6. Normal hepatic biliary segmental anatomy (Couinaud)
Anatomic Variants of the biliary Tree: MRCP Findings
Mortelé KJ and Ros PR. AJR 2001; 177:389-394Mortelé KJ and Ros PR. AJR 2001; 177:389-394
7. Rt. post segmental duct
Fuses from a left
(medial) approach to
form right hepatic
duct
: HOOK LIKE
CONFIGURATION
Horizontal course
6
7
19. Choledochal cysts
• Classified into 5 types
• Can occur in the presence of pancreatico-
biliary maljunction (PBM)
• Treatment for choledochal cysts is surgical
excision of the cyst with construction
• Most ominous complication is malignancy
20. Biliary Tract Cysts
• Choledochal cysts
• Consist of cystic dilatations of the extra-
hepatic biliary tree
• Uncommon abnormality and 90% diagnosed
before age 30
• Infantile form presentation identical to biliary
atresia
• 50% present with combination of jaundice,
abdominal pain, and an abdominal mass
23. Gallstones – Natural History
• 80% of patients, gallstones are clinically
silent
• 20% of patients develop symptoms
over 15-20 years (1-2% per year)
• 50-70% continued to have symptoms
and complications
• More than 90% of complications are
preceded by biliary colic
24. echogenic focus that casts an acoustic shadow and seeks gravitational
dependence
25. Acute Calculous Cholecystitis
• Impacted stone in the cystic duct
• 75% are preceded by attacks of biliary colic
• Visceral epigastric pain – mod to severe, irradiated to RUQ,
back, shoulder, chest and lasting > 6 h
• Fever, Right subcostal tenderness with inspiratory arrest
( Murphy’s sign) , palpable GB
• Leucocytosis, mild elevation of BIL, Amylase
• 50% resolve spontaneously in 7-10 days without surgery
• DS: US, EUS, CT
• 10% are complicated by perforation.
30. Echogenic Bile/Microlithiasis
• Non gravity dependent echoes within GB
cholesterol monohydrate
crystals and calcium bilirubinate granules
embedded in a gel matrix of mucous glycoproteins
31. Side Lobe Artifact
INTRA LUMINAL ECHOES:Sludge,Artifacts,Milk of Calcium,Membranes,Blood,
Pus, Neoplasm
36. ADENOMYOMATOSIS : echogenic polypoid mass that does not cast an
acoustic shadow or move with gravity.
• Proliferation of the epithelium
associated with muscular
hypertrophy and mucosal–
submucosal diverticula
(Rokitansky-Aschoff sinuses on CT)
• may simulate cholesterol polyps
and intraluminal or
intramural gas or stones.
37. Ascending Cholangitis
•Impacted stone in CBD causing bile stasis
•Bacterial superinfection
•Charcot’s triad : pain, jaundice, fever – 70%
•Mental confusion, hypotension, RUQ tenderness
•Jaundice (>80%)
•Peritoneal signs (15%)
•Elevated WBC, BIL, APH (blood cult usually pos)
•Emergent decompression of the CBD
(ERCP, PTC)
41. Gallstone ileus
• Obstruction of the small bowel by a large gallstone
–A stone ulcerates through the gallbladder into the
duodenum and causes obstruction at the terminal
ileum/rt colon
• Symptoms : - vomiting, abdominal pain, distension,
obstructive bowel sounds
• Investigations: X-ray, US/CT - air in CBD
• Treatment : Laparotomy and removal of stone from
small bowel and cholecystectomy.
42.
43.
44.
45. major
major complication of acute
cholecystitis is associated with
intramural hemorrhage,
necrosis microabscesses,
mucosal ulcers, and
intraluminal
purulent debris, hemorrhage,
and strands of fibrinous
exudate.Gangrenous
cholecystitis is
associated with increased
morbidity and mortality and
requires emergency surgery.
Clinical findings in this disorder
are
nonspecific and it may be
difficult to identify gangrenous
cholecystitis prospectiv
Gall Bladder perforation can
occour
Fundus-Poor blood supply!
46. Mirizzi’s Syndrome
Inflammatory phenomenon secondary to a
pressure ulcer caused by an impacted gallstone
at the gallbladder infundibulum
The impacted gallstone causes first external
obstruction of the CBD
Eventually erodes into the bile duct evolving into a
cholecystocholedochal fistula with different
degrees of communication between the GB and
CBD
49. Lemmmel’s Syndrome
Duodenal diverticula syndrome
Secondary to extrinsic compression by
periampullary diverticula in the absence of
additional pathology (cholelithiasis, tumor)
• The hypothesized mechanisms:
• Alterations of the papillary motility
• Bacterial contamination
• Extrinsic compression of the Main biliary tract
51. Acute Acalculous Cholecystitis
• Presence of an inflamed gallbladder in the absence of an
obstructed cystic or common bile duct
• Typically occurs in the setting of a critically ill patient (eg,
severe burns, multiple traumas, lengthy postoperative care,
prolonged intensive care)
• Accounts for 5% of cholecystectomies
• Etiology is thought to have ischemic basis, and gangrenous
gallbladder may result
• Increased rate of complications and mortality
• An uncommon subtype known as acute emphysematous
cholecystitis generally is caused by infection with clostridial
organisms and occlusion of the cystic artery associated with
atherosclerotic vascular disease and, often, diabetes.
52.
53. Biliary ductopenic disorders
• interlobular ductopenia as result of
inflammatory condition:
• PSC
• PBC
• GVHD
• Liver allograft resection
• Drug induced liver disease
• idiopathic
54. Extrinsic compression of the bile
ducts
• Biliary tract tumor
• Carcinoma of the head of pancreas
• Acute and chronic pancreatitis
• Lymph nodes – lymphoma or metastasis
• Benign stricture of biliary ducts
58. Cholangiocarcinoma
Diagnosis and Initial Workup
• Jaundice
• Weight loss, anorexia, abdominal pain, fever
• US – bile duct dilatation
• 3-phase CT
• MRCP/MRI
• ERCP with Brush biopsy
• Percutaneous Cholangiography with Internal
Stent and Brush Biopsy
59. MRCP: Cholangiocarcinoma at the Bifurcation
Klatskin tumour - Cholangiocarcinoma of junction of right & left
hepatic ducts:intense DESMOPLASTIC-difficult to identify.
65. Clinical manifestation of hydatid
cyst
• Most patients with hepatic uncomplicated hydatid cyst are
asymptomatic
Possible symptoms and signs are: RUQ pain , epigastric
pain , fever , fatigue , nausea and dyspepsia ,hepatomegaly
and abdominal mass
Complications:
Superinfection of hydatid cysts
Rupture to adjacent structures (peritoneal spillage,
cholangitis, pancreatitis, anaphylaxis)
Rare – portal HTN, hepatic vein thrombosis,
secondary biliary cirrhosis
66. Diagnosis
History of exposure
Chest and abdominal X-ray
Ultrasound (diagnostic method of choice)
CT (better information about location, depth , mandatory
before planning operation)
MRI (for NS, venous system and biliary complications )
Serology (positive – confirms infection, negative test
does not exclude)
67. Gharbi’s US classification
Type I - Pure fluid collection
Type II - Fluid collection with a detached membrane
Type III - Fluid collection with multiple septa and or daughter cysts
Type IV - Hyperechoic with high internal echoes
Type V - Cysts with reflecting, calcified walls
68. Treatment of hepatic hydatid
cyst
The treatment of hepatic hydatid cysts is
strongly indicated in order to prevent cyst
complications
The therapeutic options are:
1. Surgical intervention – remains the
cornerstone of radical treatment
2. Percutaneous drainage
3. Drug therapy
69. Surgical options
Open surgical techniques
Radical removal of pericystic membrane and parasitic
content
Marsupialization (partial cysto-pericystectomy)
Contraindications: severe comorbidity
Complications: biliary fistula, cyst infection, pleural
effusion, peritonitis, abscess, anaphylactic shock
Laparoscopic surgery
Contraindications: Deep intraparenchimal cysts
> 3 cysts, with thick calcified wall
Complications: intra-abdominal seeding due to
pneumoperitoneum
70. Paliative procedures
PAIR - puncture-aspiration-injection-reaspiration
Indicated for type I , II and III cysts
Inoperable patients, pregnant women
Multiple disseminated cysts
Contraindications:
IV, V types of cysts,
ruptured cysts into biliary tree or peritoneum
ERCP – Naso-biliary drainage – biliary endoprosthesis
Combined therapy with albendazole is an effective and safe
alternative to surgery for uncomplicated hydatid cysts
71. Indications for drug therapy:
WHO Guidelines 1996
Inoperable primary liver or lung echinococcosis
Multiple echinococcal multiorgan and peritoneal
cysts
Preoperative or pre-drainage (at least 4 days
before surgery and 1 m (ABZ) or 3 m (MBZ) after)
Poor patient status
Contraindications:
Large cysts that are at risk of rupture
Pregnancy ,chronic liver disease or depressed BM
72. Biliary Stricture – Non Cancerous
Causes
Noncancerous causes of bile duct stricture
include:
•Injury to the bile ducts during surgery for
gallbladder removal
•Pancreatitis (inflammation of the pancreas)
•Primary sclerosing cholangitis
• Gallstones (benign CBD stricture, papillary
stenosis
•Blunt trauma to the abdomen
73. Primary Sclerosing Cholangitis
•Chronic cholestatic biliary disease characterized by
non-suppurative inflammation and fibrosis of the
biliary ductal system
•Cause is unknown but is associated with
autoimmune inflammatory diseases, such as
chronic ulcerative colitis and Crohn’s colitis, and
rare conditions, such as Riedel thyroiditis and
retroperitoneal fibrosis
•Most patients present with fatigue and pruritus
and, occasionally, jaundice
74. PSC
•Natural history is variable but involves
progressive destruction of the bile ducts,
leading to cirrhosis and liver failure
•Clinical features of cholangitis (ie, fever, right
upper quadrant pain, jaundice) are uncommon
unless the biliary system has been
instrumented.
76. Primary Biliary Cirrhosis
•Progressive cholestatic biliary disease that
presents with fatigue and itching or
asymptomatic elevation of the alkaline
phosphatase.
•Jaundice develops with progressive destruction
of bile ductules that eventually leads to liver
cirrhosis and hepatic failure.
•Autoimmune illness has a familial
predisposition
77. PBC
Antimitochondrial antibodies (AMA) are present
in 95% of patients
Goals of treatment are to slow the progression
rate of the disease and to alleviate the
symptoms (eg, pruritus, osteoporosis, sicca
syndrome)
Liver transplantation appears to be the only life-
saving procedure.
79. ERCP
Endoscopic retrograde
cholangiopancreatography (ERCP)
•Endoscopic tube is placed into the
patient’s mouth, through the
stomach, and into the duodenal
portion of the small intestine.
•Contrast is introduced into the
biliary tract through the endoscope,
in a retrograde manner.
•X-rays taken
86. Biliary Stent - Percutaneous transhepatic
approach PTC
For biliary stent placement
using a percutaneous
approach:
•A fine needle is inserted
between the 4th and 5th rib on
the patient’s right side
•The puncture is through the
liver
•The needle is inserted into an
intrahepatic duct under image
guidance.
Photo on file at Medtronic
87. Biliary Stent - Percutaneous Approach
Success rate 95% when ducts are dilated
• 5-10% rate of major complications which include:
•Sepsis
•Bile leak
•Intraperitoneal haemorrhage, Haemobilia
•Hepatic and perihepatic abscess, Pneumothorax
•Skin infection and granuloma at the catheter entry site
• Contraindicated in patients with bleeding diatheses and
significant ascites.
88. Indications For Biliary Stenting
Indications for stent insertion include:
•Ampullary Stenosis
•Bile duct injury
•Benign or malignant biliary obstruction
•Prevention of obstruction where stone
extraction is not possible at that time
•Pancreatic duct strictures, stones and
sphincter of Oddi dysfunction
89. Stent Placement -Endoscopic Approach
• A catheter is inserted through
the endoscope into the
ostium of the common bile
duct.
• While maintaining the
endoscope position in the
duodenum, a wire is inserted
through the catheter into the
bile duct.
• The stent delivery system is
then inserted over the wire
to the site of obstruction,
where the stent is deployed.
90. Stent Placement – Endoscopic
Approach
Success rate of ERCP 90-95%
Complication rate of approximately 3-5%.
Complications:
• Pancreatitis
• Bleeding
• Perforation
• Infection
• Cardiopulmonary depression from conscious sedation.
This suggests that pancreatic juice enters the bile, causes a proteolytic and inflammatory injury to the duct wall, and leads to biliary cyst formation.
sification scheme was proposed by Todani, which defines 5 cyst types, with groups I and IV having subtypes.
Type I involves a cystic dilatation of the extrahepatic biliary system. In subtype 1a (most common), the entire extrahepatic duct is diffusely involved. In subtype 1b (rare), a localized portion of the common bile duct is segmentally cystic. In subtype 1c (uncommon), the common bile duct is diffusely dilated.
Type II (rare) is a diverticulum of the extrahepatic bile duct.
Type III (uncommon) is a cystic dilatation of the intraduodenal portion of the common bile duct (sometimes referred to as a choledochocele).
Type IV has multiple cysts. Subtype IVa (uncommon) involves both the intrahepatic and extrahepatic biliary system, while subtype IVb (rare) has multiple cysts confined to the extrahepatic system.
