This document discusses hepatobiliary pancreatic imaging findings and procedures. It includes radiographic images and descriptions of gallstones, bile duct stones, chronic pancreatitis, and worm in the bile duct. Imaging modalities discussed include plain radiography, ultrasound, ERCP, MRCP, and CT. Procedures described include ERCP, T-tube cholangiography, sphincterotomy, lithotripsy, and surgical treatments. Complications and management strategies for various hepatobiliary pancreatic conditions are also summarized.

1. 6. Hepato biliary pancreatic

2. Plain radiograph showing radiopaque stones in the gallbladder.
Radio opaque stones are rare (10 per cent); most are lucent.
Triradiate or mercedez benz sign; sea gull sign

3. Porcelain gall bladder.

4. Endoscopic retrograde cholangiopancreatography:
normal cholangiogram.
Pancratic duct
Hepatic duct
cbd
scope

5. ERCP demonstrating the biliary tract with multiple stones in the distal common bile duct.
CBD
LUCENT SHADOWS
OF STONES
DILATED PROXIMAL DUCTS

6. ERCP showing
common duct obstruction due to a stone (arrow).
Stone

7. PTC-- the biliary tract shows
the multiple strictures typical of primary sclerosing cholangitis.
Ptc needle

8. Transhepatic cholangiogram showing a stricture of the
common hepatic duct

9. T-tube cholangiogram- filling defect
Retained stone

10. Barium meal - Pseudocyst displacing the stomach

11. Stones in pancreatic duct-tropical pancreatitis

13. ERCP - There is a long linear filling defect in the bile
duct suggestive of a round worm in the bile duct

14. ERCP- The pancreatic duct is dilated, suggestive of chronic pancreatitis

15. ERCP showing dilated pancreatric duct. The common bile duct is dilated and there is narrowing at the
terminal part of the common bile duct. The gallbladder is opacified and there is a radiolucent filling
defect in the lumen of the gallbladder. So, this is suggestive of chronic pancreatitis with CBD
compression and cholelithiasis

16. T-tube cholangiogram – The T-tube is seen in situ. The common bile duct, hepatic ducts and the
intrahepatic biliary radicles are dilated and there are two filling defects within the lumen of the bile
duct. These are suggestive of residual radiolucent common bile duct stones. The dye has gone into
the duodenum suggesting no obstruction in the terminal bile duct

17. T-tube cholangiogram -- The bile duct is dilated and there is a radiolucent filling defect at the lower
end of the bile duct. The dye, however, has reached the duodenum. This X-ray appearance is
suggestive of residual
stone in the bile duct following choledo cholithotomy

18. What percentage of gallstone and kidney stones are radiopaque? About 10% gallstones and 90% kidney stones are radiopaque.
• What are the D/D of a radiopaque shadow in RUQ region? Kidney stone, Gallstones, Pancreatic calculi, Foreign body, Fecolith, Phleboliths, calcified lymph node, calcified renal
tuberculosis, calcified adrenal gland, chip fracture of a transverse process of vertebra or calcification of costal cartilage.
• How will you confirm your diagnosis? by lateral view - Gall stone lies anterior and Kidney stone lies posterior to the vertebral body or overlaps the vertebral body „ by an ultrasonography.
• What is limey bile? Bile with a mixture of calcium carbonate and calcium phosphate,
• What are the different types of gallstones?
• What are the characteristics of cholesterol gallstones?
• What are the characteristics pigment stones?
• What are the characteristics of mixed stones?
• What are the composition of gallstone?
• How does the cholesterol stone forms?
• How does the pigment stone forms?
• How patients with gallstone disease presents?
• What do you mean by silent or asymptomatic gallstones?
• What is the chance of such patients developing symptoms in follow-up?
• Most of the series has shown that the chance of developing symptoms is around 10% in 5 years follow-up and 15–20% in 15 years follow-
up.

19. • Do all patient with silent stone need treatment? As the chance of developing symptoms in follow-up is not very high
(10% in 5 years follow-up) routine cholecystectomy for all silent gallstones is not indicated.
• What are the indications of treatment for silent gallstones? Elderly patients with diabetes mellitus, Patients on
immunosuppressive therapy or on dialysis, Family history of carcinoma gallbladder or patient living in an area with high incidence of gall bladder carcinoma, Large
gall stones >2.5 cm, Multiple small gallstones.
• How an ERCP is done?
• How do you know that the cannula has gone into the pancreatic duct or the bile duct? If the
cannula goes obliquely across the vertebral body it is most likely to go into the pancreatic duct. If the cannula has gone into the bile duct it will be seen
going vertically up along the side of the vertebral body.
• How will you extract stone from bile duct endoscopically? An endoscopic sphincterotomy is done at
12’oclock position: Dormia basket extraction.
• What are the complications of ERCP? ERcP may be associated with a number of complications: „cholangitis „Acute pancreatitis „
Bleeding „Duodenal injury.
• What are the consequences of worm in bile duct? „Majority of adult worms migrating into the bile duct dies after few weeks. „The
dead worm may form a nidus for formation of primary bile duct stones—Usually pigment stones „Spontaneous expulsion. „Secondary infection of the bile duct with E. coli
leading to suppurative cholangitis „cholangiectatic liver abscess. „Empyema gallbladder. „Bile duct stricture.

20. • How will you manage a patient with worm in bile duct? „Uncomplicated case: Treatment with antispasmodic drugs may
relax the sphincter of oddi and may allow spontaneous expulsion of the worm into the duodenum „Treatment of complications. „Removal of warm by endoscopic
sphincterotomy or by open operation—choledochotomy.
• How can you see pancreatic stones better? Majority of the pancreatic stones are radiopaque, so are better seen in a plain X-ray
of abdomen.
• How else you can visualize the pancreatic duct? „Magnetic resonance cholan giopancreaticography (MRcP) „cT scan of
pancreas .
• What is the normal dimension of pancreatic duct? In the head region—5 mm, In the body—3 mm, In the tail—2 mm.
• What is chronic pancreatitis? What are the most common causes of chronic pancreatitis?
• What is pancreas divisum?
• How does patient with chronic pancreatitis usually presents? „Abdominal pain „Variable weight loss „Insulin
dependent diabetes mellitus.„Steatorrhea
• What is the medical treatment for chronic pancreatitis? „Diet: A diet low in fat is helpful. „Stop alcohol. „Pancreatic
enzyme supplementation. „Treatment of acute exacerbation—nil orally, IV fluid, analgesics, prophylactic antibiotics. „control of diabetes—Requires insulin.
• Patients with chronic pancreatitis are more prone to hypoglycemic attacks when treated with
insulin, why? In chronic pancreatitis there is associated glucagon deficiency, so the chance of hypoglycemia is more.

21. • What are the indications of surgery in chronic pancreatitis? „Pain-persistent severe pain „common bile duct
obstruction. „Duodenal obstruction. „colonic obstruction. „Suspicion of pancreatic cancer. „complication of pseudocyst. „Portal vein obstruction causing portal
hypertension.
• What are the indication for pancreatic resection—distal pancreatectomy or Whipple’s
operation in chronic pancreatitis? „chronic pancreatitis with a normal duct diameter. „Failure of previous pancreaticojejunostomy. „
Pathologic change is confined to one part of the pancreas and the rest of the pancreas is normal.
• How T-tube cholangiography is done?
• How will you differentiate an air bubble from a filing defect due to a stone? An air bubble in T-tube
cholangiogram will appear as: „Perfectly round. „Dense black filling defect „Air bubble goes up in head-up position and goes down with head-down position. A filling
defect to a calculus is not densely black, usually not completely round and change direction opposite to the air bubble with change of posture, if the stone is
impacted there will be no change of position of the filling/defect with change of posture.
• How will you manage retained stone patient? mechanical flushing with heparinised saline, dormia basket extraction, contact
dissolution, Burhenne technique, ESWL, Laparoscopic choledocholithotomy, open choledocholithotomy.
• What is contact dissolution? If the stone is a pure cholesterol one, contact dissolution by infusing monooctanoin or methyl terbutyl ether via
the T-tube tract may be helpful.
• What is Burhene technique for extraction of residual bile duct stones?
• What is the role of extracorporeal shock wave lithotripsy?

22. • If the retained stone is detected after the removal of T tube how will you manage ? Endoscopic
sphincterotomy and stone extraction by a Dormia basket, Extracorporeal shock wave lithotripsy—If the stone is large it may not be suitable for EcSWL with
adjunctive procedure like endoscopic extraction, biliary lavage and stenting, Percutaneous transhepatic route and Dormia basket extraction through
cholangioscope, Laparoscopic or open choledocholithotomy.