Imaging Assessment Of The Billiary System

Ministery of Health of the Republic of Moldova

State University of Medicine and Pharmacy

“N. Testemitanu”

Department of Radiology and Medical Imaging

DIPLOMA THESIS

IMAGING ASSESSMENT OF THE BILLIARY SYSTEM

Name of the student [anonimizat]

year , group VI, gr. 1050

Scientifical coordinator Anatolie Obadă

university assistant

Chisinau 2016

ABBREVIATIONS

PTC Percutaneous Transhepatic Cholangiography

OCG Oral Cholecystography

CT Computed Tomography

IVC Intravenous Cholangiogram

ERCP Endoscopic Retrograde Cholangiopancreatography

MRCP Magnetic Resonance Cholangiopancreatography

IDA Iminodiacetic Acid

HIDA Hepatobiliary Iminodiacetic Acid

CHD Common Hepatic Duct

CD Common Duct

CBD Common Bile Duct

CCK Cholecystokinin

STATEMENT

I hereby declare that the license thesis titled: “IMAGING ASSESSMENT OF THE BILIARY SYSTEM”

Is written by me and has never been submitted to another university or institution of higher education in the country or abroad. Also, that all sources used, including those on the Internet, are given in the paper with the rules for avoiding plagiarism:

– all the fragments of text reproduced exactly, even in his own translation from another language are written between quotation marks and have a detailed reference source;

– Reformulation of the texts in own words written by other authors have detailed reference;

– summarizing the ideas of other authors have detailed reference to the original text.

Date:

Fadi Arram

CONTENTS

PREFACE………………………………………………………..……………..……..4

1 Actuality and the research level of the investigated theme….…………………….4

2 The aim and the objectives of the thesis …..……………………………………..4

3 The scientific news of the obtained results…………………………………………..4

CHAPTER I – BIBLIOGRAPHIC ANALYSIS…………………………………….6

1.1 Biliary System…………………………………..…….…….…………………….6

1.1.1 Structure…………………………………….………………………………..6

1.1.2 Physiology………………………………………………………………………….7

1.1.3 Biliary Disorders ……..……….……………………………………………….7

1.3 Diagnostic Methods………………………………………….…………………..9

1.3.1 Computed Tomography (CT)…………………………………………………9

1.3.2 Oral Cholecystography (OCG)……………………………….………………9

1.3.3 Percutaneous Trans-hepatic Cholangiography (PTC)………..……………..10

1.3.4 Operative and T-tube cholangiogram……………………………………….10

1.3.5 Intravenous Cholangiogram (IVC)………………………………………….11

1.3.6 Endoscopic Retrograde Cholangiopancreatography (ERCP)……………….12

1.3.7 Magnetic Resonance Cholangiopancreatography (MRCP)…………………13

1.3.8 Ultrasound…….……………………………………………………………………………14

1.3.9 Nuclear IDA scan (Cholescintigraphy)……………………………………..16

CHAPTER II –MATERIAL AND RESEARCH METHODS…………………23

CHAPTER III –PERSONAL RESULTS AND DISCUSSION.……….……….27

CHAPTER IV – CONCLUSION…………………………………………………34

BIBLIOGRAPHY………………………………………………………………

PREFACE

1.1 Actuality, and the research level of the investigated theme

There are many diseases of the biliary system that does include gallstones, cholecystitis, bile duct cancer, and cholangitis. A condition of gallstones found in the gallbladder we call it cholelithiasis or in a case we will find a gallstone in the bile ducts we call it choledocholithiasis. Occlusion by gallstones may lead to a serious life threatening infection of the bile ducts, liver and pancreas. According to the investigation the clinician must make sure that the bile tract occlusion is not caused by a cancer. Women’s between in age 20 – 60 have higher risk to improve gallstones as in men’s in the same age interval. Gallstones are found more likely in persons more than 60 years old and in Native Americans of all ages. Also obese person is another factor which linked with the estrogen level and affects women primarily. Another factors which lead to gallstones such as long periods of fasting, rapid weight loss, diabetes, sickle cell disease, and cholesterol lowering drugs.

1.2 The aims and objectives of the thesis

The intentions and the aim of this work is to carry out the importance and uses of all imaging assessment of biliary system; which can help us to identify the key of pathologic features of this diseases entity at presentation, showing the differences between the radiological methods that we can use and the role of using them to differentiate between the biliary duct diseases.

Objectives:

Speak about the uses of operative and T-tube cholangiogram in analyzing biliary stones.

Speak about the role and uses of MR imaging of the biliary tract.

Speak about the importance and uses of Ultrasound imaging of the gallbladder what can be visualized on the scan.

Speak about the role of Endoscopic Retrograde Cholangiopancreatography in diagnosing and treating biliary disorders.

1.3 The scientific news of the obtained results

A lot of people worldwide go through ERCP procedure each year to identify and to treat the pathologies of the bile ducts, pancreas, gallbladder and liver. We know that x-ray imaging is not enough to make a final diagnosis or therapeutic intervention we need a direct visualization such as cholangioscopy may be done. Cholangioscopy is a procedure which examined the bile ducts by using an endoscope to allow a direct imagining of the biliary tract during endoscopic retrograde cholangiopancreatography while the pancreatoscopy is a procedure performed to examine the pancreatic ducts. During the direct visualization of the bile ducts with ERCP can help us to obtain biopsy specimens which lead us to the correct diagnosis and abnormalities and guide us to put the sufficient treatment.

CHAPTER I – BIBLIOGRAPGIC ANALYSIS

2.1 Biliary System

This three organs liver, gallbladder and small intestine are linked together by a chain of thin tubes that we called them bile ducts. The BD is a part of the digestive system and we consider that the gallbladder is also a part of the biliary system surely with the bile ducts.

2.1.1 Structure

The common bile duct (CBD) is so thin tube is about 10–12.5 cm in length. A chain of ducts join together and lastly they form CBD:

1. Intrahepatic bile duct:

A lot of small tubules within the liver collect bile from the liver cells.

These small tubules join together and they form the small duct. After that these small ducts join to another larger ducts which we call them the right and left hepatic ducts.

2. Extrahepatic bile duct:

Then the right and left hepatic ducts leave the liver and they form the common hepatic duct (CHD).

The CHD and the cystic duct they join together and form the CBD. The cystic duct is connected with the gallbladder to the common bile duct.

The CBD passes through the pancreas before it empties into the first part of the small intestine in the duodenum. At the end the common bile duct is connected with the pancreatic duct to form the last station which we call it the ampulla of Vater and it enter the duodenum directly.

2.1.2 Physiology

The extrahepatic bile ducts are part of a network of ducts that carry bile from the liver and gallbladder to the small intestine. Bile is a yellowish-green fluid made by the liver. Bile flows from the liver, through the hepatic ducts, into the cystic duct and to the gallbladder, where it is stored.

Bile helps digest the fat in foods. Bile is mainly made up of:

bile salts

bile pigments (such as bilirubin)

cholesterol

water

If the bile is not needed for digestion, it flows into the cystic duct and then into the gallbladder, where it is stored. When bile is needed to digest food, the gallbladder contracts and releases bile into the cystic duct. The bile then flows into the common bile duct and is emptied into the small intestine, where it breaks down fats.

Bile – Micelles of cholesterol, phospholipids, bile salts & bile pigment (bilirubin, biliverdin)

Fat in food Cholecystokinin Bile secretion.

Cholesterol (Fat crystal) – Bile salts (soap)

Excess cholesterol, low bile salt Stone formation.

Stasis, Inflammation, infection Ca

2.2 Biliary System Disorders

Certain conditions of the biliary system can be seen during radiographic imaging such as with ultrasound, CT, MRI, or nuclear radioisotope imaging. These include biliary atresia, choledochal cysts, biliary sludge, cholelithiasis, acute cholecystitis, chronic cholecystitis, and gallbladder neoplasm. Biliary atresia is the most common occlusion seen in infants and young children. It has two main causes, either congenital or as a result of viral infection shortly after birth. This disorder is caused by progressive obliliteration of the extrahepatic ducts and progresses to the intrahepatic ducts. The course of the disease is from distal to proximal parts of the biliary tree. This disorder is quite serious and needs to be diagnosed and treated as soon as possible. It causes scarring and fibrosis of the intrahepatic ducts if the disease progresses. About 50% of neonates present with mild jaundice that clears up in a few days, biliary atresia is a condition that most often begins a week or two after birth. It is marked by a sudden onset of jaundice and high serum bilirubin level. The two most serious conditions that are seen with sudden onset jaundice in neonates are biliary atresia and neonatal hepatitis. Other less serious causes are inspissated bile syndrome, enzyme deficiencies or metabolic disorders, and choledochal cysts. Biliary atresia is twice as common in males as females; however, neonatal hepatitis is four times more common in females than males. Although there is surgical options for biliary atresia the victim usually dies within a few years as there is no cure. Liver transplant has shown some promise towards a longer live expectancy.

Intrahepatic Occlusion:

-Biliary atresia – congenital.

-Primary Biliary cirrhosis .

-Sclerosing cholangitis.

-Cystic fibrosis (mucovisidosis) – thick bile.

Extrahepatic Occlusion:

-Dislodged gallstones.

-Cancer Common Bile Duct, Cancer Head of pancreas.

-inflammatory stricture of Common Bile Duct.

-accidental surgical ligation of Common Bile Duct.

2.3 Diagnostic Methods

Imaging Assessment of the biliary system and the biliary tract are commonly performed in most radiological departments. These include all radiology modalities especially ultrasound, magnetic resonance imaging , computed tomography , nuclear medicine, interventional procedures, and fluoroscopy imaging. We will look at how all of these imaging modalities show the gallbladder and biliary ducts and discuss their advantages and disadvantages.

1.3.1 Computed Tomography (CT)

Computed tomography can be used to image the hepatobiliary system, with the exception of the gallbladder which is better imaged with ultrasound procedure. Magnetic resonance cholangiopancreatography is a better modality than CT for detecting the biliary tract, but CT is better for hepatic imaging and in cases where it is not clear whether a problem is originating in the gallbladder, liver, or bile ducts. What is similar between CT and magnetic resonance imaging allows for a more thorough estimation of the liver and other abdominal structures than ultrasound. In contrast to ultrasound, successful CT of the liver can be obtained despite obesity, overlying bowel gas, or ascites. One of the advantages of CT is that the scan can help determine the type of gallstones if it’s cholesterol or pigmented and determining the pathological dilation of the extrahepatic bile ducts, and can detect pancreatic cancer with 100% accuracy. While CT is not the imaging modality of choice for visualizing the biliary tree; however just in a few cases the bile ducts stones can be identified.

In this two CT images determine gallstones in the gallbladder. On the left side shows a multiple distinct large stones. The CT image on the right side shows a small stones in the gallbladder.

1.3.2 Oral Cholecystography (OCG)

Is a non-invasive radiographic procedures that is used if an inconclusive ultrasound report. It is a simple, economical and least invasive and highly effective method of investigating the gallbladder problems. The route of entry is by mouth

The oral cholecystogram studied the opacification of the gallbladder.

So simple process we involve the patient not eat any fatty foods befor the procedure it’s about 6 hours before ingesting the oral contrast media because it will be dissolved and absorbed into the liver and then secreted in bile duct. This procedure had a good particularity for detecting a cystic duct and patent gallbladder. In case the cystic duct was easily recognizable, cholelithiasis when present could be so clear. In conditions like occlusion of the cystic duct, hepatitis, or occlusion of the hepatic ducts can lead to non-visualization of the gallbladder. The most common cause of non-visualization of the gallbladder by Oral Cholecystography was bad patient preparation. Usually the patient had to drink another dose of oral contrast agent to clarify the causes of non-visualization of the gallbladder. More disadvantages about Oral Cholecystography we have another cases that will not visualize the gallbladder in case if the serum bilirubin is higher than 4 mg per 100 mL, because the high level of serum bilirubin indicates impaired enterhepatic circulation, which lead to poor absorption and secretion.

Upright patient position is the usual position which radiographs recommend for imaging the gallbladder, in this case the gallstones have a tendency to layer in the most dependent portion of the gallbladder. Another position when the patient is in the lateral decubitus position using a horizontal x-ray beam. The Oral Cholecystography also can be used to see function of the gallbladder. Also we administrate cholecystagogue preparation such as Neo-Cholex, Bile-Evac, or fatty food is given for stimulating the contraction of the gallbladder. Cholecystagogues stimulate the duodenum to secrete cholecystokinin. During the contractions of the gallbladder the contrast is forced out of the gallbladder and documenting the patency of the cystic duct.

The 4 fluorospot images which are on the left side are made by an oral cholecystogram. This is an old procedure and is not used today to estimate the gallbladder. We can see the fundus of the gallblader (indicated by arrow) and body of the gallbladder (indicated by arrowhead). In case of nonvisualized gallbladder indicates an occlusion of the biliary tree, or cystic duct. We demonstrates bowel gas below the gallbladder we can see it in oblique view on the right.

1.3.3 Percutaneous Transhepatic Cholangiography (PTC)

Percutaneous Transhepatic Cholangiography is purely old and historical radiological method and it’s not used in this time. It was a diagnostic and therapeutic procedure in cases of suspected occlusive jaundice and dilated bile ducts by drainage during the procedure. Sometimes they removed the stones by this procedure and eliminating the risk of open surgical intervention. Today we have many other invasive procedures with a lower risk than PTC. In this study was a type of invasive cholangiography that implicated direct puncture of the biliary ducts. The procedure done by a fine needle passed from the surface of the skin through the liver into the biliary duct and one of risks of this procedure included a possible puncture of the lung, hemorrhage from the liver and vascular injury. This wasn’t an easy procedure to do so the benefits of this procedure had to far outweigh its risk before it was performed.

In this two images explain the “skinny needle” way to puncture the bile duct during PTC. By using a thin needle injected into the BD and the contrast media is injected. We can demonstrate the biliary tree even in case of any occlusions. We can see on the left image a positive contrast in the bile duct and in the right image is negative. We can see also the thin needle on both images.

1.3.4 Operative and T-tube cholangiogram

The operative cholangiogram we call it also the immediate cholangiogram because it’s performed during cholecystectomy procedure. During investigations the doctor suspects residual cholelithiasis can be in the biliary ducts the operative cholangiogram performed. Even it can be done either before or after elimination of the gallbladder. The cystic duct is situated just proximal to the neck of the gallbladder. The catheter is injected into the cystic duct more exactly near its joining the common hepatic duct around 6 to 10 ml is injected (water soluble iodinated radiocontrast). The surgeon should be careful to not inject the air since even a small quantity of air can mimic a radiolucent biliary stone. We should see so clearly the entire biliary tree with contrast leaking into the duodenum.

Operative cholangiogram can also clearly specify of the biliary tract and hepato-pancreatic ampulla. mass lesions, Dilatations of the biliary ducts, and strictures can also be estimate. It’s unlike the ERCP it’s not a therapeutic method to remove the stones from the biliary tree. Images are taken by using fluoroscopic C-arm that’s how they can be estimated. Fluoroscopic C-arm imaging is more useful to plain films because the time to process images is much longer with plain films. And images from the C-arm are good because they can be sent through Ethernet connection to picture archiving and communication system so that discussion with a radiologist is available if it will be needed. This procedure will saves a lot of time when the patient is under anesthesia and the technologist is not required to get out and in of the surgical suite to currier films. The operative cholangiogram procedure can be performed through a laparoscope with open surgery, or with open surgery.

In this two images shows the T-tube cholangiogram. The t-tube is inserted into the CBD. We can see surgical clips in both images meaning that’s a post-operative.

1.3.5 Intravenous Cholangiogram (IVC)

The intravenous cholangiogram is a radiologic (x-ray) procedure that is used primarily to look at the larger bile ducts within the liver and the bile ducts outside the liver. The procedure can be used to locate gallstones within these bile ducts. Intravenous Cholangiogram also can be used to identify other causes of obstruction to the flow of bile, for example, narrowing’s (strictures) of the bile ducts and cancers that may impair the normal flow of bile. To do an Intravenous Cholangiogram, an iodine-containing dye is injected intravenously into the blood. The dye is then removed from blood by the liver which excretes it into the bile. The iodine is concentrated enough just as it is secreted into bile that it does not need to be further concentrated by the gallbladder in order to outline the bile ducts and any gallstones that may be within them. The gallbladder is not always seen on an Intravenous Cholangiogram since the iodine-containing bile may bypass the gallbladder entirely and empty directly into the small intestine. Occasional serious allergic reactions can occur to any iodine-containing dye. These reactions can usually be treated but they rarely may result in the death of the patient. The Intravenous Cholangiogram is not used nearly as much today as it used to be. Its use always was limited because it did not work when there was more than a minimal amount of jaundice, and many of the conditions it was used for caused substantial jaundice. The Intravenous Cholangiogram has been largely replaced by other diagnostic procedures endoscopic retrograde cholangiopancreatography, endoscopic ultrasound and, increasingly, by MRI cholangiography, none of which are affected by jaundice.

1.3.6 Endoscopic Retrograde Cholangiopancreatography (ERCP)

Endoscopy refers to the lighting or illumination of an organ from inside using an endoscope. Cholangiopancreatography means imaging of the biliary ducts and pancreatic duct. The word endoscopic retrograde cholangiopancreatography talk about imaging the biliary ducts and pancreatic duct by using a retrograde way through the endoscope. Endoscopic retrograde cholangiopancreatography considered both diagnostic method and therapeutic procedure. Usually it’s performed with other radiological modalities such as ultrasound or MRCP when it’s not leading to a firm conclusion. It can be used as a preoperative either postoperative to plan a cholecystectomy and to remove stones that have become stucked in the biliary ducts. Some examples of therapeutic procerdure with endoscopic retrograde cholangiopancreatography include but are not limited to dilating stricture biliary or pancreatic ducts, removal pancreatic duct stones of or biliary, cutting the sphincter of Vater to increase narrowing of the opening, also we can take a biopsy or tissue sample by brushing, or putting a stent to facilitate bile flow.

As we said befor about a special type of endoscope which we call it a duodenoscope we used it to perform cholangiopancreatoscopy. It’s allow us to detect for examples pancreatitis, ductal strictures, treat large intraductal stones, and also we can identify and take tissue samples to make diagnoses of ductal diseases such as hemobilia, and intraductal papillary mucinous tumors. The patient should be sedated and the endoscope tube passed via the mouth down to the esophagus into the stomach. The gastroenterologist has the ability to see what is inside of the gastrointestinal tract via the endoscope tube allowing the expansion of the endoscope through the pyloric sphincter into the descending duodenum until sphincter of Vater.

The nursing assist the gastroenterologist in tending to the patient. This will includes if the patient has used any allergies to medicines during the procedure, charting the procedure for the medical record, getting the patient’s consent for the procedure, monitoring vital signs and blood oxygen saturation, grounding the patient in case of a sphincterotomy, monitoring the electrocardiogram, and administering medications. During inserting the tube the patient should be given sedatives such as diazepam (Valium), midazolam (Versed), and meperdine (Demerol) until the wanted amount of sedation is reached. We may also give the patient antibiotics befor the procedure to decrease the risk of pancreatitis. We should give also an antispasmodic drug such as glucagon to relax the sphincter of Oddi for inserting the endoscope and cannula insertion and to reduce spasms of the duodenum. . We introduce air into the gut to inflate the stomach and bowel for inserting the endoscope easly. The radiographer operates fluoroscopic equipment and exposes fluorospot images to document radiographs for interpretation. Nursing personnel tend to the patient and assist the gastroenterologist, two persons are needed to flush and change catheters. After the procedure is done the patient is kept nothing by mouth 4-10 hours from the time when the throat is paralyzed. It will decrease the risk of food or liquid aspiration until local and general anesthetics wear off.

1.3.7 Magnetic Resonance Cholangiopancreatography (MRCP)

Some time ago the only available techniques were for demonstrating choledocholithiasis operative cholangiography with cholecystectomy and percutaneous cholangiography and ERCP. Today we have the MRCP which is an available non-invasive magnetic resonance imaging (MRI) exam that shows us the entire pancreatic duct, biliary tree, and the gallbladder. It is usually done before an endoscopic retrograde cholangiopancreatogram (ERCP) for determination if the therapeutic ERCP is necessary. By contrast, ERCP is both a therapeutic and diagnostic procedure tool for detecting and eliminating biliary tract stones. So MRCP is an alternative procedure for those patients who need biliary imaging, but in this procedure we have renal complications or allergy to iodinated contrast media.

MRCP is a modern radiographic imaging practice and research. While the image resolution of the magnetic resonance cholangiogram is comparable to ERCP it is not as good. Oppositely, MRCP can detect areas of the hepatic and biliary duct that could not be seen when there is occlusion. So MRCP has increased to the level of clinical relevance as a pre-ERCP and preoperative diagnostic tool for estimation of choledocholithiasis (is the presence of gallstone in the CBD). Today the statistics on MRCP sounds good for example retrospective studies show a positive predictive value of 0.95 and a negative predictive value of 0.97 for bile duct stones. Research shows and proven about 74% of clinically suspected bile duct stones are confirmed negative by using MRCP, this finding reduces the risk of unnecessary using of ERCP. Also it’s an excellent way to image the pancreatic duct size, detect normal or obstructed Wirsung duct and we can determine the etiology of ductal obstruction or other diseases with MRCP. In evaluating the normal pancreatic duct with MRCP the specificity and sensitivity is 98% and 94%. The same as for ERCP is 100%; but ERCP does not sufficiently demonstrate pancreatic neoplasms. With ERCP we can see the pancreatic neoplasm; but, with MRCP we can identify the pancreatic neoplasm 100% of the time and correctly identifies the chronic pancreatitis.

MRCP procedures are taken in different ways 3-D formats, coronal, and axial providing imaging referencing in multiple planes. It is important for that the entire of pancreas, biliary ducts, and gallbladder are included in the3-D images, coronal, and axial. There are two techniques for imaging the biliary tract are combined together: single-slice thick-slab and multi-section thin-slice MRCP. The Studies show that these combined techniques should be together in the imaging protocol to have the most out of the enhanced and unenhanced MR scan. We administrate intravenously fentanyl before MRCP has been shown to improve the quantitative and qualitative visualization of the biliary tree. The motivation for both techniques is that single-shot thin-slice imaging is higher to multisection thin slice for bile duct imaging.

1.3.8 Ultrasound

Ultrasound modality is performed to estimate patients for cholecystitis and biliary stones. With ultrasound we can detect the cystic duct and neck of the gallbladder occlusion also in case of inflammation and distension of the gallbladder. Also it can determine carcinoma of the gallbladder, high percent of malignancy and metastasized so quickly. It is important because the cancer of the gallbladder has a low prognosis so if we found any early diagnosis of this condition is considered lifesaving of the patient. On ultrasound the gallbladder usually can be found between the quadrate and right lobe of the liver on the bottom. Sometimes the fundus may be folded and giving a Phrygian cap appearance, which makes the gallbladder look septated (divided by or having a septum) on the ultrasound. If we see this we should differentiate it from a double gallbladder or septate. The cystic duct which joins the neck of gallbladder to the common bile duct is about 2-4 cm and the common hepatic duct (CHD) is about 2.5 cm in length and goes to the right of the hepatic artery and portal vein. The common bile duct (CBD) in generally long is about 7.5 to 10 cm. It goes posterior to the head of the pancreas and it can be enclosed distally in the pancreas. The junction or intersection of the CBD and CHD is called the common duct (CD).

For imaging the biliary tract with ultrasound the patient should be NPO (nothing-by-mouth). Fasting will distend the bile ducts and gallbladder and decrease bowel gas that may disturb the visualization of the gallbladder. Also food can increase the wall thickness of the gallbladder and it will looks like a pathological wall thickening. For small children 4 hours is sufficient fasting, and 6-8 hours for age more than 12. And smoking is also forbidden during the fasting time because smoking will increase the contraction of the bile ducts. Ultrasound should be done before administrating any barium for gastrointestinal imaging, or when the stomach and hepatic flexure are clear of barium after gastrointestinal imaging procedure.

The scan procedure may be different depending on the patient’s condition and the pathological indications for the procedure. Imaging may be in the coronal, sagittal, transverse, and appropriate oblique planes are made. The sonographer will collect the patient history to include before abdominal surgery, especially cholecystostomy or cholecystectomy and also he makes the physical assessment for example a surgical scars which are not accounted for the patient history, jaundice, and palpation of abdomen cavity looking for a mass or felt for tenderness or solidness. During the procedure the patient may be positioned in the upright positions, left lateral decubitus, left posterior oblique, or supine as needed.

The gallbladder longitudinally appears as a pear-shaped with a thin white walls and surrounding with a black fluid. Normally the gallbladder wall is echogenic, thin and mild posterior enhancement, and an anechoic lumen. The bile acoustic impedance is low because the bile is near the consistency of water, as bile does not reduce the sound waves. So when imaging near the neck shows an acoustic shadow that’s mean present a stone in the cystic duct, because there is no acoustic shadowing posterior to the gallbladder. The bile ducts and gallbladder are evaluated for shape and size, contents, wall thickness, caliper, and course. During the scan the sonographer looks for a positive Murphy’s sign. The transducer or thumb is placed above the costal margin of the gallbladder. During a deep inspiration from the patient they may stop suddenly due to a severe pain before catching their breath, which means a positive Murphy’s sign. The sonographer will image the gallbladder for the period of the elicited response to document a positive finding.

1.3.9 Iminodiacetic Acid scan (Cholescintigraphy)

Nuclear hepatobiliary scan we call it also as cholescintigraphy by using the radioisotope imino diacetic acid (IDA) to make an image of the biliary system. Long time ago the IDA scan has been called as the hepatobiliary iminodiacetic acid (HIDA) scan. Usually physicians use this procedure to estimate the function of the cystic duct if we suspect a cholecystitis. IDA scan can also identify biliary occlusion, atresia, and bile leak. IDA is a dynamic scan that can assesses the cystic duct patency and function of the gallbladder. Agents such as Hepatolite or Choletec (Technetium-99m-IDA) are administered intravenously. All this agents are bilirubin analogues they have the same function biliary uptake as bilirubin used to make bile. After that they are secreted into the biliary tract letting them to be taken up by the liver and then secreted into the biliary tract and we concentrate in the gallbladder functioning. If the biliary tract is functioning well we should see the entire bilirubin pathway from the filling of gallbladder until it will pass through the CBD and duodenum must be visualized.

Preparation of the patient for the exam must include a good clinical history for compatibility for the study and mild fasting. Require fasting 4-6 hours before the exam. A small amount of water may be taken, 4 to 12 hours before the exam is forbidden to take narcotic medications because they will make a constriction of sphincter of Oddi. And a prolonged fasting is not good because it may cause false positive scan result if the patient didn’t eat or drink (nothing by mouth) more than 24 hours. The patient history should include morphine tolerance, prior cholecysectomy, and the patient may have or not a current pancreatitis. Sometimes morphine is given during the test and morphine allergy or contraindicated to give morphine with pancreatitis.

In adults dose administrating is starting with 1.5 to 5 mCi (millicuries) IDA administered intravenously. We gather serial images of the liver and gallbladder needed at 5 min intervals for 1 hour in the scintillation camera. The scan is considered completed in case if the duodenum and gallbladder are seen on the one-hour of scan. In case the gallbladder is not seen after 1 hour then the cause can includes an chronic or acute cholecystitis and we should continue our studies. In period of 2-4 hours fails to visualize the gallbladder the specificity will increase and be greater than before for acute cholecystitis. Delay the imaging may last to 24 hours to get a better diagnostic study in cases of severe liver impairment.

There are other alternative methods to perform the IDA scan, such as, Morphine sulfate given to constrict the sphincter of Oddi, or cholecystokinin can be administered to contract the gallbladder. Also we can assess the ejection fraction of the bile from the gallbladder as it contracts. What is specific for acute cholecystitis with complete or partial occlusion of the cystic duct that it can be improved by giving CCK. When appropriate, we give it intravenously over 3-5 minutes in such a way 0.01-0.02 µg/kg of body weight. This scan can give us the percentage of releasing of the bile with the gallbladder contraction which we call it the ejection fraction. Giving morphine sulfate intravenously 0.04-0.01 mg/kg will make a constriction of the duodenal papilla. This will increase the retrograde flow of bile laden with the radioactive compound into the gallbladder when the cystic duct is patent. And this will decrease the time for gallbladder filling; and very important point that the patient must not have allergy to morphine or pancreatitis.

CHAPTER II –MATERIAL AND RESEARCH METHODS

First article

Title: CT and MR cholangiography: advantages and pitfalls in perioperative evaluation of biliary tree

Author: 1 T HYODO, MD, 1 S KUMANO, MD, 2 F KUSHIHATA, MD, 1 M OKADA, MD, PhD, 3 M HIRATA, MD, 4 T TSUDA, MD, 2 Y TAKADA, MD, 4 T MOCHIZUKI, MD and 1 T MURAKAMI, MD, PhD

Aim: This article describes anatomical variants of the biliary tree with surgical significance, followed by comparison of CT and MR cholangiographies

MRCP, MR cholangiopancreatography; DIC-CT,drip infusion cholangiography with CT

Second Article

Title: Screening and Outcomes in Biliary Atresia: Summary of a National Institutes of Health Workshop

Author: Ronald J. Sokol1, Ross W. Shepherd2, Riccardo Superina3, Jorge A. Bezerra4, Patricia Robuck5, and Jay H. Hoofnagle5

Contemporary Outcome of Biliary Atresia Following Kasai Hepatoportoenterostomy (HPE) and Liver Transplantation

CHAPTER III – RESULTS AND DISCUSSION

Result of the first article

CT and MR cholangiopancreatography (MRCP) to provide minimally invasive alternatives to endoscopic retrograde cholangiopancreatography for the pre- and post-operative assessment of biliary disease.

CT and MR cholangiography are minimally invasive methods that provide precise depiction of the biliary system. DIC-CT allows detailed evaluation of biliary anatomy thanks to the high resolution of images, though the availability of intravenous cholangiographic contrast media is limited to a few countries. MRCP is most widely used as a non-invasive means of evaluating biliary diseases, particularly in patients with dilated bile ducts. Gd-EOB-DTPA-enhanced hepatobiliary phase MRI can delineate the biliary tree and potentially provide additional information regarding biliary flow. Clinicians need to understand the characteristics of each study technique to optimally utilise these

Conventional MR cholangiopancreatography

A 61-year-old female with suspected bile leakage 6 days after hepatic resection (S3 and S4) for hepatocellular carcinoma. Drip infusion cholangiography with CT was performed to detect bile duct injury. (a) On an axial 32-mm-thick slab maximumintensity projection image, the proximal site of B2 (arrow) was not visualised. (b) Axial image demonstrating bile leak from the cut margin of the liver as excreted contrast medium (arrowhead).

Choledocholithiasis after cholecystectomy. Coronal multiplanar reconstruction (section width, 1.25 mm) of drip infusion cholangiography with CT demonstrates a large stone (arrow) in the common bile duct. Pneumobilia in the right hepatic bile duct (arrowhead) is also recognised.

Results of the second article

1. Earlier diagnosis (<30-45 days of life) is associated with improved outcomes following the Kasai portoenterostomy and longer survival with the native liver

2. A younger age at the time of HPE consistently has been found to be associated with

better outcomes. These findings justify further efforts to improve early diagnosis

and prompt referral and treatment of BA.

3. In other countries, surgical results of HPE have been optimized by the limitation of

the procedure to centers of proven expertise. Attempts should be made to gather

data from US centers assessing outcomes with respect to known risk factors and the

experience of the center and surgeon (cases per year). This analysis might be done

through an Internet-based registry organized by the academic societies of pediatric

gastroenterology (North American Society for Pediatric Gastroenterology,

Hepatology, and Nutrition) and surgery (American Pediatric Surgical Association).

4. International working groups should be formulated to develop standardized

definitions for assessing outcomes. For example, “resolution of jaundice” might be

defined as a total serum bilirubin level below 2 mg/dL (34 μM) at 3 months after

HPE. “Survival with the native liver” should be reported at fixed and agreed-on

times, such as 2, 5, and 10 years of age. “Successful outcome of HPE” might be

defined as survival without transplantation and without listing at specific times.

Furthermore, children with the native liver could be further categorized according

to the degree of liver dysfunction, serum bili-rubin levels, or signs of chronic liver

disease and portal hypertension.

5. A meta-analysis should be conducted combining the raw data of a number of large

reported contemporary series of patients who have undergone HPE in different

countries, with the goal of achieving a definitive analysis of the effects of the age at

HPE, the center experience, the anatomic pattern of bile duct atresia, the presence

of other anomalies, and the histological features on surgical and other outcomes.

Such an analysis would be most helpful in defining the optimal age for HPE and at

what age the success rates of the procedure begin to decline.

6. A prospective trial of aggressive nutritional support and its effects on pretransplant

and posttransplant outcomes is justified. Practice guidelines should be developed

for integrating nutritional support into the overall management of BA.

7. A longitudinal and long-term analysis of neurodevelopmental outcome and its

predictors and modifiers should be conducted in a cohort of BA patients, including

the posttransplantation period.

8. National and international efforts should be coordinated for the investigation of the

potential benefits and risks of corticosteroid (or any other) therapy during the

perioperative period. The utilization of standardized treatment and follow-up

protocols and data sharing by different groups of investigators would enhance these

efforts.