This document provides information about the hepatobiliary system and various imaging modalities used to evaluate it. It begins with an overview of ultrasound, CT, MRI, ERCP, and nuclear medicine techniques. Key anatomical structures such as the gallbladder, bile ducts, and pancreas are described. Various imaging planes and protocols for MRCP and secretin-enhanced MRCP are outlined. ERCP, CT cholangiography, and T-tube cholangiography techniques are also summarized.

1. Hepato Billary system I
• Presenter
• Sujan poudel
• BSC MIT 2015
• MODERATOR
• Mr. Ranjit kumar Jha
• Assistant professor
BPKIHS

2. Modalities
• USG
• Conventional x ray/ Fluroscopy
• MRI
• ERCP
• Nuclear medicine 99Tc- labelled N-substituted iminodiacetic acid, e.g.'9
Tc-HIDA, as the agents to study the action of the biliary tree.

3. General terms used for billiary system
• Cholegraphy is general term for radiographic
study of billiary system
• Cholecystography is radiographic investigation
of gall bladder
• Cholangiography is radiographic study of
billiary ducts.

4. Prefixs associatd with billiary system
Root forms MEANING
chole- Relationship with bile
Cysto- Bag or sac
Choledocho- CBD
Cholangio- Bile ducts

5. Anatomy
• Bile drains from the ductular and canalicular network of the acini.
• These ducts run with branches of the portal vein and hepatic artery
in the portal triad. The smallest interlobular ducts join to form
septal bile ducts, and these finally unite to form the left and right
hepatic ducts
• The left hepatic duct drains the three segments 2, 3 and 4 of the
left liver,
• Right hepatic duct arises from the union of two main sectorial
ducts:
• An anterior division draining segments 5 and 8 and a posterior
division draining 6 and 7
• The right and left main hepatic ducts fuse at the hilum, anterior to
the bifurcation of the portal vein, to form the common hepatic duct,

6. • The main bile duct is
divided into two segments:
the common hepatic duct
and common bile duct,
divided by the cystic duct
The common bile duct
passes inferiorly posterior
to the first part of the
duodenum and pancreatic
head. In the majority it then
forms a short common
channel with the main
pancreatic duct within the
wall of the duodenum,
termed the ampulla of Vater

7. Preference of modalities for
investigations
• Initial evaluation for acute billiary disease should
be done with ultrasound .
• Sensitivity ultrasound 83% CT 39%
• Ultrasound has sensitivity of 95% for detecting
ductal dilation where as poor in detecting
choledocholithiasis
• Identification of choledocholithiasis should be
correlated clinically and ERCP for stone removal.
• ERCP and MRCP remain referance standard for
definative diagnosis of billiary disease.

8. CT cholangiography
• Done through biliary
injection of contrast agent
through a percutaneous
catheter or by ERCP.
• Higher sensitivity.
Indirect contrast installation
• iodipamide meglumine is
infused IV over a 30-minute
period, supplemented with
IV hyoscine just before
imaging, to relax the
sphincter of Oddi
Direct contrast installation

9. continue
Advantages
• Less prone to artefacts than
MRCP.
• More readily avilable.
uses
• CT cholangiography can also
be performed without
contrast agent
administration by using
minimum intensity
projection (MinIP) where
bile act as negative contrast
within biliary lumen.

10. Drip infusion cholangiography with CT
• CT data acquisition 30–60 min after drip
infusion of iotroxate meglumine (Biliscopin)
• It assists in visualisation of the biliary tree by
biliary excretion of the contrast medium
without structural modification.

11. MRCP
• Uses heavily T2-weighted sequences, the signal of static or slow-
moving fluid-filled structures such as the bile and pancreatic ducts is
greatly increased, resulting in increased duct-to-background
contrast.
• MRCP is performed with heavily T2-weighted sequences by using
fast spin-echo or single-shot fast spin-echo software and both a
thick-collimation (single-section) and thin-collimation
(multisection) technique with a torso phased-array coil.
• The coronal plane is used to provide a cholangiographic display, and
the axial plane is used to evaluate the pancreatic duct and distal
common bile duct.
• Fast spin-echo MRCP is performed by using respiratory gating; a
long echo train (ie, 32); a long repetition time (three to five
respiratory cycles, 8,000–10,000 msec); an echo time greater than
250 msec; fat saturation; thin collimation (3 mm with no gap); and
three excitations. Imaging time is usually 4–6 minutes.

12. Planes for assessment
planes Structure shown
Coronal oblique through tail of pancreas
Straight coronal with subsequent sections
obtained 15 degree apart
common hepatic duct, left hepatic ducts,
and proximal pancreatic duct
LPO common bile duct, right hepatic ducts,
distal pancreatic duct including the
ampulla.

13. Advantages and disadvantages over
ERCP
Advantages
• noninvasive;
• uses no radiation;
• requires no anesthesia;
• Is less operator dependent;
• allows better visualization of
ducts proximal to an obstruction;
• when combined with
conventional T1- and T2-weighted
sequences, allows detection of
extraductal disease.
Disadvantages
• a) decreased spatial resolution,
making MRCP less sensitive to
abnormalities of the peripheral
intrahepatic ducts (eg, sclerosing
cholangitis) and pancreatic ductal
side branches (eg, chronic
pancreatitis)
• (b) imaging in the physiologic,
nondistended state, which
decreases the sensitivity to subtle
ductal abnormalities.

14. Secretin enhanced MRCP
• To evaluate exocrine function by observing the
T2 bright fluid secreted by the pancreas in
response to stimulation of pancreatic exocrine
function by IV secretin.
• Dynamic study of pancreatic duct can be done.
• Uses secretin to stimulates pancreatic duct
epithelial cells to produce a bicarbonate-rich
fluid.
• Three forms of secretin are available i.e. biologic,
porcine, synthetic human secretin.

15. Protocol for secretin MRCP
• Elimination of preexisting T2 bright of gastric and
duodenal fluid signal is done by superparamagnetic
iron oxide containing MR contrast agent ( ferumoxsil)
• Administered as two bottles 300mL each 30 min and
just before examination to shorten T2 times as it gets
mixed with gastric and duodenal fluid
• So T2 bright pancreatic fluid secreted by pancreas in
response to secretin can be easily identified on dark
background
• As an alternative various natural negative contrast can
be used like blueberry juice, pineapple juice due to
their high manganese content.

16. Sequences for Secretin enhanced MRCP
sequences Timing Structure covered Objectives
breath-hold thick
oblique coronal fat-
suppressed heavily
T2-weighted long-
TE ( HASTE)
Initial phase pancreas and
duodenum
To access position
of pancreas and
duodenum.
IV test dose of 0.2 μg of human secretin is given than again 0.2 μg/kg is administered
over 1 minute with the patient in the gantry
Sequences Timing Structure
covered
Objectives
breath-hold oblique coronal
heavily T2-weighted fat-
suppressed long-TE HASTE
sequence (thickslab MRCP
sequence)
Every 30
seconds for 10
minutes
pancreas and
duodenum
dynamic assessment of
pancreatic exocrine
function in response to
secretin
axial and coronal HASTE
through the abdomen.
After end of 10
min dynamic
assessment
pancreas and
whole duodenum
• To access total amount of
T2 bright fluid secreted
into the duodenum in
response to secretin
• assessment of changes in

17. ERCP
It is a diagnostic and interventional procedure technique using
both endoscopy and fluoroscopy for examination and
intervention of the biliary tree and pancreatic ducts.
Indication
 diagnosis of jaundice
 evaluation of known or suspected pancreatic disease
 pre- or postoperative assessment of the biliary tree in
patients undergoing laparoscopic cholecystectomy
 For detection of strictures and tumors,
 To localize the site of duct leakage in pancreatic ascites,
check for pancreas divisum.
 collect secretions for cytologic and chemical analysis

18. Technique
 It involves passing an
endoscope to the
descending duodenum
 cannulating the ampulla of
Vater, after which contrast can
be injected outlining the
biliary tree and various
procedures can be performed.
Requirements
• Side viewing endoscope.
• Polythene catheters.
• Fluoroscopic unit with spot
film device.
• Pancreas : LOCM 240 mg I/ml
• Bile ducts : LOCM 150 mg I/ml
• Nil orally 4 h prior to
procedure.
• Premediaction

19. filming's
• Pancreas
• Prone and both posterior
obliques.
• Bile ducts
Early fillings to show calculi
Prone- straight and posterior
oblique.
Supine- straight both obliques
Delayed films to assess
gallbladder and emptying of
CBD.
complications
• Acute pancreatitis
• Damage by endoscope eg
rupture of esophagus,
damage to ampulla
• Bacteraemia,septicaemia
etc

20. Application
 sphincterotomy,
 removal of common bile
duct stones
 lithotripsy
 biliary drainage, and
stricture dilation
 Recent GI surgery
 severe cardiopulmonary
disease
 acute pancreatitis not due
to gallstone disease
LIMITATIONS
Highly Operator dependent

21. T tube cholangiography
• T-tube cholangiograms are a fluoroscopic study
performed in the setting of hepatobiliary
disease.
• Typically a T-shaped tube is left in the common
bile duct at the time of surgery (e.g.
cholecystectomy) and allows for exploration of
the common bile duct (choledochotomy) and
retrieval of common bile duct stones.
• At a later date (usually approximately 10 days),
imaging of the biliary tree (cholangiogram) is
performed via the tube.

23. Technique
• Patient lies supine on x-ray
table.
• Drainage tube clamped off
near to the patient and clean
thoroughly with antiseptics.
• 23-G needle, extension tubing
and 20ml syringe are
assembled and filled with
contrast medium, needle is
inserted into tubing between
patient and clamp.
Requirements
• HOCM or LOCM 150 mg I/ml
20-30 ml
• Fluoroscopy unit with spot film
device.

24. Filming
• If the intrahepatic ducts do not fill, the patient
can be tilted trendelenburg and further contrast
injected into the T-tube.
• The patient may need to lie on their left hand
side to fill the left hepatic duct.
• At least 2 views of the entire biliary tree
should be recorded by spot film (DSI)
• oblique views are often taken

25. • The T-tube is made of very flexible plastic. T-tubes
are usually sized between 10 French (10F) and 16
French (16F).
Complications
• biliary peritonitis
• cholangitis