Liver Function and Biliary System Quiz

Methods of Imaging the Hepatobiliary System

• Plain film: Not a routine indication, but may incidentally show air in the biliary tree or portal venous system, or opaque calculi or pancreatic calcification.
• Ultrasound (US):
  • Transabdominal
  • Endoscopic
  • Intraoperative
• Computed Tomography (CT):
  • Routine staging (portal venous phase) CT
  • Triple-phase characterization CT
  • CT cholangiography
• Magnetic Resonance Imaging (MRI):
• Endoscopic Retrograde Cholangiopancreatography (ERCP):
• Percutaneous Transhepatic Cholangiography (PTC):
• Operative Cholangiography:
• Postoperative (T-tube) Cholangiography:
• Angiography (diagnostic and interventional):
• Radionuclide imaging:
  • Static (with colloid)
  • Dynamic (with iminodiacetic acid derivatives)

Methods of Imaging the Pancreas

• Plain abdominal films: Not a routine indication, but may incidentally demonstrate air within the biliary tree or portal venous system, opaque calculi, or pancreatic calcification.
• Ultrasound (US):
  • Transabdominal
  • Intraoperative
  • Endoscopic
• Computed Tomography (CT):
• Magnetic Resonance Imaging (MRI):
• ERCP:
• Arteriography:
  • Celiac axis
  • Superior mesenteric artery

Ultrasound of the Liver

• Indications:

  • Suspected focal or diffuse liver lesion
  • Jaundice
  • Abnormal liver function tests
  • Right upper-quadrant pain or mass
  • Hepatomegaly
  • Suspected portal hypertension
  • Staging known extrahepatic malignancy (superseded by CT)
  • Pyrexia of unknown origin (superseded by CT for patients over 30 years old)
  • To provide real-time image guidance for biopsy needle placement
  • Assessment of portal vein, hepatic artery or hepatic veins
  • Assessment of patients with surgical shunts or TIPS procedures
  • Follow-up after surgical resection or liver transplant

• Patient Preparation: Fasting or restriction to clear fluids only required if gallbladder also to be studied.

• Equipment: 3-5 MHz transducer and contact gel.

• Technique: Patient supine. Longitudinal and transverse scans, additional scans if needed. Ultrasound of the liver uses microbubble agents to enable contrast enhancement of focal liver lesions, analogous to contrast-enhanced CT or MRI.

Computed Tomography of the Liver and Biliary Tree

• Indications:

  • Suspected focal or diffuse liver lesion
  • Staging of known primary or secondary malignancy
  • Abnormal liver function tests
  • Right upper-quadrant pain or mass
  • Hepatomegaly
  • Suspected portal hypertension
  • Characterization of liver lesion
  • Pyrexia of unknown origin
  • Biopsy needle placement
  • Assessment of portal vein and hepatic vessels
  • Patients with surgical shunts, TIPS procedures
  • Post-surgical follow-up

• Technique: Single-phase (portal phase) contrast-enhanced computed tomography. The liver is imaged during peak parenchymal enhancement (around 60-70 seconds after bolus injection). Oral contrast can be given but not always needed

Computed Tomographic Cholangiography

• Indications:

  • Screening for cholelithiasis
  • Preoperative evaluation of anatomy
  • Suspected traumatic bile duct injury
  • Other biliary abnormalities (e.g., cholesterol polyps, adenomyomatosis)

• Technique: Intra venous cholangiographic agent is used to opacify the biliary tree. Isotropic data from thin slices are reconstructed to provide high resolution 3D images.

Computed Tomography of the Pancreas

• Indications:

  • Suspected pancreatic tumor
  • Pancreatitis or complications
  • Epigastric mass
  • Epigastric pain
  • Jaundice
  • Guided biopsy and/or drainage

• Patient Preparation: Nil by mouth, preferably overnight.

• Equipment: 3-5 MHz transducer and contact gel.

• Technique: Patient supine. Identify the pancreas, and evaluate the head and tail. Use longitudinal and oblique scans. Evaluate the pancreatic parenchyma, which will increase in reflectivity with age.

Intraoperative Cholangiography

• Indications: Performed during cholecystectomy or bile duct surgery to avoid surgical exploration of the common bile duct.
• Contraindications: None
• Contrast Medium: High osmolar or low osmolar contrast media (150-180 i.e. low iodine content to avoid obscuring any calculi). 20ml usually should suffice.
• Equipment: Operating table with CR/DR or film cassette tunnel, mobile x-ray/imaging machine
• Technique: Using a fine catheter, the surgeon cannulates the cystic duct with contrast medium, ensuring air bubbles are excluded. After 5 and 20ml of contrast inject images are taken.

Postoperative (T-Tube) Cholangiography

• Indications: Exclude biliary tract calculi where operative cholangiography was not performed, or results unsatisfactory/suspect. Assess biliary leaks after biliary surgery.
• Contraindications: None.
• Contrast Medium: High osmolar or low osmolar contrast media (150 mg I mL-1; 20-30 mL).
• Equipment: Fluoroscopy unit with spot image device.
• Patient Preparation: Antibiotics may be required.

Percutaneous Transhepatic Cholangiography

• Indications:
  • Pre-therapeutic intervention for relief of obstructive jaundice, or to drain infected bile.
  • To place a biliary stent.
• Contraindications: None
• Contrast Medium: High osmolar or low osmolar contrast media (150 mg/mL - 20-60 mL).
• Equipment: Fluoroscopy unit with spot film device A 22G needle
• Technique: Patient supine. A suitable duct in the right lobe is chosen. A 22g Chiba needle is inserted into the chosen duct under ultrasound or fluoroscopic guidance. Using a coaxial introducer system (over a 0.018 guidewire) the 0.035 guidewire allows access to the bile ducts. This is successful insertion, a sheath is inserted.

Percutaneous Extraction of Retained Biliary Calculi

• Indications: Retained biliary calculi seen in T-tube cholangiogram (incidence 3%)
• Contraindications: Small T-tube (<12-F), Tortuous T-tube course. Acute pancreatitis, presence of drain tract cross-connections.
• Contrast Medium: High osmolar or low osmolar contrast media (150 mg I mL-1; 20-60 mL).
• Equipment: Fluoroscopy unit with digital spot film device (tilting table optional), a fine, flexible, 22G needle (with stilette), appropriate catheters, and guidewire.
• Technique: Coned supine PA image of the right side of the abdomen. Perform transhepatic extraction. The patient is supine . A 22G Chiba needle inserted into the liver parenchyma, under guidance of US or CT, with the needle slowly withdrawn. Contrast medium injected.

Methods of Imaging the Urinary Tract

• Plain radiography: Predominantly to evaluate renal tract calcifications, with CT being more sensitive.
• Excretion urography (IVU): Less frequently used now, largely replaced by US, CT, or MRI. Indications: haematuria, renal colic, recurrent urinary tract infection, loin pain, suspected urinary tract pathology.
• Ultrasound (US): Can evaluate renal mass lesions, renal parenchymal disease, renal obstruction (loin pain), haematuria, hypertension, renal cystic disease, renal size, assessment of bladder outflow obstruction, urinary tract infections, and in patients following renal transplant.
• Computed tomography (CT): Evaluates renal tract calcifications and other pathologies. Indications: renal colic/renal stone disease, renal tumour, renal/perirenal collection, loin mass, staging/follow-up of renal, collecting system, or prostatic cancers, investigation of renal tract obstruction, assessment of renal vessels for stenosis or fistula, or other malformations.
• Magnetic resonance imaging (MRI): Can assess renal lesions, prostate, bladder, urography, adrenals, angiography , etcetera. Indications are similar to CT, although CT is often preferred due to availability, cost and time constraints.

Magnetic Resonance Imaging of the Prostate

• Technique: Patient supine, phased-array body coil, endorectal coil.
• Indications: Local staging of prostate and bladder cancers, pelvic lymph node staging, renal masses, screening/follow-up for individuals with Von Hippel-Lindau disease, MR urography if IV/CT urography contraindicated, Mr angiography assessing renal artery stenosis.

Retrograde Pyeloureterography & Hysterosalpingography

• Indications: Demonstration of an obstructive lesion site and nature, evaluation/demonstration of the pelvicalyceal system if there are urothelial abnormalities, follow-up of tubal or post-sterilization surgery, and assessment of Caesarean section uterine scar problems.
• Contraindications: Acute urinary tract infection.
• Contrast Medium: High osmolar or low osmolar contrast media (150–200 mg I mL-1; 10 mL).
• Technique: Performed in the operating theatre, via catheterization by a cystoscope (into the ureter) and contrast injection under fluoroscopic control.

Percutaneous Antegrade Pyelography and Nephrostomy

• Indications: Renal tract obstruction, pyonephrosis, prior to percutaneous nephrolithotomy, and ureter or bladder fistulas.

• Contraindications: Uncontrolled bleeding diathesis

• Contrast Medium: High or low osmolar contrast material.

• Equipment: Puncturing needle, drainage catheter, guidewires, and fluoroscopy or US machine

Renal Arteriography

• Indications:
  • Renal artery stenosis prior to angioplasty or stent placement
  • Renal artery aneurysm, arteriovenous malformation, dissection or thrombosis
  • Assessment of living-related renal transplant donors
  • Embolization of vascular renal tumor prior to surgery
  • Hematuria following trauma, including biopsy
  • Pre-embolization of angiomyolipoma (AML) or therapeutic embolization of a bleeding AML.
• Contrast Medium: Low osmolar contrast material.
• Equipment: Fluoroscopy unit, pump injector, catheters. (Specific catheter choices are dependent on the specific type of procedure required.)

Methods of Imaging in the Female Reproductive System

• Indications: Infertility to assess tubal patency, recurrent miscarriages, evaluation of suspected incompetent cervix/ congenital anomalies/uterus, post-sterilization obstruction, evaluation of Caesarean uterine scar integrity.
• Contraindications: Period of menstruation, pregnancy or unprotected intercourse, suspected pelvic inflammatory disease (PID) in past 6 months, significant contrast sensitivity.
• Equipment: Fluoroscopy unit, vaginal speculum, Vulsellum forceps and HSG balloon catheter or Margolin cannula for narrow cervical regions.

Ultrasound of the Scrotum

• Indications: suspected testicular tumor, suspected epididymo-orchitis, hydrocele
• Technique: Patient supine, with legs together for support. Scrotum examined with 7.5-15 MHz transducer and longitudinal and transverse scans.

Test your knowledge on liver function tests, biliary abnormalities, and related medical imaging procedures. This quiz covers essential conditions, assessment techniques, and physiological principles important for understanding the liver and biliary system. Perfect for students and professionals in the medical field.