Bililary ultrasound DR/ AMR SALAH 1 Dr /Amr Salah

bililary ultrasound DR/ AMR SALAH 1 Dr /Amr Salah dramrsalah84@gmail.com

Contents 1- AnatomyNormal - Variant 2- CongenitalCholedochal cyst – caroli’s disease – biliary atresia 3- InfectiousAcute cholangitis – recurrent pyogenic cholangitis 4- IdiopathicPSC 5- StonesCholedocholithiasis – mirrizi’s syndrome 6- Benign neoplasmBiliary cystadenoma – bile duct adenoma- Biliary papillomatosis 7- Malignant neoplasmCholangiocarcinoma - Ampullary carcinoma – biliary cystadenocarcinoma 8- Trauma and postop Bile leak – Biloma – stent

Contents 3 Dr /Amr Salah dramrsalah84@gmail.com Anatomy and Anomalies- AtresiaBile duct wall thickeningContents : stone / mass / echogenicityDilatation : inside / outside / others Extra : estimation of jaundice Following : operation and stent

anatomy PART I Dr /Amr Salah dramrsalah84@gmail.com 4

Intra segmental Dr /Amr Salah dramrsalah84@gmail.com 6

Dr /Amr Salah dramrsalah84@gmail.com 11

Proximal >>>liver Distal >>>>pancreas and duodenum Order = division CHD >>>1 st order ( RT and LT)>>>>2 nd order Central >>>porta hepatis Peripheral >>>higher order Intra hepatic duct may be anterior or posterior or around the portal vein Dr /Amr Salah dramrsalah84@gmail.com 17

CHD :1 st – RT and LT 2 nd Dr /Amr Salah dramrsalah84@gmail.com 18

Visualization of 3 rd or higher order branches ?? Abnormal 2 nd to advanced higher less than 2 mm Dr /Amr Salah dramrsalah84@gmail.com 20

Dr /Amr Salah dramrsalah84@gmail.com 22 RP RA L 2

Normal The normal caliber of the CH/CBD max ~7mm May be 10 mm in older age and post surgical The site of insertion of the cystic duct to CHD>>>>CBD The common bile duct should measure less than 1 mm in neonates less than 2 mm in infants up to 1 year old less than 4 mm in older children and less than 7 mm in adolescents and adults. Dr /Amr Salah dramrsalah84@gmail.com 23

Biliary atresia Dr /Amr Salah dramrsalah84@gmail.com 24

Biliary atresia Congenital biliary disorder, which is characterized by an absence or severe deficiency of the extrahepatic biliary treebiliary tree It is one of the most common causes of neonatal cholestasis, causing cirrhosis immediately and leading to death and accounts for over half of children who undergo liver transplantation. cirrhosis Dr /Amr Salah dramrsalah84@gmail.com 25

Clinical presentation It precipitates within the first three months of life. Infants with biliary atresia may appear normal and healthy at birth. Most often, symptoms develop between two weeks to two months of life, and may include : jaundice (conjugated hyperbilirubinemia) jaundice dark yellow or brown urine pale or clay-colored (acholic) stools hepatomegaly Dr /Amr Salah dramrsalah84@gmail.com 26

Types There are two different forms of biliary atresia non-syndromic BA (~90%): isolated atresia of bile ducts syndromic BA (~10%): associated with various congenital anomalies such as polysplenia, asplenia, heterotaxy syndrome and intestinal malrotation.polyspleniaheterotaxy syndrome Dr /Amr Salah dramrsalah84@gmail.com 28

Ultrasound 1.Triangular cord sign triangular or tubular echogenic cord of fibrous tissue seen in the porta hepatis porta hepatis more than 4 mm thickness of the echogenic anterior wall of the right portal vein (EARPV) measured on a longitudinal ultrasound scan 2. larger hepatic arterial caliber an enlarged hepatic artery and hepatic arterial flow that extended to the hepatic surface were seen in all patients with BA 3. gallbladder ghost trial : atretic gall bladder + irregular contour + lack of complete mucosal lining Dr /Amr Salah dramrsalah84@gmail.com 29

Triangular cord sign Dr /Amr Salah dramrsalah84@gmail.com 32

TC sign Dr /Amr Salah dramrsalah84@gmail.com 33

Gall bladder ghost sign Dr /Amr Salah dramrsalah84@gmail.com 34

Prominent subcapsular HA Dr /Amr Salah dramrsalah84@gmail.com 35

Biliary Atresia Dr /Amr Salah dramrsalah84@gmail.com 36 Ghost GB Enlarged HA Pv TC sign HA capsular sign

Non biliary atresia Dr /Amr Salah dramrsalah84@gmail.com 37 No TC sign Normal GB Normal diameter HA PV NO HA capsular sign

Contents 1- AnatomyNormal - Variant 2- CongenitalCholedochal cyst – caroli’s disease – biliary atresia 3- InfectiousAcute cholangitis – recurrent pyogenic cholangitis – 4- IdiopathicPSC 5- StonesCholedocholithiasis – mirrizi’s syndrome 6- Benign neoplasmBiliary cystadenoma – bile duct adenoma- Biliary papillomatosis 7- Malignant neoplasmCholangiocarcinoma - Ampullary carcinoma – biliary cystadenocarcinoma 8- Trauma and postop Bile leak – biloma – benign stricture

Contents 39 Dr /Amr Salah dramrsalah84@gmail.com Anatomy and Anomalies/AtresiaBile duct wall thickeningContents : stone / mass / echogenicityDilatation : inside – outside - others Extra : estimation of jaundice Following : operation and stent

Bile duct wall thickening PART II Dr /Amr Salah dramrsalah84@gmail.com 41

Causes 1.Cholangitis : ascending – recurrent pyogenic – primary sclerosing 2.Cholangiocarcinoma 3.HCC 4.AIDS cholangiopathy 5.IBD Dr /Amr Salah dramrsalah84@gmail.com 42

Causes of CBD wall thickening Normal diameter ~ 1.5 mm More than 5 mm Cholangicarcinoma focalDiffuse Concentric Especially in the distal CBD Pancreatitis Pancreatic cancer CBD stone Acute / ascending cholangitis Recurrent pyogenic cholangitis Eccentric Cholangiocarcinoma PSC Cholangiohepatopathy PSC Dr /Amr Salah dramrsalah84@gmail.com 43

Cholangitis Broad descriptive term / Inflammation of the bile duct It has many forms and can arise from a number of situations: primary sclerosing cholangitis infective cholangitis Acute/ascending cholangitis Recurrent pyogenic cholangitis - oriental cholangitis chemotherapy induced cholangitis eosinophilic cholangitis Dr /Amr Salah dramrsalah84@gmail.com 45

Primary sclerosing cholangitis Dr /Amr Salah dramrsalah84@gmail.com 46

Primary sclerosing cholangitis Primary sclerosing >>>>secondary sclerosing cholangitis Primary = unknown cause Causes of secondary : AIDS – cancer – radiation – post operative Dr /Amr Salah dramrsalah84@gmail.com 47 1ry Sclerosing >>>>>1ry biliary cholangitis / cirrhosis Biliary cirrhosis >>>>affect mainly the distal biliary radicels …just you see cirrhosis by imaging Women > men High antibody titers ( AMA)

Primary sclerosing cholangitis An uncommon idiopathic inflammatory condition, which affects the biliary tree resulting in multiple strictures and eventual cirrhosisstricturescirrhosis The diagnosis can be made when there are classical imaging features in the correct clinical context, and secondary causes of cholangitis have been excluded PSC is strongly associated with inflammatory bowel disease (IBD) (in 70% cases ), especially ulcerative colitis and thus shares similar demographics: young to middle-aged males (≈4 th decade) are most frequently affectedinflammatory bowel disease (IBD)ulcerative colitis Dr /Amr Salah dramrsalah84@gmail.com 49

Best diagnostic clue Beaded appearance Location : CBD : almost always affected Intra and extra HBR : 70 – 90 % intra or extra alone : less than 20 % Dr /Amr Salah dramrsalah84@gmail.com 50

Clinical presentation Middle age male : rule of 70% 70 % male – 70 % ulcerative colitis – 70 % less than 45y Asymptomatic individuals are identified upon investigation of persistently deranged liver function tests fatigue. More specific symptoms include pruritus, jaundice or GI bleeding Elevated serum alkaline phosphatase Dr /Amr Salah dramrsalah84@gmail.com 51

Associations ulcerative colitis Sjogren syndrome retroperitoneal fibrosis mediastinal fibrosis Riedel thyroiditis orbital pseudotumor antibody titers are usually absent or low. Liver function tests will usually have a cholestatic pattern with elevated alkaline phosphatase (ALP) and bilirubin Dr /Amr Salah dramrsalah84@gmail.com 52

Ultrasound Bright echogenic portal triad Signs of portal hypertension Irregular wall thickening ( beaded) Proximal biliary dilatation Gall bladder abnormalities : stones / thick wall …50% DD : bilharziasis Dr /Amr Salah dramrsalah84@gmail.com 53

CBD Dr /Amr Salah dramrsalah84@gmail.com 56

Radiological findings The entire biliary tree (both intra and extrahepatic) may be involved, with multiple strictures scattered along its length The end result of PSC is cirrhosis which is usually characterized by a markedly distorted biliary tract with atrophy of the entire liver with the exception of the caudate lobe which is hypertrophied in almost all cases (68-98%)cirrhosiscaudate lobe Atrophy involving the left lobe is a feature which somewhat distinguishes it from cirrhosis from other causes, in which the left lobe is usually hypertrophied Dr /Amr Salah dramrsalah84@gmail.com 58

Complications cholangiocarcinoma develops in ~15% patients cholangiocarcinoma colorectal cancer 4x greater risk compared to IBD patients without PSC 10x greater risk compared to general population hepatocellular carcinoma: appears to be not increased beyond other causes of cirrhosis hepatocellular carcinoma Dr /Amr Salah dramrsalah84@gmail.com 59

Differential diagnosis Cirrhosis Caudate lobe not as frequently or as markedly enlarged left lobe usually also hypertrophied secondary sclerosing cholangitis AIDS associated cholangitis biliary strictures from other causes, e.g. surgery, ischaemia primary biliary cirrhosis young women more frequently affected high antibody titres Dr /Amr Salah dramrsalah84@gmail.com 60

PSC P : pruritus– beaded – portal HTN – proximal dilatation– DD: bilharziasis S : Seventy rule 70 % middle age – 70 % male – 70 % UC C : Eventually with cirrhosis Dr /Amr Salah dramrsalah84@gmail.com 61

Contents 1- AnatomyNormal - Variant 2- CongenitalCholedochal cyst – caroli’s disease – biliary atresia 3- InfectiousAcute cholangitis – recurrent pyogenic cholangitis 4- IdiopathicPSC 5- StonesCholedocholithiasis – mirrizi’s syndrome 6- Benign neoplasmBiliary cystadenoma – bile duct adenoma- Biliary papillomatosis 7- Malignant neoplasmCholangiocarcinoma - Ampullary carcinoma – biliary cystadenocarcinoma 8- Trauma and postop Bile leak – biloma – benign stricture

ascending cholangitis Dr /Amr Salah dramrsalah84@gmail.com 63

Ascending cholangitis / acute cholangitis form of cholangitis and refers to the acute bacterial infection of the biliary tree.cholangitisbiliary tree It is a condition with high mortality that necessitates emergent biliary decompression. The classical presentation is the Charcot triad of fever, right upper quadrant abdominal pain, and jaundice, which is only seen in ~40% of patients.Charcot triad Patients can also present with Reynold pentad, which is Charcot triad with shock and altered mental statusReynold pentad Dr /Amr Salah dramrsalah84@gmail.com 64

Etiology Gram-negative enteric bacteria, most commonly Escherichia coli, are the primary pathogens. Acute cholangitis is seen in the setting of biliary tree obstruction : choledocholithiasis (~80%) choledocholithiasis malignancy (~20%) sclerosing cholangitis biliary tree procedures, e.g. ERCPERCP Dr /Amr Salah dramrsalah84@gmail.com 65

Radiographic features Acute cholangitis is typically a clinical diagnosis with imaging performed to determine if there is evidence of : 1.intrahepatic and/or extrahepatic duct dilatation (indicating obstruction/stasis) 2.bile duct wall thickening or focal outpouchings 3.cholelithiasis/choledocholithiasischolelithiasischoledocholithiasis Dr /Amr Salah dramrsalah84@gmail.com 66

Ultrasound A hallmark finding is thickening of the walls of the bile ducts in the appropriate clinical setting. Ultrasound may also show biliary dilatation with calculi, with or without pus, which appears as debris material within the common bile duct. Periportal hypo/hyper echogenicity adjacent to dilated IHBR Gall bladder : thick wall ± stone Liver : intrahepatic abscess Dr /Amr Salah dramrsalah84@gmail.com 67

Dr /Amr Salah dramrsalah84@gmail.com 68 PvCBD

Pathognomonic / periportal hyperechogenicty Dr /Amr Salah dramrsalah84@gmail.com 72

To recap PSC P : pruritus – beaded – bilharziasis S : seventy 70% rule C : cirrhosis Dr /Amr Salah dramrsalah84@gmail.com 74 Acute /Ascending cholangitis A : ascending pattern C : clinical

Recurrent pyogenic cholangitis Dr /Amr Salah dramrsalah84@gmail.com 75

Recurrent pyogenic / oriental cholangitis Dr /Amr Salah dramrsalah84@gmail.com 76

Recurrent pyogenic / oriental cholangitis intra and extrahepatic bile duct strictures and dilatation with an intraductal pigmented stone formation. Clinical presentation Residing in or immigrated from Southeast Asia The common clinical presentation is that of recurrent right upper quadrant pain, fever, and jaundice.jaundice Leukocytosis with elevated alkaline phosphatase and bilirubin are seen. Dr /Amr Salah dramrsalah84@gmail.com 77

Best diagnostic clue 1.Intra and extra hepatic biliary stones within dilated duct 2.No gall bladder stones May the stones fills the duct give serpiginous pattern Dr /Amr Salah dramrsalah84@gmail.com 78

To recap Recurrent pyogenic cholangitis R : radicles dilatation / liver P : presence of pigmented stones C : coming from southeast Asia Dr /Amr Salah dramrsalah84@gmail.com 84 PSC P : pruritus – beaded – bilharziasis S : seventy 70% rule C : cirrhosis acute /Ascending cholangitis A : ascending pattern C : clinical

Contents 86 Dr /Amr Salah dramrsalah84@gmail.com Anatomy and anomaliesBile duct wall thickeningContents : stone / mass / echogenicityDilatation : inside – outside - others Extra : estimation of jaundice Following : operation and stent

Abnormal intra ductal Contents PART III Dr /Amr Salah dramrsalah84@gmail.com 87

DD 1.Stone 2.Mass 3.Air Blood Parasite Sludge ball Pus Dr /Amr Salah dramrsalah84@gmail.com 88

Intraductal stones Dr /Amr Salah dramrsalah84@gmail.com 89

Bile duct stones / Choledocholithiasis Clinical presentation Stones within the bile ducts are often asymptomatic and may be found incidentally, however, more frequently they lead to symptomatic presentation with: 1.biliary colicbiliary colic 2.ascending cholangitisascending cholangitis 3.obstructive jaundiceobstructive jaundice 4.acute pancreatitisacute pancreatitis Dr /Amr Salah dramrsalah84@gmail.com 90

Primary and secondary Dr /Amr Salah dramrsalah84@gmail.com 91

Primary vs. secondary Secondary 95% : stone migrated from gall bladder 1ry 5% : de nevo formation within the biliary tree Causes : P : Post operative /trauma - Parasite C : Congenital – Cholangitis – Chronic hemolytic anemia Dr /Amr Salah dramrsalah84@gmail.com 92

crescent sign: bile eccentrically outlines luminal stone, creating a low attenuation crescent Dr /Amr Salah dramrsalah84@gmail.com 96

Intraductal masses Dr /Amr Salah dramrsalah84@gmail.com 100

Intra ductal mass Dr /Amr Salah dramrsalah84@gmail.com 101

Cholangiocarcinoma Infiltrative mass + biliary dilatation 90% extra hepatic 10 % intra hepatic 50 % distal CBD Check signs of malignancy Dr /Amr Salah dramrsalah84@gmail.com 102

Dr /Amr Salah dramrsalah84@gmail.com 104 lesion CBD

Distal cholangiocarcinoma Dr /Amr Salah dramrsalah84@gmail.com 105

Dr /Amr Salah dramrsalah84@gmail.com 106 Distal cholangiocarcinoma

Dr /Amr Salah dramrsalah84@gmail.com 107 CBD

Intraductal air Dr /Amr Salah dramrsalah84@gmail.com 108

Pneumobilia, also known as aerobilia Recent biliary instrumentation : ERCP, PTC Incompetent sphincter of Oddi sphincterotomy (~50% pneumobilia at 1 year) following passage of a gallstone Congenital biliary-enteric surgical anastomosis : Cholecystoenterostomy Whipple procedure spontaneous biliary-enteric fistula gallstone ileus peptic ulcer disease traumatic neoplasm, eg. cholangiocarcinoma, ampullary cancer Dr /Amr Salah dramrsalah84@gmail.com 109

Radiographic features Pneumobilia is typically seen as linear branching gas within the liver most prominent in central large caliber ducts as the flow of bile pushes gas toward the hilum. This is in contrast to portal venous gas where peripheral small caliber branching gas is usually seen due to the hepatopetal flow of blood away from the hilum.portal venous gashepatopetal flow portal venous gas: peripheral common bile duct gas: central Dr /Amr Salah dramrsalah84@gmail.com 110

Bright echogenic foci with linear configuration Dr /Amr Salah dramrsalah84@gmail.com 115

Intraductal air vs. intra ductal stone Dr /Amr Salah dramrsalah84@gmail.com 116

DD Portal vein gases : mostly peripheral Intra ductal stones : posterior shadowing Calcified granuloma : not related to portal tract Dr /Amr Salah dramrsalah84@gmail.com 122

Dr /Amr Salah dramrsalah84@gmail.com 123 Portal vein gases peripheral Common bile + biliary gases Central DD : P with P and C with C

DD 1.Stone 2.Mass 3.Air Blood Parasite Sludge ball Pus Dr /Amr Salah dramrsalah84@gmail.com 124

Haemobilia Etiology Iatrogenic: surgical or percutaneous procedures (~67%) Trauma (~5%) associated with pseudoaneurysm formation from central liver traumapseudoaneurysmliver trauma may manifest several (2-4) weeks after the initial injury Vascular malformations (7%) e.g. hepatic artery aneurysm or arteriovenous malformation can cause massive hemobilia Malignancy (e.g. hepatocellular carcinoma - most common, gallbladder metastases)hepatocellular carcinomagallbladder metastases Dr /Amr Salah dramrsalah84@gmail.com 125

Sludge Dr /Amr Salah dramrsalah84@gmail.com 129

Pus = clinical Dr /Amr Salah dramrsalah84@gmail.com 131 CBD

Clinical Dr /Amr Salah dramrsalah84@gmail.com 132

Biliary ascaris Dr /Amr Salah dramrsalah84@gmail.com 133

Biliary ascaris Dr /Amr Salah dramrsalah84@gmail.com 135

DD 1.Stone : hyper echoic with distal shadowing 2.Mass : iso echoic with ?? Internal vascularity 3.Air : hyper echoic with dirty shadow Blood : history of trauma / recent surgery Parasite : parallel lines / gall bladder ascaris Sludge ball : sludge in GB Pus : clinical Dr /Amr Salah dramrsalah84@gmail.com 138

Dilatation of the biliary tree PART IV Dr /Amr Salah dramrsalah84@gmail.com 140

N.B: 1- What it the meaning of dilatation ?? intrahepatic bile ducts : >2 mm, >40% of adjacent portal vein ( double parallel/duct signs ) extrahepatic bile ducts : >6 mm +1 mm per decade above 60 years of age, >10 mm post-cholecystectomy 2 - Level of obstruction ?? Focal intra hepatic – diffuse intra hepatic – extra hepatic – intra and extra 3 - Cause of obstruction ?? Inside – outside – others Dr /Amr Salah dramrsalah84@gmail.com 145

Double parallel /duct sign Dr /Amr Salah dramrsalah84@gmail.com 146

Double duct sign Dr /Amr Salah dramrsalah84@gmail.com 149

Causes Inside: Stones – mass – air – pus – sludge – ascaris – blood Mimics : Mirrizi syndrome Outside : intra hepatic – hilar – extra hepatic Others: Congenital : cariole's disease – choledochal cyst Infection : acute cholangitis – recurrent pyogenic – PSC Tumor : ampullary cancer Other : Sphincter of oddi dyskinesia - Pregnancy Dr /Amr Salah dramrsalah84@gmail.com 152

Classification Dr /Amr Salah dramrsalah84@gmail.com 153 InsideOutsideOthers

Inside Dr /Amr Salah dramrsalah84@gmail.com 154

Inside : mimics Dr /Amr Salah dramrsalah84@gmail.com 155

Mimics : Mirizzi syndrome extrinsic compression of an extrahepatic biliary duct from one or more calculi within the cystic duct or gallbladdercystic ductgallbladder Patients may present with recurrent episodes of jaundice and cholangitis.jaundicecholangitis It can be associated with acute cholecystitis. acute cholecystitis Fistulae can develop between the gallbladder and the common duct, and the stone may pass into the common duct. Dr /Amr Salah dramrsalah84@gmail.com 157

Mirrizi syndrome Dr /Amr Salah dramrsalah84@gmail.com 160

Mirrizi syndrome Dr /Amr Salah dramrsalah84@gmail.com 161

Outside Level Intra hepatic ( lobar ) : cholangiocarcinoma - HCC Hilar ( bi lobar ): klatskin tumor – lymph nodes Pancreatic (extra hepatic) : pancreatic head mass – pancreatitis Dr /Amr Salah dramrsalah84@gmail.com 163

Bilobar vs. lobar Dr /Amr Salah dramrsalah84@gmail.com 164

Cholangiocarcinoma It tends to have a poor prognosis and high morbidity. It is the second most common primary hepatic tumour, with intrahepatic cholangiocarcinomas (ICCs) accounting for 10-20% of primary liver tumours.primary hepatic tumour Dr /Amr Salah dramrsalah84@gmail.com 165

Porta hepatis lymph nodes Dr /Amr Salah dramrsalah84@gmail.com 173

Pancreatic : benign vs. malignant Dr /Amr Salah dramrsalah84@gmail.com 176 Malignant compressionBenign compression

Normal pancreas Dr /Amr Salah dramrsalah84@gmail.com 177

Pancreatic head mass Dr /Amr Salah dramrsalah84@gmail.com 178

Pancreatic duct dilatation Dr /Amr Salah dramrsalah84@gmail.com 180

Pancreatitis Dr /Amr Salah dramrsalah84@gmail.com 181

Pancreatitis Dr /Amr Salah dramrsalah84@gmail.com 182

Pancreas Dr /Amr Salah dramrsalah84@gmail.com 184

Dilatation with no masses Congenital : cariole's disease – choledochal cyst Infection : acute cholangitis – recurrent pyogenic – PSC Tumor : ampullary cancer / cholangiocarcinoma Other : Sphincter of oddi dyskinesia - Pregnancy Dr /Amr Salah dramrsalah84@gmail.com 185

Choledochal cyst Dr /Amr Salah dramrsalah84@gmail.com 186

Choledochal cyst congenital cystic dilatations of the biliary treebiliary tree Although they may be discovered at any age, 60% are diagnosed before the age of 10 years There is a strong female predilection with M:F ratio of 1:4. Dr /Amr Salah dramrsalah84@gmail.com 187

Todani classification 0 >>>normal 1 >> most common ( extra) Two >>diverticulum Three > choledococele 4 > second most common ( extra /intra) 5>>>caroli’s disease (intra) Dr /Amr Salah dramrsalah84@gmail.com 188

Complications stone formation: most common malignancy cholangiocarcinoma lifetime incidence 10-15% the cyst may rupture leading to bile peritonitis most frequently seen in neonates pancreatitis Dr /Amr Salah dramrsalah84@gmail.com 191

Type1 Dr /Amr Salah dramrsalah84@gmail.com 192

Type 1 Dr /Amr Salah dramrsalah84@gmail.com 193

Complicated by cholangiocarcinoma Dr /Amr Salah dramrsalah84@gmail.com 195

Type IV : intra + extra Dr /Amr Salah dramrsalah84@gmail.com 199

Type 5 : Caroli disease congenital disorder comprising of multifocal cystic dilatation of segmental intrahepatic bile ducts Clinical presentation Presentation is in childhood or young adulthood. The simple type presents with RUQ pain and recurrent attacks of cholangitis with fever and jaundice.jaundice The periportal fibrosis ( syndrome) type may present with pain or signs of portal hypertension, including hematemesis from esophageal varices Dr /Amr Salah dramrsalah84@gmail.com 200

Associations simple Caroli disease is uncommon; it occurs more frequently with congenital hepatic fibrosis, constituting the Caroli syndromecongenital hepatic fibrosis medullary sponge kidney autosomal dominant polycystic kidney disease (ADPKD) autosomal dominant polycystic kidney disease autosomal recessive polycystic kidney disease (ARPKD) autosomal recessive polycystic kidney disease Dr /Amr Salah dramrsalah84@gmail.com 201

Radiological features Ultrasound may show dilated intrahepatic bile ducts (IHBD) intraductal bridging: echogenic septa traversing the dilated bile duct lumen small portal venous branches partially or completely surrounded by dilated bile ducts intraductal calculi CT multiple hypodense rounded areas which are inseparable from the dilated intrahepatic bile ducts “central dot” sign enhancing dots within the dilated intrahepatic bile ducts, representing portal radicles 1 Dr /Amr Salah dramrsalah84@gmail.com 202

Estimation of jaundice PART V Dr /Amr Salah dramrsalah84@gmail.com 209

Jaundice Dr /Amr Salah dramrsalah84@gmail.com 210

Dr /Amr Salah dramrsalah84@gmail.com 211 pre hep post

Jaundice Jaundice refers to a clinical sign of hyperbilirubinaemia (serum bilirubin >2.5 mg/dL) which has many causes. It is often a clue to a diagnosis.hyperbilirubinaemia It can be largely divided into two types: non-obstructive, i.e. prehepatic and hepatic causes obstructive, i.e. posthepatic causes Imaging has a major role in detecting the obstructive causes. Dr /Amr Salah dramrsalah84@gmail.com 212

Causes prehepatic haemolytic anaemia / hypersplenism hepatic acute hepatitis / acute liver failure / cirrhosis /Gilbert syndrome post-hepatic (or obstructive jaundice) Benign causes Stone strictures, e.g. post-inflammatory/infectious, primary sclerosing cholangitis, traumatic or operativetraumatic or external biliary tree compression, e.g. pancreatic pseudocyst, Mirizzi syndrome Malignant causes portal lymphadenopathy / Cholangiocarcinoma /Carcinoma of head of pancreas / HCC Dr /Amr Salah dramrsalah84@gmail.com 213

Jaundice in infant Unconjugated hyperbilirubinemia is a normal physiologic event that occurs in approximately 60% of normal full-term infants and in 80% of preterm infants. The bilirubin level normally increases by day 2–3 and peaks by day 5–7, reaching as high as 12 mg/dL in normal full-term babies and up to 14 mg/dL in normal premature infants by the end of the first week of life Dr /Amr Salah dramrsalah84@gmail.com 215

Risk 1.The onset of jaundice within the first 24 hours of life 2.Rate of rise of serum bilirubin levels greater than 5 mg/dL in 24 hours 3.Direct bilirubin level greater than 1 mg/dL at any time 4.The persistence or new onset of jaundice in infants 2 weeks of age or older may no longer be physiologic The three most common causes of jaundice in neonates are hepatitis, biliary atresia, and choledochal cyst Dr /Amr Salah dramrsalah84@gmail.com 216

Post operative stent / Biloma PART VI Dr /Amr Salah dramrsalah84@gmail.com 218

Complicated by pancreatitis Dr /Amr Salah dramrsalah84@gmail.com 222

Biloma  80-year-old woman presented with a cystic liver lesion following a laparoscopic cholecystectomy.  Biloma.  Extra biliary collections of bile. they can be either intra- or extrahepatic. Dr /Amr Salah dramrsalah84@gmail.com 225

A Anatomy Atresia Division – measurements – anomalies TC signs – ghost gall bladder – dilated HA Capsular HA sign B : bile duct wall thickening PSC AC RPC P : beaded-pruiritis / S:70 rule / C : cirrhosis A : acute / C : clinical R : radicles / P: pigmented stone / C:coming from asia C : contents Stone Air Mass Others: : shadow / echogenic / GB stones : shadowing / echogenic /moving : soft tissue / vascularity : pus / blood : clinical parasites/sludge ball D : dilatation Intra Extra Others : contents : level of obstruction : intra hepatic / central / distal CBD : choledochal cyst / pregnancy / infectious / sphincter of oddi E : estimation of jaundice Adult Neonates F following operation Stent Biloma : normal / complicated : history of trauma / surgery 227

THANK YOU Dr /Amr Salah dramrsalah84@gmail.com 228

Bililary ultrasound DR/ AMR SALAH 1 Dr /Amr Salah

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