• Heavily T2-weighted coronal oblique fast spin-echo sequence to obtain source data (aligned along the plane of the common bile duct (CBD)) Stationary water appears as areas of high SI and adjacent soft tissue is low SI (therefore it is not reliant on contrast excretion and can be used in jaundiced patients) Fasting reduces any unwanted signal from the adjacent intestine Breath-hold or non-breath-hold (respiratory triggered) imaging • Source data allows MIP reformats to be generated (highlighting fluid-filled structures) – usually a number of coronal MIP reformats over 180° • Secretin: this stimulates exocrine pancreatic secretion, distending the pancreatic duct and improving its visualization (acts immediately, returning to baseline at 10 min) • Functional MR cholangiography: using delayed imaging at 30–60 mins with the hepatobiliary excreted contrast agents Gd-EOB-DTPA (Primovist) or Gd-BOPTA (MultiHance) • Normal morphology: only central intrahepatic ducts are normally seen (≤ 3mm) extrahepatic ducts ≤ 7mm (CBD up to 10mm post cholecystectomy) pancreatic duct ≤ 3mm accessory pancreatic duct in 45% • Right posterior hepatic duct (segments VI/VII): almost horizontal course • Right anterior hepatic duct (segments V/VIII): more vertical course • Left hepatic duct (segments II–IV): joins the right to form the common hepatic duct separate drainage of segment I • Cystic duct insertion into common hepatic duct: right lateral (50%) anterior (30%) posterior (20%) • Common variants: an aberrant right posterior duct draining into the common hepatic duct or cystic duct drainage of the right anterior or posterior duct into the left hepatic duct a triple confluence at the hilum • Technique: volume averaging artefacts in MIP reformats can obscure filling defects – source images must always be reviewed MIP reformats can also over- and underestimate strictures • Normal variants: a long cystic duct running parallel to the CBD, stimulating a distended CBD a contracted sphincter mimicking an impacted stone • Intraductal factors mimicking filling defects: aerobilia (non-dependent) flow phenomena (central signal void) debris haemorrhage • Extraductal factors: pulsatile vascular compression from adjacent vessels mimicking a stricture (but no proximal dilatation) susceptibility artefact from surgical clips • Hepatobiliary iminodiacetic acid (HIDA) scintigraphy: this is a bilirubin analogue labelled with 99mTc It is injected intravenously with serial images obtained over 2–4 h (it requires near-normal bilirubin levels) • There is normally accumulation of isotope within liver, bile ducts, gallbladder, duodenum and small bowel by 1 h • This allows direct bile and pancreatic duct opacification, as well as visual assessment of the duodenum and ampulla of Vater It also allows for: biopsy brushings sphincterotomy stone extraction biliary stenting biliary stricture dilatation • The main complication is the precipitation of pancreatitis • The main pitfall is the presence of underfilled ducts above a stricture • Stones present within the gallbladder – this affects 15% of the Western population (F>M) there is a small lifetime risk of developing a gallbladder carcinoma • Gallstone composition: cholesterol (70%) pigment stones composed of calcium bilirubinate (up to 30%) • Reasons for non-visualization of the gallbladder: a previous cholecystectomy a non-fasting state an abnormal gallbladder position emphysematous cholecystitis a gallbladder full of stones • Biliary sludge: this is composed of calcium bilirubinate granules, cholesterol crystals and glycoproteins it is commonly see with fasting states, critically ill patients, pregnancy, and in those patients receiving total parenteral nutrition it resolves spontaneously in 50% of cases
Biliary
METHODS OF INVESTIGATION
MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY (MRCP)
Technique
Normal anatomy
Imaging pitfalls
HEPATOBILIARY SCINTIGRAPHY
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP)
CHOLELITHIASIS AND CHOLEDOCHOLITHIASIS
CHOLELITHIASIS
DEFINITION
PEARLS
CHOLECYSTITIS
ACUTE CALCULOUS CHOLECYSTITIS