venous phase) CT b. Triple phase ‘characterization’ CT c. CT cholangiography.
- 12. 4. MRI 5. Endoscopic retrograde cholangiopancreatography (ERCP) 6. Percutaneous transhepatic cholangiography (PTC) 7. Operative cholangiography 8. Post-operative (T-tube) cholangiography 9. Angiography – diagnostic and interventional 10. Radionuclide imaging: a. Static, with colloid b. Dynamic, with iminodiacetic acid derivatives.
- 13. Plain film `May be useful to demonstrate air within the biliary tree or portal venous system, opaque calculi or pancreatic calcification.
- 14. • Preliminary radiographs may demonstrate enlargement and calcification but these may be difficult to differentite from biliary calculi, renal calculi or calcification in the costal cartilages. • The structure and position of liver is such that normally a combination of imaging modalities are employed in its investigation.
- 15. ULTRASOUND OF THE GALLBLADDER AND BILIARY SYSTEM Indications 1. Suspected gallstones 2. Right upper quadrant pain 3. Jaundice 4. Fever of unknown origin 5. Acute pancreatitis 6. To assess gallbladder function 7. Guided percutaneous procedures.
- 16. Contraindications None. Patient preparation Fasting for at least 6 h, preferably overnight.Water may be permitted. Equipment 3–5-MHz transducer and contact gel. Selection of the appropriate pre-set protocol and positioning of focal zone will depend upon the type of machine, manufacturer and patient habitus. A standoff may be used for a very anterior gallbladder.
- 17. Technique 1. The patient is supine. 2. The gallbladder can be located by following the reflective main lobar fissure from the right portal vein to the gallbladder fossa 3. Developmental anomalies are rare but the gallbladder may be intrahepatic or on a long mesentery
- 18. 4. The gallbladder is scanned slowly along its long axis and transversely fromthe fundus to the neck leading to the cystic duct. 5. It must be re-scanned in the left lateral decubitus or erect positions because stones may be missed if only supine scans are used. 6. Visualization of the neck and cystic ducts may be improved by head down tilt. The normal gallbladder wall is never more than 3-mm thick.
- 22. Additional views Assessment of gallbladder function 1. Fasting gallbladder volume may be assessed by measuring longitudinal, transverse and antero-posterior (AP) diameters. 2. Normal gallbladder contraction reduces the volume by more than 25%, 30 min after a standard fatty meal. Somatostatin, calcitonin, indometacin and nifedipine antagonize this contraction.
- 23. Intrahepatic bile ducts 1. Left lobe: transverse epigastric scan 2. Right lobe: subcostal or intercostal longitudinal oblique. Normal intrahepatic ducts are visualized with modern scanners. Intrahepatic ducts are dilated if their diameter is more than 40% of the accompanying portal vein branch. There is normally acoustic enhancement posterior to dilated ducts but not portal veins. Dilated ducts have a beaded branching appearance.
- 24. Extrahepatic bile ducts 1. The patient is supine or in the right anterior oblique position. 2. The upper common duct is demonstrated on a longitudinal oblique, subcostal or intercostal scan running anterior to the portal vein. The right hepatic artery is often seen crossing transversely between the two. 3. The common duct may be followed downwards along its length through the head of the pancreas to the ampulla and, when visualized, transverse scans should also be performed to improve detection of intraduct stones.
- 25. Post- cholecystectomy There is disagreement as to whether the normal common duct dilates after cholecystectomy. Symptomatic patients and those with abnormal liver function tests should have further investigations if the common duct measures more than 6mm.
- 26. COMPUTED TOMOGRAPHY OF THE LIVER AND BILIARY TREE Indications 1. Suspected focal or diffuse liver lesion 2. Staging known primary or secondary malignancy 3. Abnormal liver-function tests 4. Right upper-quadrant pain or mass 5. Hepatomegaly 6. Suspected portal hypertension 7. Characterization of liver lesion
- 27. 8. Pyrexia of unknown origin 9. To facilitate the placement of needles for biopsy, etc. 10. Assessment of portal vein, hepatic artery or hepatic veins 11. Assessment of patients with surgical shunts or transjugular intrahepatic portosystemic shunt (TIPS) procedures 12. Follow-up after surgical resection or liver transplant.
- 28. Contraindications Pregnancy Contraindication to iodinated intravenous (i.v.) contrast medium (contrast-enhanced computed tomography (CECT))
- 29. Technique Single-phase (portal phase) contrast- enhanced CT Multi-phasic contrast-enhanced CT
- 30. COMPUTED TOMOGRAPHIC CHOLANGIOGRAPHY Magnetic resonance (MR) cholangiography is non-invasive butsometimes fails to display the normal intra-hepatic ducts. Multidetector CT cholangiography can be useful in this instance. With this technique the biliary tree is opacified using an i.v. cholangiographic agent. Isotropic data from 0.625mm section thickness can be reconstructed to provide high-resolution three- dimensional images.
- 31. • One inherent advantage of CT cholangiography compared with MRC is its higher spatial resolution. This advantage translates into better depiction of ductal detail in some instances. • However, despite the lower resolution of MRC, MRC has been shown to be highly sensitive and specific in the evaluation of suspected biliary strictures following liver transplantation
- 32. Contraindications Allergy to iodinated contrast agents. Indications 1. Screening for cholelithiasis 2. Pre-operative screening of anatomy 3. Supected traumatic bile-duct injury 4. Other biliary abnormalities, e.g. cholesterol polyps, adenomyomatosis and congenital abnormalities. Adv-Differentiate obstructive and non obstructive jauncice with cause and location of abstruction
- 33. Technique 1. Patient fasted for at least 6 h 2. 100ml i.v. cholangiographic agent, e.g. meglumine iotroxate, infused for 50 min as a biliary contrast1 or iodipamide meglumine 52%- 20ml diluted with 80ml of normal saline infused over 30 min. 3. CT scans should be obtained at least 35 min after infusion of contrast agent.
- 34. Contrast medium cnhanced CT sections may enable characterstion of focal lesions. Gall stones can represent a variety of appearences, depending upon their constitution. Most gallstones have an attenuation cofficient highrt than that of surrounding bile. But pure cholesterol stones can also be detected as areas of reduced atteuation.
- 35. REFERENCE: https://en.wikipedia.org/wiki/Biliary_tract https://www.youtube.com/watch?v=d4MV8aRZd Kw https://www.youtube.com/watch?v=d30sRw5uh Ds https://www.researchgate.net/publication/30147 8331_Ultrasound_of_the_gallbladder_- _is_it_necessary_to_fast A radiological guide to Radioloical Procedures- Chapman Clarks special procedure in diagnostic imaging .
Editor's Notes
- and how they work together to make, store and secrete bile. Bile consists of water, electrolytes, bile acids, cholesterol, phospholipids and conjugated bilirubin. Some components are synthesised by hepatocytes (liver cells), the rest are extracted from the blood by the liver. Bile is secreted by the liver into small ducts that join to form the common hepatic duct. Between meals, secreted bile is stored in the gall bladder. During a meal, the bile is secreted into the duodenum to rid the body of waste stored in the bile as well as aid in the absorption of dietary fats and oils.
- The liver Anatomy: The liver lies to the right of the stomach and overlies the gallbladder. The human liver in adults weighs between 1.4-1.6 kilograms (3.1-3.6 pounds). It is a soft, pinkishbrown, triangular organ. It is both the largest internal organ and the largest gland in the human body. The liver is a vital organ present in vertebrates and some other animals. A human can last up to 24 hours without liver function. It plays a major role in metabolism and has a number of functions in the body. It produces bile, an alkaline compound which aids in digestion, via the emulsification of lipids. It also performs and regulates a wide variety of high-volume biochemical reactions requiring very specialized tissues. Functions: The Liver produces and excretes bile required for emulsifying fats. Some of the drains directly into the duodenum, and some are stored in the gallbladder. It also plays several roles in carbohydrate metabolism and lipid metabolism. The conversion of ammonia to urea is performed by the liver. It produces the major osmolar component of blood serum, albumin.
- Anatomy: The Gallbladder is connected to the liver and the duodenum by the biliary tract. The cystic duct connects the gallbladder to the common hepatic duct to form the common bile duct. The common bile duct the joins the pancreatic duct and enters through the hepatic pancreatic ampulla at the major duodenal papilla. The gallbladder is a pear or oval shaped digestive organ located under the right side of the liver, and connected to the small tubes called bile ducts and to the small intestine through which bile flows. It is about 3-4 inches long in humans and appears dark green because of bile. It stores and concentrates bile and helps in digestion of fats. Every day the liver produces almost a liter of bile and the gallbladder helps in storing and concentrating. The hormone causes the Gallbladder to contract, joining bile into the common bile duct. A valve which opens only when food is present in the intestine, allows bile to flow from the common bile duct into duodenum. Sometimes the substances contained in bile crystallize in the Gallbladder forming Gall stones, a disease of gallbladder. Function: Bile is continually being made and secreted by the liver into bile ducts in varying amounts. Some of it goes directly into the small intestine and into the gallbladder. The gallbladder stores the bile to help to breakdown the fats of fatty meals. It also acts as a reservoir that uptakes excess bile when there is pressure in the bile ducts. Necessity of the gallbladder The Gallbladder seems to be a vestigial organ. Indeed, gallbladders have been removed from people for over one hundred years without any known side effects. However if one eats a particularly rich and or fatty meal, some degree of diarrhea may result
- It begins with many small branches which end in the common bile duct, referred as trunk of the biliary tree. It is divided in three parts: Cystic duct Common hepatic duct Common bile duct The biliary tract (biliary tree) is the common anatomy term for the path by which bile is secreted by the liver on its way to the abdomen or small intestine. It is referred to as a tree because it begins with many small branches end in the common bile duct, sometimes referred to as the trunk of the biliary tree. Bile flows in opposite direction to that of the blood present in the other two channels. Cystic duct The cystic duct is the short duct that joins the gallbladder to common bile duct. It usually lies next to the cystic artery. It ranges from 2 to 5 mm and its length from 10 to 60 mm. The number of folds varies between 2 to 14. The human cystic duct functions for the transport of bile during both filling and emptying the gallbladder. Common hepatic duct The common hepatic duct is formed by the convergence of the right hepatic duct and the left hepatic duct. The common hepatic duct then joins the cystic duct coming from the gallbladder to form the common bile duct. It measures usually 6-8 cm in length and approximately 6 mm wide in adults. The hepatic duct transports more volume in the people who have had their gallbladder removed. Common bile duct The duct that carries bile from the gallbladder and liver into the duodenum is called common bile duct. The common bile duct is formed by the function of the cystic duct that comes from the gallbladder and the common hepatic duct that comes from the liver.
- Unfortunately the affect of abdominal gas on sound waves often resulted in sub-standard images. Realising the importance of reducing gas, patient fasting was introduced in an attempt to overcome the problem Historically the gallbladder was one of the first organs imaged with ultrasound.