Imaging Anatomy of Hepatoduodenal Ligament: Revisited

Transcription

1 Imaging Anatomy of Hepatoduodenal Ligament: Revisited Poster No.: C-0512 Congress: ECR 2014 Type: Educational Exhibit Authors: R. M. S. V. Vadapalli, A. Roychowdhury, A. S. Vadapalli ; Hyderabad/IN, Worcester, MA/US, Pune/IN Keywords: Anatomy, Biliary Tract / Gallbladder, Liver, CT, MR, PET-CT, Diagnostic procedure, elearning, Normal variants, Neoplasia, Lymphoma, Metastases DOI: /ecr2014/C-0512 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 94

2 Learning objectives 1. To highlight the key Imaging Anatomical features of hepatoduodenal ligament (HDL) on HRCT, MRI and 3D MRCP images 2. Common and Uncommon pathologies which Involve the HDL are presented as a Pictorial essay. 3. What a Surgeon Must Hear from an Imaging specialist about variations of HDL. Page 2 of 94

3 Background It is the fold of peritoneum which extends to the liver from the lesser curvature of the stomach and the commencement of the duodenum. It is continuous with the two layers which cover the anterorsuperior and posteroinferior surfaces of the stomach and about the first 2 cm of the duodenum. The hepatogastric ligament and the hepatoduodenal ligament: The portion of the lesser omentum extending between the liver and stomach is named the hepatogastric ligament, and that between the liver and duodenum the hepatoduodenal ligament. Hepatoduodenal ligament-contains common bile duct, proper hepatic a. and hepatic portal v. Three key structures in the hepatoduodenal ligament: At the right border of the hepatoduodenal ligament the two layers are continuous, and form a free margin which is the anterior wall of the epiploic foramen. In the free margin the two layers of the hepatoduodenal ligament enclose the proper hepatic artery, hepatic portal vein and common bile duct (These three structures are called three key structures in the hepatoduodenal ligament), a few lymph nodes and lymph vessels, and the hepatic plexus of nerves. The common bile duct is situated anteriorly, the hepatic portal vein posteriorly and the proper hepatic artery is at the left of the common bile duct. The inferior vena cava lies behind the epiploic foramen. Page 3 of 94

4 Images for this section: Fig. 49: Portal Triad in HDL Page 4 of 94

5 Fig. 50: 3D VR Reconstruction from a 3D Portal phase of CECT Dataset showing HepatoDuodenal Ligament Anatomy Page 5 of 94

6 Fig. 51: Gall Stone Ileus with Pneumobilia on Min IP Projection CT reformat showing HDL and the neighborhood. Page 6 of 94

7 Fig. 52: Xantho granulomatous Cholecystitis with HDL Involvement Page 7 of 94

8 Fig. 53: Xantho granulomatous Cholecystitis with HDL Involvement Page 8 of 94

9 Fig. 54: HDL Lymphadenopathy Page 9 of 94

10 Fig. 55: Sub hepatic Appendicitis with inflammatory mass,peri hepatitis,hdl involvement Page 10 of 94

11 Findings and procedure details Diseases involving Hepatoduodenal Ligament: Inflammatory: Chronic active hepatitis Acute Cholecystitis. Pyogenic cholangitis Pancreatitis acute Acute on chronic pancreatitis Duodenal ulcers if perforation occurs Duodenal Diverticulitis Subhepatic appendix Perihepatitis ( Fitz Curtis hughes's Syndrome) Iatrogenic: Displaced migrated PEG tubes Parasitic infestations: Ruptured Hydatid disease Ascariasis Fascioliasis Bezoars: Rapunzel syndrome Lymphandeopathy at HDL - inflammatory conditions mentioned above -Castleman's disease of HDL and duodenum Page 11 of 94

12 -Nonhodgkin's Lymphoma with metastatic nodes at HDL -Nodal metastases from GB cholangiocarcinoma,colon cancers cancer,pancreatic cancer,intra hepatic -Duodenal adenocarcinoma, RCC, Melanoma Vascular: Varices in Portal hypertension Portal bilopathy Neoplasms involving the HDL: Gall bladder: Gall bladder carcinoma with direct extension CBD: cholangiocarcinoma at the hilum with extrahepatic extension and HDL involvement Neoplasms of stomach: Malignant GIST Adeno carcinoma stomach Gastric Lymphoma Neoplasms of Duodenum: Duodenal lymphoma Paraganglioma Duodenal GIST Brunner's gland adenoma of duodenum if ulcerated and if perforated Plasmacytoma Neoplasms of hepatic Flexure and right side of transverse colon: Hepatic flexure adenocarcinoma Invading the duodenum and HDL Page 12 of 94

13 Metastases to duodenum and HDL: RCC Carcinoma Colon Melanoma Fig. 1: HDL anatomy References: chippendale apts near Golconda cross roads, flat 202, Vijaya diagnostics and Page 13 of 94

14 Fig. 2: Key anatomical Pearls:Duodenal Neighbourhood and HDL References: chippendale apts near Golconda cross roads, flat 202, Vijaya diagnostics and Page 14 of 94

15 Fig. 3: Key Pathological and Imaging correlates :Duodenal Neighbourhood and Hepato-duodenal Ligament References: chippendale apts near Golconda cross roads, flat 202, Vijaya diagnostics and Page 15 of 94

16 Fig. 4: Periduodenal pathology:checklist References: chippendale apts near Golconda cross roads, flat 202, Vijaya diagnostics and Page 16 of 94

17 Fig. 5: The Duodenal neighbourhood Imaging pearls every resident must know References: chippendale apts near Golconda cross roads, flat 202, Vijaya diagnostics and Page 17 of 94

18 Fig. 6: Duodenal bulb proximity to Hepato duodenal ligament References: chippendale apts near Golconda cross roads, flat 202, Vijaya diagnostics and Page 18 of 94

19 Fig. 7: Bouveret's syndrome References: chippendale apts near Golconda cross roads, flat 202, Vijaya diagnostics and Page 19 of 94

20 Fig. 8: Hepatobiliary duodenal Ascariasis: Migration in to HDL can occur if perforation occurs References: chippendale apts near Golconda cross roads, flat 202, Vijaya diagnostics and Page 20 of 94

21 Fig. 9: Rapunzel syndrome with trichobezoar extension in to duodenum and jejunal and ileal loops:perforation as a complication can involve HDL References: chippendale apts near Golconda cross roads, flat 202, Vijaya diagnostics and Page 21 of 94

22 Fig. 10: Duodenal Diverticulitis : Its proximity to HDL.Perforation and contiguous spread can involve HDL References: chippendale apts near Golconda cross roads, flat 202, Vijaya diagnostics and Page 22 of 94

23 Fig. 11: Duodenal GIST can exophytically grow in to HDL(Rare) References: Department of radiology UMASS Roychowduary Coauthor Page 23 of 94

24 Fig. 12: Gastric GIST with HDL invasion References: chippendale apts near Golconda cross roads, flat 202, Vijaya diagnostics and Page 24 of 94

25 Fig. 13: HDL Paraganglioma References: chippendale apts near Golconda cross roads, flat 202, Vijaya diagnostics and Page 25 of 94

26 Fig. 14: Invasive pancreatic head carcinoma and Peri ampullary cancer can directly invade HDL or metastasize to HDL References: chippendale apts near Golconda cross roads, flat 202, Vijaya diagnostics and Page 26 of 94

27 Fig. 15: Plasmacytoma of Duodenum with Imminent HDL invasion References: chippendale apts near Golconda cross roads, flat 202, Vijaya diagnostics and Page 27 of 94

28 Fig. 16: Plasmacytoma of Duodenum with Imminent HDL invasion References: Department of radiology UMASS Roychowduary Coauthor Page 28 of 94

29 Fig. 17: Plasmacytoma of Duodenum with Imminent HDL invasion References: Department of radiology UMASS Roychowduary Coauthor Page 29 of 94

30 Fig. 18: Invasive Leiomyosarcoma (Malignant GIST) and Hepatic flexure adeno carcinoma invading HDL References: chippendale apts near Golconda cross roads, flat 202, Vijaya diagnostics and Page 30 of 94

31 Fig. 19: Metachronous Post operative recurrent RCC invading Duodenum and HDL References: chippendale apts near Golconda cross roads, flat 202, Vijaya diagnostics and Page 31 of 94

32 Fig. 20: Portal Bilopathy with Duodenal and HDL Varices References: chippendale apts near Golconda cross roads, flat 202, Vijaya diagnostics and Page 32 of 94

33 Fig. 21: Spontaneous Intramural hematoma of Duodenum can involve HDL References: Department of radiology UMASS Roychowduary Coauthor Page 33 of 94

34 Fig. 22: Groove Pancreatitis with oedema and necrosis of HDL References: chippendale apts near Golconda cross roads, flat 202, Vijaya diagnostics and Page 34 of 94

35 Fig. 24: Mesenteric fat necrosis and edem of Pancreatitis can involve HDL Migrated PEG tube can perforate through HDL: Potential source cause of HDL pathology in patients with migrated PEG tube. References: Department of radiology UMASS Roychowduary Coauthor Page 35 of 94

36 Fig. 25: Duodenal lymphoma DU3 segment with aneurysmal dilatation with HDL nodes. References: chippendale apts near Golconda cross roads, flat 202, Vijaya diagnostics and Page 36 of 94

37 Fig. 60: Gall Bladder Carcinoma with Invasion of Porta, CHD, Biliary Obstruction with invasion of CHD: Thick slab MRCP Study References: chippendale apts near Golconda cross roads, flat 202, Vijaya diagnostics and Page 37 of 94

38 Fig. 53: Xantho granulomatous Cholecystitis with HDL Involvement References: chippendale apts near Golconda cross roads, flat 202, Vijaya diagnostics and Page 38 of 94

39 Images for this section: Fig. 1: HDL anatomy Page 39 of 94

40 Fig. 2: Key anatomical Pearls:Duodenal Neighbourhood and HDL Page 40 of 94

41 Fig. 3: Key Pathological and Imaging correlates :Duodenal Neighbourhood and Hepatoduodenal Ligament Page 41 of 94

42 Fig. 4: Periduodenal pathology:checklist Page 42 of 94

43 Fig. 5: The Duodenal neighbourhood Imaging pearls every resident must know Page 43 of 94

44 Fig. 6: Duodenal bulb proximity to Hepato duodenal ligament Page 44 of 94

45 Fig. 7: Bouveret's syndrome Page 45 of 94

46 Fig. 8: Hepatobiliary duodenal Ascariasis: Migration in to HDL can occur if perforation occurs Page 46 of 94

47 Fig. 9: Rapunzel syndrome with trichobezoar extension in to duodenum and jejunal and ileal loops:perforation as a complication can involve HDL Page 47 of 94

48 Fig. 10: Duodenal Diverticulitis : Its proximity to HDL.Perforation and contiguous spread can involve HDL Page 48 of 94

49 Fig. 11: Duodenal GIST can exophytically grow in to HDL(Rare) Department of radiology UMASS Roychowduary Coauthor Page 49 of 94

50 Fig. 12: Gastric GIST with HDL invasion Page 50 of 94

51 Fig. 13: HDL Paraganglioma Page 51 of 94

52 Fig. 14: Invasive pancreatic head carcinoma and Peri ampullary cancer can directly invade HDL or metastasize to HDL Page 52 of 94

53 Fig. 15: Plasmacytoma of Duodenum with Imminent HDL invasion Page 53 of 94

54 Fig. 16: Plasmacytoma of Duodenum with Imminent HDL invasion Department of radiology UMASS Roychowduary Coauthor Page 54 of 94

55 Fig. 17: Plasmacytoma of Duodenum with Imminent HDL invasion Department of radiology UMASS Roychowduary Coauthor Page 55 of 94

56 Fig. 18: Invasive Leiomyosarcoma (Malignant GIST) and Hepatic flexure adeno carcinoma invading HDL Page 56 of 94

57 Fig. 19: Metachronous Post operative recurrent RCC invading Duodenum and HDL Page 57 of 94

58 Fig. 20: Portal Bilopathy with Duodenal and HDL Varices Page 58 of 94

59 Fig. 21: Spontaneous Intramural hematoma of Duodenum can involve HDL Department of radiology UMASS Roychowduary Coauthor Page 59 of 94

60 Fig. 22: Groove Pancreatitis with oedema and necrosis of HDL Page 60 of 94

61 Fig. 23: Groove Pancreatitis with oedema and necrosis of HDL Page 61 of 94

62 Fig. 24: Mesenteric fat necrosis and edem of Pancreatitis can involve HDL Migrated PEG tube can perforate through HDL: Potential source cause of HDL pathology in patients with migrated PEG tube. Department of radiology UMASS Roychowduary Coauthor Page 62 of 94

63 Fig. 25: Duodenal lymphoma DU3 segment with aneurysmal dilatation with HDL nodes. Page 63 of 94

64 Fig. 26: Porcelain Gallbladder with Carcinoma Gallbladder with HDL and Portahepatic invasion and metastatic nodes and biliary Obstruction. Page 64 of 94

65 Fig. 27: Porcelain Gallbladder with Carcinoma Gallbladder with HDL and Portahepatic invasion and metastatic nodes and biliary Obstruction. Page 65 of 94

66 Fig. 28: Porcelain Gallbladder with Carcinoma Gallbladder with HDL and Portahepatic invasion and metastatic nodes and biliary Obstruction. Page 66 of 94

67 Fig. 29: Porcelain Gallbladder with Carcinoma Gallbladder with HDL and Portahepatic invasion and metastatic nodes and biliary Obstruction. Page 67 of 94

68 Fig. 30: Porcelain Gallbladder with Carcinoma Gallbladder with HDL and Portahepatic invasion and metastatic nodes and biliary Obstruction. Page 68 of 94

69 Fig. 31: Porcelain Gallbladder with Carcinoma Gallbladder with HDL and Portahepatic invasion and metastatic nodes and biliary Obstruction. Page 69 of 94

70 Fig. 32: MRCP:Porcelain Gallbladder with Carcinoma Gallbladder with HDL and Portahepatic invasion and metastatic nodes and biliary Obstruction. Page 70 of 94

71 Fig. 33: Delayed phase DCE MRI Liver shows enhancement in gall bladder mass Page 71 of 94

72 Fig. 34: Calcified malignant GIST Invading HDL Page 72 of 94

73 Fig. 35: Calcified malignant GIST Invading HDL Page 73 of 94

74 Fig. 36: Acute Pancreatitis with mesenteric fat necrosis involving HDL Page 74 of 94

75 Fig. 37: Acute on Chronic Pancreatitis with fluid in HDL Page 75 of 94

76 Fig. 38: HDL Varices in portal bilopathy Page 76 of 94

77 Fig. 39: HDL Varices in portal bilopathy Page 77 of 94

78 Fig. 40: HDL Varices in portal bilopathy with bile duct indentations and extrinsic impressions in this 3D VR image MRCP Page 78 of 94

79 Fig. 41: MRI:Ruptured Hydatid cyst with HDL extension Page 79 of 94

80 Fig. 42: MRI:Ruptured Hydatid cyst with HDL extension Page 80 of 94

81 Fig. 43: MRI:Ruptured Hydatid cyst with HDL extension :AXIAL Page 81 of 94

82 Fig. 44: 3D MRCP:Ruptured Hydatid cyst with HDL extension Page 82 of 94

83 Fig. 45: MRI:Ruptured Hydatid cyst with HDL extension Page 83 of 94

84 Fig. 47: CECT Axial:Duodenal lymphoma invading HDL and portal triad Page 84 of 94

85 Fig. 48: CECT Coronal Recon:Duodenal lymphoma invading HDL and portal triad Page 85 of 94

86 Fig. 46: Duodenal lymphoma invading HDL and portal triad Page 86 of 94

87 Fig. 56: Intrahepatic Hilar ductal Confluence Cholangio carcinoma with Biliary obstruction,involvement of HDL and Nodal metastases Page 87 of 94

88 Fig. 57: Intrahepatic Hilar ductal Confluence Cholangio carcinoma with Biliary obstruction,involvement of HDL and Nodal metastases Page 88 of 94

89 Fig. 58: Gastric carcinoma involving Pylorus with gastro hepatic Ligament,Hepato Duodenal Ligament invasion with direct hepatic invasion Page 89 of 94

90 Fig. 59: Transverse Colon and hepatic Flexural Carcinoma with nodal metastases to HDL Page 90 of 94

91 Fig. 60: Gall Bladder Carcinoma with Invasion of Porta, CHD, Biliary Obstruction with invasion of CHD: Thick slab MRCP Study Page 91 of 94

92 Conclusion This Exhibit highlights the Normal anatomy and variations in the Hepatoduodenal Ligament (HDL) with an emphasis on key pathologies. Surgical landmarks and Potential surgical landmines are explained as this needs to be communicated to the Surgeon. The New Generation Visualization formats like 3D Volume rendering with Virtual Laproscopic visualization as well as Extra Luminal Navigation are used to elucidate the anatomical relationships. Page 92 of 94

93 Personal information Rammohan Vadapalli MD Page 93 of 94

94 References 1.Applied Peritoneal Anatomy - A Pictorial review. Poster No.: C-1925,Congress: ECR 2011 Type: Educational Exhibit Authors: R. Patel, I. Beal, K. Planche; London/UK DOI: /ecr2011/C Morton A Meyers. Dynamic Radiology of the Abdomen. 3. Yoo et al. Greater and Lesser Omenta: Normal anatomy and pathologic processes. Radiographics 2007;27: DeMeo et al. Anatomic CT Demonstration of the peritoneal spaces, ligaments and mesenteries: Normal and pathologic processes. Radiographics 1995; 15: Elsayes et al. MRI of the peritoneum: Spectrum of abnormalities. AJR 2006; 186: Page 94 of 94