Transcript File - BINZHOU MEDICAL UNIVERSITY

Gallbladder and Bile Ducts
Chuan Lu
Department of Diagnostic Radiology
Taishan Medical University
Anatomy
Various Modalities in Biliary Imaging
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US
MRCP
CT
ERCP
Percutaneous transhepatic
cholangiography
Sagittal image of gallbladder
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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 ；
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Transverse image of the liver
• right /left intrahepatic duct
just to proximal CHD: 2-3mm ；
Common bile duct
CBD:≥8mm =dilated
MR
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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 normalsized extrahepatic ducts distal to the level of
occlusion.
MRCP
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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.
MRCP
The MRCP creates an enhanced MRI and may be
adjusted to optimally visualize the biliary and
pancreatic ducts.
MRCP显示胆系
MRCP
MRCP显示胆系
CT
Modern multidetector computed tomography
is a new diagnostic imaging tool that allows
multiplanar reformation.
CT cholangiography performed with 64channel multidetector .CT scanners could
provide much more information regarding the
biliary tree and its abnormalities.
Imaging Techniques
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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 thinsection 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.
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Anterior (a) and right superior (b) VR images
show the right posterior hepatic duct (arrow in a)
draining into the left hepatic duct.
ERCP :Endoscopic Retrograde
Cholangiopancreatography
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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
Modality
Advantages
ERCP
Permits simultaneous biopsy or
Treatment
MRCP
Noninvasive, no radiation exposure
US
Noninvasive, easily available,
no radiation exposure
Disadvantages
Invasive, may not be possible due to altered anatomy
following surgery
Prone to artifact, provides little functional information,
difficult to diagnose calcification, difficult to perform in
periampullary area
Operator dependent, poor demonstration of peripheral
intrahepatic bile ducts, less consistent
Multidetector CT
cholangiography
Information regarding biliary
kinetics and function available,
high spatial resolution,
short scanning time
Radiation exposure, side effects of the biliary agent,
limited in patients with poor hepatic function
Cholecystolithiasis
•Gallstone with shadowing: high-level
intraluminal echoes+ acoustic
shadowing(100%diagnostic)
• Mobility of the stone by moving the patient
during ultrasound scanning
Cholecystolithiasis
•Gallstone with shadowing: high-level
intraluminal echoes+ acoustic
shadowing(100%diagnostic)
• Mobility of the stone by moving the patient
during ultrasound scanning
Cholecystolithiasis
Gallstone with shadowing: high-level intraluminal
echoes+ acoustic shadowing(100%diagnostic)
Mobility of the stone by moving the patient during
ultrasound scanning
Cholecystolithiasis
Gallstone with shadowing: high-level intraluminal echoes+ acoustic
shadowing(100%diagnostic)
Mobility of the stone by moving the patient during ultrasound scanning
Cholecystolithiasis
Sludge
Nonshadowing echogenic homogenerous
mass shifting position slowly
False-negative US (5%):
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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
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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%)
Cholangiolithiasis
• Stone visualization in 13-77%(more readily with
CBD dilatation + good visibility of pancreatic head)
•Dilatation of CBD
•Acoustic shadowing
Cholangiolithiasis 2
Stone visualization with CBD
dilatation
Acute cholecystitis
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Wall thickening (over 3mm) and irregularity
Hazy delineation of gallbladder wall
Focal tenderness over gallbladder (sonographic
Murphy’s sign)
Cholelithiasis
Acute cholecystitis
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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
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Gallbladder stones
Smooth /irregular GB wall
thickening
(mean of 5mm)
Mean volume of 42ml
Chronic Cholecystitis
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Gallbladder stones
Smooth /irregular GB wall thickening (mean
of 5mm)
Mean volume of 42ml
Gallbladder polyp
Polypoid / fungating intraluminal mass
with wide base
Polypoid / fungating intraluminal mass with wide
base
Gallbladder Carcinoma
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Associated with:
Disorder of gallbladder:
 Cholelithiasis in 64-98%
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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
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Gallbladder carcinoma occurs in only 1% of all patients with gallstones!
Histo:
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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
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fundus (60%),
body (30%),
neck (10%)
Growth types:
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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 types:
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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
US:
 gallbladder replaced by mass with irregular
margins + heterogeneous echotexture (=
tumor necrosis)
 immobile intraluminal well-defined
round/oval mass
Replacement of gallbladder by
mass
(gallbladder replaced by mass with irregular margins +
heterogeneous echotexture (= tumor necrosis)
immobile intraluminal well-defined
round/oval mass
Focal asymmetric irregular thickening of GB wall
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
A.Extrahepatic tumor(Klatskin’s tumor -tumor located in the hepatic
duct bifurcation)
B. intrahepatic tumor resulting in biliary duct dilation.
US
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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.
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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.
Obstructive type :
U/V-shaped obstruction with nipple ,rattail, smooth/
irregular termination
Mass within/surrounding the ducts at point of obstruction
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.
Stenotic type: strictured rigid lumen with
irregular margin+ prestenotic dilatation
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 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
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
Thank You