Radiology of Hepatobiliary System

Pancreas and Spleen

Nugzar Liparteliani
 Imaging Modalities
• Plain X-ray
• Ultrasound
• Computed Tomography
• Magnetic Resonance Imaging
• Angiography and Interventional procedures
• Others: ERCP, PTC, intra-op & T-tube Cholangiogram
• Radionuclide Imaging: HIDA, Sulfur colloid
• PET/CT
Couinaud’s
segments
Billiary tree
Plain X-Ray
ULTRASOUND
CT with contrast
Nuclear Medicine
PET/CT
 ERCP
Imaging

This radiograph taken during an ERCP procedure demonstrates the hepatic ducts;
common hepatic duct, cystic duct, and common bile duct are demonstrated. Note
the spiral appearance of the cystic duct due which is the valve of Heister. The
pancreatic ducts and ampulla of Vater are not demonstrated
1 Common bile duct
2 Common hepatic duct
3 Cystic duct
4 Endoscope in duodenom
5 Gallbladder
6 Amper´s ampulla
7 Left hepatic duct
8 Neck of gallbladder
9 Pancreatic duct
10 Right hepatic duct
MRCP Imaging
 Upper abdominal calcification
may be an important sign of disease
Gallstones ,Porcelain gallbladder
Urinary Calculi
Calcified adrenal glands
Pancreatic calcification
Tumor calcification
……………
Gallstones
 15% -20%of gallstones
contain sufficient
calcium to be identified
on plain film
 right upper quadrant
 laminated appearance
(a dense outer rim and
more radiolucent
center)
Porcelain gallbladder
 calcification in the wall of the
gallbladder
 indicative of chronic obstruction
of the cystic duct, chronic
gallbladder inflammation, and an
increased risk of gallbladder
carcinoma
Kidney stones
• About 85% of urinary
calculi are visible on
plain film.
• Staghorn Calculus
a large calculus
occupying the collecting
system of the left
kidney and assuming its
shape
Calcified adrenal glands
 associated with
adrenal hemorrhage
in the newborn,
tuberculosis, and
Addison disease
 either side of the
first lumbar vertebra
Pancreatic Calcifications

• chronic alcohol-induced
pancreatitis
• Coarse and punctate
calcifications
• extend upward across
the left upper quadrant
Diffuse Liver Disease

  Fatty liver

 Cirrhosis
 Fatty liver(Steatosis)
 In normal adults, the precontrast attenuation
value of the liver is consistently higher than
that of the spleen
 Milder degrees of diffuse steatosis :the
attenuation value of the liver is less than that
of the spleen
 Marked diffuse steatosis :the liver parenchyma
is lower in attenuation than the hepatic blood
vessels
Diffuse Fatty liver
• The attenuation value of the liver
parenchyma is markedly lower
than that of the spleen

• The intrahepatic vessels stand

out as hyperattenuating
structures
Focal fatty infiltration
• The same imaging features as
diffuse infiltration
• Vessels run their normal course
through the area of involvement
(lack of mass effect )
 Cirrhosis
 hypertrophy of the caudate lobe and left lobe
with shrinkage of the right lobe
 inhomogeneity of hepatic parenchyma,

 irregularity (nodularity) of the liver surface,

 Extrahepatic signs :evidence of portal
hypertension, splenomegaly, and ascites
Cirrhosis
• nodularity of the liver contour
• atrophy of the medial segment
(M) and enlargement of the
lateral segment
• prominent notch in the right
posterior surface of the liver
 Focal Liver diseases

Cyst
Hemangioma
Hepatocellular carcinoma
 metastasis
Cyst:CT appearance

 a well-circumscribed, homogeneous mass of near-water-

attenuation value (less than 20 HU)
 no enhancement after IV contrast medium administration
Liver Cysts
• Two large well-
circumscribed,
homogeneous, near-
water-density masses
• no discernible wall
 Hemangioma

 the most common benign liver tumor

 fed by hepatic artery branches

 internal circulation is slow
 generally remain stable in size over time
 Diagnosis
• Ultrasound, an imaging method that uses high-frequency sound waves to
produce images of the liver
• Computerized tomography (CT) scanning, which combines a series of X-ray
images taken from different angles around your body and uses computer
processing to create cross-sectional images (slices) of the liver
• Magnetic resonance imaging (MRI), a technique that uses a magnetic field and
radio waves to create detailed images of the liver
• Scintigraphy, a type of nuclear imaging that uses a radioactive tracer material
to produce images of the liver
• well-defined, hypodense on unenhanced scans
• Enhancement pattern : nodular enhancement from the
periphery of the lesion and proceeding toward the center
gradually
Precontrast CT :an attenuation value similar to that of the blood in the
inferior vena cava(IVC)
 Arterial phase :multiple areas of globular, peripheral enhancement.
 Note that the enhanced portions of the mass have an attenuation value
similar to that of the intrahepatic vessels.
• Equilibrium phase : near-complete enhancement of
the mass with an attenuation value equivalent to
that of the blood in the inferior vena cava(IVC) and
hepatic veins
T2WI:marked hyperintense
99m
Tc-RBC
SPECT scan
 Hepatocellular carcinoma (Hepatoma)
• The most common primary malignancy of the liver
• Risk factors : cirrhosis, chronic hepatitis
• Growth patterns:
solitary massive, multinodular, and diffuse infiltrative
• Serum α-fetoprotein(AFP) levels are often elevated
 Hypervascular :contrast enhancement on arterial phase
images, with diminishing enhancement on delayed phase
images
 Tumor thrombus
 Tumor capsule: a sharply marginated rim
ULTRASOUND OF HEPATOMA
 Necrosis: central low density

 The satellite lesions

T2WI T1WI

AP PP DP
Portal Vein Thrombosis

 Multiple hypodense nodules

----HCC
 Filling defect with the vein
 Metastases
 The most common malignant
masses in the liver
 Most commonly originate from
the GI tract, breast, and lung
 Necrosis, fibrosis, calcification,
or hemorrhage within the mass
 The most common
enhancement pattern
:continuous ring-like
enhancement
• Multiple
• Hypoattenuating lesions
with mild continuous rim
enhancement
 T2WI:a central area
of hyperintensity
 rim enhancement
 Gallstones
• Gallstones (commonly misspelled gall stones or gall stone) are solid particles that form from
bile cholesterol and bilirubin in the gallbladder.
• There are two types of gallstones:
1) cholesterol stones and
2) pigment stones.

• Patients with cholesterol stones are more common in the United States; cholesterol stones
make up a majority of all gallstones (in the U.S., about 80%). They form when there is too
much cholesterol in the bile.
• Pigment stones form when there is excess bilirubin in the bile.
 Biliary Dilatation
• Diameter of intrahepatic bile ducts larger than 40% of the
diameter of the adjacent portal vein
• Dilation of the common duct greater than 6 mm
• Gallbladder diameter greater than 5 cm
Normal MR Cholangiopancreatography (MRCP).
Causes of Biliary Tract Obstruction
 Choledocholithiasis

 approximately 20% of cases of obstructive

jaundice in the adult
 CT:high-density calcification within the duct

 MRCP has shown good sensitivity (86% to

100%) and specificity (85% to 100%) for ductal
stones
 MRCP

Filling defects
 Cholangiocarcinoma
 arise from the epithelium of bile ducts and are usually
adenocarcinomas
 Growth patterns include mass forming, periductal infiltrating,
and intraductal polypoid
• Mass forming

• periductal infiltrating

• Intraductal polypoid
Peripheral cholangiocarcinoma

Delayed enhancement
biliary dilatation
Atrophy (liver)
Perihilar and extrahepatic cholangiocarcinomas

 typically exhibit an infiltrating growth pattern

 focal, circumferential thickening of the bile
duct with proximal dilatation
 perihilar lesions may be similar in appearance
to the intrahepatic, mass-forming type of
cholangiocarcinoma, or may manifest as an
intraluminal polypoid mass
 ANATOMY OF PANCREAS
• Length – 15 cm.
• Head, uncinate process, neck, body, tail
• Gradually tapering “Horse shoe” shape.
• Head – 23 +/- 3 mm
• Neck – 19 +/- 2.5 mm
• Body – 20 +/- 3 mm
• Tail – 15 +/- 2.5 mm
 IMAGING MODALITIES
Imaging of pancreas

• Radiograph – detect calcification (practically

of no help)
• Barium studies – indirect signs (not helpful)
• USG – differentiation of cystic and solid
lesions (screening tool & for follow-up)
• CT scan – modality of choice
• MRI and MRCP – complimentary to CT
 ULTRASONOGRAPHY
Imaging of pancreas
• Widely available
• Easily accessible
• Can be repeated as often as necessary
• Cheap
• No ionizing radiation
• Portability
• Other causes of medical and surgical acute abdomen can be
identified and excluded

PRIMARILY USED AS SCREENING TOOL & FOR FOLLOW UP

 CT SCAN
Imaging of pancreas
• Gold standard for all pancreatic pathologies
• Detects complications
• Helps in staging of tumors
• Post processing techniques are of additional help

MPR MIP-VESSELS
CURVED MPR-DUCTS
GOLD STANDARD FOR PANCREAS
MRI MRCP
 MRI/MRCP
Imaging of pancreas

• Pancreatic Duct

• Side branches

• Lower end of CBD

MAINLY A PROBLEM SOLVING TOOL

 PATHOLOGY
Imaging of pancreas

• Pancreatitis

• Pancreatic divisum

• Tumors

• Traumatic – Laceration and pancreatic duct

injury
 ACUTE PANCREATITIS
Imaging of pancreas

• Increase in the volume of pancreas

• Oedematous changes
• Peripancreatic fluid collections
• Peripancreatic fat stranding
• Haemorrhagic areas
• Pancreatic necrosis
• Superinfection
• Vascular complications
 ACUTE PANCREATITIS
CT Scan
NECROSIS SPL.V.THROMBOSIS

PSEUDOANEURYSM

PSEUDOANEURYSM
ACUTE PANCREATITIS
CT Scan
INFECTED
COLLECTION
 CHRONIC PANCREATITIS
Ultrasonography

USG cannot diagnose chronic pancreatitis despite

advanced disease stage at times.
 CHRONIC PANCREATITIS
CT Scan

• Parenchymal atrophy / focal bulge

• Parenchymal Calcification

• Ductal dilatation

• Pseudocyst and other complications

• Peripancreatic fascial thickening and
blurring of pancreatic margins Chronic pancreatitis Pseudocyst

• Vascular Cx : PV/SV thrombosis, SA

pseudoaneurysm CT is more sensitive in diagnosing pancreatic calcification
and parenchymal atrophy than USG.
CT is considered as modality of choice in diagnosing chronic
pancreatitis.
 PANCREATIC DIVISUM
Recurrent pancreatitis

Causes repeated acute pancreatitis. Failure

of the dorsal and ventral pancreatic
primordia to fuse.

The dorsal duct drains into the duodenum at

the minor papilla, and the ventral duct drains
via the major ampulla with the CBD.

MRCP easily reveals the dorsal pancreatic duct

in patients with divisum, whereas cannulation
of the minor papilla of such patients for ERCP is
frequently unsuccessful . Dorsal PD

36-year-old woman with h/O Pancreatitis.

Ventral PD
MRCP shows separate dorsal and ventral pancreatic
duct systems consistent with divisum.
 PANCREATIC TUMORS
Imaging of pancreas

• Benign

• Primary malignant

• Endocrine tumors

• Metastasis
 PANCREATIC TUMORS
Imaging features

• Morphologic and contour

changes
• Mass effect
• Density changes
• Contrast enhancement
• Pancreatic duct changes
• Secondary signs
 Pancreatic carcinoma
• a highly lethal tumor
• CT is recommended for initial imaging
assessment
• CT:a hypodense mass that distorts the contour
of the gland
• obstruction of the common bile duct and
pancreatic duct and atrophy of pancreatic
tissue beyond the tumor
A B

C D
 PANCREATIC TUMORS
CT Scan

Hypovascular

Lymphnodes
Peritonea
l nodules
 Signs of unresectability
• tumor involvement of adjacent organs
• enlarged regional lymph nodes (>15 mm)
• encasement or obstruction of peripancreatic arteries or veins
• metastases in the liver
• peritoneal carcinomatosis
Pancreatic Carcinoma: Nonresectable

• encases and narrows the celiac

axis and its branches
• partially envelopes the aorta
 VENOUS ENCASEMENT & RESECTABILITY
Pancreatic tumors

• Encasement or involvement of celiac trunk,

hepatic artery, gastroduodenal artery or Unresectable
superior mesenteric artery – unresectable.
 MUCINOUS CYSTADENOMA
PANCREATIC TUMORS

•40-50 YEARS
•“MOTHER LESION”
•MALIGNANT POTENTIAL
•MACROCYSTIC
•USUALLY 1 CYST
•PERIPHERAL CALCIFICATION (25%)
•BODY AND TAIL (90%)
 SEROUS CYSTADENOMA
PANCREATIC TUMORS

•60-70 YEARS
“GRANDMOTHER LESION”
•BENIGN
•LOBULATED
•MICROCYSTIC
•CENTRAL SCAR (18%)
 INTRADUCTAL PAPILLARY MUCINOUS NEOPLASM (IPMN)
PANCREATIC TUMORS
Branch duct type IPMT
Dilatation of the branch ducts

• Classification based on the duct

architecture

Main duct type- diffuse or segmental

dilatation of the MPD
Branch duct type-dilatation of branch
ducts
Combined type – Main + branch
ducts
 LYMPHOMA
PANCREATIC TUMORS

•Focal or diffuse mass

without dilatation of PD.
•Associated with large
lymphnodes.
•Common in immuno-
compromised patients.
SPLEEN
ULTRASOUND
CT SCAN
SPLEEN MRI
 NUCLEAR MEDICINE
99mTC sulfur colloid.
 NUCLEAR MEDICINE
99mTC denat RBC SCAN.
 SPLEEN
ANATOMICAL VARIATION
1. Accessory spleen or splenunculi:
• Not uncommon and found in 10-30% of the population.
• Mostly lie along the spleen itself, tail of pancreas, along
splenic artery, at hilum of spleen or in omental ligament.
• X-ray: It may appear as mass indenting stomach.
• USG: Appears a solid mass which is isoechoic to the
spleen.
• CT scan: They have density and enhancing characteristics
similar to the rest of the spleen
• Splenic scintigraphy: It is the investigation of choice to
locate normal functioning splenic tissue.
Splenunculi abutting the tail of pancreas
Polysplenia:
• Associated with other anomalies too, eg: Congenital heart disease, gut
malrotation, IVC or portal anomalies etc.
Splenic pathology.
 Splenomegaly

 X-ray of abdomen showing enlarged spleen

 Splenic masses
1. Splenic abscess: They are rarely seen in
spleen. May be solitary or multiple.
Splenic h y da t i d
cyst.
 Primary splenic malignancy: Very rare in
occurance but angiosarcoma can occur as multiple
focal lesions.
• USG features are non specific and include
splenomegaly with cystic and solid masses
with mixed echogenicity.
• CT may show solitary or multiple nodular masses
of heterogeneous low attenuation in an enlarged
spleen. There are generally irregular and poorly
defined contours. Some of these masses may
show peripheral enhancement.
 Metastases: Of all metastases 7% is seen in spleen. Occurs
genereally in presence of wide spread metastases elsewhere.
Lymphomatous involvement of spleen is relatively common where
there is splenic enlargement without an identifiable focal
abnormality.
These lesions are usually necrotic and are seen as low density
lesions on CT. They show ring enhancement on contrast study.
On USG they most commonly appear as a hypoechoic lesion,
although can be iso- or hyperechoic.
Splenic Trauma
 Grading

42-year-old man with grade IV

traumatic splenic injury. Axial
CT images show multiple
splenic lacerations extending
to hilum with active contrast
extravasation and
hemoperitoneum.
 Vascular Disorders
The spleen is as liable to infarcts
as other organs and tissue.
Wedge-shaped defects may be
seen on ultrasound and CT.
They are usually an incidental
fining, but are more common in
patients with hyper-splenism.
Splenomegaly occurs in portal
hypertension and other causes of
increased back pressures on the
portal venous system, such as
portal vein thrombosis.
Wandering spleen in a 7-
year-old girl.(a) Contrast-
enhanced CT scan reveals an
anterior mass at the level of the
cecal pole (solid arrows) with
vessels entering
posteromedially (open arrow).
(b) Tc-99m sulfur colloid
scintigram shows the mass to
be an abnormally located spleen
(arrow). The liver also
demonstrates radiotracer
uptake (top).
• Plain film radiographs of the abdomen are important for the
assessment of the acute abdomen
• CT, US, and MR provide comprehensive evaluation of the
abdomen, including the peritoneal cavity, retroperitoneal
compartments, abdominal and pelvic organs, blood vessels,
and lymph nodes