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Hepatobiliary X-ray

Protocols

X-ray  Hydatid cyst:

Image

CXR-1

CXR-1: Chest X-ray PA view showing a huge mass with clear margin occupying the left upper and midzones,


obscuring the left upper border of heart. Another mass in left lower zone.


  1. Q: What single investigation do you suggest?
  2. A: Chest X-ray, right lateral view.
    • • If the mass is in posterior mediastinum, it is neurofibroma.
    • • If the mass is in anterior mediastinum, it is dermoid cyst.





Differential diagnoses:

  • • Hydatid cyst
  • • Neurofibroma
  • • Dermoid cyst
  1. Q: What are the presentations of hydatid cyst of lung?
  2. A: As follows:
    • • Asymptomatic.
    • • Sometimes there may be cough, breathlessness, secondary infection (causing lung abscess).
    • • The cyst may rupture into the tracheobronchial tree or pleural cavity. Rupture may be associated with the
    • sudden onset of cough and fever. If the contents of the cyst are expelled into the airway, expectoration of a clear salty
    • or peppery-tasting fluid containing fragments of hydatid membrane and scolices may occur.

Magnetic resonance cholangiopancreatography (MRCP)


 What is MRCP?

  1. A: Magnetic resonance cholangiopancreatography (MRCP) is a noninvasive imaging technique to

  3. visualize intrahepatic and extrahepatic biliary tree and pancreatic ductal system.

It can provide the diagnostic range equivalent to ERCP and so it can replace ERCP in high-risk patients to avoid significant morbidity.


Fig:Cholelithiasis with choledocholithiasis.


X-RAY-A: This is an MRCP showing multiple gallstones as well as multiple common bile duct stones.

Diagnosis: Cholelithiasis with choledocholithiasis.


Image


Fig-B: Biliary stricture.


X-RAY-B: This is an MRCP showing:

  • • Smooth narrowing of the distal common bile duct.
  • • There is intrahepatic and extrahepatic biliary dilatation.
  • • No distal CBD stone or pancreatic head mass is seen.

Diagnosis: Biliary stricture.

  1. Q: What are the causes of biliary stricture?
  2. A: It may be benign or malignant.
    1. 1. Causes of benign biliary strictures:
      • • Postoperative injury after cholecystectomy
      • • Pancreatitis
      • • Primary sclerosing cholangitis (PSC)
    2. 2. Causes of malignant biliary strictures:
      • • Pancreatic cancer
      • • Ampullary carcinoma
      • • Gallbladder carcinoma and cholangiocarcinoma
  1. Q: What are the symptoms of biliary stricture?
  2. A: As follows:
    • • Pain in the upper right side of the abdomen
    • • Obstructive jaundice
    • • Nausea or vomiting
    • • Fever, if secondary infection


      • Image

    Fig-C: Cholangiocarcinoma.

    X-RAY-C: This is an MRCP showing dilatation of the intrahepatic bile ducts with disconnection between the left- and right-sided ducts and the common duct. The distal CBD and pancreatic duct appear normal.

    Diagnosis: Cholangiocarcinoma.


    Image


    Fig-D: Periampullary tumour.

    X-RAY-D: This is an MRCP showing intrahepatic bile ducts and CBD are grossly dilated with distal narrowing. Pancreatic duct appears normal.

    Diagnosis: Periampullary tumour.



    1. Q: What other investigations should be done?
    2. A: As follows:
      • • USG of HBS
      • • Liver function test
      • • CT- or USG-guided FNAC

    Image


    1. Fig-E:Calcific pancreatitis.

      X-RAY-E: This is an MRCP showing dilatation of the main pancreatic duct. There is a stone in the proximal pancreatic duct.


      Diagnosis: Calcific pancreatitis.

      1. Q: What other investigations can be done?
      2. A: As follows:
        • • USG of HBS
        • • Plain X-ray abdomen


    1. Q: What are the indications of MRCP?
    2. A: Any hepatobiliary or pancreatic disease, such as:
      • • Choledocholithiasis and cholelithiasis
      • • Biliary obstruction
      • • Biliary strictures
      • • Chronic pancreatitis
      • • Pancreatic cystic lesions
      • • Trauma to biliary system
      • • Congenital anomalies of the cystic and hepatic ducts
      • • Postsurgical biliary anatomy and complications
    1. Q: What are the complications of MRCP?
    2. A: As follows:
      • • Pancreatitis
      • • Cholecystitis
      • • Traumatic injury
      • • Hypersensitivity due to dye




    Endoscopic retrograde cholangiopancreatography (ERCP):

    Image

    Fig-A:Normal ERCP.

    ERCR finding fig-A: This is an ERCP showing normal pancreatic duct and normal intrahepatic and extrahepatic biliary tree and gallbladder.

    Diagnosis: Normal ERCP.

    Image

    Fig-B; Choledocholithiasis.

    ERCR finding fig-B:

    This is an ERCP showing dilatation of common bile duct and intrahepatic biliary tree. Multiple translucent shadows within the common bile duct.

    Diagnosis: Choledocholithiasis (stone in common bile duct).

    1. Q: What investigations can be done?
    2. A: As follows:
      • • USG of hepatobiliary system
      • • MRCP
      • • Serum lipid profile
      • • Blood sugar
      • • Liver function test (serum bilirubin, SGPT, alkaline phosphatase, prothrombin time, total protein and A/G ratio)
    1. Q: What are the complications of choledocholithiasis?
    2. A: As follows:
      • • Obstructive jaundice
      • • Cholangitis
      • • Stricture of common bile duct
      • • Acute pancreatitis
      • • Liver abscess
      • • Cholangiocarcinoma


        • Image

      Fig-C:Pancreatic calculi.

      ERCP finding fig-C:This is an ERCP showing dilatation of pancreatic duct. Multiple translucent shadows within the pancreatic duct.

      Diagnosis: Pancreatic calculi.

      1. Q: What are the presentations of choledocholithiasis?
      2. A: As follows:
        • • May be asymptomatic
        • • Obstructive jaundice
        • • Severe generalized itching, clay-coloured stool
        • • Pain in the right hypochondrium or epigastric pain
        • • Fever, chill and rigor, features of cholangitis
        • • Anorexia, nausea, vomiting
      1. Q: How to treat?
      2. A: As follows:
        • • Sphincterotomy and stone is removed during ERCP.
        • • If it fails, then open surgery.

      Image

      Fig-F:Roundworm in common bile duct.

      ERCP finding fig-F:

      This is an ERCP showing dilatation of common bile duct and intrahepatic biliary tree. A linear translucent shadow within the common bile duct.

      Diagnosis: Roundworm (ascariasis) in common bile duct.

      1. Q: How does the patient present with this worm?
      2. A: As follows:
        • • Upper abdominal pain, mostly in right hypochondrium
        • • Anorexia, nausea, vomiting
        • • Features of obstructive jaundice and cholangitis
      1. Q: How to treat such a case?
      2. A: The worm is removed during ERCP. Antihelminthic drug should be given (such as albendazole or mebendazole or pyrantel pamoate).
      1. Q: What are the other sites in which the worm can cause obstruction?
      2. A: As follows:
        • • Small intestine, commonly in ileocaecal valve (mainly in early age)
        • • May invade appendix (causing appendicitis)

      Image


        • Fig-G: ERCP (choledochal cyst).

        aERCP finding fig-G:

        This is an ERCP showing cyst with dilatation of extrahepatic and intrahepatic biliary tree.

        Diagnosis: Choledochal cyst.

        1. Q: What other investigations can be done?
        2. A: As follows:
          • • USG of hepatobiliary system
          • • MRCP
          • • CT scan of hepatobiliary system
          • • Also liver function test


            • Image
            • Fig -H: ERCP (cholangiocarcinoma).




          sERCP Finding Fig-H: This is an ERCP showing irregularity with stricture at the lower part of common bile duct.

          Diagnosis: Cholangiocarcinoma.

          1. Q: How to confirm the diagnosis?
          2. A: CT-guided FNAC.
          1. Q: How to treat cholangiocarcinoma?
          2. A: Complete surgical resection if possible. Other options are:
            • • Stenting
            • • Photodynamic therapy (PDT)
            • • Radiation therapy
            • • Chemotherapy
            • • Symptomatic and supportive treatment should be given
            • Image
            • Fig-L: Pancreatic carcinoma.
            • ERCP Finding fig-L: This is an ERCP showing complete obstruction of pancreatic duct. Biliary tree is slightly dilated.


                  Diagnosis: Carcinoma of pancreas.

                            Q: What other investigations can be done?

                              A: As follows:

                                • Ultrasonography.

                                • CT scan.

                                • MRI.

                                • MRCP.

                                • CT- or USG-guided FNAC.

                                • Serum CA 19-9.

                                • Blood sugar, CBC, ESR.

                                • Liver function test may be done.

                                Q: What is primary sclerosing cholangitis?

                                A: Primary sclerosing cholangitis is a chronic cholestatic liver disease characterized by fibrosing inflammatory

                                destruction of intrahepatic and extrahepatic bile ducts that leads to gradual obliteration of biliary tree and

                                ultimately biliary cirrhosis, portal hypertension and hepatic failure.

                                Q: What are the clinical features of primary sclerosing cholangitis?

                                A: Common in males. Seventy-five per cent is associated with inflammatory bowel disease, commonly ulcerative colitis.

                                  Cholangiocarcinoma may occur in 10%–30% of cases.

                                    • May be asymptomatic. Diagnosed incidentally with abnormal liver function test, mainly high

                                    serum alkaline phosphatase. Also during ultrasonography.

                                    • Features of inflammatory bowel disease.

                                    • Anorexia, nausea, vomiting, fatigue, malaise, weight loss.

                                    • Pain in right hypochondrium.

                                    • Pruritus.

                                    • Features of malabsorption, cholestasis (stool is clay- or muddy-coloured).

                                    Signs are:

                                      • Scratch marks on whole body.

                                      • Jaundice.

                                      • Hepatomegaly.

                                      • In advanced cases: Stigmata of CLD may be present.

                                        Q: What investigations should be done in primary sclerosing cholangitis?

                                          A: As follows:

                                            • Liver function tests (high alkaline phosphatase is common).

                                            • Ultrasonography of hepatobiliary system.

                                            • P-ANCA is high in 60% of cases.

                                            • MRCP (it is the key investigation).

                                            • ERCP may be done in some cases (if therapeutic intervention is indicated).

                                            • Liver biopsy.

                                            • P-ANCA: Positive in 60%–80% of cases in ulcerative colitis.

                                            • ANA and anti-smooth muscle antibody may be positive.


                                            Q: How to treat primary sclerosing cholangitis?

                                                1. A: As follows:

                                                          • Symptomatic: Cholestyramine for pruritus, ursodeoxycholic acid, fat-soluble vitamin supplementation.

                                                          • Immunosuppressive drugs, such as prednisolone, azathioprine, cyclosporin, tacrolimus, MTX. Anti-TNF agents,

                                                          such as etanercept or infliximab, may be given.

                                                          • In some cases, endoscopic biliary intervention with balloon dilatation and stenting may improve biochemistry and symptoms.

                                                          • Orthotopic livEr transplantation is the definitive treatment. The only curative treatment is liver transplantation.