Chapter 5

The Hepatobiliary System

Chapter Outline

Anatomy and Physiology

The Liver

The Biliary Tree

The Gallbladder

The Pancreas

Imaging Considerations

Radiographs

Contrast Studies

Diagnostic Medical Sonography

Computed Tomography

Nuclear Medicine Procedures

Magnetic Resonance Imaging

Inflammatory Diseases

Cirrhosis

Viral Hepatitis

Cholelithiasis

Cholecystitis

Pancreatitis

Metabolic Diseases

Jaundice
Neoplastic Diseases

Hepatocellular Adenoma

Hemangioma

Hepatocellular Carcinoma (Hepatoma)

Metastatic Liver Disease

Carcinoma of the Gallbladder

Carcinoma of the Pancreas

Learning Objectives

upon completion of chapter 5, the reader should be able to:

• Describe the anatomic components of the hepatobiliary system and how they are

visualized radiographically.

• Discuss the role of other imaging modalities in imaging of the hepatobiliary system,

particularly ultrasound, MRI, and CT.

• Characterize a given condition as inflammatory, metabolic, or neoplastic.

• Identify the pathogenesis of the pathologies cited and the typical treatments for them.

• Describe, in general, the radiographic appearance of each of the given pathologies.

Key Terms

Ascites

Carcinoma of the gallbladder

Cholecystitis

Cholelithiasis

Cirrhosis
Gallstone lleus

Hemangioma

Hepatitis

Hepatocellular adenoma

Hepatocellular carcinoma

Hepatomegaly

Pancreatic cancer

Pancreatitis

Pseudocyst

Medical jaundice

Metastatic liver disease

Milk of calcium

Surgical jaundice

<1>ANATOMY AND PHYSIOLOGY

The hepatobiliary system is composed of the liver, gallbladder, and biliary tree (Fig. 5-1). The

pancreas is closely related and shares a portion of the biliary ductal system, hence its inclusion

here.

<2>The Liver

The liver is the largest organ in the body and is sheltered by the ribs in the right-upper

quadrant of the abdomen. It is kept in position by peritoneal ligaments and intraabdominal

pressure from muscles of the abdominal wall. The functions of the liver are multiple, including

metabolism of substances delivered via its portal circulation, synthesis of substances including
those concerned with blood clotting, storage of vitamin B and other materials, and detoxification

and excretion of various substances.

The liver has a double supply of blood, coming from the hepatic artery and the portal vein. The

hepatic artery usually originates from the celiac axis and takes oxygenated blood to the liver.

The portal vein is formed by the union of the superior mesenteric and splenic veins. It is located

within the liver and serves to return venous blood from the abdominal viscera to the inferior

vena cava (IVC). Any interference with blood flow, such as might occur with liver disease,

results in consequences elsewhere in the abdominal viscera and spleen.

<2>The Biliary Tree

A system of ducts acts to drain bile produced in the liver into the duodenum (Fig. 5-2). Bile

from the liver’s two main lobes is drained by the right and left hepatic ducts. These unite to form

the common hepatic duct, which is joined usually in its midportion by the cystic duct from the

gallbladder. Together, the cystic duct and the common hepatic duct form the common bile duct.

The common bile duct descends posterior to the descending duodenum to enter at its

posteromedial aspect. Before its entrance into the duodenum, the common bile duct may be

joined by the pancreatic duct from the head of the pancreas. The short part of the common bile

duct, after joining the pancreatic duct, is known as the hepatopancreatic ampulla or, more

commonly, the ampulla of Vater.

The flow of both bile and pancreatic juice into the duodenum is regulated by the

hepatopancreatic sphincter, more commonly known as the sphincter of Oddi. The release of bile
into the duodenum is triggered by cholecystokinin, a hormone released by the presence of fatty

foods in the stomach. The purpose of bile is to emulsify fats so that they may be absorbed.

<2>The Gallbladder

The gallbladder is a pear-shaped sac located on the undersurface on the right lobe of the liver.

Normally, the walls are quite thin, but they often thicken in the presence of inflammation. The

sole function of the gallbladder is to store and concentrate bile that has been produced in the

liver.

<2>The Pancreas

The pancreas is an elongated, flat organ that obliquely crosses the left side of the abdomen

behind the stomach; it is a powerful digestive organ. Its functions are both exocrine and

endocrine. Exocrine function is concerned with production of digestive enzymes. These are

discharged through the pancreatic duct into the duodenum. The endocrine portion of the

pancreas consists of multiple clusters of specialized cells, the islets of Langerhans. Their

function is to produce insulin and glucagon, which are discharged directly into the blood from

the pancreas. Insulin and glucagon regulate carbohydrate metabolism.

<1>IMAGING CONSIDERATIONS

<2>Radiographs

A conventional abdominal radiograph may contain information about the hepatobiliary system

through the demonstration of faint calcifications that might otherwise be obscured by contrast

media. A plain radiograph of the gallbladder may demonstrate milk of calcium as a semiliquid

sludge (Fig. 5-3) composed of calcium carbonate mixed with bile in the gallbladder. The hazy
radiopacity results from a settling of bile as a result of an obstruction at the neck of the

gallbladder, or it can develop in patients who have been fasting or have been on

hyperalimentation.

Gas may occasionally be seen in the wall or lumen of the gallbladder because of the presence of

gas-forming organisms in the gallbladder walls. This is most generally seen in patients with

poorly controlled diabetes. Gas visualized in the biliary tree may also be a result of a

spontaneous fistula, as might be seen in gallstone ileus, or postoperative biliary anastomosis.

<2>Contrast Studies

<3>Oral Cholecystogram

An examination formerly widely used to study the biliary system is an oral cholecystogram

(OCG), although it has been largely replaced by ultrasound. An OCG is a functional examination

in that the contrast medium is absorbed in the small bowel and passes through the portal vein to

the liver. The contrast agent is excreted from the liver with bile and is stored in the gallbladder.

About 25% of all patients’ gallbladders fail to visualize on the first attempt at oral

cholecystography. The most common causes of nonvisualization are an obstruction of the cystic

duct secondary to a stone and chronic cholecystitis, with poor concentration of the contrast

agent.

<3>Percutaneous Transhepatic Cholangiography

A percutaneous transhepatic cholangiogram (PTC) is used to visualize the biliary tree and

involves insertion of a needle into the biliary tree by puncture directly through the wall of the

abdomen. With the use of a flexible, 22-gauge, skinny needle (Chiba), this procedure is safe and
fairly easy to perform. The subsequent injection of contrast medium (Fig.5-4) is useful in

distinguishing medical jaundice, caused by hepatocellular dysfunction, from surgical jaundice,

which results from biliary obstruction. Also, the examination is useful for detecting the presence

of calculi or a tumor in the distal common bile duct. It has a high success rate in imaging the

biliary ductal system, is less expensive than an endoscopic retrograde cholangiopancreatogram,

and has a low complication rate of approximately 3.5%. It also may be immediately followed by

a therapeutic procedure such as a biliary drainage, stone removal or crushing via contact

lithotripsy or laser fragmentation, stent placement, or biopsy. This procedure is preferred in the

evaluation of proximal obstructions involving the hepatic duct bifurcation, which is difficult to

image with the retrograde approach via an ERCP.

<3>Endoscopic Retrograde Cholangiopancreatogram

The endoscopic retrograde cholangiopancreatogram (ERCP), an imaging procedure performed

by a gastroenterologist, is a means of visualizing the biliary system and main pancreatic duct,

which provides drainage for the pancreatic enzymes into both the digestive tract and the

common bile duct. A fiberoptic endoscope is passed through the duodenal C-loop to visualize

the ampulla of Vater. A thin catheter is then directed into the orifice of the common bile duct or

pancreatic duct, followed by an injection of contrast medium (Fig.5-5). In many cases, the ERCP

is preferred over the transhepatic cholangiogram and is often preceded with an ultrasonic

examination or CT investigation of the pancreas. Although an ERCP is more expensive than a

PTC, it is often used to visualize nondilated ducts, distal obstructions, patients with bleeding

disorders, and the pancreas. The complication rate (2% to 3%) is similar to that of PTC and also

offers the ability to perform therapeutic procedures such as sphincterotomy, stone extractions,

stent placement, and biliary dilatation. Cytology and biopsy may also be performed.
<3>Operative Cholangiography

Operative cholangiography is performed during surgery at the time of a cholecystectomy to

detect biliary calculi and the need for common bile duct exploration (Fig. 5-6). A needle is

placed directly into the cystic duct or common bile duct by the surgeon, and a small volume

(5 ml) of contrast material is injected, followed by a radiograph. A second injection of 5 ml is

made, followed by a second radiograph. The resulting images are reviewed for possible areas of

concern before completion of the surgery. It is imperative that no air bubbles be injected into the

ductal system with the contrast agent during this procedure because they can mimic stones.

<3>T-Tube Cholangiography

T-tube cholangiography is used after a cholecystectomy to demonstrate patency of the common

bile duct and to check for calculi. With a T-shaped tube already inserted surgically into the

common bile duct, contrast medium is injected to verify removal of all calculi. The radiologist

must take care not to inject air bubbles because they may give the radiographic appearance of

radiolucent calculi.

<2>Diagnostic Medical Sonography

Real-time diagnostic medical sonography is now the modality of choice for evaluating the

gallbladder (Fig. 5-7) and biliary tree. This procedure is noninvasive, and the gallbladder can be

satisfactorily imaged in almost all fasting patients regardless of the body habitus or clinical

condition of the patient. When sonography is performed by a skilled sonographer, it has been

proven to be almost 100% accurate in detecting gallstones, which are demonstrated

as echogenic areas within the echo-free gallbladder. Thickening of the gallbladder wall is also
easily identified. It is also an excellent tool for determining the presence of common bile duct

obstruction, evaluation of the intrahepatic biliary ductal system, and identification of abscesses.

The liver may also be evaluated by sonography because of its ideal location in the right-upper

quadrant and broad contact with the abdominal wall. Hepatic lesions of 1 cm or greater are

easily identified with cystic lesions appearing echo-free and solid masses appearing echogenic,

allowing excellent guidance for aspiration and biopsy of these lesions.

Doppler flow technology enhances the diagnostic capabilities of ultrasound to allow for clear

analysis of the circulatory dynamics, including portal blood flow and hepatic artery thrombosis

following liver transplantation. Doppler sonography can also differentiate between vessels and

biliary ducts based on flow characteristics.

<2>Computed Tomography

The role of computed tomography (CT) in the hepatobiliary system is similar to its role in the GI

tract. It is the accepted modality for following malignancies and assessing masses, particularly of

the gallbladder, liver, and pancreas. It is also helpful in evaluating complications of cholecystitis,

such as perforations and abscess formations. The use of spiral or helical CT ensures that the

entire liver is imaged in one breath, eliminating respiratory artifact and in many cases

demonstrating the liver parenchyma and associated structures better than sonography. In addition

to the excellent contrast resolution offered by CT, the use of large-bolus IV injections during

dynamic CT examination has also improved evaluations of the hepatobiliary ductal system and

blood flow via three-phase imaging of the liver to capture the arterial and portal venous blood

flow (Fig. 5-8). If a biliary obstruction is not visible on sonographic examination, CT can

generally identify the location and extent of the obstruction. Lacerations of the liver and
resultant abdominal bleeding are readily detected on CT (Fig.5-9), as well as metastatic lesions

within the liver. CT also demonstrates good visualization of pancreatic tumors and pseudocysts.

In addition, CT-guided biopsy procedures for the liver (Fig.5-10), pancreas, and kidney allow

for analysis and drainage and offer significant advantages over conventional surgical biopsy and

drainage.

<2>Nuclear Medicine Procedures

Single-photon emission computed tomography (SPECT) examinations provide excellent

detection of hepatobiliary lesions, especially those located deep within the liver parenchyma.

SPECT provides a noninvasive method of evaluating hepatic function as well as hepatic and

splenic perfusion. Because nuclear medicine imaging provides information regarding

physiologic function, these scans can often provide information before any anatomic changes

become visible with CT. White cells labeled with radioactive indium are useful in locating sites

of infection for treatment.

Cholescintography scans performed in nuclear medicine are very useful to confirm

cholecystitis, and they may be useful for distinguishing acute from chronic cholecystitis

(Fig. 5-11). Radioactive technetium is cleared from the blood plasma into the bile,

demonstrating the physiologic function of the liver, excretion into the biliary ductal system, and

visualization of the gallbladder about 1 hour postinjection. Delays in visualization or

nonvisualization of the gallbladder indicates pathology. In addition, it is a noninvasive method

of evaluating biliary drainage, hepatobiliary leaks following trauma or surgery, and segmental

obstruction.
<2>Magnetic Resonance Imaging

The role of magnetic resonance imaging (MRI) of the hepatobiliary system has improved greatly

as a result of shorter scan times, which allow the acquisition of several images of the abdomen in

a single breath. MRI is often used in conjunction with CT to evaluate pathologies and anomalies

of the peritoneum, especially the liver and pancreas. MRI may also be used to identify

retroperitoneal bleeds following trauma (Fig. 5-12). Contrast-enhanced three-dimensional

dynamic scans of the liver imaged at timed intervals help to differentiate certain tumors from

hemangiomas.

The magnetic resonance cholangiopancreatography (MRCP) is an imaging procedure that

utilizes MR to visualize the gallbladder and biliary system. The MRCP is non-invasive and does

not require the use of a contrast agent (Fig. 5-13). A heavily T2 weighted sequence is used to

suppress the tissues around the biliary system allowing the gallbladder and bile ducts to show up

bright enabling visualization of stones or other obstructions. The MRCP usually accompanies

other imaging sequences of the liver but takes only about 15 seconds

to acquire.

<1>INFLAMMATORY DISEASES

<2>Cirrhosis

Cirrhosis is a chronic liver condition in which the liver parenchyma and architecture are

destroyed, fibrous tissue is laid down, and regenerative nodules are formed. In its early stages, it

is usually asymptomatic, as it can take months or even years before damage becomes apparent.

Cirrhosis affects the entire liver and is considered an end-stage condition resulting from liver

damage by chronic alcohol abuse, drugs, autoimmune disorders, metabolic and genetic disease,
chronic hepatitis, cardiac problems, and chronic biliary tract obstruction. It is the third leading

cause of death in the United States in individuals between the ages of 45 and 65, with one third

of the deaths secondary to hemorrhage from esophageal varices.

The scarring and formation of regenerative nodules associated with cirrhosis can have serious

complications for the afflicted individual. The two functional impairments caused by cirrhosis

are impaired liver function resulting from hepatocyte damage, generally resulting in jaundice,

and portal hypertension. Because of interference of portal blood flow through the liver, portal

hypertension may lead to development of collateral venous connections to the venae cavae. Most

commonly, such connections involve the esophageal veins, which dilate to become esophageal

varices, as described in the preceding chapter. These are best evaluated with endoscopy but may

be seen on an esophagram. Also, the patient with cirrhosis has a tendency to bleed because the

liver is unable to make the necessary clotting factors found in plasma or as a result of an

esophageal variceal rupture. Such hemorrhaging may be, in fact, the first indication of portal

hypertension.

Ascites, the accumulation of fluid within the peritoneal cavity (Fig. 5-14), is also seen as a result

of portal hypertension and the leakage of excessive fluids from the portal capillaries. Much of

this excess fluid is composed of hepatic lymph weeping from the liver surface. It is associated

with approximately 50% of deaths from cirrhosis. Ascites may also result from chronic hepatitis,

congestive heart failure, renal failure, and certain cancers. Abdominal ultrasound is commonly

used in the detection or confirmation of ascites. Diagnostic and therapeutic paracentesis may be

conducted with sonographic guidance in order to locate a site that will allow fluid to be removed

and avoid damage to the floating bowel loops. A diagnostic paracentesis involves removal of 50
to 100 ml of peritoneal fluid for analysis. Patients with ascites generally complain of nonspecific

abdominal pain and dyspnea. Medical treatment of ascites includes bed rest, dietary restrictions

of sodium, use of diuretics to avoid excess fluid accumulation, and treatment of the underlying

cause.

It is important for the technologist to be aware of the clinical diagnosis of ascites because the

fluid accumulation can make it difficult to adequately penetrate the abdomen. An increase in

exposure factors is necessary to obtain a diagnostic-quality radiograph. Radiographically, large

amounts of ascitic fluid give the abdomen a dense, gray, ground-glass appearance. With the

patient in a supine position, the fluid accumulates in the pelvis and ascends to either side of the

bladder to give it a dog-eared appearance. Gradually, the margins of the liver, spleen, kidneys,

and psoas muscles become indistinct as the volume of fluid increases. Loops of bowel filled with

gas float centrally, and a lateral decubitus radiograph demonstrates the fluid descending and the

gas-filled loops of bowel floating on top.

Conventional radiographic signs of cirrhosis are few and not specific. Morphologic changes in

the liver from cirrhosis may cause displacement of other abdominal organs such as the stomach,

duodenum, colon, gallbladder, and kidney. The primary means of evaluating the complications

arising from cirrhosis is CT. Fatty infiltration of the liver, an initial feature in alcoholic liver

disease, is well visualized by CT. The most characteristic finding in cirrhosis is an increase in

the ratio of the caudate lobe and the right lobe because with cirrhosis the right lobe and medial

segment of the left lobe atrophy while the caudate lobe and the lateral segment of the left lobe

hypertrophy. Because of its dual arterial blood supply, the caudate lobe of the liver is usually

spared in cirrhosis. Studies show that individuals with cirrhosis have an increased risk of
developing hepatic carcinoma, so CT is also of value in assessing the presence of complications

of cirrhosis, such as ascites and hepatocellular carcinoma.

Diagnostic medical sonography is helpful in suggesting the presence of liver cirrhosis and

enlargement of the liver and spleen. Doppler is utilized to detect portal hypertension and

evaluate portosystemic collateral circulation. It is used to measure the vessel size of the portal

vein, which ranges from 0.64 to 1cm in a normal adult. A portal vein larger than 1.3 cm in

diameter is indicative of portal hypertension. In addition, the portal vein should distend with

deep inspiration, but in patients with portal hypertension, the vein lacks distensibility. Doppler

integration of the portal vein allows tracing of the flow of blood within the vessel. Normal

portal vein flow is toward the liver; however, during portal hypertension, the flow is shunted

away from the liver because of the diseased liver’s inability to accept the flow of blood. As a

result, the splenic vein commonly tries to handle this resistance by diverting the flow toward the

spleen. In many cases, these patients develop splenic varices from the increased flow from the

portal vein. Sonographic evaluation of venous structures such as the superior mesenteric and

splenic veins adds additional information for the clinician. However, final diagnosis of cirrhosis

is generally accomplished by biopsy of liver tissue, often performed under ultrasonic guidance.

Treatment of cirrhosis depends on the extent of liver damage and the involvement of other

organs (e.g., the esophagus and stomach). The primary goal of treatment is to eliminate the

underlying causes of the disease and to treat its complications. Surgical treatment of portal

hypertension may be achieved by diverting blood from the portocollateral system into the lower-

pressure systemic circulation. This is accomplished by placing a shunt, eliminating the chance of

variceal bleeding. A distal splenorenal shunt, in which the splenic vein is divided, with the distal
portion anastomosed to the left renal vein, is most commonly used. If the patient is not a

candidate for this type of shunt, a total shunt, either portocaval or mesocaval, must be placed. A

palliative procedure, the transjugular intrahepatic portosystemic shunt (TIPS), may also be used

to divert the pressure of portal hypertension. The TIPS procedure is commonly performed in the

cardiovascular interventional area of radiology. A catheter is placed in the right internal jugular

vein and pushed through the right atrium into the IVC. The needle end of the catheter is punched

into the closest portal vein in the liver. Commonly, the needle is inserted into the right portal

vein. Using angioplasty, the tract is enlarged such that a shunt can be placed in order to reroute

the flow of portal blood through the liver and into the IVC. Sonography is invaluable at

assessing the long-term effect of this shunt. Typically Doppler tracings are taken at the portal

end, the midshunt, and the hepatic vein end of the shunt to insure that flow through it allows the

flow of blood to proceed through the liver to the IVC. However, all of the aforementioned

shunts have a tendency to thrombose, requiring patency to be assessed by angiography, CT, or

ultrasound. The prognosis for patients with associated complications of cirrhosis such as ascites

is poor, but advances in liver transplantation have changed the long-term outcome for many

patients.

<2>Viral Hepatitis

Hepatitis is a relatively common liver condition, with an estimated 70,000 cases reported

annually. At least six types of viral agents have been identified that cause acute inflammation of

the liver. This inflammation interferes with the liver’s ability to excrete bilirubin, the orange or

yellowish pigment in bile. Evidence of the disease is seen clinically by nausea, vomiting,

discomfort, and tenderness over the liver area, and laboratory results indicate a disturbance in

liver function. Additional signs and symptoms include fatigue, anorexia, photophobia, and
general malaise. Jaundice may also develop within 1 or 2 weeks because of the disturbance of

bilirubin excretion. If the liver inflammation lasts 6 months or more, the condition is classified

as chronic.

Hepatitis A (HAV) is a single-stranded RNA picornavirus. It is excreted in the GI tract in fecal

material and is spread by contact with an infected individual, normally through ingestion of

contaminated food, such as raw shellfish, or water. It is the most common form and highly

contagious. The incubation period of the disease is relatively short (15 to 50 days), and its course

is usually mild. HAV does not lead to chronic hepatitis or cirrhosis of the liver.

Hepatitis B (HBV) is transmitted parenterally in infected serum or blood products. Its incubation

period is much longer (50 to 160 days), and its effects are more severe than those of HAV. The

etiologic make-up of the hepatitis B virus is very complex, consisting of a viral core of DNA

that replicates within the cells of the liver. The viral core is covered with a surface coat. HBV

can result in an asymptomatic carrier state, acute hepatitis, chronic hepatitis, cirrhosis, and

hepatocellular carcinoma. Most health care workers are now required to receive a HBV vaccine.

Vaccination has dramatically reduced the incidence of infection, and the vaccines are safe with

very few side effects.

Hepatitis C (HCV) is caused by a parenterally transmitted RNA virus. Type C accounts for 80%

of the cases of hepatitis that develop after blood transfusions. A routine test for anti–HCV

antibody has been developed, so transmission via transfused blood has been significantly

decreased. HCV can cause either acute or chronic hepatitis, with 10% to 20% of these patients

eventually developing cirrhosis of the liver.

Hepatitis D (HDV) is caused by an RNA virus and only occurs concurrently with acute or

chronic HBV. It cannot occur alone. Hepatitis E virus (HEV) is also an RNA viral agent. It is

most commonly responsible for outbreaks of waterborne epidemic acute hepatitis in developing

countries. Although the infection may be severe, it does not progress to a chronic state. Hepatitis

G (HGV) has been recently isolated and can also be transmitted by blood products. It can also

result in chronic hepatitis.

The diagnosis of viral hepatitis is usually made through laboratory testing because the disease is

carried in the bloodstream during the acute phase. Evidence of hepatitis may be seen

radiographically on a plain film of the abdomen that demonstrates hepatomegaly, or enlargement

of the liver, although this is a nonspecific finding. Cellular necrosis can be confirmed through

nuclear medicine scanning of the liver, CT, or a liver biopsy. Ultrasound is also useful in

distinguishing the characteristics of the liver.

HAV is usually mild; the majority of patients recover without complications. Treatment

generally consists of bed rest and medication to fight nausea and vomiting. In a healthy

individual, the liver regenerates after hepatitis damage, and complete recovery is gained. Patients

with type B, type C, type D, and type G generally progress into chronic hepatitis. In some, the

disease may become progressive and lead to liver failure.

<2>Cholelithiasis

The incidence of cholelithiasis (gallstones) is fairly common, with at least 20% of all persons in

the United States developing them by the age of 65 years. Women are more likely than men to
have them. Their occurrence is also greater in diabetics, the obese, the elderly and in individuals

eating a Western diet. Heredity plays a role in their development. Although most commonly

found in the gallbladder, they can be located anywhere in the biliary tree. Symptoms associated

with cholelithiasis may be vague, including bloating, nausea, and pain in the right-upper

quadrant. Sludge can develop within the gallbladder and may be identified sonographically.

Sometimes the sludge develops in patients who have been fasting or who have been on

hyperalimentation and is a normal variant from underutilization of the bile in the gallbladder; in

other cases the sludge may be a precursor to the development of gallstones.

The characteristics of gallstones are quite varied. They may occur as a single stone or as multiple

stones. About 80% of all stones comprise a mixture of cholesterol, bile pigment (bilirubin), and

calcium salts. The remaining 20% are composed of pure cholesterol or a calcium-bilirubin

mixture. Most stones are radiolucent because only about 10% of all stones contain enough

calcium to be radiopaque. Those that are radiopaque may be difficult to distinguish from renal

stones, but oblique radiographs help separate the two structures (kidney and gallbladder) from

each other, demonstrating the gallbladder anterior to the kidney. As noted before, sonography

readily demonstrates the presence of cholelithiasis (Fig.5-15). The best image is obtained when

the gallbladder is distended and filled with bile; therefore, patients should fast 8 hours before

sonographic examination. The three major sonographic criteria for gallstones include (1) an

echogenic focus, (2) acoustic shadowing below the stone, and (3) gravitational dependence.

Gallstones can be the size of a pinhead to the size of a large marble. The small stones tend to

travel into the biliary tree and may result in obstruction. Obstruction of the bile duct causes pain

and jaundice and may result in cholangitis.

Surgical removal of the gallbladder (cholecystectomy) is usually the treatment of choice with

over 500,000 performed annually in the United States. Since its introduction in 1988,

laparoscopic cholecystectomy has replaced many traditional open cholecystectomies. This

technique allows a less traumatic entry, excision, and removal of the gallbladder, with a

shortened hospitalization and reduced costs. Radiographers are commonly called to the operating

environment to film injections of contrast medium into the exposed biliary duct to determine if

all stones have been removed. If additional stones are suspected but not visualized, a T-tube may

be inserted to allow for later study, as noted earlier.

<2>Cholecystitis

Cholecystitis is an acute inflammation of the gallbladder. It is characterized clinically by

a sudden onset of pain, fever, nausea, and vomiting. It is common in individuals with chronically

symptomatic cholelithiasis. Its diagnosis is clinically suspected and supported through an

ultrasound examination or radionuclide cholescintography. A radiopharmaceutical comprised of

99m
Tc in combination with disopropyliminodiacetic acid (DISIDA) allows visualization of the

biliary ductal system and results in a highly sensitive examination with consistently reliable

results. Nonvisualization of the gallbladder is a good indicator of acute cholecystitis. Repeated

attacks of acute cholecystitis cause damage to the gallbladder, thickening of the walls (Fig.5-16),

and decreased function.

Complications of untreated gallbladder disease include infarction and a possible gangrenous

state, prompting a rupture of the walls. Perforation of the gallbladder occurs in approximately

5% to 15% of all patients with acute cholecystitis and can be diagnosed in several ways.

Cholescintography provides the best images of perforation; however, stones may be visible
outside the gallbladder on plain abdominal films, CT images, or sonographic images. Ultrasound

and CT often also demonstrate a nonspecific pericholecystic fluid collection. If a rupture does

occur, bile peritonitis may result and require immediate treatment.

Occasionally, a stone can erode through the wall of the gallbladder in cases of chronic

cholecystitis and create a fistula to the bowel, most frequently the duodenum. If the stone

becomes impacted in the small bowel and causes an obstruction, the condition is referred to as

gallstone ileus. Gallstone ileus is characterized by air in the biliary ductal system, clearly visible

on a conventional abdominal radiograph. The radiopaque gallstone may also be visible within

the bowel surrounded by intestinal gas. Surgical removal of the stone is necessary to relieve the

obstruction. Treatment of chronic cholecystitis also includes laparoscopic removal of the

inflamed gallbladder.

<2>Pancreatitis

An inflammation of the pancreatic tissue is known as pancreatitis. It is one of the most complex

and clinically challenging disorders of the abdomen and is classified as acute or chronic,

according to clinical, morphologic, and histologic criteria. Acute pancreatitis resolves without

imparing the histologic make-up of the pancreas and most often results from biliary tract disease.

However, chronic pancreatitis does impair the histologic make-up of the pancreas, resulting in

irreversible changes in pancreatic function. Its causes include excessive and chronic alcohol

consumption and obstruction of the ampulla of Vater by a gallstone or tumor, and even the

injection of contrast media during an ERCP has been known to cause pancreatitis. Once

activated by any of these causes, trypsin, the pancreatic enzyme that is normally excreted

through the ducts into the duodenum, begins to autodigest the organ itself. This can be quite
serious and carries a high mortality rate. Hemorrhagic pancreatitis is a complication of

pancreatitis and consists of erosion into local tissues and blood vessels, with subsequent

hemorrhaging into the retroperitoneal space. A pseudocyst is a fluid collection caused by

pancreatitis. It is readily visualized by sonographic or CT examination (Fig. 5-17).

Symptoms of pancreatitis vary from mild abdominal pain, nausea, and vomiting to severe pain

and shock. Radiographic indications of pancreatitis are subtle and previously centered on

displacement of the duodenal C-loop or the stomach by the diseased pancreas or calcified stones

within the pancreatic or biliary ducts. However, CT has made a major contribution to the

diagnosis and staging of acute pancreatitis. It adequately demonstrates not only the pancreas

itself but also the retroperitoneum, the ligaments, the mesenteries, and the omenta. The infected

pancreas is usually enlarged, with a shaggy and irregular contour. In advanced cases, fluid

collections are demonstrated within the pancreas, as well as within the retroperitoneum. An

ERCP is of value in determining the reasons for acute recurrent pancreatitis, chronic pancreatitis,

or the complications associated with pancreatitis. Because pancreatic disease is often

asymptomatic in the early stages of disease, ultrasound is good for assessing the texture and size

of the organ. The pancreas is routinely imaged as part of the right upper quadrant sonogram. In

most ultrasound examinations, the head and body of the pancreas can be measured and compared

to normal values for the age of the patient. Pancreatitis is suggested on a sonogram by the

decreased echo texture and an associated enlargement in the size of the organ (Fig.5-18). In

addition, recent advances in MR allow for noninvasive, contrast-free imaging of the biliary tree.

Laboratory testing is the most common way to diagnose pancreatitis, through evaluation of

serum and occasionally the urine amylase level.

Management of patients with pancreatitis consists of a pain-relieving drug in mild cases and

maintaining proper fluid levels to prevent shock, a frequent occurrence in acute pancreatitis.

Proper dietary restrictions (e.g., abstinence from alcohol) are also important. The role of surgery

in chronic pancreatitis remains controversial in regard to the effectiveness of results. The

prognosis is excellent in patients with mild pancreatic inflammation and edema. However, a

swollen pancreas with extravasation of fluid within the retroperitoneum or pancreatic necrosis,

as demonstrated by CT, results in a more severe prognosis. Although most CT examination are

performed with the use of IV contrast agents, research has shown that use of contrast agents

during the onset of acute pancreatitis may cause necrosis in areas with poor blood supply.

Pancreatric necrosis increases the mortality and incidence of infection, so patients should be well

hydrated before a contrast-enhanced CT examination is performed. Chronic pancreatitis also

increases the risk of developing pancreatic cancer, so most patients are continuously monitored

for malignancy.

<1>METABOLIC DISEASES

<2>Jaundice

Jaundice, the yellowish discoloration of the skin and whites of the eyes, is not a disease itself but

rather a sign of disease. The accumulation of excess bile pigments (i.e., bilirubin) in the body

tissues “stains” the skin and eyes this yellowish color. Normally, bile and its pigments are

secreted into the bowel and eliminated. Bilirubin is a type of bile pigment that is produced when

hemoglobin breaks down. Normal serum bilirubin levels are equal to or less than 1 mg per

100 ml but must exceed 3 mg per 100 ml to be visible to the observer.

Medical (nonobstructive) jaundice occurs because of hemolytic disease in which too many red

blood cells are destroyed or because of liver damage from cirrhosis or hepatitis. Its most

common appearance is transient in the first few days after birth, when more bile pigments are

released than can be handled. A liver that is damaged from disease simply cannot excrete the

bilirubin in a normal fashion, and it enters the bloodstream.

Surgical (obstructive) jaundice occurs when the biliary system is obstructed and prevents bile

from entering the duodenum. A common cause of this obstruction is blockage of the common

bile duct caused by stones or masses. The longer the obstruction persists, the more likely it is

that complications (e.g., liver injury, infection, or bleeding) will arise.

The jaundiced patient often undergoes an ultrasound examination of the liver, biliary tree, and

pancreas to determine if the jaundice is obstructive (Fig. 5-19) or nonobstructive. The common

bile duct is readily identified, and, generally speaking, a normal size implies nonobstructive

jaundice and a dilated common bile duct suggests an obstruction. A variety of other methods

may be used to diagnose the cause of jaundice, including ERCP, MRCP, and CT. An ultrasound

or CT-directed needle biopsy may be used if an intrahepatic cause of the hepatitis is suspected.

Treatment of jaundice centers on diagnosis and treatment of its underlying cause. In the case of

obstructive jaundice, surgical excision of the obstructing body may be necessary. Endoscopic

removal of common duct stones is frequently done, and endoscopy also offers the opportunity to

stent or bypass a tumor.

<1>NEOPLASTIC DISEASES

<2>Hepatocellular Adenoma
A hepatocellular adenoma is a benign tumor of the liver. Most are asymptomatic, but the

incidence of this disease has increased over the past few years. Hepatocellular adenomas occur

most often in women using oral contraceptives, which play a role in the development of these

benign lesions. In terms of imaging, both CT and ultrasound are useful in demonstrating hepatic

lesions.

Hemangioma

A hemangioma is the most common tumor of the liver. It is a benign neoplasm composed of

newly formed blood vessels, and these neoplasms can form in other places within the body. For

instance, a port-wine stain on the face (a superficial purplish red birthmark) is an example of a

hemangioma elsewhere in the body. Hemangiomas are generally well-circumscribed, solitary

tumors. They can range in size from microscopic to 20cm. They are more common in women

than in men, especially postmenopausal women.

Normally the texture of the liver is homogeneous on sonographic evaluation, but occasionally an

area of increased echogenicity may be demonstrated. When this appears as a solitary, round

lesion, the diagnosis is usually a hemangioma. These lesions generally do not become malignant;

however, ultrasound may be used to assess the lesion if there is suspicion that it has changed in

size or character. In most cases, a hemangioma is insignificant, but it can present symptoms such

as right-upper quadrant pain as a result of tissue displacement or bleeding. Diagnosis can be

complicated when it occurs with a known malignancy because its characteristics may be difficult

to distinguish from metastasis. Nuclear medicine scans using labeled red blood cells that are

attracted to the highly vascular tumor are virtually diagnositic in assessing the presence of a

hemangioma. These scans demonstrate the tumor as a defect in early phases and display
prolonged and persistent uptake on delayed scans. A CT of the liver following an injection of IV

contrast demonstrates the hemangioma with peripheral enhancement. MRI demonstrates marked

hyperintensity on T2-weighted images, which corresponds with fibrosis within the tumor.

Following an IV injection of a gadolinium contrast agent, peripheral enhancement of the

hemangioma occurs in early scans, followed by filling in of the tumor (Fig. 5-20), similar to the

appearance on an enhanced CT examination.

<2>Hepatocellular Carcinoma (Hepatoma)

Hepatocellular carcinoma, a primary neoplasm of the liver, is uncommon in the United States,

accounting for fewer than 2% of all cancers. An association between cirrhosis and hepatocellular

carcinoma exists, with chronic hepatitis B or C and alcoholism associated with each. Most

primary hepatomas originate in liver parenchyma, creating a large central mass with smaller

satellite nodules. Although vascular invasion is common, death occurs from liver failure, often

without extension of the cancer outside the liver.

Patients with cirrhosis who experience an unexpected deterioration, patients with increased

jaundice, abdominal pain, weight loss, a right upper quadrant mass, ascites, or a rapid increase in

liver size are suspect for hepatocellular carcinoma. Plain abdominal radiographs may

demonstrate hepatomegaly. Ultrasound and CT are often used to reveal the extent of the tumor

(Fig. 5-21). Arteriography may demonstrate the increased vascularity associated with a

carcinoma. A definitive diagnosis requires a liver biopsy, generally under sonographic guidance.

Surgical resection of the hepatocellular carcinoma represents the only possibility for cure. Those

hepatomas that are diffuse or have multiple nodules generally preclude surgery. The general lack
of radiosensitivity of these tumors makes radiotherapy ineffective. Patients treated with

chemotherapy demonstrate tumor shrinkage and an addition of a few months to their lives. The

disease, however, is generally fatal except for those who have had successful resection of a

single liver mass.

<2>Metastatic Liver Disease

Metastatic liver lesions are much more common than primary carcinoma because of the liver’s

role in filtering blood. The liver is a common site for metastasis from other primary sites such as

the colon, pancreas, stomach, lung, and breast (Fig. 5-22). Primary cancers located in the

abdomen, especially those drained by the portal venous system, often metastasize to the liver

(Fig. 5-23). Ultrasound is most commonly used to screen patients for metastatic liver disease;

however, CT and MR also offer an accurate diagnosis. Again, liver biopsy, often under

sonographic guidance, provides the definitive diagnosis.

<2>Carcinoma of the Gallbladder

Carcinoma of the gallbladder occurs infrequently, but most neoplasms within the gallbladder

are malignant. Most primary carcinomas of the gallbladder, approximately 85%, are

adenocarcinomas, with the remaining 15% being anaplastic or squamous cell cancers.

Carcinoma of the gallbladder is more common in women and the elderly, with gallstones present

in about 75% of all cases. The symptoms are nonspecific, right-upper quadrant including pain,

jaundice, and weight loss. Another risk factor associated with the development of gallbladder

carcinoma is a “porcelain” gallbladder, which results from chronic cholecystitis (Fig.5-24).

Approximately 22% of patients with porcelain gallbladders develop carcinoma.

The best methods of imaging gallbladder carcinoma include CT and ultrasound.

Radiographically, the appearance of the carcinoma may vary. It may appear as a mass replacing

the gallbladder or as a polypoid mass within the gallbladder, or the appearance may be as subtle

as focal thickening of the gallbladder wall. Clinically and radiographically, this cancer may be

difficult to differentiate from cholecystitis with pericholecystic fluid accumulation or an abscess.

Unfortunately, the prognosis with gallbladder carcinoma is often poor because metastases to the

liver usually occur before the primary disease is diagnosed (Fig. 5-25). It may spread via direct

invasion of the liver, via intraductal tumor extension, or via the lymphatic system to regional

lymph nodes. Approximately 88% of these patients die within 1 year of diagnosis, and only 4%

survive 5 years following diagnosis.

<2>Carcinoma of the Pancreas

Pancreatic cancer is usually rapidly fatal and is the fifth most common cause of cancer death

within the United States. Its diagnosis is difficult because of the location of the pancreas and

lack of symptoms before extensive local spread. Even with advances in CT and ultrasound, the

prognosis is poor. In most cases, the tumor is well advanced before the diagnosis is made. Its

incidence is greater in men than in women and in blacks than in whites. A clear-cut association

with cigarette smoking has been demonstrated, and other risk factors include alcoholism, chronic

pancreatitis, diabetes mellitus, and a family history of adenocarcinoma. Most tumors

(approximately 90%) arise as epithelial tumors of the duct (adenocarcinoma) and cause

pancreatic obstruction (Fig. 5-26). In addition, the majority (60% to 70%) of these neoplasms

arise in the head of the pancreas, followed by the body (10% to 15%), and then the tail (5% to

10%). The rich supply of nerves to the pancreas results in pain as a prominent feature of this

carcinoma. The tumor infiltrates and replaces normal tissue without significant hemorrhage,
necrosis, or calcification. Symptoms are nonspecific, including pain, weight loss, jaundice,

fatigue, nausea, vomiting, and diabetes.

Carcinomas of the pancreatic head may be visible on barium studies of the stomach and small

bowel because the head of the pancreas lies within the duodenal C-loop. Carcinomas of the body

and tail may affect the duodenojejunal junction and cause distortion on a barium-filled small-

bowel study. When ultrasound is used to evaluate the biliary tree, the sequence of images begins

with the right and left branches of the common hepatic duct within the liver and concludes by

scanning the common bile duct to its termination at the ampulla of Vater. Tumors of the

pancreatic head cause enlargement and can result in compression of the duodenum. With the

compression of the duodenum, the ampulla of Vater is also compressed, causing a dilation of the

distal common bile duct. Sonographic images of a common bile duct that begins coursing

normally but increases in size distally to more than 1.0cm in diameter should suggest the

possibility of a pancreatic head mass. CT is the best method of imaging the pancreas, with the

most common finding a mass deforming the pancreas. However, in most cases, the tumor is not

resectable because of its size by the time the mass is visible on the CT image. If the lesion is not

resectable, a percutaneous needle aspiration under CT guidance is performed to biopsy the

tissue. In cases where the tumor is resectable, CT offers information regarding the staging of the

disease. Radical surgery as a treatment mode is about the only hope for cure, but it carries a high

mortality rate. Radiation therapy is difficult because of the proximity to very radiosensitive

structures such as the spinal cord, and chemotherapy also produces poor results. The prognosis

with pancreatic carcinoma is very poor, demonstrating only a 2% survival rate for 5 years.

Summary
Pathology Summary: The Hepatobiliary System

Pathology Imaging Modalities of Choice Additive or

Subtractive Pathology

Cirrhosis CT Both

Ascites CT and ultrasound Additive

Hepatitis CT, nuclear medicine, None

and ultrasound

Cholecystitis Ultrasound and CT None

Cholelithiasis Ultrasound and CT Calcified stones, additive

Pancreatitis CT, ERCP, and ultrasound None

Hemangioma CT, nuclear medicine, angiography,

and ultrasound None

Hepatoma CT and nuclear medicine Additive

Hepatocellular adenoma CT and ultrasound Additive

Hepatocellular carcinoma CT and ultrasound Subtractive

Metastatic disease of the liverCT and ultrasound Subtractive

Carcinoma of the gallbladder CT and ultrasound None

Carcinoma of the pancreas CT and ultrasound Subtractive

Review Questions

1. Bile drains from the liver’s right and left hepatic ducts directly into the:

a. common bile duct

b. common hepatic

c. cystic duct
 d. duodenum

2. The noninvasive modality of choice for visualization of gallbladder disease, which does not

employ ionizing radiation, is:

a. CT

b. diagnostic medical sonography

c. MRI

d. nuclear medicine

3. Impairment of normal liver function might result in:

a. cirrhosis

b. jaundice

c. milk of calcium

d. viral hepatitis

4. Patients with liver cirrhosis have a tendency to develop:

1. ascites

2. esophageal varices

3. jaundice

a. 1 and 2

b. 1 and 3

c. 2 and 3

d. 1, 2, and 3

5. Which types of viral hepatitis may be transmitted via blood or blood products?

a. A

b. B

c. C
 d. E

e. both a and d

f. both b and c

6. The radiographic appearance of a porcelain gallbladder may be an indication of:

a. biliary obstruction

b. carcinoma of the gallbladder

c. cirrhosis

d. cholelithiasis

7. The yellowish discoloration of the skin associated with jaundice is caused by:

a. an accumulation of milk of calcium

b. infected fecal material transmission

c. paralysis of the small-bowel wall

d. presence of bilirubin in the blood

e. none of the above

8. Gallstone ileus refers to impaction of a gallstone in the:

a. biliary tree

b. gallbladder

c. liver

d. small bowel

9. The diagnostic imaging modalities of choice for following the progress of a liver malignancy

are:

1. CT

2. radiography

3. ultrasonography
 a. 1,2

b. 1,3

c. 2,3

d. 1,2,3

10. A malignant liver tumor is a(n):

a. hepatitis

b. hemangioma

c. hepatocellular carcinoma

d. jaundice

11. Compare and contrast medical versus surgical jaundice.

12. Explain why cholelithiasis in a nonfunctioning gallbladder can be imaged with sonography

and an oral cholangiogram would be ineffective in assisting a diagnosis.

13. What are the advantages of imaging the biliary ductal system antegrade with a PTC versus

retrograde with an ERCP? What are the disadvantages with PTC?

14. Explain why cancers of the gallbladder and pancreas carry a poor prognosis.

15. Describe the physiologic cause of esophageal varices in conjunction with cirrhosis of the

liver.

Figure Legends

Figure 5-1 The hepatobiliary system and the pancreas.

Figure 5-2 The biliary system.

Figure 5-3 Milk of calcium bile as seen in the bottom of this gallbladder in an erect spot

film.

Figure 5-4 Demonstration of the biliary system via a percutaneous transhepatic

cholangiogram (PTC).

Figure 5-5 An endoscopic retrograde cholangiopancreatogram (ERCP) showing abrupt

termination of the pancreatic duct about 4 cm from its opening.

Figure 5-6 A digital image of an operative cholangiogram taken during surgery.

Figure 5-7 A sagittal sonographic view of the gallbladder demonstrating stones.

Figure 5-8 A, B, Three phase CT of the liver following a bolus injection of IV contrast

demonstrating the arterial circulation. C, D, Three-phase CT of liver delayed

images demonstrating the portal venous flow.

Figure 5-9 CT of this 39-year-old woman after a car accident reveals large lacerations to

the liver.

Figure 5-10 CT of needle biopsy in this 87-year-old woman clearly demonstrates the

needle in the liver.

Figure 5-11 Nuclear medicine hepatobiliary scan demonstrates ready ejection of the

radionuclide from the gallbladder through sequential images into the

duodenum.

Figure 5-12 T2 Tru-Fisp axial MR image of the abdomen demonstrating a retroperitoneal

hemorrhage.

Figure 5-13 MRI is capable of imaging the biliary system without the use of contrast

agents.

Figure 5-14 Cirrhosis of the liver as indicated on this CT scan showing a shrunken liver
with significant ascites around it within the abdomen.

Figure 5-15 A sagittal sonographic image of a dilated gallbladder containing stones.

Figure 5-16 Sonogram demonstrating a thickened wall of the gallbladder, often indicative
of cholecystitis.

Figure 5-17 Pancreatitis with demonstration of a 5-cm pseudocyst in the tail as seen on
CT.

Figure 5-18 Transverse sonographic image of the

pancreas.

Figure 5-19 A sagittal sonographic image demonstrating a stone (arrow) lodged in the
distal portion of the common bile duct close to the ampulla of Vater (A)
resulting in dilation and obstruction of the common bile duct.

Figure 5-20 An axial MRI slice through the liver reveals a hemangioma.

Figure 5-21 Large, heterogeneous lesion in the liver consistent with hepatoma.

Figure 5-22 CT of the liver demonstrating metastatic spread from bronchogenic carcinoma
(arrows).

Figure 5-23 CT scan after duodenal cancer resection in a 21-year-old woman demonstrates
local recurrence and metastases to the liver on its lateral border in this slice.
Figure 5-24 A “porcelain” gallbladder in a 70-year-old man with a history of recurrent
indigestion.

Figure 5-25 Gallbladder carcinoma, resulting in metastasis to surrounding structures, as

seen on this CT of a 23-year-old man. The gallbladder (arrow) is surrounded
by metastasis, with significant metastasis into the pancreas area and right
kidney.

Figure 5-26 Pancreatic carcinoma in the head of the pancreas, as indicated by atrophy of
the pancreatic body and tail. Numbers shown are for density
sampling, with 10, 20, and 30 in the pancreas.