1. Imaging in Surgical Obstructive Jaundice
Dr. Himadri Sikhor Das,
MD,PDCC
MATRIX
Guwahati

2. Introduction & Scope of Discussion
biliary tract obstruction is a common clinical & radiological problem.
Imaging Modalities
Pros /Cons
Few Disease s & Cases

3. Primary Aim of imaging confirm presence of obstruction
level of obstruction
cause of obstruction
complementary information relating to the underlying diagnosis (eg., Staging information in cases of malignancy).
Guide to best therapeutic approach

4. IMAGING MODALITIES :

5. X-ray Can visualize: Calcified stones,
Emphysematous cholecystitis (gas in GB wall),
Biliary fistula (gas within biliary system)
Porcelain gallbladder.
** widely replaced by the USG .

6. X-Ray

7. X-ray Can visualize: Calcified stones,
Emphysematous cholecystitis (gas in GB wall),
Biliary fistula (gas within biliary system)
Porcelain gallbladder.
** widely replaced by the USG .

8. USG Usual screening modality- (acc. 90% for pts. with jaundice)
CBD dilatation precedes IHBR dilatation (Normal 5-7 mm)
High resolution US equipment, normal IHBR can be seen.
Not > 2mm and not >40% of the diameter of the accompanying portal veins.

9. ENDOSCOPIC ULTRASOUND (EUS) mainly for pancreatico-biliary pathologies
98% diagnostic accuracy in patients with obstructive jaundice.
it allows diagnostic tissue sampling via EU guided fine-needle aspiration(EUSFNA)
Sensitivity of EUS for focal pancreatic masses has been reported to be superior to CT scanning( traditional /spiral) , particularly for tumors <3 cm in diameter.
Compared to MRCP diagnosis of biliary stricture, EUS has been reported to be more specific (100% vs 76%)

10. Nuclear medicine studies
Performed using 99mTC-labelled N-substituted iminodiacetic acid compounds (99mTC-HIDA).
Can be used to detect :
Low-grade biliary obstructions,
Acute cholecystitis,
Biliary leaks,
Internal fistulas.
Not often used but it still useful for evaluation of biliary dyskynesia or sphincter of Oddi dysfunction.

11. Normal hepatobiliary scintigraphy
A: liver parenchyma
B: gallbladder
C: small bowel
D: common bile duct
E: intrahepatic bile duct
Normal hepatobiliary scintigraphy

12. Scintigraphy in Acute Cholecystitis: Findings
The liver is visualized
Excretion of bile through IHBR’s & CBD to small bowel.
The gallbladder is not seen.

13. CT CT technology advancements have improved ability of CT to image
patients with obstructive biliopathy
Spiral scanners & Multidetector CT
- 3D Imaging
- Phasic Studies
- Dual phase CT angiography

14. CT Scan
USG detects ductal dilation but fails or inconclusive regarding level and cause of obstruction
Mostly in suspicion of malignant conditions
localization of primary tumors and mets
Best for Pancreatic Carcinoma(Highly sensitive for lesion >1mm)

15. Percutaneous Transhepatic Cholangiogram (PTC)
PTC is indicated when percutaneous intervention is needed and ERCP either is inappropriate or has failed.
Can be used to drain biliary obstructions.

16. Endoscopic Retrograde Cholangio Pancreatography (ERCP)
Primary method of direct cholangiography, with therapeutic potential.
Allows examination of upper GIT, the ampulla of vater, and pancreatic duct.
Biopsies of multiple sites can be taken using this technique.
**ERCP causes less discomfort than PTC, but acute pancreatitis is a common complication (which is rarely seen in PTC).

17. ERCP
The most important indication for ERCP is obstructive jaundice, as it can demonstrate the cause and extent of the obstruction.
ERCP is the preferred method of examination of patient with possible Choledocholithiasis, because the stones can be extracted with balloons or gaskets after sphincterotomy is performed.

18. ERCP showing stones

19. ERCP: showing slightly dilated common bile duct with calculus and normal pancreatic duct

20. MAGNETIC RESONANCE CHOLANGIO- PANCREATOGRAPHY (MRCP)
Noninvasive
Entire biliary tree and pancreatic duct can be seen
Best for Intra Hepatic stones and CHOLEDOCHAL CYST
SINGLE BEST FOR CHOLANGIOCARCINOMA
MRCP is better to determine the extent and type of tumor as compared to ERCP

21. Advantages of MRCP over ERCP/PTC
Non invasive, avoids complications of ERCP (5%)
No ionising radiation / contrast material
Useful in incomplete or failed ERCP or in
patients with surgical alteration of GI.T
Contd….

22. Disadvantages Contd… MRCP technique dependent /patient habitus
Entirely diagnostic in contrast to ERCP which provides access for therapeutic interventions.
**However, as CT /USG are faster, easier, and more readily available, so ]used more frequently than MRCP.

23. Common Causes of Obstructive Jaundice
Biliary Calculus Disease
Ca GB , Pancreas
Biliary stricture (mainly iatrogenic)
Cholangitis (inflammation of the common bile duct)
Congenital structural defects
Choledochal cysts(Cysts of the bile duct)
Lymph node enlargement
Pancreatitis
Parasitic infection
Trauma/including surgical complications etc

24. Choledocholithiasis US detection rate : 18% to 70%
CT detection rate : 76% to 86%
MRCP -
sensitivity : 90% to 100%
specificity : 92% to 100%
Exceeding that of ERCP.

28. CBD Strictures POST OPERATIVE Comparative evaluation by
US & ERCP/PTC (Vashisht et al)

29. Smooth tapering stenosis : 41%
Abrupt cut off of CBD : 18%
Presence of nodule without
acoustic shadowing : 16%

30. CBD Strictures classification (Bismuth H)
High or hilar stricture ( preservation of
confluence)
Low CHD strictures
Hepatic duct stump more then 2 cms
Mid CHD (stump < 2cms)

31. Stricture involving confluence/anomalous distribution of segmental branches
High or hilar stricture ( Interrupting the confluence)

32. Choledochal Cyst Congenital cysts of the bile ducts
Usually manifest in childhood
Triad of jaundice, Rt. upper quadrant pain and a palpable subcostal mass

33. Type I - Fusiform cyst within the porta in continuity with CBD.
Type II - Eccentric fluid filled cyst with a
narrow neck seen separate from CBD

34. Type IV Multiple cysts involving both intra and extra hepatic bile ducts.
Type V
Single or multiple intrahepatic
bile duct cysts.
Type III Localized cystic dilatation of distal intramural duodenal portion of CBD

35. Tuberculosis

36. Cholangiocarcinoma Most common tumour of the bile duct.
can be classified as
Intrahepatic (peripheral lesions)
Hilar lesion (the most common location, klatskin tumour)
Distal ductal tumour

39. Primary Sclerosing Cholangitis
Chronic progressive hepatobiliary disorder of unknown etiology.
Occurs in young men commonly.
Associated with inflammatory bowel disease.
Typically strictures alternate with normal or mildly dilated ducts resulting in beaded appearance.

40. Primary Sclerosing Cholangitis

41. Primary Sclerosing Cholangitis
Narrowed abnormal intra-heptic bile ducts.
Normal Extra hepatic BD

42. Carcinoma Gall Bladder
The most common biliary tract malignancy
Gall stones co-exist in 75% patients.
Cholecystitis frequent association, calcified G.B. likely to become cancerous.

43. Carcinoma G.B Imaging US,CT MR – Three patterns described
Most common (45-65%), subhepatic mass replacing or obscuring the gall bladder, often invading the liver.
Intraluminal polypoid mass arising in G. B. wall.
Focal or diffuse mural thickening

44. Carcinoma G.B Biliary obstruction
Due to direct invasion
Via hepatoduodenal ligament
Compression by lymphadenopathy

47. Ampulla /Periampullary carcinoma
Ampullary region is a common site for carcinoma which may
arise from the head of the pancreas.
Ampullary region from lower end of CBD
Ampulla itself or duodenal mucosa.

48. Conclusion
For evaluation of lesions causing obstructive biliopathy, protocol includes US,-CT/MRCP.
ERCP instead of MRCP if therapeutic intervention planned.

49. THANK YOU