Hepatobiliary Radiology 肝膽系統放射線學. Leung Ting Kai ( 梁庭繼 ) TMUH (02) #1131

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1 Hepatobiliary Radiology 肝膽系統放射線學 Leung Ting Kai ( 梁庭繼 ) TMUH (02) #1131

2 1/Anatomy of liver, bile duct, gall bladder and pancreas 2/Common diseases of hepatobiliary disease 3/Diagnostic radiology of hepatobiliary disease 4/Interventional radiology for hepatobiliary disease.

3 1/Anatomy of liver, bile duct, gall bladder and pancreas

4 Anatomy of Liver Right Liver Lobe Left Liver Lobe Gall bladder 一般位於第 IV segment, 靠近第 VIII segment,

5 Functional hepatic anatomy Normal supply % of hepatic tissue Hepatic arterial system:25% Portal venous system:75%

6 Biliary system Common bile duct Proximal of duodenum Bilary ductal anatomy Common hepatic duct

7 Celiac trunk and supply

8 Gall bladder

9 Celiac Type 腹腔動脈幹 Celiac trunk SMA

10 roper hepatic artery

11

12 pancreas 胰臟之動脈血管供應 duodenum The blood supply of the pancreas is derived from branches of the gastroduodenal artery, superior pancreaticoduodenal artery, inferior mesenteric artery known as the inferior pancreaticoduodenal artery(branch of SMA). The splenic artery supplies the remainder of the gland. The venous drainage of the pancreas is into the portal system.

13 ERCP

14 2/Common diseases of hepatobiliary disease (benign & malignant intrahepatic neoplasm and infectious hepatic disease, non-obstructive & obstructive cholangiopathy, cholecystic disease and neoplasm,benign & malignant pancreatic neoplasm and infectious pancreatic disease,etc)

15 3/Diagnostic radiology of hepatobiliary disease (CT, MRI, Intravenous cholangiography, sonography, nuclear medicine )

16 Dynamic study for hepatic tumors

17 Dynamic 3-phases post contrast liver CT Precontrast phase Postcontrast phases: 1/Hepatic arterial phase (HAP) 15~20 seconds after injection at a rate of 4~6 ml/sec 2/Portal venous phase (PVP) 60~90 seconds after injection. 3/Delay(equilibrium) phase 3~15 minutes after injection.

18 Dynamic liver CT--Hemangioma Precontrast phase Hepatic arterial phase

19 Dynamic liver CT--Hemangioma Portal venous phase Delay (equilibrium) phase

20 Dynamic liver MRI--Hemangioma

21 Focal nodular hyperplasia >young women(75%) >no malignant transformation. >central scar >relative isodense~hyper dense. >hypervascular

22 Hepatic adenoma >women predominate >associate with oral >contraceptives and resolve after hormone therapy. >Solitary and encapsulated >hypervascular or hypovascular

23 Three phases post contrast CT for hepatocellular carcinoma(typical). Portal phase. Partial wash out of HCC. Delay phase. HCC is low attenuating with a hyperdense capsule Arterial phase. Typical HCC is high attenuating. The feeding artery is well demonstrated.

24 Metastasis of liver tumors >target sign or bull eye appearance >30% of patients who die of malignancy have liver metastasis. >The liver is the most common site of metastatic disease from colorectal carcinoma. >Higher mortality than hepatocellular carcinoma.

25 Portal venous thrombosis Predisposing factors: Malignancy(HCC) Hepatitis Trauma Shunts Hypercoagulable states(pregnancy)

26 Liver blunt trauma Liver injury is the most common intraabdominal site of injury; however, one must inspect other organs(spleen, bowel) for coexistent trauma.

27 CT guide biopsy of liver tumor

28 Manifestation of liver cirrhosis

29 Regenerative nodules Liver cirrhosis with nodular surface

30 Fatty liver disease

31 Pyogenic abscess Air fluid level >E coli, aerobic streptocci, anaerobes,etc >Air component, air fluid level >Cause: ascending cholangitis, trauma, surgery or portal phlebitis.

32 Amebic abscess >Do not contain gas >irregular borders double target sign septation >internal septations >multiple abscess

33 Milk of calcium

34 Porcelain gall bladder is a condition in which the wall of the gallbladder becomes covered with calcium deposits. It sometimes occurs after the gallbladder has been severely inflamed. People with this condition may have a high risk of developing gallbladder cancer

35 Gall bladder carcinoma

36 Cholangiocarcinoma CBD stricture

37 Choledochal cyst Cystic lesion Cystic dilate

38 Splenic infarct The common cause of focal filling defects on contrast enhanced CT with wedge shaped appearance.

39 Traumatic splenic laceration

40 Pancreatitis classification Acute pancreatitis: >Mild degree:interstitial edema(or with peripancreatic fat stranding). >Severe degree:necrosis and fluid collections

41 CT staging of Acute pancreatitis (Value of predicting clinical outcome) GradeA:normal pancreatic appearance or peripancreatic fat stranding. GradeB:focal or diffuse enlargement of pancreas GradeC:Pancreatic abnormalities and peripancreatic inflammation GradeD:1 peripancreatic fluid collection. GradeE:>2 peripancreatic fluid collections and /or gas in or adjacent to the pancreas

42 Pancreatitis: Grade A

43 Stage E

44 Stage E (necrotizing)

45 Pancreatitis classification Chronic pancreatitis: >Pseudocysts(communication with pancreatic duct), >obstructed common bile duct, >venous thrombosis (splenic, portal and mesenteric veins) & >increased incidence of carcinoma.

46 Chronic pancreatitis

47 ERCP diagnosis

48 serous cystadenocarcinoma

49 Types of cholangiography 1/ERCP(radiology department is the land owner) 2/PTC(our territory) 3/MRCP(our territory)

50 Stone impact Normal CBD aberrant right hepatic duct u PD,~2mm Gallstone obstructs the GB infundibulum. Low signal intensity a patient after cholecystectomy. MRCP (maximum intensity projection MIP)

51 4/Interventional radiology for hepatobiliary disease. (diagnostic angiography, transarterial embolization, percutaneous transhepatic cholangiography, T-tube cholangiography, percutaneous transhepatic cholangio-drainage,)

52 Nerve Artery Vein

53 Tools

54

55 eliac trunk Portal venous phase Arterial phase

56 Superior mesentery artery Portal vein

57 插播 國考題 下列何者最終不流入肝門脈系統 : (a) 肝靜脈 hepatic vein (b) 上腸繫膜動脈 SMA (c) 下腸繫膜動脈 IMA (d) 脾靜脈 Splenic vein a

58 Catheter and Guide wire

59 catheter Guide wire

60

61 Diameter 3 French= 1.0 mm 4 French = 1.3 mm 5 French = 1.7 mm

62

63 Embolized hepatoma catheter

64 肝臟 TAE 原理 >Hepatic T.A.E 在 1978 年由 Yamada and colleagues 發明 > 就是利用 Seldinger 法, 把導管放到動脈血管 (hepatic artery) 內, 再經由導管注入栓塞物質以堵塞某些動脈而達到治療效果的ㄧ種方法 > 其目的無非在止血或使腫瘤缺血而壞死, 但非腫瘤部份, 因還有門靜脈血液供應 (supply 75% of normal hepatic tissue) 而存活

65 肝臟栓塞的禁忌 Contraindication 門靜脈堵塞 (PVT) 嚴重肝硬化 (liver cirrhosis) 肝功能極度不良 (heptic failure) 黃疸病人 (High D/T bilirubin)

66 >Materials used in embolization include : >Absorbable: gelatin sponge (Gelfoam), IBCA( 強力膠 ) >Non-absorbable :coils 線圈, ivalon and balloon 氣球.

67 >Absorbable: gelatin sponge (Gelfoam), IBCA( 強力膠 ) 其他短期栓塞物質 > 自體血凝塊 (autologous blood clot) > 血凝塊 (blood clot) 加 amicar((aminocaproic acid-- inhibitor of fibrinolysis ) or thrombin

68 Gel foam pieces

69 Lipiodol and chemotherapy

70 After mixing of lipiodol and adriamycin

71 Selective hepatic angiography

72 During embolisation Transarterial embolization Post TAE Subtraction

73 Pre-embolized contrast injection

74 Post embolization Subtraction

75 T.A.E 步驟 > 確定腫瘤位置 > 確定門靜脈 (portal vein) 是否有阻塞及是否有瘻管 (A-V shunt) > 選擇要栓塞血管 > 用藥範例 : a/ 1 支約 10cc b/ 2 支 Adriamycin (10mg/ 支 )+Normal saline c/5cc mixture of Gelfoam (0.05gm/ pack)+contrast medium

76 T.A.E 併發症 較常發生的術後症候群 : 1. 暫時性疼痛 (boring or belching like, abdomen distension) 2. 輕度發燒 fever 約 3-5 天 3. 組織壞死與缺血

77 較少發生的術後症候群 : > 非腫瘤肝組織梗塞 > 膽囊梗塞疼痛 > 胃, 十二指腸潰瘍 其他極少見併發症 : 肝膿腫, 肝腦症, 暫時性高血壓, 電解質失衡, 脫水, 胰臟炎, 肺炎

78 插播 國考題 介入性血管攝影 (interventional angiography) 中, 有利用導管注入物質達到治療的目的方法, 其中常利用材料為 Ivalon (polyvinyl alcohol),coils,gelfoam... 等稱之為 : (a)catherization (b)angioplasty (c)embolization (d)bypass c

79 Interventional Radiology for biliary system 介入性肝膽診斷治療醫學與其他腹部的介入性手術

80 Type of Procedures:non-vascular Biliary intervention( 膽道方面的放射介入治療 ) a) PTCD Percutaneous transhepatic cholangio-drainage 經皮肝膽引流導管植入 (sono-guide or CTguide) b) T-tube cholangiography c) PTCCD ( 經皮肝膽囊引流 ) (sono-guide or CT-guide)

81 PTC

82 Percutaneous transhepatic cholangio-drainage puncture Inserting tube drainage

83 Common bile duct and biliary stone by Endoscopic Retrograde Cholangiopancreatography ERCP ERCP Filling defect

84 Surgical treatment with T-tube cholangiography and its placement.

85 Summary Anatomy of liver, bile duct, gall bladder and pancreas Common diseases of hepatobiliary system Diagnostic radiology of hepatobiliary disease Interventional radiology for hepatobiliary disease.