In the name In the name of Godof God

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Edited by : Dr. A. ForouzmehrEdited by : Dr. A. Forouzmehr

RadiologistRadiologist

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-50-60% of cases own normal anatomy-50-60% of cases own normal anatomy-40-50% belongs to the normal variations, that is -40-50% belongs to the normal variations, that is

seen in the following:seen in the following:1.Right posterior duct , into left main hepatic duct : 13%2.Trifurcation of biliary confluence .3.Aberrant right hepatic duct, draining into CHD, or

cystic duct, or CBD.4.Low cystic duct insertion.5.Proxymal cystic duct insertion.-congenital abnormalities of bile ducts:-congenital abnormalities of bile ducts:1. 5 types of choledochal cysts.

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1- location of GB and normal variant GB stone: Non-visible GB neck stone

or cystic duct stones , by sonography

3 mirizzi syndrom : 1% in cholecystitis

4-cholecystitis .

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A-choledocolithiasis .

B-biliary stricture .

C-cholangitis: 1.infectious .

2.recurrent pyogenic

3.primary sclerosing

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-Sonographic detection: 21-63%

-False positive MRCP:

-pneumobilia

-hemobilia

-intra-ductal tumor

-crossing hepatic artery

-false negative MRCP:

-small stones(3-5 mm)

-impacted stones.

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A-Benign :

smooth, concentric, short segments

B-Malignant :

abrupt, exentric, long segment

-clinical symptoms: epigastric pain, chills, fever, jaundice

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A- Iatrogenic:

any procedure on bile ducts.=> 95%

B-inflammatory:

-Pancreatitis .10%

-Radiation

-TB , HIV .

-Autoimmune(SLE,poliartritis nodosa). C-Cholangitis .

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CholangitisCholangitis

• Infectious cholangitis . Recurrent pyogenic chlangitis . Primary sclerosing colangitis (PSC).

-post cholecystectomy

-biliary-entric . anastomosis

-liver transplantation & partial hepatectomy

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A.Early complications:

-retained CBD stones

-clipped CBD or hepatic duct

-transected CBD or hepatic duct

-bile leak

B.Late complications:

-CBD stricture(usually after laparoscopic resection)

-oddi’s dysfunction

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A common feature of both the initial and late postoperative

complications of cholecystectomy is , the biliary dilatation, measure maximally

13mm & taper slowly.

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-obstruction

-cholangitis

-intra-hepatic stricture

-bile leaks

-intra-hepatic bile stones

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Papillary disordersPapillary disorders

A-Papillitis : - causes are: -choledocolithiasis -cholangitis -pancreatitisB- Papillary stricture:C-oddi’s dysfunction : (in the absence of any mass

or stricture, dilated CBD, pancreatic duct or both at the level of ampulla , cause of ODD’S DYSFUNCTION will be created).

D- Papillary & ampullary adenoma.

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) GB carcinoma :

- The most common tumor of biliary system . -Liver involvement at the time of diagnosis is 65% .

-Lymphatic incidence is 50%.

-5 years survival is 13% .

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GB carcinoma (findings):

1-focal or diffuse moral thickening 70% infiltrative,>10mm,25%malig

2-Soft tissue mass occupying or replasing lumen of GB(usually with stone)

3-Intraluminal polypoi mass>10mm

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Cholangiocarcinoma: Predisposing factors:

20% prevalance .)1.Hepatolithiasis

2.Choledocal cysts (10-20%)3.alchohol(10%)

4.diabetes,cirrhosis,PSC

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Cholangiocarcinoma (location):

A-extrahepatic:85-90% .

-Portahepatis(hilar) :60-70% .

-Other parts 20-30%

B-Intra hepatic:5-15%

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Hilar cholangiocarcinoma(klatskin tumor):-Arised from the right,left or common branch-70% infiltrative type .-Rarly mass presented-Thickness of duct >5mm=malignancy-Signs of malignant stricture-Segmental or lobal atrophy of liver-Only 20-40% is resectable-Diffusion weighted imaging is the best choice for Diffusion weighted imaging is the best choice for

diagnosisdiagnosis

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Distal extrahepatic cholangiocarcinoma(presentations):

1.intramural infiltration

2.Larg segment with gradual tapering

3.Asymmetric and irregular contour

4.Nodular rapid cut-off at transitional zone

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Peri ampullary tumors:

Deffinition: tumors arising within 2cm of deudenal papilla

-may arising from ampulla,deudenom,bile duct,or pancreas

Peri ampullary tumors

-it sholud be differentiated from physiologic contraction .of odd’s sphincter

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Intra-hepatic cholangiocarcinoma:

1-Mass forming type:

-usually large ,labulated contour ,heteroge

-peripheral inhancement,satellate nodules, liver retraction

2-Peri ductal , segmental type .3-Intra ductal growing type

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MRCP findings:MRCP findings:

1.Abrupt obstruction of CBD & .pancreatic duct(doubl-duct sign)

2.Atrophy of body and tail of pancreas .

.3.Lymphadenopathy

.4.Encasement of celiac artery