03/02/1443

RADIOLOGICAL INVESTIGATION OF THE BILIARY TRACT

1-Plain radiograph
A plain radiograph of the gall bladder will show radio-opaque
gallstones in 10% of patients with gallstones . Rarely, the centre of a
stone may contain radiolucent gas ‘Mercedes-Benz’ sign . A plain X-ray
may also show the rare cases of calcification of the gall bladder, as so
called ‘porcelain’ gall bladder .
The importance of this appearance is an association with carcinoma
in up to 25% of patients. Gas may be seen in the wall of the gall
bladder (emphysematous cholecystitis). Gas in the biliary tree may be
seen after endoscopic sphincterotomy or surgical anastomosis.

2-Oral cholecystography and intravenous cholangiography

Oral and intravenous cholecystography are of historical interest only .

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3-Ultrasonography
Transabdominal ultrasonography is the initial
imaging modality of choice as it is accurate, readily available,
inexpensive and quick to perform. However, it is operator
dependent and may be suboptimal due to excessive body fat and
intraluminal bowel gas. It can demonstrate biliary calculi, the size
of the gall bladder, the thickness of the gall bladder wall, the
presence of inflammation around the gall bladder, the size of the
common bile duct and, occasionally, the presence of stones within
the biliary tree.

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In the patient who presents with obstructive jaundice,

ultrasonography can identify
- intra- and extrahepatic biliary dilatation and the level of
obstruction.
- the cause of the obstruction may also be identified, such as
gallstones in the gall bladder, common hepatic or common bile
duct stones or lesions in the wall of the duct suggestive of a
cholangiocarcinoma or enlargement of the pancreatic head
Endoscopic ultrasonography uses a specially designed endoscope with an
ultrasound transducer at its tip, which allows visualisation of the liver and biliary
tree from within the stomach and duodenum. it useful in detecting stones
within the bile ducts( choledocholithiasis). In addition, it has been shown to be
highly accurate in diagnosing and staging both pancreatic and periampullary
cancers.

Radioisotope scanning (scintigraphy )

Technetium-99m (99mTc)-labelled derivatives of iminodiacetic

acid (HIDA scan ) when injected intravenously, selectively
taken up by the retroendothelial cells of the liver and
excreted into bile. This allows visualisation of the biliary tree and
gall bladder. Non-visualisation of the gall
bladder is suggestive of acute cholecystitis. If the patient has a
contracted gall bladder, as often occurs in chronic cholecystitis,
gall bladder visualisation may be reduced or delayed.
Biliary scintigraphy may also be helpful in diagnosing bile leaks
and iatrogenic biliary obstruction. When there is a suspicion of a
bile leak following a cholecystectomy, radioisotope imaging
should be performed.

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Computerised tomography

This imaging modality allows visualisation of the liver, bile ducts,

gall bladder and pancreas. It is particularly useful in detecting
hepatic and pancreatic lesions and is the modality of choice in
the staging of cancers of the liver, gall bladder, bile ducts and
pancreas. It can identify the extent of the primary tumour and
defines its relationship to other organs and blood vessels . In
addition, the presence of enlarged lymph nodes or
metastatic disease can be seen.
For benign biliary diseases, computerised tomography is not that
useful an investigation. Gallstones are usually not visualised
Magnetic resonance cholangiopancreatography. It is non-invasive
, Contrast is not required and, excellent images can be obtained of
the biliary tree that demonstrate ductal obstruction, strictures or
other intraductal abnormalities.

Endoscopic retrograde
cholangiopancreatography
This technique remains widely used. Using a side-viewing
endoscope,
the ampulla of Vater can be identified and cannulated.
Injection of water-soluble contrast directly into the bile duct
provides excellent images of the ductal anatomy and
can identify causes of obstruction such as stones or
malignant strictures , Bile can be sent for cytological and
microbiological examination, and brushings can be taken from
strictures for cytological studies. Therapeutic interventions such as
stone removal or stent placement to relieve the obstruction
can be performed. Thus, ERCP has evolved into a mainly
therapeutic rather than a diagnostic uses .

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Percutaneous transhepatic cholangiography

This is an invasive technique in which the bile ducts are
cannulated directly. It is only done once a bleeding tendency has
been excluded, Antibiotics should be given prior to the procedure.
Usually,, a needle is introduced percutaneously into the liver
substance. Under radiological control (either ultrasound or CT), a
bile duct is cannulated. Successful entry is confirmed by aspiration
of bile. Water-soluble contrast medium is injected to demonstrate
the biliary system. In addition, PTC enables the placement of a
catheter into the bile ducts to provide external biliary drainage or
the insertion of stents.

Peroperative cholangiography

During open or laparoscopic cholecystectomy, a catheter can be

placed in the cystic duct and contrast injected directly into the
biliary tree. The technique defines the anatomy and is mainly
used to exclude the presence of stones within the bile ducts .

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Operative biliary endoscopy (choledochoscopy)

At operation, a flexible fibreoptic endoscope can be passed down

the cystic duct into the common bile duct enabling stone
identification and removal under direct vision. After exploration of
the bile duct, a tube can be left in the cystic duct remnant or in the
common bile duct (a T-tube) and drainage of the biliary tree
established. After 7–10 days, a track will be established. This track
can be used for the passage of a choledochoscope to remove
residual stones .

CONGENITAL ABNORMALITIES OF THE

GALL BLADDER AND BILE DUCTS
Embryology

Absence of the gall bladder

Occasionally, the gall bladder is absent. Failure to visualise the
gall bladder is not necessarily a pathological problem.
The Phrygian cap
The Phrygian cap is present in 2–6% and may be mistaken for a
pathological deformity of the organ. ‘Phrygian cap’ refers to hats
worn by the people of Phrygia.

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Floating gall bladder

The organ may hang on a mesentery, which makes it liable to
undergo torsion.
Double gall bladder
Rarely, the gall bladder is duplicated.
Absence of the cystic duct
This is usually a pathological, anomaly and indicates the recent
passage of a stone or the
presence of a stone at the lower end of the cystic duct, which is
ulcerating into the common bile duct. The main danger at surgery
is damage to the bile duct.
Low insertion of the cystic duct
The cystic duct opens into the common bile duct near the ampulla.
All variations of this anomaly can occur .
An accessory cholecystohepatic duct
Ducts passing directly into the gall bladder from the liver do
occur .

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EXTRAHEPATIC BILIARY ATRESIA

Aetiology and pathology
Atresia is uncommon affects males and females equally. The
extrahepatic bile ducts are progressively destroyed by an
inflammatory process, which starts
around the time of birth. eventually result in biliary cirrhosis and
portal hypertension. Untreated, death from the consequences of
liver failure occurs before the age of 3 years.
The inflammatory destruction of the bile ducts has been classified
into three main types
• type I: atresia restricted to the common bile duct;
• type II: atresia of the common hepatic duct;
• type III: atresia of the right and left hepatic ducts.

Clinical features
About one-third of patients are jaundiced at birth. In all, however,
jaundice is present by the end of the first week and deepens
progressively. The meconium may be a little bile-stained, but
later the stools are pale and the urine is dark. Pruritus is severe.
Clubbing and skin xanthomas.
Differential diagnosis
This includes any form of jaundice in a neonate giving a cholestatic
picture. Examples are alpha-1-antitrypsin deficiency, cholestasis
associated with intravenous feeding, choledochal cyst and
inspissated bile syndrome. Neonatal hepatitis is the most difficult
to differentiate.

Liver biopsy and radioisotope scans are essential

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Treatment
Patent segments of proximal bile duct are found in 10% of type I
lesions. A direct Roux-en-Y hepaticojejunostomy will achieve bile
flow in 75%, but progressive fibrosis results in disappointing long
term results. A simple biliary–enteric anastomosis is not possible
in the majority of cases in which the proximal hepatic ducts are
either very small (type II) or atretic (type III). These are treated
by the Kasai procedure. Liver transplantation should be considered
in children in whom a portoenterostomy is unsuccessful
Postoperative complications include bacterial cholangitis. Repeated
attacks lead to hepatic fibrosis, portal hypertension, with one-third
having variceal bleeding.

CONGENITAL DILATATION OF THE

INTRAHEPATIC DUCTS (CAROLI’S DISEASE)
This rare condition is characterised by multiple irregular saccular
dilatations of the intrahepatic ducts with a normal extrahepatic
biliary system. The aetiology is unknown, but it is considered to be
hereditary. It can be divided into a simple and a periportal fibrotic
type. The periportal fibrotic type presents in childhood and is
associated with biliary stasis, stone formation and cholangitis. In
contrast, the simple type presents later with episodes of abdominal
pain and biliary sepsis. Associated conditions include congenital
hepatic fibrosis, polycystic liver
treatment are antibiotics for the cholangitis and the removal of
calculi, lobectomy may be indicated.

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Choledochal cyst
Choledochal cysts are congenital dilatations of the intra- and/or
extrahepatic biliary system. The pathogenesis is unclear. Type I
cysts are the most common 75% of patients.
Patients may present at any age with jaundice, fever, abdominal
pain and a right upper quadrant mass on examination. Pancreatitis
is a not infrequent presentation in adults. Patients with
choledochal cysts have an increased risk of developing
cholangiocarcinoma .
Ultrasonography will confirm the presence of an abnormal
cyst and magnetic resonance imaging (MRI/MRCP) will reveal
the anatomy, CT is also useful for the extent of the intra- or
extrahepatic dilatation.

Type Ia and b: diffuse cystic. Note extension into the pancreas of type Ib. Type II:
diverticulum of the common bile duct. Type III: diverticulum within the
pancreas. Type IV: extension into the liver. Type V: cystic dilatation only
of the intrahepatic ducts.

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Radical excision of the cyst is the treatment of choice with

reconstruction of the biliary tract using a Roux-en-Y loop of
jejunum. Complete resection of the cyst is important because of
the association with the development of cholangiocarcinoma.

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