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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 
bilia...
ANATOMY OF BILIARY TREE 
Biliary tree is divided into: 
 Intrahepatic ducts 
 Extrahepatic ducts 
INTRAHEPATIC DUCTS 
 ...
 The Rt.hepatic duct drains four segments of 
Rt.lobe of liver through two segmental divisions 
,an anterior division dra...
EXTRA HEPATIC BILE DUCTS 
 The right and left hepatic ducts fuse at the 
hilum ,anterior to bifurcation of the portal vei...
ARTERIAL SUPPLY 
Three segments of supply. 
 Supply to the Supraduodenal part is essentially axial 
from Retroduodenal ar...
DEVELOPMENTAL INTRAHEPATIC 
BILIARY ANOMALIES 
Variations occur: 
 Triple confluence of the Rt.posterior sectoral, Rt.ant...
EXTRAHEPATIC BILIARY ANOMALIES 
A number of anomalies with important radiological 
implications are; 
 Agenesis of gall b...
INVESTIGATION 
Radiological investigations comprise of : 
 Plain radiograph 
 Ultrasound 
 Computed tomography 
 Magne...
Plain Radoigraph 
 Plain radiograph is usually taken as part of 
sequence of investigation of abdominal 
pain. 
 It give...
ULTRASOUND 
 the first line investigation particularly calculous disease(over 
98% accuracy). 
 Preperation: 
Fasting fo...
COMPUTED TOMOGRAPHY 
 The sensitivity of CT in differentiating hepatocellular 
from obstructive jaundice and in determini...
RADIONUCLIDE IMAGING 
99mTc-HIDA is used to study the action of biliary tree. 
TECHNIQUE 
 Between 2 and 10 mCi of 99mTc-...
99mTc-HIDA scan. Biliary obstruction. Activity on the serial 
images is concentrated in the liver and none has traversed t...
INDIRECT CHOLANGIOGRAPHY 
ORAL CHOLANGIOGRAPHY 
 It has a limited role in anatomical and functional 
assessment of gall b...
Small Cholesterol calculi which float in the erect 
posture 
(A) Prone (B) Erect
PERCUTANEOUS 
CHOLANGIOGRAPHY (PTC) 
 Direct puncture of the intrahepatic ducts using a fine-gauge 
Chiba needle allows d...
ENDOSCOPIC RETROGRADE 
CHOLANGIOPANCREATOGRAPHY (ERCP) 
 ERCP is a technique that combines endoscopy and fluoroscpy 
Thro...
Risk factors involve in ERCP are: 
 Pancreatitis 
 Gut perforation 
 Sphincterotomy associated bleeding.
OPERATIVE CHOLANGIOGRAPHY 
Operative cholangiography prior starting surgical 
procedure is done commonly at the time of 
c...
DEVELOPMENTAL DISORDERS OF CHILDHOOD 
 BILIARY ATRESIA 
 CHOLEDOCHAL CYST 
 CAROLI,S DISEASE
BILIARY ATRESIA 
 Atresia of the extrahepatic bile ducts in newborn 
infants of unknown etiology. 
 Incidence is 0.8-1.0...
Severe biliary atresia with obliteration of intrahepatic bile 
ducts. Hyperplastic lymphatics allow some drainage of bile ...
Choledochal cyst 
 Cystic dilatation of extrahepatic bile ducts in chilldhood 
Presented by; 
 jaundice from obstruction...
Fusiform choledochal cyst with a 
long common channel and 
associated stricture at the 
pancreaticobiliary junction. 
CT o...
CAROLI,S DISEASE 
 It is characterised by multifocal, saccular dilatation of 
intrahepatic bile ducts sparing the extrahe...
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 TUM...
Inspissated bile plug syndrome 
 Infants may present with jaundice secondary to plugs 
of thickened bile or rarely obstru...
Cholelithiasis 
 Cholelithiasis is being increasingly 
diagnosed in childhood. 
 Phototherapy,infection,ileal resection ...
DISORDERS OF GALL BLADDER 
GALL STONES 
 Upto 17% of adult population have gallstones. About 
50% of detected calculi rem...
CALCULUS CHOLECYSTITIS 
 This results when a calculus obstructing the cystic duct cause 
infection of static bile and the...
Calcium carbonate(mulberry) 
stones 
Mercedes Benz' stone; characteristic 
appearance on the plain embolisation 
radiograp...
on u/s in the acute phase; 
 Echogenic intraluminal foci representing calculi 
 Mural thickening >3mm with a halo around...
U/S AND CECT SHOWING TINY STONES, SLUDGE AND GALL BLADDER 
WALL THICKENING AS WELL AS ECHOGENIC INFLAMATORY CHANGES 
IN AD...
COMPLICATIONS OF CHOLECYSTITIS 
 Persistent transmural infection may result in a 
gangrenous gall bladder that may perfor...
PORCELAIN GALL BLADDER 
 A porcelain gallbladder is a rare disorder in 
which chronic cholecystitis produces mural 
calci...
U/S AND PLAIN RADIOGRAPH SHOWING GB WALL 
CALCIFICATIONS i.e. PORCELAIN GALL BLADDER
Acalculus cholecystitis 
 Approx. 5% cases of acute cholecystitis occur in 
the absence of gall stones. 
 Etiology is mu...
EMPHYSEMATOUS CHOLECYSTITIS 
 infection from gas forming organisms like Clostridium Welchii 
within the GB wall or lumen....
Emphysematous cholecystitis showing (A) gas in the 
lumen and wall of the gallbladder and (B) a gas-fluid 
level in the er...
CHOLESTEROSIS 
There is diffuse deposition of cholesterol 
on the gall bladder mucosa. 
Generally asymptomatic. 
Deposits ...
ADENOMYOMATOSIS 
 It is a benign, usually asymptomatic condition that 
may produce diffuse or focal wall thickening due t...
Oral cholangiography reveals three types of pictures , 
 Fundal nodular filling defect 
 Strictures at any site with in ...
Fundal nodule of adenomyomatosis before and aftergallbladder contraction. 
Note long cystic duct medial to common bile duc...
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 usu...
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 mal...
GB CARCINOMA WITH MARKED GENERALISED WALL THICKENING WITH FEW 
CALCULI REPRESENTING FILLED LUMEN/CE-CT IMAGE SHOWS THICK W...
DISORDERS OF BILE DUCTS 
COMMON BILE DUCT AND INTRA HEPATIC STONES 
 The spectrum of presentation of common duct 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; ...
Benign postcholecystectomy stricture of Stricture of a hepaticojejunostomy. 
common duct (arrow). Typical site at 
the lev...
 CHRONIC PANCREATITIS 
Any cause pancreatitis may result in a low bile duct 
stricture and biliary obstruction. 
 BLUNT ...
PRIMARY SCLEROSING CHOLANGITIS 
This is a disease of unknown aetiology, characterized by an 
inflammatory process affectin...
Characteristic stricturing of sclerosing cholangitis involving 
the intra- and extrahepatic biliary system.
PARASITIC INFECTION 
 The common parasites which infest the biliary system are; 
 CLONORCHIS SINENSIS: 
This is endemic ...
 ECCHINOCOCCUS GRANULOSUS 
In hydatid disease of liver, biliary manifestations like 
cholangitis and jaundice result from...
Ascoris lumbricoides. Ascaris worm 
in the biliary ducts. 
Cholecystostomy tube study showing 
multiple worms extending fr...
TUMOURS OF BILE DUCT 
CHOLANGIOCARCINOMA/KLATSKIN 
 This develops at young age mostly presents under 
the age of 50.There...
Cholangiocarcinoma of the hilum with a characteristic stricture 
involving the confluence of the main left and right hepat...
Ampullary and Pancreatic carcinoma 
Ampullary and Pancreatic carcinoma. 
 These are the most common causes of a malignant...
Billiary cystadenoma and Cystadenocarcinoma. 
 These are rare tumours of biliary epithelium present as 
complex, cystic m...
Low common bile duct stricture, 
with characteristic features of 
extrinsic compression from a 
pancreatic mass (arrow). 
...
INDICATIONS OF ENDOSCOPIC 
SPHINCTEROTOMY 
 CBD stones with or without GB stones 
 CBD stones following cholecystectomy ...
INDICATIONS OF STENTING FOR BENIGN BILE DUCT 
DISORDERS 
 Early structuring or anastomotic leak following liver 
transpla...
TYPES OF STENT 
 PLASTIC STENTS: They are made of Teflon 
 METALLIC STENTS: They are further divided into 
Self-expandin...
ANGIOGRAPHIC INTERVENTION 
 The main indication of angiographic intervention is 
embolization in the presence of haemobil...
Biliary tract
Biliary tract
Biliary tract
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Biliary tract

  1. 1.  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 duodenum.
  2. 2. ANATOMY OF BILIARY TREE Biliary tree is divided into:  Intrahepatic ducts  Extrahepatic ducts INTRAHEPATIC DUCTS  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.
  3. 3.  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 left lobe.  Caudate lobe has a variable drainage pattern but in majority, 78% drainage is into both main ducts.
  4. 4. 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
  5. 5. ARTERIAL SUPPLY 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.
  6. 6. DEVELOPMENTAL INTRAHEPATIC BILIARY ANOMALIES Variations occur:  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.
  7. 7. EXTRAHEPATIC BILIARY ANOMALIES A number of anomalies with important radiological implications are;  Agenesis of gall bladder.  Bilobar gall bladder.  Folded gall bladder.  Congenital diverticulum.  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.
  8. 8. INVESTIGATION Radiological investigations comprise of :  Plain radiograph  Ultrasound  Computed tomography  Magnetic resonance imaging  Radionuclide imaging  Indirect cholangiography
  9. 9. Plain Radoigraph  Plain radiograph is usually taken as part of sequence of investigation of abdominal pain.  It gives information about radiopaque stones, mural calcification, mural gas and gas in biliary tree.
  10. 10. ULTRASOUND  the first line investigation particularly calculous disease(over 98% accuracy).  Preperation: 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
  11. 11. COMPUTED TOMOGRAPHY  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 biliary tumours.
  12. 12. RADIONUCLIDE IMAGING 99mTc-HIDA is used to study the action of biliary tree. TECHNIQUE  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 evaluate excretion.  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 INDICATIONS  Neonatal and childhood jaundice  Cholesystitis  Biliary obstruction and Biliary leaks
  13. 13. 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.
  14. 14. INDIRECT CHOLANGIOGRAPHY ORAL CHOLANGIOGRAPHY  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 used is  sodium ipodite (Biloptin),  Calcium ipodite(Solubiloptin).
  15. 15. Small Cholesterol calculi which float in the erect posture (A) Prone (B) Erect
  16. 16. PERCUTANEOUS CHOLANGIOGRAPHY (PTC)  Direct puncture of the intrahepatic ducts using a fine-gauge Chiba needle allows demonstration of biliary tree with relative safety. INDICATIONS  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.
  17. 17. ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP)  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 purposes.  INDICATIONS  Obstructive jaundice  Gall stones with dilated bile ducts / Removal of stones  Sphincter of oddi dysfunction / Sphincterotomy  Bile duct tumors  Dilatation of strictures
  18. 18. Risk factors involve in ERCP are:  Pancreatitis  Gut perforation  Sphincterotomy associated bleeding.
  19. 19. OPERATIVE CHOLANGIOGRAPHY Operative cholangiography prior starting surgical procedure is done commonly at the time of cholecystectomy for:  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.
  20. 20. DEVELOPMENTAL DISORDERS OF CHILDHOOD  BILIARY ATRESIA  CHOLEDOCHAL CYST  CAROLI,S DISEASE
  21. 21. BILIARY ATRESIA  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 hyperbilirubinaemia.  u/s reveals hypoplastic gall bladder, a cystic cavity at porta and features of cirrhosis early in life.  Treatment is early portoenterostomy.
  22. 22. 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.
  23. 23. Choledochal cyst  Cystic dilatation of extrahepatic bile ducts in chilldhood Presented by;  jaundice from obstruction and cholangitis.  abdominal pain from pancreatitis.  Cholangiography reveals a long common pancreaticobiliary channel. TYPES 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.
  24. 24. Fusiform choledochal cyst with a long common channel and associated stricture at the pancreaticobiliary junction. CT of a large choledocal cyst with biliary obstruction
  25. 25. CAROLI,S DISEASE  It is characterised by multifocal, saccular dilatation of intrahepatic bile ducts sparing the extrahepatic ones.  Biliary stasis lead to cholangitis,ductal calculi and liver abscesses.  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.
  26. 26. Caroli's disease with characteristic strictures and segmental intrahepatic dilated ducts.
  27. 27. ACQUIRED DISORDERS OF CHILDHOOD  INSPISSATED BILE PLUG SYNDROME  SPONTANEOUS PERFORATION OF BILE DUCT  BILE DUCT TUMOURS  CHOLILITHIASIS  BILIARY STRICTURES  CHOLANGIOPATHIES OF CHILDHOOD
  28. 28. Inspissated bile plug syndrome  Infants may present with jaundice secondary to plugs of thickened bile or rarely obstructing calculi ,and acholic stools.  Aetiological factors include prematurity, prolonged parenteral nutrition,hemolysis developmental choledochal anomalies etc  Treatment is saline irrigation at percutaneous cholangiography or surgical intervention.
  29. 29. Cholelithiasis  Cholelithiasis is being increasingly diagnosed in childhood.  Phototherapy,infection,ileal resection hemolytic diseases contribute to this rising incident.  Spontaneous resolution is often reported in infancy, therefore conservative management is advisable.
  30. 30. DISORDERS OF GALL BLADDER GALL STONES  Upto 17% of adult population have gallstones. About 50% of detected calculi remain asymptomatic over a 10 year period. Stones may be of CHOLESTEROL PURE PIGMENT CALCIUM BILE SALTS MIXED
  31. 31. CALCULUS CHOLECYSTITIS  This results when a calculus obstructing the cystic duct cause infection of static bile and the gall bladder mucosa.  Differentiated into ACUTE CHOLECYSTITIS CHRONIC CHOLECYSTITIS RADIOLOGICAL INVESTIGATIONS PLAIN RADIOGRAPH 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)
  32. 32. Calcium carbonate(mulberry) stones Mercedes Benz' stone; characteristic appearance on the plain embolisation radiograph (arrowheads) and after removal (insert).
  33. 33. 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 state.
  34. 34. U/S AND CECT SHOWING TINY STONES, SLUDGE AND GALL BLADDER WALL THICKENING AS WELL AS ECHOGENIC INFLAMATORY CHANGES IN ADJACENT FAT
  35. 35. 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 ILEUS.  In acute cholecystitis, if local inflammatory process involves the common hepatic or common bile duct, condition is called MIRRIZZI SYNDROME.
  36. 36. PORCELAIN GALL BLADDER  A porcelain gallbladder is a rare disorder in which chronic cholecystitis produces mural calcification.  It is a precancerous condition.  In these patients a prophylactic cholecystectomy has been advocated because of its association with gallbladder carcinoma .
  37. 37. U/S AND PLAIN RADIOGRAPH SHOWING GB WALL CALCIFICATIONS i.e. PORCELAIN GALL BLADDER
  38. 38. Acalculus cholecystitis  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 .
  39. 39. EMPHYSEMATOUS CHOLECYSTITIS  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 cholecystitis.  PLAIN RADIOGRAPH shows gas shadows from the wall and lumen of GB along with gas-fluid levels demonstrated on erect posture.  SONOGRAPHICALLY 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.
  40. 40. Emphysematous cholecystitis showing (A) gas in the lumen and wall of the gallbladder and (B) a gas-fluid level in the erect posture.
  41. 41. CHOLESTEROSIS There is diffuse deposition of cholesterol on the gall bladder mucosa. Generally asymptomatic. Deposits are usually 1-2mm, multiple and fixed on scanning
  42. 42. ADENOMYOMATOSIS  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 Rokitansky_Aschoff sinuses.  Sonographically, the cholesterol crystals deposited in Rokitansky-Aschoff sinuses result in bright reflections and short comet-tail artefacts arising from GB wall
  43. 43. 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.
  44. 44. Fundal nodule of adenomyomatosis before and aftergallbladder contraction. Note long cystic duct medial to common bile duct,a congenital anomaly.
  45. 45. ADENOMYOMATOSIS SHOWING COMET-TAIL ARTEFACTS FROM THE SUPERFICIAL WALL OF GALL BLADDER
  46. 46. 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 bladder. SONOGRAPHICALLY  Appear as a non-mobile, non-shadowing “ball on the wall”.
  47. 47. Gall bladder polyp fixed to the ventral wall of the gallbladder.
  48. 48. 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 predisposing factors. RADIOLOGICALLY  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.
  49. 49. 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
  50. 50. 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.
  51. 51. Very large gallstone (arrow) in dilated bile duct shown at ERCP. ‘Meniscus’ sign of impacted stone (arrow) in bile duct.
  52. 52. 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 stricturing.  Hepatic resection; These operations carry the risk of arterial devascularisation of hepatic artery.  Transplantation; An anastomotic stricture will occur in 5-14 % of liver transplants.
  53. 53. Benign postcholecystectomy stricture of Stricture of a hepaticojejunostomy. common duct (arrow). Typical site at the level of ligation of cystic duct.
  54. 54.  CHRONIC PANCREATITIS 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 stricture formation.
  55. 55. PRIMARY SCLEROSING CHOLANGITIS This is a disease of unknown aetiology, characterized by an inflammatory process affecting the intra and extra hepatic ducts. 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 prognosis. 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.
  56. 56. Characteristic stricturing of sclerosing cholangitis involving the intra- and extrahepatic biliary system.
  57. 57. PARASITIC INFECTION  The common parasites which infest the biliary system are;  CLONORCHIS SINENSIS: 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 asymptomatic.  ASCARIS LUMBRICOIDES 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
  58. 58.  ECCHINOCOCCUS GRANULOSUS 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 ultrasound.  ENTAMOEBA HISTOLYTICA Amoebiasis may produce liver abscess which communicate segmental bile ducts producing cholangitis.
  59. 59. Ascoris lumbricoides. Ascaris worm in the biliary ducts. Cholecystostomy tube study showing multiple worms extending from common bile duct into duodenum.
  60. 60. TUMOURS OF BILE DUCT CHOLANGIOCARCINOMA/KLATSKIN  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.
  61. 61. Cholangiocarcinoma of the hilum with a characteristic stricture involving the confluence of the main left and right hepatic ducts.
  62. 62. Ampullary and Pancreatic carcinoma Ampullary and Pancreatic carcinoma.  These are the most common causes of a malignant bile duct stricture. 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 metastasis .
  63. 63. 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.
  64. 64. 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.
  65. 65. INDICATIONS OF ENDOSCOPIC SPHINCTEROTOMY  CBD stones with or without GB stones  CBD stones following cholecystectomy with or without a T-tube in place.  Ampullary carcinoma  Malignant bile duct strictures prior to stent insertion  Benign papillary stenosis  Post surgical strictures before dilatation or stent placement  Choledochal fistula  Choledochocele.
  66. 66. INDICATIONS OF STENTING FOR BENIGN BILE DUCT DISORDERS  Early structuring or anastomotic leak following liver transplant.  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.
  67. 67. 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)
  68. 68. ANGIOGRAPHIC INTERVENTION  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  Liver tumours  Vascular malformations  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.
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