BILIARY SYSTEM

LEARNING OBJECTIVES
• Identify the procedures of the specified organ
system and their modifications of positioning in
visualizing the anatomy of interest
ORGANS OF THE
BILIARY SYSTEM
LIVER
• The largest gland in the body
• Irregularly wedge shaped
• Divided by the falciform ligament
• Large Right lobe
• Smaller Left lobe
• The gland secretes bile at the
rate of 1-3 pints (1-1.5L) each
day
HILUM OF THE LIVER
• Called the Porta Hepatis
• Transversely between the 2 minor lobes
• Portal vein and Hepatic artery
• Convey blood to the liver
• Both enters the porta hepatis
• Ends in:
• Portal vein: Sinusoids;
Hepatic artery: Capillaries
PORTAL SYSTEM
• Portal vein
• Veins from the walls of
the stomach
• Veins from the greater
part of the intestinal tract
and gallbladder
• Veins from the pancreas
and the spleen
• Hepatic veins
BILIARY SYSTEM
• Cystic duct (from Gall
bladder) → Cystic Duct +
Common hepatic duct →
Common bile duct → CBD +
Pancreatic duct → Ampulla of
Vater
• Choledochal sphincter
• Sphincter of Oddi
• Major duodenal papilla
GALLBLADDER
• Balloon liked and pear-shaped
organ that sits just under the liver
• It stores bile produced by the
liver
• After meals, the gallbladder is
empty and flat, like a deflated
balloon
• Before a meal, the gallbladder
may be full of bile
PANCREAS
• Elongated gland across
the posterior
abdominal wall
CHOLEGRAPHY
INDICATIONS
• Cholelithiasis
• Choledocholithiasis
• Cholecystitis
• Biliary Stenosis
• Neoplasm
• Congenital Anomalies
CONTRAINDICATIONS
• Vomiting and • Liver dysfunction
diarrhea • Hepatocellular disease
• Pyloric obstruction • Elevated bilirubin
• Malabsorption • Known allergies to
syndrome iodinated CM
• Severe jaundice
TYPE OF CM AND
ROUTE OF ADMINISTRATION
• Iodinated water soluble
• Oral
• Absorbed by the intestine carried to liver via portal veins
then entering GB
• Taken:
• 1-3 hrs. for maximum opacification of Biliary tract
• 10-12 hrs. for GB
• 6-12 tablets for adults, 4-6 for children or with
Cholecystopaque
TYPE OF CM AND
ROUTE OF ADMINISTRATION
• Iodinated water soluble
• Intravenous
• Single bolus or drip-infusion
• To include in blood circulation enters liver via
hepatic artery then entering GB
TYPE OF CM AND
ROUTE OF ADMINISTRATION
• Direct into the biliary ducts
• PTC, IOC, T-tube Cholangiography
• Cholecystokinin
• Hormone injected
PREPARATIONS
• Cleansing Enema
• Light Supper/ Light Evening Meal
• Give Laxative (optional) administered 24 hrs.
before ingestion or injection of CM
• Tablets CM
• NPO at midnight
• No breakfast
PROJECTIONS
PROJECTIONS BODY/PART POSITION CR/RP SS AND EC
SS:
- Taken to locate the
GB and check patient
Perpendicular to RUQ preparation and
- 3” to right of spine - Check
PA (Scout) - Prone
and then 4” superior concentration of the
- Right side of
to iliac crest contrast medium in
abdomen
the GB, which may be
centered to the IR
taken 24 hrs. before
examination
Perpendicular, 2-4” SS:
PA Upright inferior to pre-located - Demonstrate
GB layering of gallstones
PROJECTIONS
PROJECTIONS BODY/PART POSITION CR/RP SS AND EC
SS:
- Best projection for
oral
cholecystography
- Semi prone Perpendicular, 4” - Places GB closest
PA Oblique
- Right side is rotated superior to the and most parallel to
(LAO) IR
15-40° iliac crest
- Demonstrate GB
free from
superimposition
PROJECTIONS
PROJECTIONS BODY/PART POSITION CR/RP SS AND EC
SS:
- Used to differentiate
gallstones from renal
stones or calcified
Perpendicular, 4” mesenteric lymph
- Recumbent superior to the nodes if needed
Left Lateral - Lying on the right iliac crest - Separate the
side superimposition of
the GB and the
vertebrae in
exceptionally thin
patients
PROJECTIONS
PROJECTIONS BODY/PART POSITION CR/RP SS AND EC
SS:
- For the
visualization of
- Recumbent Perpendicular small gallstones
Right Lateral - Lying on the right and horizontal, used to
Decubitus side 4” superior to demonstrate stones
the iliac crest that are lighter than
bile and that are
visualized only by
stratification colon
OTHER PROCEDURES
• Fatty Meal
• Given after satisfactory visualization of GB with
administration or intake of food or hormonal
substance that causes GB to contract
• Post Fatty Film or Delayed Film
• After 15-30 mins. fatty meal intake similar
series are taken to check the emptying power of
GB
INTRAVENOUS
CHOLANGIOGRAPHY
INDICATIONS
• GB is not visualized in OCG
• PT underwent cholecystectomy
• PT is experiencing severe vomiting and diarrhea
CONTRAINDICATIONS
• PT with liver disease
• Biliary ducts are not intact
• Elevated bilirubin
• Obstructive jaundice and post-cholecystectomy
PROJECTIONS
• AP Scout
• AP RPO
• 15-40° rotation
• Perpendicular to level of Iliac Crest
• Timed from the completion of the injection,
duct studies are ordinarily obtained at 10-
minute intervals until satisfactory visualization
is obtained
PERCUTANEOUS
TRANSHEPATIC
CHOLANGIOGRAPHY
INDICATIONS
• Obstructive Jaundice
• Stone Extraction
• Biliary Drainage
PTC COMPLICATIONS
• Leakage of bile into peritoneal cavity
• Hemorrhage
• Pneumothorax
• Sepsis/Infection
PROCEDURE
• Place the patient on the radiographic table in the
supine position. The patient's right side is surgically
prepared and appropriately draped
• Administer a local anesthetic then the Chiba needle
is held parallel to the floor and inserted through the
right lateral intercostal space and advanced toward
the liver hilum
PROCEDURE
• Under fluoroscopic control, the needle is slowly
withdrawn until the contrast medium is seen to fill the
biliary ducts
• Most instances the biliary tree is readily located
because the ducts are generally dilated
• After the biliary ducts are filled, the needle is
completely withdrawn and serial or spot AP
projections of the biliary area are taken
OPERATIVE/
IMMEDIATE
CHOLANGIOGRAPHY
INDICATIONS
• Investigate patency of biliary duct
• Determine the functional status of
hepatopancreatic ampulla
• Reveal choleliths that are not detected previously
• Demonstrate small lesions, strictures, or
dilatation within biliary tracts
POST-OPERATIVE
DELAYED AND T-TUBE
CHOLANGIOGRAPHY
INDICATIONS
• Residual or undetected choleliths
• Evaluate status of biliary ducts
• Demonstrate small lesions, strictures, or
dilatation within biliary tracts
MATERIALS AND
PREPARATIONS
• T-tube
• Flexible rubber tube about the size of straw
with crossbar extending into hepatic and
common bile duct and base into cystic duct
• Bile drainage until edema of CBD subsides
and route for administration of CM
TYPE OF CM
• Water soluble Urographic CM
ENDOSCOPIC
RETROGRADE
CHOLANGIOGRAPHY
INDICATIONS
• Residual or undetected choleliths
• Evaluate status of biliary ducts
• Demonstrate small lesions, strictures, or
dilatation within biliary tracts
MATERIALS AND
PREPARATIONS
• Stone basket
• Anesthesia
• NPO for 1 hr. before the examination
TYPE OF CM
• Dense contrast agents opacify small duct very
well, but they may obscure small stone
• If small stones are suspected, use of a more dilute
contrast medium is suggested by Cotton
PROCEDURE
• The endoscopist will spray a local anesthetic on the
PT’s throat and locates the ampulla of vater with an
endoscope
• Afterwards, a small cannula is passed through the
endoscope and directed into the ampulla
• Once the cannula is properly placed, the contrast
medium is injected into the common bile duct
PROCEDURE
• The patient may then be moved, fluoroscopy
performed, and spot radiographs taken
• The injected contrast material will drain from normal
ducts within approximately 5 minutes, radiographs
must be exposed immediately
PROCEDURE
CHOLEGASTO-
INTESTINAL SERIES
TYPE OF CM
• BaSO4
• Telepaque
• Water-soluble ionic CM
PROJECTIONS
• PA Scout
• PA and PA Oblique (LAO) for GB
• Esophagogram
• UGIS
• Post-motor for GB
• Delayed AP Abdomen
END.