HEPATOBILIARY

IMAGING
BILIARY IMAGING MODALITIES
 Ultrasonography (USG)
 CONVENTIONAL RADIOLOGY
 Simple X-ray of the Abdomen
 Oral Cholecystography (OCG)
 Intravenous Cholecycto-Cholangiography (ICCG)
 Endoscopic Retrograde Cholangio-Pancreatography ERCP
 Percutaneous Transhepatic Cholangiography(PTC)
 Per/Postoperative Cholangiography
 Nuclear Medicine (Hepato-Biliary Scintigraphy, Hepato-Splenic
Scintigraphy, SPECT, PET)
 CT
 MRI
 Magnetic Resonance Cholangio-Pancreatography (MRCP)
Ultrasonography
The imaging modality of choice for the gallbladder. It is fast,
real-time, non-invasive, and does not utilize ionizing radiation.
High sensitivity for detection of cholelithiasis. Diagnosis based
on visualization of a mobile, hyperechoic, intraluminal mass
with acoustic shadowing.
High sensitivity for detection of acute cholecystitis. Diagnosis
based on presence of cholelithiasis, gallbladder wall
thickening, pericholecystic fluid.
Limited by skill of operator, and patient’s body habitus.
Acute Cholecystitis
Gallbladder Hydrops. Acute
A Cholecystitis
A) Acute Cholecystitis
B) Gallbladder Microlitiasis
Gallbladder polyp
Gallbladder Adenomatous Polyp
Simple X-ray of the Abdomen
This was an imaging technique used in the past, but has
been widely replaced by the ultrasound.
Can be used to visualize calcified stones, emphysematous
cholecystitis (gas within the wall of the gallbladder),
biliary fistula (gas within the biliary system), porcelain
gallbladder.
Simple abdominal x-ray demonstrating calcified gallbladder stones
(opaque)
Calcified gallbladder stones
(opaque)
 opaque stones Porcelain
gallbladder
Simple X-ray of the Abdomen
Calcified gallbladder stones
Porcelain gallbladder
Aerobilia - gas within the
biliary system.
(cause: bilio-digestive
anastomizes ,
emphysematous
cholecystitis)

- replaced by USG

Emphysematous
Aerobilia cholecystitis
Oral Cholecystography (OCG)
OCG used to be the imaging modality of choice for detecting
cholelithiasis. It is now used as an adjunct to ultrasound. It is
obtained when the patient has the symptoms of cholelithiasis,
but a negative ultrasound.
It is more useful that ultrasound for visualizing large stones, and
also is useful for counting the number of stones present.
Contraindications:
 Patients with bilirubin > 3mg/dL
 Pregnancy.
Technique:
 Per-oral CM administration 12-16h before X-ray examination
 Can be used cholecystokinetic medication or cholecystochinetic meal. X-
rays a made at 15’,30’,45’,60’.
Partially replaced by USG.
 COLECISTOGRAFIE PER OS:
A) normal contraction after Boyden meal (A meal consisting of three or four egg
yolks, beaten up in milk and sweetened, used to test the evacuation time of the
gallbladder.)
B),C) Gallbladder litiasis (lucent stones)
Percutaneous Transhepatic Cholangiogram
(PTC)
PTC is indicated when percutaneous intervention is
needed and ERCP either is inappropriate or has failed.
Can be used to drain biliary obstructions.
Percutaneous Transhepatic Cholangiogram (PTC)
 Obstructive Jaundice (PTC)

catheter

Stone
Obstructive Jaundice (PTC)

Stones
Endoscopic Retrograde
Cholangiopancreatography (ERCP)
ERCP is the primary method of direct cholangiography,
and has therapeutic potential. It also allows for
examination of the upper GI tract, the papilla of Vater,
and the pancreatic duct. Biopsies of multiple sites can be
taken using this technique.
ERCP causes less discomfort than PTC, but acute
pancreatitis is a common complication (which is rarely
seen in PTC).
ERCP: The endoscope is introduced and is threaded around to the sphincter of Oddi.
There, dye can be injected into the ducts. Instruments can also be inserted through the
scope to remove stones, insert drains, remove tissue samples, of perform other
treatments.
ERCP
The most important indication for ERCP is obstructive
jaundice, as it can demonstrate the cause and extent of the
obstruction.
ERCP is the preferred method of examination of patient
with possible choledocholithiasis, because the stones can
be extracted with balloons or gaskets after sphincterotomy
is performed.
 ERCP:
NORMAL

COLEDOC

WIRSUNG

ENDOSCOP
ERCP showing stones
ERCP: showing slightly dilated common bile duct with calculus and
normal pancreatic duct
ERCP: demonstrating stone in the duct (arrow)
Radiolucent stone in ductus choledocus (ERCP)
 Postoperative Cholangiography
(tube Kehr – tube “T” in biliary ducts)

To detect restant stones

and acute postoperative
obstructions

tube Kehr

Persistent postoperative stone

(radiolucent)
Postoperative Cholangiography
Magnetic Resonance
Cholangiopancreatography (MRCP)
MRCP is becoming a more viable imaging technique,
as MRI technology improves. However, CT and
ultrasound are faster, easier, and more readily
available, so they are used more frequently than
MRCP.
MRCP is emerging as a new tool for non-invasive
evaluation of the pancreatic and biliary ductal
systems.
MRCP is gradually replacing PTC and ERCP for
diagnostic purposes.
 MRCP

Bile ducts anatomy

Intrahepatic
- Right hepatic duct:
- posterior rhd
- anterior rhd
- Left hepatic duct
 MRCP

Bile ducts anatomy

Extrahepatic
MRCP
MRCP with stones in the duct
MRCP with stone in the bile duct
MRCP with stones in the gallbladder
 MRCP

Tumor of the head

of the pancreas
 MRCP

Tumor of the head of the pancreas

 MRCP

Cholangiocarcinoma
 HEPATIC IMAGING MODALITIES

Plain Radiography
Ultrasound
CT
MRI
Nuclear Medicine
PLAIN RADIOGRAPHY
 Limited value for assessing the liver

 Can demonstrate gross hepatomegaly and hepatic calcification.

 True borders of the normal liver can only be identified if directly outlined
by fat or by free intraperitoneal air.

 The lungs and diaphragm delineate the apparent superior liver border but a
subphrenic collection or a subpulmonary effusion may be misinterpreted as
part of the liver itself.

 As the anterior and inferior border of the liver often extends inferior to the
gas-containing lumina of the stomach, duodenum and hepatic flexure of the
colon, these gas-filled structures are unreliable guides to the inferior border.
PLAIN RADIOGRAPHY

Plain abdominal radiograph

demonstrating the lower
margin of the liver, marked
with H.
 Simple X-ray
of the Abdomen.

Calcified Hydatid cyst

Simple X-ray of the Abdomen. Hepatic Abscess
Liver Anatomy

The anatomic divisions of the CT of the normal liver showing

liver showing the vasculature general anatomy.
and biliary system.
Liver Anatomy

A more inferior CT of the MRI of the normal liver with

normal liver with adjacent labeled adjacent structures.
structures.
Ultrasound
 First choice imaging modality for pains, abnormal or suspected liver masses.
 Relatively inexpensive, widely available, and moderately sensitive to
localized lesions.
 Limited utility in the presence of diffuse diseases such as cirrhosis or fatty
infiltration, or when air is present.
 The liver is typically homogeneous in appearance.

 In general, fluid is anechoic so intrahepatic vessels including portal veins

and hepatic veins are visible.

 The biliary ducts are thin tubes, the walls of which are 1.5 mm or less. The
ducts increase in caliber distally from the liver.
Ultrasound


Transverse US liver, Hepatic vein branches Normal liver doppler.

showing homogeneous may be identified by their
parenchyma, the radiating pattern as they
hyperechoic
enter the IVC.
diaphragm the linear
portal vein, and the
parallel biliary duct
(arrow).
CT
 CT is often employed after US to image focal disease.

 It is easy to compare in serial studies.

 Air and bone do not interfere with CT examinations as with US.

 CT angiography is a noninvasive means of imaging hepatic vasculature.

 For diffuse hepatocellular disease, CT is probably the first study used, however not
as sensitive to liver lesions as MRI.

 CT is the only commonly accepted means for analyzing abdominal trauma,

particularly of the liver. CT is reasonably accurate in the detection of trauma-related
abnormalities of the liver, biliary system, and pancreas.
MRI

 MR imaging may be the most sensitive modality for detecting and

characterizing diffuse diseases of the liver, including cirrhosis and
hemochromatosis, especially when combined with contrast agents.

 Newer MR pulse sequences, contrast agents, and fast scanning techniques

arguably make MR imaging the optimal means for both detection and
characterization of focal liver lesions of all types.

 Often used to characterize focal lesions discovered during survey

techniques like US or CT.

 Angiography may be used to study collateral formation in cirrhosis.

Nuclear Medicine
It is most often used to further evaluate masses or tumors.
NM has only infrequent applications in diffuse disease.
Better utility in focal disease such as malignancy or
hemangioma.
Hepatobiliarry scintigraphy