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Gallbladder and Bile Ducts. Chuan Lu Department of Diagnostic Radiology Taishan Medical University. Anatomy. Various Modalities in Biliary Imaging. US MRCP CT ERCP Percutaneous transhepatic cholangiography. Sagittal image of gallbladder. Gallbladder and Bile Ducts.

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gallbladder and bile ducts

Gallbladder and Bile Ducts

Chuan Lu

Department of Diagnostic Radiology

Taishan Medical University

various modalities in biliary imaging
Various Modalities in Biliary Imaging
  • US
  • MRCP
  • CT
  • ERCP
  • Percutaneous transhepatic

cholangiography

gallbladder and bile ducts6
Gallbladder and Bile Ducts
  • Normal size of gallbladder:

7~9cm in length ;

3~4cm in width;

Wall thickness : 2~3mm

  • Normal size of bile ducts :

CBD:≥8mm =dilated

right /left intrahepatic duct just to proximal CHD: 2-3mm ;

transverse image of the liver
Transverse image of the liver
  • right /left intrahepatic duct just to proximal CHD: 2-3mm ;
common bile duct
Common bile duct

CBD:≥8mm =dilated

slide9
MR
  • Magnetic resonance imaging is slightly superior to computed tomography in visualization of tumors. The recent addition of magnetic resonance cholangiography allows visualization of both dilated biliary ducts proximal to the tumor and normal-sized extrahepatic ducts distal to the level of occlusion.
slide10
MRCP
  • Magnetic resonance cholangiography (MRCP) images obtained from the newest diagnostic equipment are comparable in quality to those obtained with Endoscopic Retrograde Cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography. Ductal or intravenous injection of contrast medium is not necessary and the patient is not exposed to irradiation.
slide12
The MRCP creates an enhanced MRI and may be adjusted to optimally visualize the biliary and pancreatic ducts.

MRCP显示胆系

slide13
MRCP

MRCP显示胆系

slide14
CT

Modern multidetector computed tomography is a new diagnostic imaging tool that allows multiplanar reformation.

CT cholangiography performed with 64-channel multidetector .CT scanners could provide much more information regarding the biliary tree and its abnormalities.

imaging techniques
Imaging Techniques

CT scans were obtained on a 64–channel helical CT scanner with the following parameters:

  • 0.5 seconds per rotation, 5-mm collimation, pitch of 0.984:1, and tube current of 120 kV per 300– 400 mAs.
  • Transverse 0.625-mm-thick sections were reformatted into thin-section coronal images, maximum- intensity-projection (MIP) images, and volume- rendered (VR) images.
  • An intravenous drip infusion of 100 mL of meglumine iotroxate (Biliscopin; Schering, Berlin,Germany) is administered for 50 minutes as a biliary contrast agent 40–60 minutes prior to scanning. This biliary agent has been approved in some countries, including Japan, and has been used for tomographic cholangiography.
slide16
Anterior (a) and right superior (b) VR images
  • show the right posterior hepatic duct (arrow in a) draining into the left hepatic duct.
slide18
ERCP, MR cholangiopancreatography, ultrasonography (US), and multidetector CT cholangiography each have their own advantages and disadvantages
advantages and disadvantages of various modalities in biliary imaging
Advantages and Disadvantages of Various Modalities in Biliary Imaging

Modality Advantages Disadvantages

ERCP Permits simultaneous biopsy orInvasive, may not be possible due to altered anatomy

Treatment following surgery

MRCP Noninvasive, no radiation exposureProne to artifact, provides little functional information,

difficult to diagnose calcification, difficult to perform in

periampullary area

US Noninvasive, easily available,Operator dependent, poor demonstration of peripheral

no radiation exposureintrahepatic bile ducts, less consistent

Multidetector CT

cholangiography

Information regarding biliaryRadiation exposure, side effects of the biliary agent,

kinetics and function available,limited in patients with poor hepatic function

high spatial resolution,

short scanning time

cholecystolithiasis
Cholecystolithiasis
  • Gallstone with shadowing: high-level intraluminal echoes+ acoustic shadowing(100%diagnostic)
  • Mobility of the stone by moving the patient during ultrasound scanning
cholecystolithiasis21
Cholecystolithiasis
  • Gallstone with shadowing: high-level intraluminal echoes+ acoustic shadowing(100%diagnostic)
  • Mobility of the stone by moving the patient during ultrasound scanning
cholecystolithiasis22
Cholecystolithiasis

Gallstone with shadowing: high-level intraluminal echoes+ acoustic shadowing(100%diagnostic)

Mobility of the stone by moving the patient during ultrasound scanning

cholecystolithiasis23
Cholecystolithiasis

Gallstone with shadowing: high-level intraluminal echoes+ acoustic shadowing(100%diagnostic)

Mobility of the stone by moving the patient during ultrasound scanning

sludge
Sludge

Nonshadowing echogenic homogenerous mass shifting position slowly

false negative us 5
False-negative US (5%):
  • contracted GB,
  • GB in anomalous/unusual location
  • small gallstone
  • gallstone impacted in GB neck/cystic duct, immobile patient
  • obese patient
  • extensive RUQ bowel gas
cholangiolithiasis
Cholangiolithiasis

Stones may develop in the gallbladder and then reflux into the biliary tree to cause focal dilatation of a segment of the biliary tree

  • Stone visualization in 13-77%(more readily with CBD dilatation+good visibility of pancreatic head)
  • Dilatation of CBD
  • Acoustic shadowing
  • No stone in gallbladder(11%)
slide30
Cholangiolithiasis
  • Stone visualization in 13-77%(more readily with CBD dilatation + good visibility of pancreatic head)
  • Dilatation of CBD
  • Acoustic shadowing
cholangiolithiasis 2
Cholangiolithiasis 2

Stone visualization with CBD dilatation

acute cholecystitis
Acute cholecystitis
  • Wall thickening (over 3mm) and irregularity
  • Hazy delineation of gallbladder wall
  • Focal tenderness over gallbladder (sonographic Murphy’s sign)
  • Cholelithiasis
acute cholecystitis33
Acute cholecystitis
  • Coarse nonshadowing nondependent echodensities= slouged necrotic mucosa/sluge/pus/clotted blood within gallbladder
  • “halo sign” =GB wall lucency =3 layered configuration with sonolucent middle layer(edema)
  • Crescent-shaped anechoic pericholecystic fluid
  • Gallbladder hydrops=distension with AP diameter >5cm
chronic cholecystitis
Chronic Cholecystitis
  • Gallbladder stones
  • Smooth /irregular GB wall thickening

(mean of 5mm)

  • Mean volume of 42ml
slide35
Chronic Cholecystitis
  • Gallbladder stones
  • Smooth /irregular GB wall thickening (mean of 5mm)
  • Mean volume of 42ml
gallbladder polyp
Gallbladder polyp

Polypoid / fungating intraluminal mass

with wide base

gallbladder carcinoma
Gallbladder Carcinoma
  • Associated with:
  • Disorder of gallbladder:
    • Cholelithiasis in 64-98%
      • Gallbladder carcinoma occurs in only 1% of all patients with gallstones!
    • Porcelain gallbladder (in 4-60%): prevalence of gallbladder carcinoma in 11-22% of autopsies
    • Chronic cholecystitis
    • Gallbladder polyp: a polyp >2 cm is likely malignant!
  • Disorder of bile ducts:
    • Primary sclerosing cholangitis
    • Congenital biliary anomalies: cystic dilatation of biliary tree, choledochal cyst, anomalous junction of pancreaticobiliary ducts, low insertion of cystic duct
  • Inflammatory bowel disease (predominantly ulcerative colitis, less common in Crohn disease)
  • Familial polyposis coli
histo
Histo:
  • diffusely infiltrating lesion (68%),
  • intraluminal polypoid growth (32%)
  • (a) adenocarcinoma (76%):
  • (b) rare epithelial cell types:
  • (c) nonepithelial cell types (2%):carcinoid, carcinosarcoma, basal cell carcinoma, lymphoma
location
Location
  • fundus (60%),
  • body (30%),
  • neck (10%)
growth types
Growth types:
  • replacement of gallbladder by mass

(37-70%)

  • focal /diffuse irregular asymmetric thickening wall(15-47%)
  • intraluminal polypoid /fungating intraluminal mass with wide base(14-25%)
growth types42
Growth types:
  • pericholecystic infiltration: in 76% focal, in 24% diffuse
  • dilatation of biliary tree (38 %):
    • infiltrative tumor growth along cystic duct
    • lymph node enlargement causing biliary obstruction
    • intraductal tumor spread
  • fine granular/punctate flecks of calcification (mucinous adenocarcinoma)
  • lymph node enlargement in porta hepatis
slide43
US:
  • gallbladder replaced by mass with irregular margins + heterogeneous echotexture (= tumor necrosis)
  • immobile intraluminal well-defined round/oval mass
slide44

Replacement of gallbladder by mass

(gallbladder replaced by mass with irregular margins + heterogeneous echotexture (= tumor necrosis)

cholangiocarcinoma extrahepatic cholangiocarcinoma bile duct carcinnoma
Cholangiocarcinoma: extrahepatic cholangiocarcinoma=bile duct carcinnoma

Growth pattern:

  • Obstructive type :U/V-shaped obstruction with nipple ,rattail, smooth/ irregular termination
  • Stenotic type: strictured rigid lumen with irregular margin+ prestenotic dilatation
  • Polypoid/ papillary type : intraluminal filling defect with irregular margins
slide48
A.Extrahepatic tumor(Klatskin’s tumor -tumor located in the hepatic duct bifurcation)

B. intrahepatic tumor resulting in biliary duct dilation.

slide49
US
  • Transabdominal ultrasound is a totally painless, non-invasive procedure. The test does not require special preparation, although it is technically easier in patients with at least six hours of fasting. Transabdominal ultrasound is usually recommended as the first imaging modality for the investigation of patients with suspected cholangiocarcinoma.
  • In hilar cholangiocarcinoma, ultrasound demonstrates bilateral dilation of intrahepatic ducts, and right and left hepatic ducts.
  • In rare cases, the tumor itself can be visualized as either a hypoechoic (decreased echodensity) or hyperechoic (increased echodensity) rounded mass located just distal to dilated biliary ducts.
slide50
Peripheral cholangiocarcinoma may be suspected if abdominal ultrasound demonstrates local dilation of intrahepatic ducts or isolated dilation of the biliary tree inside one lobe of the liver.
  • In both peripheral and hilar cholangiocarcinoma, biliary ducts distal to the obstruction (common hepatic duct and common bile duct) are not dilated. In patients with hilar cholangiocarcinoma and complete obstruction of both right and left hepatic ducts, extrahepatic bile ducts and the gallbladder appear empty (collapsed) because there is no bile flow out of the liver.
  • In patients with distal cholangiocarcinoma, ultrasound demonstrates dilated intra- and extrahepatic ducts along with significant dilation of the gallbladder. Peripherally located tumors cause segmental or lobular obstruction of the biliary tree. Bile flow from the rest of the liver is preserved.
  • Extrahepatic bile ducts and the gallbladder appear normal (filled with bile) in patients with peripheral cholangiocarcinoma.
slide51

Obstructive type :U/V-shaped obstruction with nipple ,rattail, smooth/ irregular terminationMass within/surrounding the ducts at point of obstruction

obstructive type
Obstructive type

the tumor itself can be visualized as either a hypoechoic (decreased echodensity) or hyperechoic (increased echodensity) rounded mass located just distal to dilated biliary ducts.

dilated intrahepatic bile ducts
Dilated intrahepatic bile ducts

In patients with distal cholangiocarcinoma, ultrasound demonstrates dilated intra- and extrahepatic ducts along with significant dilation of the gallbladder. Peripherally located tumors cause segmental or lobular obstruction of the biliary tree. Bile flow from the rest of the liver is preserved

dilated intrahepatic bile ducts55
Dilated intrahepatic bile ducts

In patients with distal cholangiocarcinoma, ultrasound demonstrates dilated intra- and extrahepatic ducts along with significant dilation of the gallbladder. Peripherally located tumors cause segmental or lobular obstruction of the biliary tree. Bile flow from the rest of the liver is preserved

slide56

In patients with distal cholangiocarcinoma, ultrasound demonstrates dilated intra- and extrahepatic ducts along with significant dilation of the gallbladder. Peripherally located tumors cause segmental or lobular obstruction of the biliary tree. Bile flow from the rest of the liver is preserved