Percutaneous cholecystostomy surgical incision of
the gallbladder especially for exploration or to remove
a gallstone.
inflammation of the gallbladder (cholecystitis), a
percutaneous cholecystotomy may be appropriate for
patients in the intensive care unit, who are likely
considered nonsurgical candidates.
Operative Cholangiography
-Operative cholangiography is performed during
surgery at the time of a cholecystectomy to detect
biliary calculi and the need for common bile duct
exploration
-A needle is placed directly into the cystic duct or
common bile duct by the surgeon and a small volume
(6 milliliters [mL]) of iodinated contrast material is
injected, followed by radiography.
-A second injection of 5 mL is made, followed by
radiography a second time. The resulting images are
reviewed for possible areas of concern before the
surgery completed
- It is imperative that no air bubbles be injected into
the ductal system with the contrast agent during this
procedure because they can mimic stones.
Tube Cholangiography
-is used after a cholecystectomy to demonstrate
patency of the common bile duct and to check for
calculi.
-With a T-shaped tube already inserted surgically into
the common bile duct, iodinated contrast medium is
injected to verify removal of all calculi.
The radiologist must take care not to inject air bubbles
because they may give the radiographic appearance of
radiolucent calculi.
Diagnostic Medical Sonography
-Real-time diagnostic medical sonography is now the
modality of choice for evaluating the gallbladder and
biliary tree.
-This procedure is noninvasive, and the gallbladder
can be imaged in almost all fasting patients regardless
of the body habitus or clinical condition of the patient.
-When sonography is performed by a skilled
sonographer, it has been proven to be almost 100%
accurate in detecting gallstones,
-which are demonstrated as echogenic areas within the
echo-free gallbladder.
-Thickening of the gallbladder wall is also easily
identified.
-Sonography is also an excellent tool for determining
the presence of common bile duct obstruction,
evaluation of the intrahepatic biliary ductal system,
and identification of abscesses.
-The liver may be evaluated by sonography because of
its ideal location in the RUQ and broad contact with
the abdominal wall.
-Hepatic lesions of 1 cm or greater are easily
identified, with cystic lesions appearing echo-free and
solid masses appearing echogenic, allowing excellent
guidance for aspiration and biopsy of these lesions.
-Doppler sonography enhances the diagnostic
capabilities of sonography to allow for clear analysis
of the circulatory dynamics,
Including:
portal blood flow
hepatic artery thrombosis
following liver transplantation.
-Doppler sonography can also differentiate between
vessels and biliary ducts based on flow characteristics.
Computed Tomography
-The role of CT in the hepatobiliary system is similar
to its role in the GI tract.
-It is the accepted modality for following
malignancies and assessing masses, particularly of the
gallbladder, liver, and pancreas.
-It is also helpful in evaluating complications of
cholecystitis such as perforations and abscess
formations.
-In addition to the excellent contrast resolution offered
by CT, the use of large-bolus intravenous (IV)
iodinated contrast media injections during dynamic CT
examination has also improved evaluations of the
hepatobiliary ductal system and blood flow via three-
phase imaging of the liver to capture the arterial and
portal venous blood flow
-If a biliary obstruction is not visible on sonographic
examination, CT is generally used to identify the
location and extent of the obstruction because it is not
limited by patient size or the presence of bowel gas.
-Lacerations of the liver and resultant abdominal
bleeding are readily detected on CT
-CT also demonstrates good visualization of pancreatic
tumors and pseudocysts.
 -MRCP is noninvasive and does not require the use of
a contrast agent
Nuclear Medicine Procedures
-A heavily T2-weighted sequence is used to suppress
Single photon emission computed tomography
the tissues around the biliary system, allowing the
(SPECT) examinations permit excellent detection of
gallbladder and bile ducts to appear bright and
hepatobiliary lesions, especially those located deep
enabling visualization of stones
within the liver parenchyma.
-SPECT provides a noninvasive method of evaluating
hepatic function as well as hepatic and splenic
perfusion.
INFLAMMATORY
-Because nuclear medicine imaging provides
DISEASES
information regarding physiologic function, combining 1. Alcohol-Induced Liver Disease
-SPECT and CT can often provide information about 2. Fatty Liver Disease
both anatomic changes and physiologic function, thus 3. Cirrhosis
enhancing the ability to diagnose pathologies earlier 4. Viral Hepatitis
than using any one modality alone. Labeling of white 5. Cholelithiasis
blood cells (WBCs) with radioactive indium is useful 6. Cholecystitis
in locating sites of infection for treatment. 7. Pancreatitis
-Chol scintigraphy performed in nuclear medicine is 8. Jaundice
very useful to confirm cholecystitis and for
distinguishing acute cholecystitis from chronic
cholecystitis. Alcohol-Induced Liver Disease
-Radioactive technetium is cleared from blood plasma -Alcohol is a known toxin, which, when metabolized
into bile, demonstrating the physiologic function of the by the liver
liver, excretion into the biliary ductal system, and Causes: cellular damage;
visualization of the gallbladder about 1 hour after
injection. Delayed visualization or nonvisualization of -Alcohol abuse has long been associated with liver
the gallbladder indicates pathology. disease.

- In addition, it is a noninvasive method of evaluating
biliary drainage, hepatobiliary leaks following trauma
or surgery, and segmental obstruction.
Magnetic Resonance Imaging
-The role of magnetic resonance imaging (MRI) of the
hepatobiliary system has improved greatly as a result
of shorter scan times, which allow the acquisition of
several images of the abdomen in a single breath.
-MRI is often used in conjunction with CT to evaluate
pathologies and anomalies of the peritoneum,
especially the liver and pancreas.
MRI may also be used to identify retroperitoneal
bleeds following trauma. Contrast enhanced three-
dimensional dynamic scans of the liver imaged at
timed intervals help to differentiate certain tumors
from hemangiomas.
Magnetic resonance cholangiopancreatography
(MRCP) is an imaging procedure that uses magnetic
resonance to visualize the gallbladder and biliary
system.
Alcoholic fatty liver- Drinking a large amount of
alcohol, even for just a few days, can lead to a build-up
of fats in the liver. This is called alcoholic fatty liver
disease,
Alcoholic cirrhosis is the destruction of normal liver
tissue.
REMEMBER:
-Alcohol cannot be stored in the human body, and
therefore, the liver must convert it, through;
oxidation, to alcohol
dehydrogenase,
acetaldehyde,
acetate,
-This leads to interference with carbohydrate and lipid
metabolism.
Oxidation also results in reduced gluconeogenesis and
increased fatty acid synthesis associated with alcohol
metabolism.
Chronic alcohol abuse often leads to fatty liver.
followed by;
hepatitis
cirrhosis,
hepatocellular carcinoma
-Fatty liver is the most frequent early response to
alcohol abuse.
-Changes in liver function result in a
buildup of lipids such as triglycerides, which are
deposited in the liver cells.
Triglycerides - This condition is usually
asymptomatic; however, patients may have
hepatomegaly. (enlarged liver)
-Fatty infiltration may be demonstrated by using CT or
sonography,
-CT is currently the examination of choice. CT
demonstrates the fatty deposits as hypodense areas
throughout the liver. Inflammation often follows fatty
changes within the liver, leading to alcoholic hepatitis.
At this stage, many patients present with jaundice.
This inflammation is diffuse throughout the liver cells
and culminates in liver necrosis. This disease may be
fatal, progressing quickly to liver failure; or if the
individual survives the hepatitis, the condition
progresses to alcoholic cirrhosis of the liver, which is
an end-stage disease
Fatty Liver Disease
-Factors other than alcohol abuse may also lead to fatty
infiltrates within the liver.
-Obese individuals with type 2 diabetes mellitus,
metabolic syndrome, hyperlipidemia, or all of these
diseases are at an increased risk of developing non-
alcoholic fatty liver disease (NAFLD). -This
pathology develops as lipids accumulate within the
hepatocytes forming free radicals.
- At some point, the liver cannot rid itself of the
excessive triglycerides. This results in an excess of
fatty acids within the liver, which leads to fatty
infiltration of the liver, termed steatosis, and fatty liver
disease.
-In the early stages, NAFLD is often asymptomatic,
and diagnosis requires biopsy of liver tissue.
-Although the disease progresses slowly, it may
advance to cirrhosis of the liver if left untreated.
-Management includes: implementation of weight
loss programs and exercise programs as treatment for
insulin resistance and associated metabolic
disturbances
Cirrhosis
is a chronic liver condition in which the liver
parenchyma and architecture are destroyed, fibrous
tissue is laid down, and regenerative nodules are
formed.
- In its early stages, it is usually asymptomatic, as it
may take months or even years before damage
becomes apparent.
-Cirrhosis affects the entire liver and is considered an
end-stage condition resulting from liver damage
caused by chronic alcohol abuse, drugs, autoimmune
disorders, metabolic and genetic disease, chronic
hepatitis, cardiac problems, and chronic biliary tract
obstruction.
The functional impairments caused by cirrhosis are
impaired liver function caused by hepatocyte damage,
generally resulting in jaundice, and portal
hypertension. Because of interference of portal blood
flow through the liver,
portal hypertension may lead to development of
collateral venous connections to the venae cavae. Most
commonly, such connections involve the esophageal
veins, which dilate to become esophageal varices,
-Also, the patient with cirrhosis has a tendency to
bleed because the liver is unable to make the necessary
clotting factors found in plasma or as a result of an
esophageal variceal rupture. Such hemorrhaging may
be, in fact, the first indication of portal hypertension.
Ascites, the accumulation of fluid within the peritoneal
cavity, is also seen as a result of portal hypertension
and the leakage of excessive fluids from the portal
capillaries.
-Much of this excess fluid is composed of hepatic
lymph weeping from the liver surface. It is associated
with approximately 50% of deaths from cirrhosis.
-Ascites may also result:
chronic hepatitis,
congestive heart failure,
renal failure, and
certain cancers.
Abdominal sonography is commonly used in the as the superior mesenteric and splenic veins adds
detection or confirmation of ascites. Diagnostic and additional information for the clinician.
therapeutic paracentesis may be conducted with
-final diagnosis of cirrhosis is generally accomplished
sonographic guidance to locate a site that will allow
by biopsy of liver tissue, often performed under
fluid to be removed and to avoid damage to the
sonographic guidance.
floating bowel loops.
Treatment: of cirrhosis depends on the extent of liver
-A diagnostic paracentesis involves removal of 50 to
damage and the involvement of other organs (e.g., the
100 mL of peritoneal fluid for analysis.
esophagus and stomach).
Patients with ascites generally complain of nonspecific
The primary goal of treatment is to eliminate the
abdominal pain and dyspnea.
underlying causes of the disease and to treat its
Medical treatment: of ascites includes complications.
bed rest, dietary Surgical treatment of portal hypertension may be
achieved by diverting blood from the portocollateral
restrictions of sodium,
system into the lower pressure systemic circulation.
use of diuretics This is accomplished by placing a shunt, eliminating
the chance of variceal bleeding. A distal splenorenal
- to avoid excess fluid accumulation, and shunt, in which the splenic vein is divided, with the
treatment of the underlying cause distal portion anastomosed to the left renal vein, is
Radiographic appearance of ascites: most commonly used. If the patient is not a candidate
for this type of shunt, a total shunt, either portocaval or
dense, gray, ground-glass appearance. mesocaval, must be placed.
-When the patient is in the supine position, fluid - A palliative procedure, the transjugular
accumulates in the pelvis and ascends to either side of intrahepatic portosystemic shunt (TIPSS),
the bladder to give it a dog-eared appearance.
Gradually, the margins of the liver, spleen, kidneys, may also be used to divert the pressure of portal
and psoas muscles become indistinct as the volume of hypertension. The TIPSS procedure is commonly
fluid increases. Loops of bowel filled with gas float performed in the cardiovascular interventional area of
centrally, and a lateral decubitus radiograph a radiology department.
demonstrates the fluid descending and the gas filled
loops of bowel floating on top.
Diagnostic medical sonography is helpful in
identifying liver cirrhosis and enlargement of the liver
and spleen.
Doppler is used to detect portal hypertension and
evaluate portosystemic collateral circulation
Viral Hepatitis
- It is used to measure the vessel
Hepatitis is a relatively common liver condition, with
size of the portal vein, which ranges from 0.64 to 1 cm an estimated 70,000 cases reported annually in the
in a normal adult. United States.
- A portal vein larger than 1.3 cm in diameter is At least six types of viral agents that cause acute
indicative of portal hypertension. inflammation of the liver have been identified This
inflammation interferes with the liver’s ability to
-Doppler integration of the portal vein allows tracing
excrete bilirubin, the orange or yellowish pigment in
of the flow of blood within the vessel. Normal portal
bile.
vein flow is toward the liver; however, with portal
hypertension, the flow is shunted away from the liver Clinical evidence/symptoms:
because of the diseased liver’s inability to accept the
flow of blood. As a result, the splenic vein tries to
handle this resistance by diverting the flow toward the
spleen. In many cases, affected persons develop
splenic varices from the increased flow from the portal
vein. Sonographic evaluation of venous structures such
 nausea,
vomiting,
discomfort,
tenderness over the liver area, and
Additional signs and symptoms include:
fatigue,
anorexia,
photophobia,
general malaise.
Jaundice
-may also develop within 1 or 2 weeks
because of the disturbance of bilirubin excretion. Hepatitis C virus (HCV) is caused by a parenterally
transmitted RNA virus. Type C accounts for 80% of
-If the liver inflammation lasts 6 months or more, the the cases of hepatitis that develop after blood
condition is classified as chronic. transfusions. A routine test for anti HCV antibody has
been developed, so transmission via transfused blood
Hepatitis A virus (HAV) is a single-stranded
has been significantly decreased.
ribonucleic acid (RNA) picornavirus. It is excreted in
the GI tract in fecal matter and is spread by contact -HCV may cause either acute or chronic hepatitis, with
with an infected individual, normally through ingestion 10% to 20% of affected patients eventually developing
of contaminated food such as raw shellfish or through cirrhosis of the liver.
contaminated water.
Hepatitis D virus (HDV) is caused by an RNA virus
It is the most common form of hepatitis and is highly and occurs only concurrently with acute or chronic
contagious. The incubation period of the disease is HBV. It cannot occur alone.
relatively short (15 to 50 days), and its course is
usually mild. HAV infection does not lead to chronic Hepatitis E virus (HEV) is also an RNA viral agent.
hepatitis or cirrhosis of the liver. It is most commonly responsible for outbreaks of
water borne epidemic acute hepatitis in developing
Hepatitis B virus (HBV) is transmitted parenterally countries. Although the infection may be severe, it
through infected serum or blood products. Its does not progress to a chronic state.
incubation period is much longer (50 to 160 days), and
its effects are more severe than those of HAV. The Hepatitis G virus (HGV), which has been recently
etiologic makeup of HBV is very complex, consisting isolated, may also be transmitted via blood products
of a viral core of deoxyribonucleic acid (DNA), which and may cause chronic hepatitis.
replicates within the cells of the liver. The viral core is The diagnosis of viral hepatitis: is usually made
covered with a surface coat. Through
- HBV may result in an asymptomatic carrier state, laboratory testing because the disease is
acute hepatitis, chronic
Treatment:
hepatitis, cirrhosis, and hepatocellular carcinoma.
Three distinct antigen–antibody systems have been bed rest
shown to have a link to HBV. These include hepatitis
medication for nausea and vomiting.
B surface antigen (HBsAg), which appears in the
incubation stage and is the first indication of HBV Cholelithiasis
infection; hepatitis B core antigen (HBcAg), which is
found in liver tissue but not in serum; and hepatitis B Cholelithiasis (gallstones) is fairly common, with at
extracellular antigen (HbeAg), which reflects active least 20% of all persons in the United States
viral replication. Most health care workers are now developing them by the age of 65 years.
required to receive HBV vaccination. Vaccination has
-Women are more likely than men to have them.
dramatically reduced the incidence of infection, and
the vaccines are safe with very few side effects
-Their occurrence is also more common in people with
diabetes, those who are obese, older adults, and
individuals who eat primarily a diet high in saturated
fat, sugar, and sodium and low in fiber and nutrient
density (Western diet). Heredity plays a role in the
development of gallstones.
Although most commonly found in the gallbladder,
gallstones can be located anywhere in the biliary tree.
Symptoms:
bloating,
nausea, and
pain in the right upper quadrant.
- Sludge may develop within the gallbladder and may
be identified sonographically. Sometimes sludge
develops in patients who have been fasting or who
have been on hyperalimentation and is a normal
variant from underusage of the bile in the gallbladder;
in other cases, sludge may be a precursor to
development of gallstones.
The characteristics of gallstones are quite varied.
They may occur as a single stone or as multiple stones.
About 80% of all stones are composed of a mixture of
cholesterol, bile pigment (bilirubin), and calcium
salts. The remaining 20% are composed of pure
cholesterol or a calcium–bilirubin mixture. Most
stones are radiolucent because only approximately
10% of all stones contain enough calcium to be
radiopaque.
-Those that are radiopaque may be difficult to
distinguish from renal stones, but oblique
radiographs help separate the two structures (kidney
and gallbladder) from each other, demonstrating the
gallbladder anterior to the kidney.
examination. The three major sonographic criteria for
gallstones include an echogenic focus,
cholecystectomy
Surgical removal of the gallbladder
(cholecystectomy) is usually the treatment of choice,
with more than 500,000 such procedures performed
annually in the United States.
Cholecystitis
is an acute inflammation of the gallbladder. It is
characterized clinically by a sudden onset of pain,
fever, nausea, and vomiting.
- It is common in individuals with chronically
symptomatic cholelithiasis.
- Its diagnosis is clinically suspected and supported
through a sonographic examination or radionuclide
cholescintigraphy.
-A radiopharmaceutical composed of technetium99m
(99mTc) in combination with
diisopropyliminodiacetic acid (DISIDA) allows
visualization of the biliary ductal system and results in
a highly sensitive examination with consistently
reliable results.
-Nonvisualization of the gallbladder is a good indicator
of acute cholecystitis. Repeated attacks of acute
cholecystitis cause damage to the gallbladder,
thickening of the walls and decreased function.
Complications: of untreated gallbladder disease
include
infarction and a possible gangrenous state,
prompting rupture of the walls.
Perforation of the gallbladder occurs in
approximately 5% to 15% of all patients with acute
cholecystitis and can be diagnosed in several ways.
Cholescintigraphy provides the best images of
perforation; however, stones may be visible outside the
gallbladder on conventional abdominal radiographs,
CT images, or sonographic images. Sonography and
CT often also demonstrate a nonspecific
pericholecystic fluid collection. If a rupture does
occur, bile peritonitis may result and require
immediate
Treatment:
Pancreatitis
- Inflammation of the pancreatic tissue is known
as pancreatitis.
-It is one of the most complex and clinically
challenging disorders of the abdomen and is classified
as acute or chronic, according to clinical, morphologic,
and histologic criteria.
-Acute pancreatitis resolves without impairing the
histologic makeup of the pancreas and most often
results from biliary tract disease.
-chronic pancreatitis does impair the histologic
makeup of the pancreas, resulting in irreversible
changes in pancreatic function.
causes include;
excessive and chronic alcohol
consumption, obstruction of the hepatopancreatic
ampulla by a gallstone or tumor, and even the injection
of contrast media during ERCP.
Hemorrhagic pancreatitis is a complication of
pancreatitis and consists of erosion into local tissues
and blood vessels, with subsequent hemorrhaging into
the retroperitoneal space.
A pseudocyst is a fluid collection caused by
pancreatitis. It is readily visualized by sonographic or
CT examination
Symptoms of pancreatitis:
vary from mild abdominal pain,
nausea,
vomiting to severe pain and shock.
REMEMBER:
-CT has made a major contribution to the diagnosis
and staging of acute pancreatitis. It adequately
demonstrates not only the pancreas itself but also the
retroperitoneum, the ligaments, the mesenteries, and
the omenta. The infected pancreas is usually enlarged,
with a shaggy and irregular contour.
-In advanced cases, fluid collections are demonstrated
within the pancreas and within the retroperitoneum.
ERCP is of value in determining the reasons for acute
recurrent pancreatitis, chronic pancreatitis, or the
prognosis is excellent in patients with mild pancreatic
inflammation and edema. However, a swollen
pancreas, with extravasation of fluid
within the retroperitoneum or pancreatic necrosis as
demonstrated by CT, results in a more severe
prognosis.
-Although most CT examinations are performed with
the use of IV contrast agents, research has shown that
use of contrast agents during the onset of acute
pancreatitis may cause necrosis in areas with poor
blood supply. Pancreatic necrosis increases mortality
and the incidence of infection, so patients should be
well hydrated before a contrast-enhanced CT
examination is performed. Chronic pancreatitis also
increases the risk for pancreatic cancer, so most
patients are continuously monitored for malignancy.
Jaundice
Jaundice, a yellowish discoloration of the skin and
whites of the eyes,
- is not a disease itself but rather a sign of disease. The
accumulation of excess bile pigments (i.e., bilirubin) in
the body tissues “stains” the skin and eyes this
yellowish color.
-Normally, bile and its pigments are secreted into the
bowel and eliminated.
Bilirubin is a type of bile pigment that is produced
when hemoglobin breaks down. Normal serum
bilirubin levels are equal to or less than 1 mg per 100
mL but must exceed 3 mg per 100 mL to be visible to
the observer.
-Medical (nonobstructive) jaundice occurs because
of hemolytic disease, in which too many red blood
cells (RBCs) are destroyed or because of liver damage
from cirrhosis or hepatitis.
-Its most common appearance is transient in the first
few days after birth, when more bile pigments are
released than can be handled.
-A liver that is damaged from disease simply cannot
excrete the bilirubin in a normal fashion, and it enters
the bloodstream.
Surgical (obstructive) jaundice occurs when the
biliary system is obstructed and prevents bile from
entering the duodenum. A common cause of this
obstruction is blockage of the common bile duct
caused by stones or masses.
-The longer the obstruction persists, the more likely it
is that complications (e.g., liver injury, infection, or
bleeding) will arise.
-The jaundiced patient often undergoes a sonographic
examination of the liver, biliary tree, and pancreas to
determine if the jaundice is obstructive or
nonobstructive.
The common bile duct is readily identified; generally,
a normal size implies nonobstructive jaundice, and a
dilated common bile duct suggests an obstruction.
-A variety of other methods may be used to diagnose:
the cause of jaundice, including
ERCP,
MRCP
CT
sonographic
CT-directed needle biopsy
 -may be used if an intrahepatic cause of the
hepatitis is suspected.
Treatment: of jaundice centers on the diagnosis and
treatment of its underlying cause.
In the case of obstructive jaundice,
- surgical excision of tobstructing
body may be necessary.
-Endoscopic removal of common
duct stones is frequently done, and endoscopy also
offers the opportunity to stent or bypass a tumor.