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B iliary S ystem

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  1. Biliary System Prefinal topic

  2. Gall Bladder is pear-shaped sac, composed of three-parts – fundus, body and neck. 7 – 10 cm long, 3 cm wide and normally holds 30 to 40cc’s of bile.

  3. 3 – primary Functions store and concentrate bile and contract when stimulated. Bile is concentrated w/in the gallbladder due to hydrolysis. Gallbladder normally contracts when foods such as fats or fatty acids are in duodenum.

  4. Biliary ducts Right & Left hepatic ducts Common hepatic duct Cystic duct

  5. Common Medical Terms Chole – “bile” is a bitter yellowish, blue and green fluid secreted by hepatocytes from the liver . Cysts- is a closed sac having a distinct membrane and division on the nearby tissue Angio – refers to the arteries or veins or blood vessels

  6. Gallbladder and Biliary duct Radiographic Terminology • Cholecystography • Radiographic examination specifically of the gallbladder. • Cholangiogram • radiographic examination of the biliary ducts. • Cholegraphy • – general term used to denote specialized exam. Of the biliary ducts. • Cholecystocholangiogram • examination of the gallbladder and biliary ducts. • Cholecystopaques(OCG) • termed for visulaization of the gallbladder by the used of contrast media.

  7. *Administration of Contrast Medium* • by mouth (oral) • by injection into a vein in a single bolus or drip infusion (intravenous) • by direct injection into the ducts ; • through percutaneoustranshepatic puncture • during biliary tract surgery (operative or immidiate) • through an indwelling drainage tube ( post-operative, delayed, or T-tube)

  8. Each method of examination is named according to; • The route of entry of the medium • The portion of the biliary tract examined

  9. Oral Cholecystography

  10. Oral Cholecystography Is a non-invasive radiographic procedures that is used if a inconclusive ultrasound report. It is a simple, economical and least invasive and highly effective method of investigating the gallbladder problems The route of entry is by mouth.

  11. Purpose: • Study radiographically the anatomy and function of the biliary system. • Function: • It measures the functional ability of the liver to remove the orally administered contrast medium from the blood stream and to excrete it along with the bile.

  12. Contraindications Advanced hepatorenal disease, those with renal impairement. Active gastrointestinal disease such as vomiting or diarrhea, which would prevent absorption of oral contrast medium. Hypersensitivity to iodine containing compound.

  13. Clinical Indications: Neoplasm Biliary stenosis – narrowing of the biliary ducts Congenital anomalies Cholelithiasis – condition of having gallstone. Cholecystitis – inflammation and blockage of the cystic duct restricts the flow of bile into the cbd due to stones.

  14. Gallstones

  15. Oral Cholecystography • Preliminary Diet • an evening meal that is fat free to prevent the possibility of emptying the gallbladder. • A noon meal that is rich in simple fats and an evening meal that is free of fats. • Oral media are usually administered about 3-hrs after evening meal. • Nothing by mouth. • Breakfast is usually withheld in all methods.

  16. Fatty Meal (Boyden Meal) Consisted of a commercially available bar or eggs and milk or eggnog. It is important to have a fatty meal as to serve as stimulant for the gallbladder. Without the fatty meal we cannot observe the function of the gallbladder empting its bile's.

  17. Routine Positions • Supine • Prone • Prone oblique • Upright • Lateral decubitus

  18. Success of oral cholecytogram: The intestinal mucosa in absorbing the contrast substance and liberating it into the portal bloodstream for conveyance to the liver. The liver in removing the opaque substance from the blood and excreting it with the bile. The GB in concentrating the opacified bile by removing 90% water content in storing the concentrated bile during interdigestive period.

  19. Intravenous Cholangiogram

  20. Intravenous Cholangiogram • Demonstrates the biliary ducts to determine if an obstruction exists due to calculi or other pathology. • Is employed in the investigation of; • Biliary ducts of cholecystectomized patients. • The biliary duct and gallbladder of non-cholecystectomized patients.

  21. Preliminary Cleansing of the Colon: Laxative Restricted diet Enemas Breakfast is withheld

  22. Contrast Medium 10 min. – timed from the completion of the injection until satisfactory visualization. 30 – 40 min. maximum pacification.

  23. Contraindications Not indicated for patients who have liver disease or for those whose biliary ducts are not intact.

  24. PercutaneousTranshepaticCholangiography

  25. PercutaneousTranshepaticCholangiography Another type that demonstrate the biliary ducts. More invasive, but it gives the radiologist more options in the diagnosis and treatment of biliary conditions. Involves direct puncture of biliary ducts with needle.

  26. Obstructed jaundice is caused by an interruption to the drainage of bile in the biliary system. The most common causes are gallstones in the common bile duct, and pancreatic cancer in the head of the pancreas

  27. Specific responsibilities of the Rad. Tech. Prepare the fluoroscopic suite Set-up the sterile tray and include the long, thin-walled needle used for puncture. Select and prepare the contrast media. Take the appropriate scout films to verify position and technique. Monitor the patient during the procedure. Change fluoro-spot films as needed.

  28. Operative & post-operative cholangiography

  29. Operative or immediate cholangiogram Perform during surgery and cholecystectomy. Introduced by mirizzi in 1932. Used in the investigation of the patency of the bile ducts and of functional status of the sphincter of hepatopancreaticampulla to reveal the presence of calculi.

  30. Functions / purpose: Investigate the patency of the biliary tract. Determine the functional status of the hepatopancreaticampulla. Reveal any choleliths not previously detected. Demonstrated small lesions, strictures or dilations within the biliary ducts.

  31. Indications Obstructive jaundice Cholangiocarcinoma Stones in the biliary passages Strictures of common bile ducts Choledochal cysts

  32. T – tube, postoperative, or delayed cholangiography

  33. T – tube, postoperative, or delayed cholangiography Radiologic terms applied to the biliary tract examination that is determined by way of the T – shaped tube left in CBD for postoperative drainage.

  34. Purpose: Performed to demonstrate the caliber and patency of the ducts. The status of the sphincter of the hepatopancreaticampulla. Presence of residual or previously undetected stones or other pathologic conditions

  35. Preliminary preparation: Drainage tube is clamped the day preceding the examination to let the tube fill with bile as preventive measure against air bubbles entering the ducts. The preceding meal is withheld. When indicated, a cleansing enema is administered about an hour before the examination.

  36. Contrast agent Is one of the water-soluble, organic contrast media. 25 – 30% density of contrast medium is used.

  37. Indications Patient must have T-tube patient's with possibility of residual small gallstones post cholecystectomy obstructive jaundice bile duct stricture surgeon unable to explore bile duct during cholecystectomy surgery

  38. Contraindications non-consent by patient to procedure contrast or iodine allergy pregnancy (? pregnancy test required) barium study within last 3 days

  39. Positions: RPO with the right upper quadrant of the abdomen is centered to the midline of the table. Stern – stress the importance of obtaining a lateral position to demonstrate the anatomic branching of the hepatic ducts and to detect any abnormality.

  40. Procedure The patient is positioned supine on the x-ray table A slightly RPO position can help to ensure the CBD is not superimposed over the patient's spine. A preliminary/scout image of the RUQ should be acquired. The tip of the t-tube is cleaned with antiseptic the t-tube should be raised and tapped to ensure there are no air bubbles lurking in the tube.

  41. A butterfly needle should be inserted into the T-tube The syringe plunger is withdrawn to remove bile from within the duct. (optional) An early filling image should be obtained. The entire biliary tree should be imaged during injection of contrast medium.

  42. Injection should continue until the entire biliary tree is opacified and there is passage of contrast into the deuodenum. If the intrahepatic ducts do not fill, the patient can be tilted trendelenburg and further contrast injected into the T-tube. The patient may need to lie on their left hand side to fill the left hepatic duct. At least 2 views of the entire biliary tree should be recorded by spot film, oblique views are often taken