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Bile is a bi-product of degraded heme part of
old red cells.
It is secreted by the liver ,transported through
biliary channels to gall bladder where it is
stored, concentrated and later delivered to the
ANATOMY OF BILIARY TREE
Biliary tree is divided into:
These comprise of ductular and canalicular network
from the acini . The smallest interlobular ducts join to
form segmental bile ducts which finally unite to form
the left and right hepatic ducts.
They travel with branches of portal vein & hepatic
artery in portal triads.
The Rt.hepatic duct drains four segments of
Rt.lobe of liver through two segmental divisions
,an anterior division drains segment 5 & 8 and
posterior division drains segment 6 & 7.
The Lt.Hepatic duct drains segment 2,3 & 4 of
Caudate lobe has a variable drainage pattern
but in majority, 78% drainage is into both main
EXTRA HEPATIC BILE DUCTS
The right and left hepatic ducts fuse at the
hilum ,anterior to bifurcation of the portal vein to
form Common Hepatic Duct which is then inserted
by cystic duct from the gall bladder and becomes
Common Bile Duct
The CBD passes inferiorly posterior to the first
part of duodenum and pancreatic head to enter the
second part of duodenum along with the main
pancreatic duct at Ampulla of Vater
Three segments of supply.
Supply to the Supraduodenal part is essentially axial
from Retroduodenal artery, Rt.hepatic artery, Cystic
artery and Gastroduodenal artery.
Hilar biliary ducts recruit their supply from a network
in continuity with the Supraduodenal supply.
Retropancreatic part of common bile duct is derived
from Retroduodenal artery.
Triple confluence of the Rt.posterior sectoral, Rt.anterior
sectoral and main Left Hepatic duct(12%)
Direct insertion of Rt.sectoral duct into main bile duct(20%)
Insertion of Rt.sectoral duct into Lt.hepatic duct(3%)
Insertion of Rt.posterior sectoral duct into Cystic duct or gall
bladder may occur.
Failure to recognise these anatomical variations at
cholangiography or surgery may result in biliary leaks or
impaired drainage lead to cholangitis.
EXTRAHEPATIC BILIARY ANOMALIES
A number of anomalies with important radiological
Agenesis of gall bladder.
Bilobar gall bladder.
Folded gall bladder.
Duplication of cystic duct with a unilocular gall bladder.
Septum of gall bladder.
Anomalies of gall bladder position i.e it may lie in an
intrahepatic, suprahepatic or retrohepatic site or herniate
through epiploic foramen.
These anomalies if complicated by disease carry high morbidity.
Plain radiograph is usually taken as part of
sequence of investigation of abdominal
It gives information about radiopaque
stones, mural calcification, mural gas and
gas in biliary tree.
the first line investigation particularly calculous disease(over
Fasting for a minimum of 6 hours
Scanning in two positions,supine and left lateral ensures to find
any missed calculus.
U/S detects dilated Intrahepatic and extrahepatic ducts,
cholelithiasis, cholecystitis, GB polyp, choledochal cyst etc
The sensitivity of CT in differentiating hepatocellular
from obstructive jaundice and in determining the level
and cause of obstruction parallels that of ultrasound.
CT is reserved for those patients in whom there is
doubt as to the cause of obstruction and in staging of
99mTc-HIDA is used to study the action of biliary tree.
Between 2 and 10 mCi of 99mTc-HIDA is administered intravenously after a
2 hr fast. Images are acquired over the next hour at 1min intervals.
Subsequent images may be required at various intervals over 24 hours to
The normal HIDA scan provides functional and morphological
information about hepatic parenchyma in the first 10 min, the extrahepatic
biliary tree by 20 min, and excretion into the bile by 1 hr
Neonatal and childhood jaundice
Biliary obstruction and Biliary leaks
99mTc-HIDA scan. Biliary obstruction. Activity on the serial
images is concentrated in the liver and none has traversed the
biliary tree into the gut. Cardiac activity is shown to decrease
as more and more of the
active agent is extracted by and concentrated in the liver.
It has a limited role in anatomical and functional
assessment of gall bladder but the diagnostic accuracy in
demonstrating gall stones is upto 90%. The media commonly
sodium ipodite (Biloptin),
Small Cholesterol calculi which float in the erect
(A) Prone (B) Erect
Direct puncture of the intrahepatic ducts using a fine-gauge
Chiba needle allows demonstration of biliary tree
with relative safety.
Obstructed jaundice with or without duct dilatation.
In defining biliary-enteric or biliary-cutaneous fistulas.
In defining levels of bile leak.
To map biliary tree as a preliminary to establish external
or internal biliary drainage with stent placement.
ERCP is a technique that combines endoscopy and fluoroscpy
Through endoscope, inject dyes into ampulla of vater and can
see the biliary tree and pancreatic duct
ERCP can be used both for diagnostic and therapeutic
Gall stones with dilated bile ducts / Removal of stones
Sphincter of oddi dysfunction / Sphincterotomy
Bile duct tumors
Dilatation of strictures
Risk factors involve in ERCP are:
Sphincterotomy associated bleeding.
Operative cholangiography prior starting surgical
procedure is done commonly at the time of
Exploration of CBD
Anomalous duct anatomy
Developmental disorders of biliary tree.
Postoperative cholangiography through a T-tube is
indicated to ensure removal of all stones.
Atresia of the extrahepatic bile ducts in newborn
infants of unknown etiology.
Incidence is 0.8-1.0 /10,000 live births.
Associated anomalies like polysplenia, situs inversus,
malrotation and absent inferior vena cava occurs in
upto 30% of cases.
Presentation is with prolonged conjugated
u/s reveals hypoplastic gall bladder, a cystic cavity at
porta and features of cirrhosis early in life.
Treatment is early portoenterostomy.
Severe biliary atresia with obliteration of intrahepatic bile
ducts. Hyperplastic lymphatics allow some drainage of bile into the
constructed portoenterostomy (Kasai procedure). This is the most
common type and carries the worst prognosis.
Cystic dilatation of extrahepatic bile ducts in chilldhood
jaundice from obstruction and cholangitis.
abdominal pain from pancreatitis.
Cholangiography reveals a long common pancreaticobiliary
TYPE I _ Cystic or fusiform
TYPE II _ Diverticulum
TYPE III _ Choledochocele of intraduodenal common bile duct.
TYPE IV_ Extra and intrahepatic cysts.
TYPE V _ Intrahepatic dilatation.
Diagnosis is mainly by u/s and cholangiography.
Treatment is redical excision of cyst and hepaticojujenostomy.
Fusiform choledochal cyst with a
long common channel and
associated stricture at the
CT of a large choledocal cyst
with biliary obstruction
It is characterised by multifocal, saccular dilatation of
intrahepatic bile ducts sparing the extrahepatic ones.
Biliary stasis lead to cholangitis,ductal calculi and liver
A specific sonographic apperance is ”central dot”
sign, occurs when dilated bile duct segment surrounds
the adjacent hepatic artery and portal vein.
It is usually associated with congenital hepatic fibrosis
and cystic disease of kidneys called AUTOSOMAL
RECESSIVE FIBRO POLYSTIC DISEASE.
Caroli's disease with characteristic strictures and
segmental intrahepatic dilated ducts.
ACQUIRED DISORDERS OF CHILDHOOD
INSPISSATED BILE PLUG SYNDROME
SPONTANEOUS PERFORATION OF BILE DUCT
BILE DUCT TUMOURS
CHOLANGIOPATHIES OF CHILDHOOD
Inspissated bile plug syndrome
Infants may present with jaundice secondary to plugs
of thickened bile or rarely obstructing calculi ,and
Aetiological factors include prematurity, prolonged
parenteral nutrition,hemolysis developmental
choledochal anomalies etc
Treatment is saline irrigation at percutaneous
cholangiography or surgical intervention.
Cholelithiasis is being increasingly
diagnosed in childhood.
hemolytic diseases contribute to this rising
Spontaneous resolution is often reported
in infancy, therefore conservative
management is advisable.
DISORDERS OF GALL BLADDER
Upto 17% of adult population have gallstones. About
50% of detected calculi remain asymptomatic over a
10 year period.
Stones may be of CHOLESTEROL
CALCIUM BILE SALTS
This results when a calculus obstructing the cystic duct cause
infection of static bile and the gall bladder mucosa.
Differentiated into ACUTE CHOLECYSTITIS
It is estimated that only 15% of gallstones are radiopaque.The
densest stones are of almost pure calcium carbonate described
as mulberry stones .They show stellate faceted appearance
with gas forming fissures(Mercedes Benz sign)
Mercedes Benz' stone; characteristic
appearance on the plain embolisation
radiograph (arrowheads) and after
on u/s in the acute phase;
Echogenic intraluminal foci representing calculi
Mural thickening >3mm with a halo around.
Peri cholicystic abscess formation.
Murphy,s sign, positive local tenderness.
Chronic cholecystitis results in a contracted gall bladder
sometimes with obliteration of lumen inspite of fasting
U/S AND CECT SHOWING TINY STONES, SLUDGE AND GALL BLADDER
WALL THICKENING AS WELL AS ECHOGENIC INFLAMATORY CHANGES
IN ADJACENT FAT
COMPLICATIONS OF CHOLECYSTITIS
Persistent transmural infection may result in a
gangrenous gall bladder that may perforate giving rise
to either a localised abcess or biliary peritonitus.
An empyema or mucocele may result if there is
continuing cystic duct obstruction.
Fistulation of calculus into small or large bowel with
associated enteric obstruction is termed GALL STONE
In acute cholecystitis, if local inflammatory process
involves the common hepatic or common bile duct,
condition is called MIRRIZZI SYNDROME.
PORCELAIN GALL BLADDER
A porcelain gallbladder is a rare disorder in
which chronic cholecystitis produces mural
It is a precancerous condition.
In these patients a prophylactic cholecystectomy
has been advocated because of its association
with gallbladder carcinoma .
U/S AND PLAIN RADIOGRAPH SHOWING GB WALL
CALCIFICATIONS i.e. PORCELAIN GALL BLADDER
Approx. 5% cases of acute cholecystitis occur in
the absence of gall stones.
Etiology is multifactorial and includes ischemia,
GB wall infection or cystic duct obstruction.
It may occur in very sick patients like after
major surgery, extensive trauma and prolonged
parentral nutrition .
infection from gas forming organisms like Clostridium Welchii
within the GB wall or lumen.
Most often occur in diabetics or immunocompromised patients.
Perforation is 5 times more likely than with calculus
shows gas shadows from the wall and lumen of GB along with
gas-fluid levels demonstrated on erect posture.
Manifests as very bright reflections from a non dependent part
of GB wall. The associated acoustic shadow is usually dirty and
in many cases has a demonstrable ring down artifact ,typical
sign of gas.
Emphysematous cholecystitis showing (A) gas in the
lumen and wall of the gallbladder and (B) a gas-fluid
level in the erect posture.
There is diffuse deposition of cholesterol
on the gall bladder mucosa.
Deposits are usually 1-2mm, multiple and
fixed on scanning
It is a benign, usually asymptomatic condition that
may produce diffuse or focal wall thickening due to
round cell infilteration,muscle hypertrophy and
mucosal herniations into the muscular layer called
Sonographically, the cholesterol crystals deposited in
Rokitansky-Aschoff sinuses result in bright reflections
and short comet-tail artefacts arising from GB wall
Oral cholangiography reveals three types of pictures ,
Fundal nodular filling defect
Strictures at any site with in gall bladder.
Epithelial sinuses, which may only become apparent
following contraction with contrast trapped within
small mural diverticula.
Fundal nodule of adenomyomatosis before and aftergallbladder contraction.
Note long cystic duct medial to common bile duct,a congenital anomaly.
ADENOMYOMATOSIS SHOWING COMET-TAIL ARTEFACTS
FROM THE SUPERFICIAL WALL OF GALL BLADDER
GALL BLADDER POLYPS
It is a benign, usually asymptomatic
condition that may produce cholesterol
polyps, which are usually small and are
the most common polypoid lesion of gall
Appear as a non-mobile, non-shadowing
“ball on the wall”.
Gall bladder polyp fixed to the ventral wall of the gallbladder.
GALL BLADDER CARCINOMA
Adenocarcinoma of gall bladder is associated with
stones in over 90% of cases.
Female to male ratio is 3: 1
Porcelain gall bladder and sclerosing cholangitis are
U/S and CT may demonstrate a soft tissue mass
within and adjacent to the gall bladder, often with
direct extension into related liver segments.
Cholangigraphy reveals biliary stricturing often with
intrahepatic ducts dilatation.
GB CARCINOMA WITH MARKED GENERALISED WALL THICKENING WITH FEW
CALCULI REPRESENTING FILLED LUMEN/CE-CT IMAGE SHOWS THICK WALLED
GALL BLADDER WITH LOCAL INFILTERATION IN ADJACENT LIVER PARENCHYMA
DISORDERS OF BILE DUCTS
COMMON BILE DUCT AND INTRA HEPATIC STONES
The spectrum of presentation of common duct stones
is wide, ranging from septicemia resulting from
untreated biliary obstruction and cholangitis to an
incidental finding on u/s.
May accompanied by Gall bladder stones.
Very large gallstone (arrow) in dilated
bile duct shown at ERCP.
‘Meniscus’ sign of impacted stone
(arrow) in bile duct.
BENIGN BILIARY STRICTURES
POST SURGICAL STRICTURES
Four main groups of operation carry the risk of stricture formation;
Cholecystectomy (open or laproscopic);
Bile duct injury,with transection or devascularisation , may result in a
post operative bile leak or stricture formation, site of cystic duct
insertion is at highest risk.
Biliary disconnection and drainage of the bile ducts;
Roux loop anastomosis to the common hepatic duct and
portoenterostomy (Kasai operation) carry a risk of anastomosis
These operations carry the risk of arterial devascularisation of hepatic
An anastomotic stricture will occur in 5-14 % of liver transplants.
Benign postcholecystectomy stricture of Stricture of a hepaticojejunostomy.
common duct (arrow). Typical site at
the level of ligation of cystic duct.
Any cause pancreatitis may result in a low bile duct
stricture and biliary obstruction.
BLUNT OR PENETRATING LIVER TRAUMA
Injury to bile duct or gall bladder occurs in approx.
5% of liver trauma cases leads to biliary leaks and
PRIMARY SCLEROSING CHOLANGITIS
This is a disease of unknown aetiology, characterized by an
inflammatory process affecting the intra and extra hepatic
The condition may occur at any age. Biliary cirrhosis and
hepatic failure ensue
There is a predisposition of developing bile duct cancer.
CHOLANGIOGRAPHY demonstrates multifocal stricturing of bile
ducts. Strictures of extrahepatic bile duct may be long or short
and multiple. Severity of extra hepatic involvement carry worse
U/S & CT may demonstrate segmental duct dilatation and
increased periductal reflectivity. Regional lymphadenopathy
may be seen ,this may be associated with features of cirrhosis
and portal hypertension.
Characteristic stricturing of sclerosing cholangitis involving
the intra- and extrahepatic biliary system.
The common parasites which infest the biliary system are;
This is endemic in South-East Asia, and enters the human
body from undercooked and contaminated fish. Live
worms within the biliary tree cause periductal fibrosis and
stone formation. However upto 75% patients remain
Endemic in Asia,Africa and South America. This worm
infests the small bowel. Upto 10%patients show biliary
infestation, among these 40% will have significant
complications. Septic cholangitis with biliary abscess,
cholecystitis with empyema and biliary strictures are the
sequelae which carry highest morbidity
In hydatid disease of liver, biliary manifestations like
cholangitis and jaundice result from rupture of the cyst
into bile duct. Diagnosis is confirmed by CT and
Amoebiasis may produce liver abscess which
communicate segmental bile ducts producing cholangitis.
Ascoris lumbricoides. Ascaris worm
in the biliary ducts.
Cholecystostomy tube study showing
multiple worms extending from common
bile duct into duodenum.
TUMOURS OF BILE DUCT
This develops at young age mostly presents under
the age of 50.There is male preponderance.
Slow growing, locally invasive tumour with frequent
involvement of hepatic artery and portal venous
system. Distant metastasis is not common, occurs in
only 12% of patients.
Tumour prognosis is poor with a survival of only 2
months if untreated.
Cholangiocarcinoma of the hilum with a characteristic stricture
involving the confluence of the main left and right hepatic ducts.
Ampullary and Pancreatic carcinoma
Ampullary and Pancreatic carcinoma.
These are the most common causes of a malignant bile duct
Indications for radiological assessment are,
Define site and size of tumour.
Confirm a tissue diagnosis by guided biopsy.
Determine operability by excluding, local involvement of
vessels, regional lymphadenopathy ,ascites and distant
Billiary cystadenoma and Cystadenocarcinoma.
These are rare tumours of biliary epithelium present as
complex, cystic masses within liver parenchyma which may
infiltrate segmental bile ducts.
Radiological assessment is based on determining segmental
distribution and vascular relationships.
Low common bile duct stricture,
with characteristic features of
extrinsic compression from a
pancreatic mass (arrow).
‘Double duct ‘ sign. Concomitant
strictures of pancreatic duct and
bile duct (arrows) diagnostic of
carcinoma of head of pancreas.
INDICATIONS OF ENDOSCOPIC
CBD stones with or without GB stones
CBD stones following cholecystectomy with or without
a T-tube in place.
Malignant bile duct strictures prior to stent insertion
Benign papillary stenosis
Post surgical strictures before dilatation or stent
INDICATIONS OF STENTING FOR BENIGN BILE DUCT
Early structuring or anastomotic leak following liver
As a preclude to definitive surgery in iatrogenic
transection of bile duct with biliary leak.
Failed stone extraction or a large impacting stone
associated with biliary obstruction
Benign strictures in patients unfit for surgery.
Recurrent anastomotic strictures following surgery.
TYPES OF STENT
PLASTIC STENTS: They are made of Teflon
METALLIC STENTS: They are further divided into
Self-expanding stents(Rosch-Z stent)
Balloon expandable stents(Palmaz-stent)
The main indication of angiographic intervention is
embolization in the presence of haemobilia.Patient
present with jaundice and GI bleeding with malena,
could be due to
Blunt or penetrating liver injury
Iatrogenic trauma, either surgical or following
percutaneous liver biopsy
Multiorgan failure with DIC.
ULTRASOUND shows reflective material within a
dilated gall bladder and bile duct.
ENDOSCOPIC CHOLANGIGRAPHY demonstrate clot
with in Bile duct and bleeding visible at the papilla.