Hepato-biliary System-

Imaging

Dr Sayed Munirpasha
Specialist Radiologist
LLH Hospital, Abu Dhabi.
Aims and objectives

• Study the Radio-anatomy of hepato-

biliary system.

• Various imaging modalities available.

• Common pathologies.
 Liver

 Largest solid organ in the body.

 Weight approximately 1.2 to 1.5kgs
 The liver performs more than 100
different functions, but the one
function most applicable to
radiographic study is the production of
large amounts of bile. It secretes from
800 to 1000 ml of bile per day.
 Couinaud classification
 The Couinaud classification of liver anatomy divides the
liver into eight functionally independent segments.

 Right hepatic vein divides the right lobe into anterior and
posterior segments.
 Middle hepatic vein divides the liver into right and left
lobes (or right and left hemiliver).
 Left hepatic vein divides the left lobe into a medial and
lateral part.
 Portal vein divides the liver into upper and lower
segments.
Anatomic liver segments
caudate lobe Segment I

Lateral segment left lobe Segment II

superior
Lateral segment left lobe Segment III
inferior
Medial segment left lobe Segment IV

Anterior segment right Segment V

lobe inferior
Posterior segment right Segment VI
lobe inferior
Posterior segment right Segment

lobe superior VII

Anterior segment right Segment

lobe superior VIII

 Choledochal cysts

 Choledochal cysts represent congenital

cystic dilatations of the biliary tree.
 Diagnosis relies on the exclusion of other
conditions. (e.g.tumour, gallbladder
calculi, inflammation) as a cause of
biliary duct dilatation.
 Imaging techniques
 Many different methods of imaging the hepatobiliary system are
available, including
 Plain films and contrast examinations of the biliary system,
 Ultrasound.
 Computed tomography (CT).
 Radionuclide imaging and magnetic resonance imaging
(MRI).
 Invasive studies such as percutaneous or operative
cholangiography and endoscopic retrograde
cholangiopancreatography (ERCP) may be indicated, as may
selective arteriography.
 ABDOMINAL PLAIN FILM

 The abdominal plain film is of value in finding gas or calcium in the biliary tract.
Approximately 10% to 15% of gallstones are calcified and readily
identifiable as gallstones on plain films.
 Occasionally the gallbladder wall is calcified (porcelain gallbladder), which is
important because of the association of this abnormality with gallbladder
carcinoma
 Gas may be seen in the center of gallstones in a triangular pattern (Mercedes-Benz
sign).
 Gas in the biliary ducts implies an abnormal connection between the gut and the
gallbladder or common bile duct
 Gas is occasionally seen in the ducts as a manifestation of cholangitis caused by a
gas-forming organism.
 Gas in the gallbladder and its wall (emphysematous cholecystitis) is the
manifestation of a similar infection and usually occurs in diabetics, secondary to
occlusion of the cystic artery caused by diabetic angiopathy.
 Gas in the portal vein, seen peripherally in the liver, implies necrotic bowel, but it
may occur with severe cholecystitis-cholangitis.
 Oral cholecystography
 Oral cholecystography was first accomplished seven
decades ago and was revolutionary. The ingestion of a
nontoxic iodinated organic compound that is absorbed
in the small bowel, excreted by the liver, and
concentrated in the bile provides the opportunity to
discover noncalcified gallstones preoperatively.
 In addition to gallstones, other intraluminal
abnormalities of the gallbladder can be detected.
 Contrast Agent- Oral-iopanoic acid and sodium
ipodate IV agents-Sodium iotroxate.
 Hepatobiliary radionuclide scanning

 Iminodiacetic acid (IDA) pharmaceuticals labelled with 99mTc

are excreted by the liver following intravenous injection and may
be used for imaging the bile duct system. Their main use is in
patients with suspected acute cholecystitis. Hepatic excretion
occurs despite relatively high serum bilirubin levels and therefore
these agents can be used when the patient is jaundiced, even with
serum bilirubin levels of up to 25(mlmol/l (15mg%).
 All that is required is that the patient fasts for 4 hours prior to the
injection of the radionuclide. Normally, the gall bladder, common
bile duct, duodenum and small bowel are all seen within the first
hour, confirming the patency of both the cystic duct and the
common bile duct. If the common bile duct and duodenum or
small bowel are seen within the first hour, but the gall bladder is
not visualized, the cystic duct is considered to be obstructed.
Hepatobiliary scan, (a) Normal IDA scan. There is obvious filling of the gall
bladder. Activity is also present in the duodenum and small bowel, (b) Cystic
duct obstruction. The IDA scan in this patient with acute right upper quadrant
pain shows the duct system but no filling of the gall bladder.
CBD-common bile duct; D-duodenum; GB-gall bladder; SB-small bowel.
Ultrasound of the liver.

 The normal liver displays considerable variation in

size and shape.
 The right hepatic lobe is much larger than the left,
which may be diminutive.
 The falciform ligament, which contains the
ligamentum teres, lies between the medial and
lateral segments of the left lobe.
 The ligamentum teres is often surrounded by fat; the
resulting echo pattern should not be confused with a
mass
Fatty Liver
Fatty Liver

 Alcohol.
 NAFLD-Hepatic manifestation of
Metabolic syndrome.
 NASH-Non Alcoholic SteatoHepatitis.
 Cirrhosis.
 Hemangioma

Cyst
 CT Scan

 Hepatic parenchyma high density (liver

> spleen > muscle).
 Homogenous appearance of
parenchyma.
 Hepatic veins and portal veins branch
through parenchyma as lower density
structures.
Normal vs cirrhotic liver
Hemangioma
Liver mets
CYST VS ABSCESS
LIVER TRAUMA
CT intravenous cholangiography (CT-IVC) Maximum intensity reformats.
 Endoscopic retrograde
cholangiopancreatography (ERCP)
 ERCP consists of injecting contrast material directly into the
common bile duct through a catheter inserted into the papilla
of Vater via an endoscope positioned in the duodenum.
The indications are:
 To determine the cause of jaundice, notably in patients with
large duct obstruction, and to undertake endoscopic treatment.
 To investigate unexplained abdominal pain thought to be
biliary in origin, when other investigations have been
equivocal. An added advantage is that the pancreatic duct
system can be demonstrated.
 To demonstrate the common bile duct in patients undergoing
laparoscopic cholecystectomy, particularly in those where the
history or biochemical investigations suggest stones in the
common bile duct. Such stones are treated by sphincterotomy
and endoscopic basket or balloon extraction.
Percutaneous transhepatic
cholangiography
 Percutaneous transhepatic cholangiography is
accomplished by injecting contrast material under
fluoroscopic vision through a narrow gauge needle
placed in the parenchyma of the liver.
 It is valuable for the same reasons as ERCP and has the
advantage of allowing the operator to institute biliary
drainage if necessary. It is increasingly reserved for
patients with biliary obstruction who need permanent or
temporary biliary drainage.
 Needle biopsy of masses, drainage of fluid collections,
and placement of external and internal drainage
(choledochoduodenal) stents all can be accomplished
percutaneously.
 MRCP
• Magnetic resonance cholangiopancreatography
(MRCP) has replaced a significant proportion of both
percutaneous transhepatic cholangiography (PTC) and
ERCP.
• It relies on heavily T2-weighted sequences that display
stationary water as high signal.
• Multiplanar thin and thick section acquisitions are
obtained using fast spin-echo techniques.
Thank You
References
• Textbook- Grainger & Allison's Diagnostic Radiology, 6th Edition.

• https://www.msdmanuals.com/professional/hepatic-and-biliary-
disorders/testing-for-hepatic-and-biliary-disorders/imaging-tests-of-the-
liver-and-gallbladder

• https://www.ncbi.nlm.nih.gov/pubmed/28069288

• https://www.ncbi.nlm.nih.gov/pubmed/2178549