Imaging of the patient with obstructive jaundice

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Imaging of the patient with obstructive jaundice

• Arye Blachar MD
• Department of Radiology
• Tel Aviv Sourasky Medical Center

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Introduction

• Cholestasis Clinical and biochemical syndrome,
  results when bile flow is impaired.
• Impairment of bile flow- hepatic cell bile
  canaliculus ? ampula of vater
• Intra hepatic hepatitis, drug toxicity,
  alcoholic liver disease, PBC, PSC, metastatic
  carcinoma, CholangioCA, etc
• Extra hepatic Pancreatic tumor, ampulary tumor,
  CholangioCA, biliary stone disease, pancreatitis,
  pancreatic pseudocyst, PD stricture

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Extra-hepatic cholestasis
Pancreatic tumor

• Malignant tumor arising from epithelium of
  exocrine pancreas
• 5th leading cause of death
• Risk smoking, diabetes, chr. Pancreatitis, high
  fat diet
• Mean age 55 yrs, peak 7th decade, mf-21
• Presentation head jaundice, pain, weight loss
  body tail weight loss. Mets to liver

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Extra-hepatic cholestasis
Pancreatic tumor - location

• Head 60-70- causes jaundice
• Body 20
• Tail 10
• Diffuse involvement 5-10
• Average diameter 2.5-3.0 cm
• Average diameter 5.0-7.0 cm

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Extra-hepatic cholestasis
Pancreatic tumor imaging

• Helping the General Surgeon
• Is there a pancreatic tumor?
• What is the tumor type?
• Is the tumor resectable?
• Are there any significant anatomical variants?

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Extra-hepatic cholestasis
Pancreatic tumor Imaging - Technique

• Pure water or milk 4
• Non-ionic contrast 120- 150cc at 4-5cc/sec
• Thin slices
• Arterial phase 25sec after the start of inj.
• Pancreatic phase 40-50sec after start of inj.
• Liver phase 70sec after the start of inj.

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Extra-hepatic cholestasis
Pancreatic tumor Imaging - Technique

• Multi plannar reformats, 3D imaging and review on
  a workstation are very helpful
• Improved tumor conspicuity
• Improved depiction of PD and CBD
• Better delineation of vascular anatomy
• Raptopoulos et al, Radiology 1998 207317-324
• Nino Murcia et al, AJR 2001 176689-693
• Prokesch et al, Radiology 2002 225759-765

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Extra-hepatic cholestasis
Pancreatic tumor - Tumor Detection

• Focal enlargement of the gland
• Hypodense mass on enhanced CT
• Secondary signs
• Mass effect or convex contour abnormality
• Atrophic distal pancreatic parenchyma
• Dilatation of CBD and MPD in the absence of
  obstructive calculus (interupted duct sign)

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Extra-hepatic cholestasis
Pancreatic tumor - Unresectability

• Vascular invasion
• Invasion of adjacent organs
• Stomach, spleen, left adrenal, mesentery
• Distal metastasis
• Liver (30), regional LN, omentum, ascites (10),
  lungs, pleura, bone

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Extra-hepatic cholestasis
Pancreatic tumor - Unresectability vascular
invasion

• Involvement of SMA, Celiac, SMV, PV or SV
  (isolated focal SV or PV?)
• Axial images CT grading of circumferential
  tumor-vessel contiguity (gt50)
  sen-84, spec-98 Lu et al AJR 1997
  1681439-1443
• MPR/3D/CTA images Evaluate change in vessel
  caliber or occlusion
• Raptopoulos et al AJR 1997 168971-977
• Prokesch et al, Radiology 2002 225759-765

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Extra-hepatic cholestasis
Pancreatic tumor Unresectability- Mets

• Hepatic Metastases
• Hypovascular best seen on PVP
• Sensitivity for detection of mets gt1cm 90
• Overall sensitivity for mets- 75
• Even small lt5mm mets may be detected
• LN mets- CT not accurate
• gt10mm sensitivity 14, specificity 85 PPV
  17 Roche ET AL, AJR 2003180475-480

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Extra-hepatic cholestasis
Pancreatic tumor - Imaging - How good are we?

• Accuracy of tumor detection 80-91 using older
  dynamic scanners. Accuracy with MDCT 95-96.
  Overall CT staging accuracy 90
• PPV for surgical unresectability 89-100 but PPV
  for resectability up to 80
• Poor performance in detecting small hepatic
  metastases, small peritoneal implants, LN
  mets in normal size LN

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Pancreatic cancer staging PET CT

• PET not yet widely used for pancreatic cancer
  staging, though promising results are being
  reported.
• FDG-PET is a very useful tool in diagnosing
  pancreatic cancer. FDG-PET may be also used as an
  adjunct for determining the treatment modality of
  pancreatic cancer and evaluating tumor response
  to therapy .
• J Clin Gastroenterol. 2006 Nov-Dec40(10)923-9

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Pancreatic cancer staging PET CT

• PET not yet widely used for pancreatic cancer
  staging, though promising results are being
  reported.
• FDG-PET is a very useful tool in diagnosing
  pancreatic cancer. FDG-PET may be also used as an
  adjunct for determining the treatment modality of
  pancreatic cancer and evaluating tumor response
  to therapy .
• J Clin Gastroenterol. 2006 Nov-Dec40(10)923-9

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Extra-hepatic cholestasis
Ampulary tumor

• Malignant epithelial tumor , ampula of vater
• Presents with jaundice, weight loss. Abd or back
  pain
• Age mean 65 yrs, no sex predeliction
• Prognosis depends on nodeal status and
  differentiation of tu, better than panc ca
• 5 yrs- 38 if resected
• Treatment Whipple if pos.

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Extra-hepatic cholestasis
Ampulary tumor

• Imaging
• Lobulated soft tissue mass at ampula
• Double duct sign
• CT Hypodense mass , distention of du helpful

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Extra-hepatic cholestasis
Cholangiocarcinoma

• Cholangio-cellular carcinoma, arises from the
  IHBD or EHBD epithelium
• 2ND most common primary hep tumor
• Types
• Intra-hepatic- peripheral (exophytic, polypoid,
  infiltrative)
• Intra-hepatic central or hilar
• Extra hepatic originates from CBD as stricture or
  mass

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Extra-hepatic cholestasis
Cholangiocarcinoma

• Age 6-7th decade, MF-32
• Risk biliary lithiasis, clonorchiasis, rec.
  pyogenic infections, PSC, IBD, caroli disease,
  choledochal cyst, thorotrast exposure, BD
  papilomatosis,alfa-1 anti-tripsin
• Presentation by location,jaundice, weight loss,
  abd pain, palpable mass
• Treat surgical resection (lt20), radiation,
  chemo, stenting
• Prognosis poor extra(1.6 5yrs), intra (30)

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Extra-hepatic cholestasis
Cholangiocarcinoma

• US dilated BD, mass hyperechogenic(75)
• CT hypodense mass, IHBD dilatation, rim
  enhancement with prog central patchy enhancement,
  persistent enhancement on delayed scan

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Extra-hepatic cholestasis
Gallstone disease

• 15-20 of the population
• Passage of gallstones through biliary system
  causes -----gt
• Biliary colic
• Acute cholecystitis
• Choledocholithiasis
• Cholecystoenteric fistula

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Extra-hepatic cholestasis
Gallstone disease- Cholelithiasis

• Incidence increases with age
• Risk factors female, fat, forty, fair, fertile -
  5F
• Obesity, rapid weight-loss, genetic
  predisposition, diabetes mellitus, cirrhosis,
  pregnancy, biliary tract infection, Crohns
  disease, sickle cell anemia
• Cholesterol (80), Ca bilirubinate (20)
• RUQ pain in 10-25 of pts. (10 years)
• Imaging US (EUS), MRI (MRCP), ERCP, CT,

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Biliary tree imaging modalities ERCP, MRCP,PTC

• CT and US are excellent for dilated ducts but not
  for assessing the entire tree.
• ERCP contrast media is placed endoscopically
  through the biliary tree.

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Biliary tree imaging modalities ERCP, MRCP, PTC

• MRCP specific MR sequence is employed to
  demonstrate the biliary tree.
• No IV contrast and definitely no biliary
  cannulation involved.

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Biliary tree imaging modalities ERCP, MRCP, PTC

• PTC direct cannulation of the biliary tree, and
  iodinated contrast injection.
• Advantageous over MRCP for showing distal, small
  duct pathology and walls irregularity.

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PTC

• Percutaneous access to
• the biliary tree, through the
• CBD, if possible, and into
• the duodenum.
• Downsides
• External drainage
• Procedural risks
• Coagulopathy
• ascites

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Biliary stone disease - summary

• US is the modality of choice for demonstrating
  gallstones.
• US is the very good for demonstrating biliary
  ducts.
• CT will show biliary ducts, less reliable for
  filling defects. Good for neoplastic disease.
• MRCP is the non invasive study
• ERCP is invasive but potentially therapeutic.
• PTC even more invasive, when ERCP is limited.

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Extra-hepatic cholestasis Cholelithiasis

• Sensitivity 90-95
• Variable SI
• Water/lipids contents
• Elevated SI on T2 in center (? 50)
• Elevated SI on T1 (? 90) Co, Fe, Mg (pigmented
  gallstones Ca Bilirrubinate)
• Ukaji M et al. Eur J Radiol 2002 Jan41(1)49-56

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Choledocholithiasis

• Asymptomatic
• Symptoms calculi in distal CBD (90)
• CBD stones
• 15 pts. with gallstones
• 15 pts. with acute cholecystitis
• Diagnosis pre laparoscopic cholecystectomy
• ERCP
• Stones in only 27-50 of pts with clinical
  suspicion

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Choledocholithiasis MR

• Normal CBD
• 98 of the pts
• Foci of low SI surrounded by bright bile
  (T2-WI)
• Stones ? 2 mm
• CBD stones
• Sensitivity 85-100
• Specificity 90-99
• Accuracy 89-97
• PPV 77-93
• NPV 94-100