radio logic anatomy of liver, biliary tree by dr. talat

RADIOLOGICAL ANATOMY OF RADIOLOGICAL ANATOMY OF LIVER, GALLBLADDER, BILIARY LIVER, GALLBLADDER, BILIARY TREE, PANCREAS AND SPLEEN TREE, PANCREAS AND SPLEEN

TALAT H.SHARIF MDTALAT H.SHARIF MD

ObjectiveObjective

To identify abdominal structures To identify abdominal structures such as liver, gallbladder, pancreas such as liver, gallbladder, pancreas and spleen on X-Rays, Contrast and spleen on X-Rays, Contrast Studies, CT Scan , Ultrasound and Studies, CT Scan , Ultrasound and MRIMRI

To be able to understand the To be able to understand the relationship of these organ with the relationship of these organ with the structures around them. structures around them.

Imaging ModalitiesImaging Modalities

X-RAYSX-RAYS ULTRASOUNDULTRASOUND CT SCANCT SCAN MRIMRI T-TUBE CHOLANGIOGRAMT-TUBE CHOLANGIOGRAM MRCPMRCP ORAL CHOLECYSTOGRAM ORAL CHOLECYSTOGRAM ENODSCOPIC RETROGRADE ENODSCOPIC RETROGRADE

CHOLANGIOPANCREATICOGRAPHY (ERCP)CHOLANGIOPANCREATICOGRAPHY (ERCP) CHOLESCINTEGRAPHYCHOLESCINTEGRAPHY

Radiographic anatomy on Radiographic anatomy on Supine abdominal filmSupine abdominal film

Standard plain abdominal film is Standard plain abdominal film is taken with the patient in the supine taken with the patient in the supine position. position.

It may help us to make a specific It may help us to make a specific diagnosis. diagnosis.

It may also provide useful It may also provide useful information for determining if any information for determining if any subsequent or more specialized, subsequent or more specialized, examinations are needed.examinations are needed.


Plain abdomen film may also Plain abdomen film may also help ushelp us

To evaluate the normal soft-To evaluate the normal soft-tissue densities /organs, and tissue densities /organs, and abnormal massesabnormal masses

To find any calcifications in the To find any calcifications in the abdomen if any.abdomen if any.


– To evaluate any gaseous lucencies , To evaluate any gaseous lucencies , their distribution and the amount of their distribution and the amount of intraluminal gas, the presence of intraluminal gas, the presence of any abnormal intraluminal any abnormal intraluminal collections, and any evidence of collections, and any evidence of extraluminal gasextraluminal gas

– To evaluate the visualized bones To evaluate the visualized bones and the lung bases. and the lung bases.

Plain Abdominal film(supine)Plain Abdominal film(supine)

Supine view shows Supine view shows normal liver, normal liver, kidneys, and psoas kidneys, and psoas muscles.muscles.

In plain-film In plain-film estimation of liver estimation of liver size is not very size is not very reliable and does not reliable and does not correlate well with correlate well with clinical estimations clinical estimations of liver size.of liver size.

Normal soft tissue densitiesNormal soft tissue densities

– The normal soft-tissue structures that The normal soft-tissue structures that can usually be identified on plain films can usually be identified on plain films of the abdomen include the liver, of the abdomen include the liver, kidneys, psoas muscles, and bladder . kidneys, psoas muscles, and bladder .

– The normal spleen and the uterus may The normal spleen and the uterus may also be identified. (not always). also be identified. (not always).

– These structures are of water These structures are of water density and are visible because density and are visible because they are largely surrounded by fat.they are largely surrounded by fat.

Normal soft tissue densitiesNormal soft tissue densities

A supine view A supine view of the abdomen of the abdomen shows normal shows normal (L), spleen (S), (L), spleen (S), kidneys (K), and kidneys (K), and psoas muscles ( psoas muscles ( Psm). The right Psm). The right kidney is lower kidney is lower than leftthan left

LiverLiver

Anatomic diagram of abdominal Anatomic diagram of abdominal organsorgans

LiverLiver The largest organ in the abdominal The largest organ in the abdominal

cavity and the most complex. cavity and the most complex. Liver occupies most of the right Liver occupies most of the right

upper quadrant. upper quadrant. upper surface of the liver is almost upper surface of the liver is almost

always adjacent to the inferior always adjacent to the inferior surface of the right hemidiaphragm. surface of the right hemidiaphragm.

Located between the fifth intercostal Located between the fifth intercostal space in the midclavicular line space in the midclavicular line downward and along the right costal downward and along the right costal margin. margin.

Weighs approximately 1800 grams in Weighs approximately 1800 grams in men and 1400 grams in women. men and 1400 grams in women.

Surfaces of the liver are smooth and Surfaces of the liver are smooth and convex in the superior, anterior and convex in the superior, anterior and right lateral regions. right lateral regions.

LiverLiver

LiverLiver

Inferior margin of the Inferior margin of the liver is defined by liver is defined by extraperitoneal fat extraperitoneal fat posteriorly and by posteriorly and by gas in the hepatic gas in the hepatic flexure and flexure and transverse colon transverse colon anteriorly. anteriorly.

Right lateral margin Right lateral margin of the liver can also of the liver can also be seen because of be seen because of adjacent fat. adjacent fat.

LiverLiver The physical The physical

examination defines examination defines the anterior margin of the anterior margin of the liver. the liver.

It is the posterior It is the posterior margin of the liver, margin of the liver, which is surrounded which is surrounded by retroperitoneal fat, by retroperitoneal fat, that is consistently that is consistently visible on radiographsvisible on radiographs

LiverLiver

Liver size is< 13 cm (Normal) Liver size is< 13 cm (Normal) > 15.5 cm is considered hepatomegaly > 15.5 cm is considered hepatomegaly

Hepatomegaly Hepatomegaly may be detected by:may be detected by:

– Elevation of the right Elevation of the right hemidiaphragm anteriorlyhemidiaphragm anteriorly

– Inferior displacement of the Inferior displacement of the hepatic flexurehepatic flexure

– Left lateral displacement of the Left lateral displacement of the stomach.stomach.

surfaces of the liver are smooth and convex in the superior, surfaces of the liver are smooth and convex in the superior, anterior and right lateral regions. anterior and right lateral regions.

Portal TriadPortal Triad

CT Scan (Porta Hepatis)CT Scan (Porta Hepatis)

Abdominal UltrasoundAbdominal Ultrasound

SAGITTAL PLANESAGITTAL PLANE

RIGHT LOBE

LIVER

DIAPHRGAM

COSTOPHRENIC SULCUS

Abdominal UltrasoundAbdominal Ultrasound

CT Scan of abdomenCT Scan of abdomen

LiverLiver The liver is divided into two lobes of The liver is divided into two lobes of

unequal size and shape. unequal size and shape. – Right lobe Right lobe

Occupies the right upper Occupies the right upper quadrant quadrant

Right hepatic vein Right hepatic vein divides right divides right lobe into anterior and posterior lobe into anterior and posterior segments segments

LiverLiver– Left lobe Left lobe

– Left hepatic vein Left hepatic vein divides left divides left lobe into medial and lateral lobe into medial and lateral segments segments

– Left lobe is much smaller and Left lobe is much smaller and has a different blood supply has a different blood supply and portal drainage from the and portal drainage from the right lobe right lobe

LiverLiver– Caudate lobe Caudate lobe

Functionally is part of both right Functionally is part of both right and left lobes because it receives and left lobes because it receives its blood supply from both right its blood supply from both right and left hepatic arteries and left hepatic arteries

– Quadrate lobeQuadrate lobeReceives its blood supply from Receives its blood supply from the left hepatic artery and is the left hepatic artery and is therefore functionally part of the therefore functionally part of the left lobe.left lobe.

Middle hepatic vein Middle hepatic vein divides right divides right from left lobe of liver from left lobe of liver

Blood supply of the LiverBlood supply of the Liver

It is important to understand the complex It is important to understand the complex blood flow through the liver blood flow through the liver

Liver receives blood from two sources-Liver receives blood from two sources-– Portal vein – 80%Portal vein – 80%– Hepatic artery – 20%Hepatic artery – 20%

It drains into the hepatic veinsIt drains into the hepatic veins The hepatic artery, portal vein and bile The hepatic artery, portal vein and bile

ducts travel together as portal triad and is ducts travel together as portal triad and is covered by connective tissue covered by connective tissue

LiverLiver

The hepatic artery arises from the celiac The hepatic artery arises from the celiac axis and courses through the upper portion axis and courses through the upper portion of the pancreas toward the liver. of the pancreas toward the liver.

The hepatic artery gives rise to the The hepatic artery gives rise to the gastroduodenal artery posterior and gastroduodenal artery posterior and superior to the duodenum. It divides to right superior to the duodenum. It divides to right and left hepatic branches and then into and left hepatic branches and then into smaller branches. In many cases, a third smaller branches. In many cases, a third artery supplies portions of segment IV and artery supplies portions of segment IV and the right lobe of the liver. the right lobe of the liver.

LiverLiver TheThe Couinaud classification accepted Couinaud classification accepted

internationally and is used in UTZ, internationally and is used in UTZ, CT, MRI. CT, MRI. It divides the liver into 8 It divides the liver into 8 independent segments each of which independent segments each of which has its own vascular inflow, outflow, has its own vascular inflow, outflow, and biliary drainage and biliary drainage

Because of this division into self-Because of this division into self-contained units, each can be contained units, each can be resected without damaging the resected without damaging the remaining remaining

LiverLiverView of the View of the liver liver showing showing plane of plane of right right hepatic vein hepatic vein as it as it courses to courses to the IVC.the IVC.

LiverLiverShaded-SurfaceShaded-Surface projection projection showing how the showing how the plane of the right plane of the right hepatic vein hepatic vein provides the provides the vertical division of vertical division of the the right liver lobe right liver lobe into anterior and into anterior and posterior segmentsposterior segments

Posterior shaded surface view of the liver Posterior shaded surface view of the liver magnified to show the relation of the magnified to show the relation of the caudate caudate lobe lobe with the IVC with the IVC medially medially and the fissure for and the fissure for

the ligamentum venosumthe ligamentum venosum laterally. laterally.

CT Scan of Liver CT Scan of Liver

COUINAD’S SegmentsCOUINAD’S Segments

right hepatic vein

Middle hepatic vein

Umbilical fissure

Left hepatic vein

Axis of intrahepatic portal vein

• I)I) Caudate lobe Caudate lobe • II)II) Left posterolateral Left posterolateral

segment segment • III)III) Left anterolateral Left anterolateral

segment segment • IVa)IVa) Left superomedial Left superomedial

segment segment • IVb)IVb) Left inferomedial Left inferomedial

segment segment • V)V) Right anteroinferior Right anteroinferior

segment segment • VI)VI) Right posteroinferior Right posteroinferior

segment segment • VII)VII) Right postero- Right postero-

superior segment superior segment • VIII)VIII) Right anterosuperior Right anterosuperior

segmentsegment

Shaded surface view showing that the course of Shaded surface view showing that the course of the the middle hepatic vein middle hepatic vein falls roughly along falls roughly along a plane a plane extending from the gallbladder fossa and the IVC. extending from the gallbladder fossa and the IVC. This plane divides theThis plane divides the right hepatic lobe from the right hepatic lobe from the

left hepatic lobeleft hepatic lobe

MIP and shaded-surface views showing that MIP and shaded-surface views showing that the the plane of the umbilical fissure divides plane of the umbilical fissure divides the the

left lobe into medial and lateral portionsleft lobe into medial and lateral portions which which need to be further divided to qualify as need to be further divided to qualify as

independent independent Couinaud Couinaud segments.segments.

Left hepatic lobeLeft hepatic lobe: MIP and shaded-surface : MIP and shaded-surface views showing that the views showing that the plane of the left plane of the left

hepatic vein subdivides the lateral portion of hepatic vein subdivides the lateral portion of the left hepatic lobe the left hepatic lobe

MIP and shaded surface views showing the MIP and shaded surface views showing the plane of the main intrahepatic portal vein plane of the main intrahepatic portal vein Note this plane (arrow on surface view) is Note this plane (arrow on surface view) is

roughly roughly horizontal horizontal but in some cases may be but in some cases may be angled angled

The dotted line indicates how this plane is The dotted line indicates how this plane is sometimes used to sometimes used to divide segment IV into divide segment IV into superior (IVa) and inferior (IVb) divisions.superior (IVa) and inferior (IVb) divisions.

UUltrasonographic view of the portal vein ltrasonographic view of the portal vein branches to thebranches to the Couinaud segments 5, 6, Couinaud segments 5, 6,

7, and 87, and 8

Ultrasonographic view of the portal Ultrasonographic view of the portal vessels locating the central portions of the vessels locating the central portions of the Couinaud segments of the left liver lobeCouinaud segments of the left liver lobe

Ultrasonographic view of the Ultrasonographic view of the confluence of the confluence of the right (rhv),right (rhv), middle middle

(mhv),(mhv), and and left (lhv)left (lhv) hepatic veins with hepatic veins with the the IVC IVC

Doppler Study of LiverDoppler Study of Liver

CT Scan of the LiverCT Scan of the Liver

Gall Bladder & Biliary TreeGall Bladder & Biliary Tree

GallbladderGallbladder Small pear-shaped sac Small pear-shaped sac Sits in between the right and quadrate Sits in between the right and quadrate

lobes of the liver lobes of the liver 30-50 cc in capacity 30-50 cc in capacity Connected to the liver by connective Connected to the liver by connective

tissue tissue Parts of the gall bladder: Parts of the gall bladder:

– Fundus Fundus – Body Body – Neck Neck

LIVER

CYSTIC DUCT

GALLBLADDER

DUODENUM

AMPULLA OF VATER

PANCREATIC DUCTS

RIGHT AND LEFT HEPATIC DUCTS

COMMON BILE DUCT

COMMON HEPATIC DUCT

Biliary Drainage SystemBiliary Drainage System

Hepatic ducts Hepatic ducts Cystic duct Cystic duct Pancreatic duct Pancreatic duct Common bile duct Common bile duct Ampulla of Vater Ampulla of Vater

GallbladderGallbladder

Relationship to other structures: Relationship to other structures: – Anterior Anterior

Anterior abdominal wall Anterior abdominal wall – Posterior Posterior

Transverse colon Transverse colon Duodenum Duodenum

– Superior Superior Under surface of liver Under surface of liver

Ultrasound of GB and Biliary Ultrasound of GB and Biliary tree tree

– Painless, non-invasive procedure. Painless, non-invasive procedure. – does not require special preparation, although does not require special preparation, although

it is technically easier in patients with at least it is technically easier in patients with at least six hours of fasting. six hours of fasting.

– Usually recommended as the first imaging Usually recommended as the first imaging modality for the investigation of patients with modality for the investigation of patients with suspected cholangiocarcinoma. suspected cholangiocarcinoma.

– In hilar cholangiocarcinoma, ultrasound In hilar cholangiocarcinoma, ultrasound demonstrates bilateral dilation of intrahepatic demonstrates bilateral dilation of intrahepatic ducts, and right and left hepatic ducts ducts, and right and left hepatic ducts

Ultrasound of GB and Biliary treeUltrasound of GB and Biliary tree

The best noninvasive test for detecting The best noninvasive test for detecting gallstones in the gallbladder is abdominal gallstones in the gallbladder is abdominal ultrasonography because of its high ultrasonography because of its high specificity and sensitivity (90–95%) specificity and sensitivity (90–95%)

Does not employ ionizing radiation, and Does not employ ionizing radiation, and provides accurate anatomical information. provides accurate anatomical information.

May also indicate distal obstruction by the May also indicate distal obstruction by the finding of dilated intrahepatic or finding of dilated intrahepatic or extrahepatic bile ducts. extrahepatic bile ducts.

Less useful for excluding gallstones Less useful for excluding gallstones obstructing the common bile duct. obstructing the common bile duct.

Ultrasound of GB and Biliary Ultrasound of GB and Biliary tree tree

GALLBLADDER ON GALLBLADDER ON ULTRASOUND ULTRASOUND

If transverse diameter of gallbladder is more than 5 cm with round configuration instead of ovoid it means that it is hydropic

Transverse diameter less than 2 cm inspite of adequate fasting means it is abnormally contracted

Gall Bladder

Portal Vein

Common Bile Duct

Ultrasound of Gallbladder and Ultrasound of Gallbladder and Biliary tree Biliary tree

Acute cholecystitis

Computed Tomography (CT) Computed Tomography (CT) of GB and Biliary Treeof GB and Biliary Tree

May detect lesions like low-density mass May detect lesions like low-density mass or stone in GB or in dilated biliary ducts . or stone in GB or in dilated biliary ducts .

Produces different pictures depending on Produces different pictures depending on location of the tumor and the level and location of the tumor and the level and degree of obstruction. degree of obstruction.

Clearly show hilar masses causing bilateral Clearly show hilar masses causing bilateral dilation of intrahepatic biliary ducts. dilation of intrahepatic biliary ducts.

May detect tumors causing dilatation of May detect tumors causing dilatation of intra- and extrahepatic bile ducts and intra- and extrahepatic bile ducts and gallbladder. gallbladder.

Computed Tomography (CT) Computed Tomography (CT) of GB and Biliary Treeof GB and Biliary Tree

Useful in demonstrating masses and dilated Useful in demonstrating masses and dilated biliary ducts, although they are not as biliary ducts, although they are not as reliable for the diagnosis of calculous reliable for the diagnosis of calculous disease. disease.

Principal use is detection of the Principal use is detection of the complications of gallstones such as complications of gallstones such as pericholecystic fluid, gas in the gallbladder pericholecystic fluid, gas in the gallbladder wall, gallbladder perforations, and wall, gallbladder perforations, and abscesses. abscesses.

May help determine which patients will May help determine which patients will require urgent surgical intervention . require urgent surgical intervention .

Computed Tomography (CT) Computed Tomography (CT) of Gallbladderof Gallbladder

Computed Tomography (CT) Computed Tomography (CT) of Gallbladder and Biliary Treeof Gallbladder and Biliary Tree

Magnetic Resonance Imaging (MRI) Magnetic Resonance Imaging (MRI)

Slightly superior to computed tomography in Slightly superior to computed tomography in visualization of body structures and tumors. visualization of body structures and tumors.

Allows visualization of both dilated biliary ducts Allows visualization of both dilated biliary ducts proximal to the tumor and normal-sized proximal to the tumor and normal-sized extrahepatic ducts distal to the level of occlusion.extrahepatic ducts distal to the level of occlusion.

Images obtained from the newest diagnostic Images obtained from the newest diagnostic equipment are comparable in quality to those equipment are comparable in quality to those obtained with Endoscopic Retrograde obtained with Endoscopic Retrograde Cholangiopancreatography (ERCP) and Cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography. percutaneous transhepatic cholangiography.

Ductal or intravenous injection of contrast Ductal or intravenous injection of contrast medium is not necessary and the patient is not medium is not necessary and the patient is not exposed to irradiation. exposed to irradiation.

MRI AbdomenMRI Abdomen

Endoscopic Retrograde Endoscopic Retrograde Cholangiopancreatography (ERCP) Cholangiopancreatography (ERCP)

Endoscopic Endoscopic Ultrasound (EUS) Ultrasound (EUS)

The patient is placed in the supine or tilted towards The patient is placed in the supine or tilted towards left. left.

During this procedure, pharyngeal topical anesthetic During this procedure, pharyngeal topical anesthetic agent are administered to prevent gagging. Pain agent are administered to prevent gagging. Pain medication and a sedative may also be given prior to medication and a sedative may also be given prior to the procedure. the procedure.

Allows physician to visualize and biopsy the mucosa Allows physician to visualize and biopsy the mucosa of the upper gastrointestinal tract. of the upper gastrointestinal tract.

Endoscopy permits visualization of the esophagus, Endoscopy permits visualization of the esophagus, stomach and duodenum. stomach and duodenum.

Enteroscope allows visualization of at least 50% of Enteroscope allows visualization of at least 50% of the small intestine, including most of the jejunum the small intestine, including most of the jejunum and part of the ileum. and part of the ileum.

Endoscopic Retrograde Endoscopic Retrograde Cholangiopancreatography (ERCP) Cholangiopancreatography (ERCP)

ERCPERCP

Endoscopic Retrograde Endoscopic Retrograde Cholangiopancreatography (ERCP)Cholangiopancreatography (ERCP)

Endoscopic procedure involves the use of Endoscopic procedure involves the use of fiberoptic endoscopes . fiberoptic endoscopes .

The side-viewing endoscope is introduced into The side-viewing endoscope is introduced into the second portion of duodenum, and contrast the second portion of duodenum, and contrast material is injected into the bile ducts via material is injected into the bile ducts via major duodenal papilla under fluoroscopic major duodenal papilla under fluoroscopic guidance . guidance .

Multiple x-ray pictures are taken to visualize Multiple x-ray pictures are taken to visualize the distribution of the contrast in the biliary the distribution of the contrast in the biliary tree. tree. ERCP ERCP can demonstrate normal size & can demonstrate normal size & structure of the extrahepatic ducts distal to structure of the extrahepatic ducts distal to occlusion and dilated intrahepatic ducts occlusion and dilated intrahepatic ducts proximal to occlusion . proximal to occlusion .

ERCPERCP

Percutaneous Transhepatic Percutaneous Transhepatic CholangiographyCholangiography


Another invasive procedure Another invasive procedure performed by a radiologist under performed by a radiologist under fluoroscopic guidance. A small fluoroscopic guidance. A small needle is introduced through the liver needle is introduced through the liver into one of the peripheral biliary into one of the peripheral biliary ducts. Contrast material is injected ducts. Contrast material is injected through the needle and x-ray through the needle and x-ray pictures obtained to document the pictures obtained to document the biliary tree anatomy. biliary tree anatomy.


For tumors of the middle third of For tumors of the middle third of extrahepatic duct, surgical options include extrahepatic duct, surgical options include resection of the mass with possible resection of the mass with possible primary end-to-end bile duct anastomosis primary end-to-end bile duct anastomosis (for early small tumors) or (for early small tumors) or hepatojejunostomy (if large portion of hepatojejunostomy (if large portion of extrahepatic ducts should be removed). extrahepatic ducts should be removed). For tumors located in distal common bile For tumors located in distal common bile duct, as inWhipple procedure duct, as inWhipple procedure

MRI and MRCPMRI and MRCP These are relatively new applications that These are relatively new applications that

utilizes MRI imaging with special software. utilizes MRI imaging with special software. Capable of producing images similar to Capable of producing images similar to

ERCP without the accompanying risks of ERCP without the accompanying risks of sedation, pancreatitis, or perforation. sedation, pancreatitis, or perforation.

Helpful in assessing biliary obstruction and Helpful in assessing biliary obstruction and pancreatic ductal anatomy. pancreatic ductal anatomy.

Effective in detecting gallstones and to Effective in detecting gallstones and to evaluate the gallbladder for the presence evaluate the gallbladder for the presence of cholecystitis. of cholecystitis.

Major shortcoming of MRCP lies in the Major shortcoming of MRCP lies in the experience of the interpreting physician. experience of the interpreting physician.

Oral Cholecystography Oral Cholecystography Considered cheap and noninvasive test. Considered cheap and noninvasive test. Patient must ingest a dose of an oral contrast agent on Patient must ingest a dose of an oral contrast agent on

the evening before the test. This contrast is absorbed the evening before the test. This contrast is absorbed and secreted into the bile. The iodine in the contrast and secreted into the bile. The iodine in the contrast produces opacification of the gallbladder lumen on a produces opacification of the gallbladder lumen on a plain radiograph the next day. Gallstones appear as plain radiograph the next day. Gallstones appear as filling defects. filling defects.

Main use of oral cholecystography is to establish Main use of oral cholecystography is to establish patency of the cystic duct. This information is required patency of the cystic duct. This information is required before attempting lithotripsy or medical methods to before attempting lithotripsy or medical methods to dissolve gallstones. dissolve gallstones.

A major drawback of oral cholecystography is that it A major drawback of oral cholecystography is that it takes 48 hours to perform, which limits its usefulness in takes 48 hours to perform, which limits its usefulness in patients with acute cholecystitis and gallstone patients with acute cholecystitis and gallstone complications and increase risk of toxicity by the complications and increase risk of toxicity by the contrast- not popular. contrast- not popular.

CholescintigraphyCholescintigraphy

Employs the use of an intravenous radioactive Employs the use of an intravenous radioactive iminodiacetic acid derivative which is rapidly iminodiacetic acid derivative which is rapidly absorbed by the liver and excreted into the bile. absorbed by the liver and excreted into the bile.

Serial scans demonstrate the radioactivity in the Serial scans demonstrate the radioactivity in the gallbladder, common bile duct, and small bowel gallbladder, common bile duct, and small bowel within 30–60 minutes. within 30–60 minutes.

A nonfunctioning gallbladder is diagnostic of A nonfunctioning gallbladder is diagnostic of acute cholecystitis. acute cholecystitis.

May be useful in determining whether May be useful in determining whether cholecystectomy will benefit a patient with cholecystectomy will benefit a patient with chronic biliary pain without gallstones. chronic biliary pain without gallstones.

Cholangiogram Cholangiogram RIGHT AND LEFT HEPATIC DUCTS

CYSTIC DUCT

COMMON BILE DUCT

COMMON HEPATIC DUCT

CT Scan with ContrastCT Scan with Contrast

PancreasPancreas

PancreasPancreas

Total length – 12.5 to 15.0 cmTotal length – 12.5 to 15.0 cm Head measures approx. 1.5- 2.0 cmHead measures approx. 1.5- 2.0 cm Neck measures approx. 1.0 cm Neck measures approx. 1.0 cm Body measures approx. 2.0 cmBody measures approx. 2.0 cm Tail measures approx. 2.0-3.0 cmTail measures approx. 2.0-3.0 cm Normal pancreatic duct 2 mmNormal pancreatic duct 2 mm The head & body are retroperitoneal The head & body are retroperitoneal

structures while tail is intraperitonealstructures while tail is intraperitoneal

PancreasPancreas

The pancreas is 12-15 cm long and is The pancreas is 12-15 cm long and is located in the epigastrium located in the epigastrium

Has four parts: Has four parts: – Head Head

Uncinate process Uncinate process – Neck Neck – Body and tailBody and tail

The head and body lie outside peritoneum The head and body lie outside peritoneum The head of the pancreas is surrounded by The head of the pancreas is surrounded by

the duodenum as it makes a C-loop the duodenum as it makes a C-loop around the pancreas around the pancreas

Imaging of Pancreas- CT scan Imaging of Pancreas- CT scan

Acute pancreatitis

Ultrasound of PancreasUltrasound of Pancreas

PancreasPancreas The pancreas lies behind the peritoneum of the The pancreas lies behind the peritoneum of the

posterior abdominal wall and is oblique in its posterior abdominal wall and is oblique in its orientation. orientation.

The head of the pancreas is on the right side and The head of the pancreas is on the right side and lies within the “C” curve of the duodenum at the lies within the “C” curve of the duodenum at the second vertebral level (L2). second vertebral level (L2).

The tip of the pancreas extends across the The tip of the pancreas extends across the abdominal cavity almost to the spleen. abdominal cavity almost to the spleen.

Collecting ducts empty digestive juices into the Collecting ducts empty digestive juices into the pancreatic duct, which runs from the head to the pancreatic duct, which runs from the head to the tail of the organ. tail of the organ.

PancreasPancreas

The pancreatic duct empties into the The pancreatic duct empties into the duodenum at the duodenal papilla, duodenum at the duodenal papilla, alongside the common bile duct.alongside the common bile duct.

Smooth circular muscle surrounding the Smooth circular muscle surrounding the end of the common bile duct (biliary end of the common bile duct (biliary sphincter) and main pancreatic duct sphincter) and main pancreatic duct (pancreatic sphincter) fuses at the level (pancreatic sphincter) fuses at the level of the ampulla of Vater is called the of the ampulla of Vater is called the sphincter of Oddi. sphincter of Oddi.

The distal end of the The distal end of the common bile duct can common bile duct can be found behind the be found behind the upper border of the upper border of the head of the pancreas. head of the pancreas. This duct courses the This duct courses the posterior aspect of the posterior aspect of the pancreatic head pancreatic head before passing before passing through the head to through the head to reach the ampulla of reach the ampulla of Vater (major papilla).Vater (major papilla).

The pancreas may be The pancreas may be divided into five major divided into five major regions—the head, neck, regions—the head, neck, body, tail and uncinate body, tail and uncinate process.process.

The uncinate process is The uncinate process is the segment of the segment of pancreatic tissue that pancreatic tissue that extends from the extends from the posterior of the head. posterior of the head. The neck of the The neck of the pancreas, a part of the pancreas, a part of the gland 3–4 cm wide, joins gland 3–4 cm wide, joins the head and body. The the head and body. The pancreatic body lies pancreatic body lies anteriorly in contact with anteriorly in contact with the antrum of the the antrum of the stomach. stomach.

The Duct of Wirsung is the main pancreatic duct The Duct of Wirsung is the main pancreatic duct extending from the tail of the organ to the major extending from the tail of the organ to the major duodenal papilla or Ampulla of Vater . The widest part duodenal papilla or Ampulla of Vater . The widest part of the duct is in the head of the pancreas (4 mm), of the duct is in the head of the pancreas (4 mm), tapering to 2 mm at the tail in adults. The duct of tapering to 2 mm at the tail in adults. The duct of Wirsung is close, and almost parallel, to the distal Wirsung is close, and almost parallel, to the distal common bile duct before combining to form a common bile duct before combining to form a common duct channel prior to approaching the common duct channel prior to approaching the duodenum. In approximately 70% of people, an duodenum. In approximately 70% of people, an accessory pancreatic duct of Santorini (dorsal accessory pancreatic duct of Santorini (dorsal pancreatic duct) is present. This duct may pancreatic duct) is present. This duct may communicate with the main pancreatic duct. The communicate with the main pancreatic duct. The degree of communication of the dorsal and ventral degree of communication of the dorsal and ventral duct varies from patient to patient. duct varies from patient to patient.

PancreasPancreas

The common bile duct traverses The common bile duct traverses through the head of the pancreas through the head of the pancreas and joins with the pancreatic duct at and joins with the pancreatic duct at the ampulla of Vater to empty bile the ampulla of Vater to empty bile into the second or descending part of into the second or descending part of the duodenum the duodenum

Both the pancreatic ducts of Both the pancreatic ducts of Santorini and Wirsung drain the Santorini and Wirsung drain the exocrine pancreas exocrine pancreas

Relationship of PancreasRelationship of Pancreas

– Head Head Posterior Posterior

– SMV SMV – Splenic vein Splenic vein – IVC IVC – Terminal portion of renal vein Terminal portion of renal vein – Right crus of diaphragm Right crus of diaphragm

Anterior Anterior – Transverse colon Transverse colon – Uncinate process passes in front of Uncinate process passes in front of

aorta aorta

Relationship to Surrounding Relationship to Surrounding StructuresStructures

Lateral Lateral –Bile duct Bile duct

– Neck Neck Anterior Anterior

–Pylorus Pylorus –Omental bursa Omental bursa

Posterior Posterior –SMV SMV –Beginning of portal vein Beginning of portal vein


– Body Body Anterior Anterior

– Stomach separated by omental bursa Stomach separated by omental bursa Posterior Posterior

– Aorta Aorta – SMA SMA – Left crus of diaphragm Left crus of diaphragm – Left adrenal Left adrenal – Left kidney Left kidney – Left renal vein Left renal vein – Splenic vein Splenic vein


Inferior Inferior – Transverse mesocolon Transverse mesocolon – Duodeno-jejunal junction Duodeno-jejunal junction – Left colic flexureLeft colic flexure

Superior border Superior border – Splenic artery Splenic artery

– Tail Tail The tail of the pancreas lies in the The tail of the pancreas lies in the

splenorenal ligament and enters the splenorenal ligament and enters the hilum of the spleen with splenic hilum of the spleen with splenic vessels. vessels.

Ultrasound of PancreasUltrasound of Pancreas

CT Scan of PancreasCT Scan of Pancreas

SpleenSpleen

Spleen on Plain X-raySpleen on Plain X-ray

Recognizable as a Recognizable as a soft-tissue density soft-tissue density measuring 8 cm measuring 8 cm to 12 cm in to 12 cm in length, high length, high under the left under the left hemidiaphragm hemidiaphragm and lateral to the and lateral to the stomach. stomach.

SpleenSpleen

Size may vary considerably(< 15 cm in Size may vary considerably(< 15 cm in adult & 50% decrease in old age). adult & 50% decrease in old age).

When enlarged, the spleen frequently When enlarged, the spleen frequently displaces the gas-filled splenic flexure of displaces the gas-filled splenic flexure of the colon in an inferomedial direction and the colon in an inferomedial direction and may also displace the stomach medially. may also displace the stomach medially.

Significant splenomegaly may be Significant splenomegaly may be diagnosed quite accurately on plain diagnosed quite accurately on plain abdominal films.abdominal films.

Ultrasound of SpleenUltrasound of Spleen

CT Scan of SpleenCT Scan of Spleen

Adrenal GlandsAdrenal Glands


Anatomically, the adrenal glands Anatomically, the adrenal glands are located in the abdomen, are located in the abdomen, situated on the anterosuperior situated on the anterosuperior aspect of the kidneysaspect of the kidneys

They are found at the level of the They are found at the level of the 12th thoracic vertebra12th thoracic vertebra

Adrenal Glands Adrenal Glands Arterial supply – Arterial supply –

– Superior suprarenal artery Superior suprarenal artery – Middle suprarenal arteryMiddle suprarenal artery– Inferior suprarenal artery Inferior suprarenal artery

Venous supply Venous supply – Suprarenal veins only Suprarenal veins only – Among all imaging modalities CT is Among all imaging modalities CT is

considered the first line of investigations, considered the first line of investigations, UTZ preferred in childrenUTZ preferred in children


Normal adrenal in adults weighs Normal adrenal in adults weighs about 3 to 6 grams each. Average about 3 to 6 grams each. Average size is 3 to 5 cm (L) X 2 to 3 cm (W)size is 3 to 5 cm (L) X 2 to 3 cm (W)

Right is triangular in shape lying Right is triangular in shape lying adjacent to the upper pole of kideny adjacent to the upper pole of kideny behind IVC.behind IVC.

Left is semilunar in shape and lies Left is semilunar in shape and lies anteromedial to the upper pole of left anteromedial to the upper pole of left kidney.kidney.

Imaging of Adrenal Glands Imaging of Adrenal Glands

The adrenal glands are located in the perirenal space near the upper pole of each kidney

Late phase of contrast enhanced Ct Late phase of contrast enhanced Ct shows a right adrenal mass with shows a right adrenal mass with central area of necrosis central area of necrosis

Normal left adrenal gland

Right adrenal mass

Contrast-enhanced axial CT scan Contrast-enhanced axial CT scan showing a right adrenal mass showing a right adrenal mass enlarging the gland and giving it a enlarging the gland and giving it a bulbous appearance bulbous appearance

Normal right adrenal gland

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radio logic anatomy of liver, biliary tree by dr. talat

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