Hepatobiliary system radiology revision notes

Hepatobiliary system
TONY SCARIA 2010 KMC

Couinad bismuth system

Cantlies line  line joining IVC
to GB contain middle hepatic V

Oral cholecystography
• Graham & cole in 1924

OCG
• Now has been replaced by USG
• Contrast media used ]
• Ipanoic acid (tele[aque)
• Biloptin
• Solubiloptin
• 2 doses of 3mg dye is given

Visualisation of GB depends upon
• Ingestion of dye
• Absorption of dye
• Blood flow to liver enterohepatic circulation
• Take up in liver (functional liver)
• Ability of liver to secrete in bile
• Ability of GB to concentrate the excreted dye
• patency of hepatic & cystic duct

Percutaneous transhepatic cholangiogram
• To diagnose upper CBD
obstruction

ERCP
• ERCP
• To diagnose lower CBD obstruction

Nuclear imaging of liver
Hepatobiliary scintigraphy Colloid scintigraphy
HIDA scan
To assess functionjg of hepatocytes & assess
functioning of biliary system
Sulphur colloid scintigraphy
Functioning of Kupffer cells

HIDA scan
• Uses
• To exclude biliary atresia
• Most accurate investigation for a/c cholecystitis
• IOC is USG

HIDA scan to detect a/c cholecystitis
• It also used to detect biliary atresia
• Technitium 99 labelled iminodiacetic acid is injected IV
it is picked up by Kupffer cells & excreted in bile
• Helps in clear visualisation of biliary tract

ERCP
• To visualise lower CBD
• Biliary & pancreatic system
• Combined endoscopic & radiographic procedure
• Iodinated contrast agents are also used

MRCP
• Non invasive
• Gadolinium based contrast is not used
• T2 weighted images are used for bile and pancreatic secretions in
biliary tree

Simple hepatic cyst
• Anechoic /hypoechoic
• With out septa
• Round or ellipsoid
• Absence of its own wall

Choledochal cyst  modani classification

Carolis disease  multiple intrahepatic cyts

Central dot sign in carolis ds
• Enhancing dots with in dilated intrahepatic bile ducts representing
portal radicles
• Portal vein around dilated biliary duct
• Type V

Cavernous haemangioma
• Mc benign tumour of liver  hemangioma
• Located in postero-superior quadrant of liver of right lobe

Radiological features of haemangioma
USG • Most of haemangioma are homogenous
echogenicity
• Or may show mixed echogenicity
MRI • Most accurate if lesion <2.5 cm
Hepatic scintigraphy • Accurate if lesion > 2.5 cm
CECT • In arterial phase  enhancement of peripheral
portion of the lesions (ring enhancement / globular
enhancement)
• Centre may remain hypodense

Light bulb appearance on MRI

Hyperechoic lesion on USG
Delayed enhancement
of centre
Early enhancement
& rapid wash out
Centripetal homogenous in
case of haemangioma after
initial peripheral nodular
enhancement
Hepatocellular
carcinoma

Intrahepatic hydatid cyst

Intrahepatic hydatid cyst
• Honey comb appearance
• Floating lily sign

Porcelain GB can be seen on x ray 
indication for cholecystectomy
• As it is premalignant

Porcelain GB

Porcelain GB on CT scan

Gall stones
• Best detected by USG

Investigation in gall stones
USG • IOC in case of detection of gall stone & obstructive
jaundice
• WES wall echo shadow
• Double arc shadow sign
Plain X ray • Only 10 % radiopaque
Oral cholecystography • Dye used is ipanoic acid
Cholangiogram • Crescentic shadow or meniscus sign
CT scan • Limited value in gall stones
• Since gall stones have radiographic density as bile
 not detectable by CT

Double arc sign

Wall echo shadow sign in c/c contracted GB

Meniscus sign d/t stone in cholangiogram

a/c cholecystitis
USG IOC
HIDA scan MOST ACCURATE (non visualisation of GB)

Air in gall stone  triradiate lucency
• Mercedez benz sign
• Sea gull sign
• Crow feet sign

Mercedez benz sign
• In gall stones
• Star shaped pattern of gas fissuring with in gall stones

Mercedez benz sign

Riglers triad in gall stone
Small bowel
obstruction
Ectopic Gall stone
Pneumobilia

GB adenomayomatosis
• Mc form cholecystoses
• Segmental or diffuse thickening of muscular wall
• In the thickened wall  small cystic spaces are present (Rokitansky
aschoff sinus)

GB adenomyomatosis

Comet tail artefacts in GB adenomyomatosis

Cholesterosis
• Deposits of cholesterol
crystals in epithelial cells
& macrophages

Pneumobilia
• Gall stone erosion & gall stone
ileus
• Infection (emphysematous
cholecystitis)
• Carcinoma of GB
• ERCP & sphincterotomy

Pneumobilia

Triangular cord sign
• Biliary atresia on USG of neonate

Linear filling defect in ERCP in ascariasis

• Budd chiari syndrome
• Spider web sign  d/t venous
collaterals

a/c pancreatitis
X ray • Gasless abdomen
• Colon cut off sign
• Sentinal loop sign
• Renal halo sign
CECT • IOC

Gas less abdomen in pancreatiits
• d/t repeated vomiting & duodenal
spasm

Sentinel loop sign
• Non specific sign
• Focal dilated proximal jejunal loop in left upper
quadrant

Renal halo sign in a/c pancreatitis
• d/t pancreatic fluid collection around
kidney

Colon cut off sign
• d/t spasm  no air in descending colon

Balthazar CT scoring system in a/c pancreatitis

c/c pancreatitis
Plain x ray • Multiple calcification across pancreas
Upper GI barium study • Reverse 3 sign in duodenum (similar appearance in
pancreatic carcinoma)
ERCP • IOC
• Chain of lake / string of pearl (d/t fibrosis)
• Rat tail stricture in CBD

Calcification in region of pancreas in case of
c/c pancreatiitis

Rat tail stricture of CBD in c/c pancreatitis

• Chain of lakes appearance in
ERCP is seen is
• Chronic pancreatitis

c/c pancreatitis
• IOC
• EUS
• MRCP chain of lake appearance
• MDCTintraductal calculus with duct dilation

Carcinoma pancreas
Double duct sign
Widening of C loop of duodenum
Mucosal irregularity
Rose thorning of medial wall of 2nd part of duodenum d/t puckering of medial wall
Scrambled egg appearance d/t irregularity
Inverse / reverse 3 sign of frostberg

frostburg inverted 3 sign
• Barium meal
• Effacement & distortion of
mucosal pattern on the medial
wall of 2nd part of duodenum
• Carcinoma head of pancreas
• Duodenum carcinoma
• c/c pancreatitis

Double duct sign

Spongy appearance with central sunburst
calcification
• Central sunburst calcification
• With multiple cystic lesion

• Spongy appearance with central sunburst calcification Serous
cystadenoma
Central sun burst

• widened duodenal
'C'loop with irregular
mucosal pattern on
upper gastrointestinal
barium series
• Carcinoma head of
pancreas

Double duct sign
• d/t simultaneous dilation of bile duct & pancreatic duct
• d/t periampullary carcinoma
• Seen in MRI CT ERCP

• Selenium 75  pancreatic scanning radio isotope used

Prune tree appearance on ERCP in primary sclerosing cholangitis

Hepatobiliary system radiology revision notes

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Hepatobiliary system radiology revision notes