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ai biliareAnatomia imagistica acailor biliare intra siextrahepatice

Aspecte normale si

patologice

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patologice Anatomia cilor biliare

intrahepatice(CBIH)- CBIH au originea n canalicule intralobulare cu

vrsare n canalele perilobulare i n spaiile porte;

- Cile biliare sunt grupatempreun cu ramurile

arteriale i portaleincepand cu spatiile porte;- Distribuia cilor biliare intrahepatice se suprapune

distribuiei venei porte;

- Fiecrui pedicul venos segmentar i sunt acolateunul sau dou canale biliare ce se dirijeaz ctrehilul hepatic pentru a forman final cele doucanale hepatice drept i stng.

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Anatomia cilor biliare

intra/ extrahepatice

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intrahepatice

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extrahepatice

-Anatomia cilor biliare extrahepatice: calea biliar principal(CBP) i vezicula biliar (VB);

-CB EXTRAHEPATICE ncep la unirea dintre cele dou canale(ductul hepatic drept i stng)ce formeaz canalul hepatic

comun

(anterior de VP) ce se ntinde pn la unirea cucanalul cistic (CC), dup care poart denumirea de canalcoledoc;

-CBP : un segment hilar;un segment intraepiploic;

un segment retroduodenopancreatic;un segment intraparietal-VB: rezervor membranos aplicat pe faa inferioar a ficatului;-VB i se descriu trei zone: fundul; corpul dispus oblic

ascendent catre posterior si spre stanga; colul ce se

continu cu canalul cistic.

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extrahepatice (CBEH)

Dimensiunile normale ale CBP, DHC i CC

Coledoc: la nivelul ligamentul gastrohepatic :

- adolesceni/ aduli- diametrul ax: 5-6mm;diametrul ax>8-10 mm= dilataie;- dup 60 de ani cretere cu 1 mm/10 ani;- dup colecistectomie diametrul 8 mm;- nou-nscut diametrul

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extrahepatice (CBEH)

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Anatomia normala a

veziculei biliare (VB)

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Dimensiunile normale ale

veziculei biliare (VB) Lungime:

sugari L: 1,5-3 cm,

copii L: 3-7cm,aduli L: 7-10 cm; Capacitate:30-50ml; Grosimea peretelui: 2-3 mm; Volumul biliar/ zi:250-1000ml secretat

de hepatocite.

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Anatomia cilor biliare extrahepatice

-anatomia jonctiunii pancreaticobiliare

(a) (c)(b) (d)
http://radiographics.rsnajnls.org/cgi/content/full/22/6/1335/F1Dhttp://radiographics.rsnajnls.org/cgi/content/full/22/6/1335/F1Chttp://radiographics.rsnajnls.org/cgi/content/full/22/6/1335/F1Bhttp://radiographics.rsnajnls.org/cgi/content/full/22/6/1335/F1A

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Tehnici de explorare radio-

imagistic Ecografia: abdominal, endoscopic; Computer-tomografia (CT); Imagistica prin rezonan magnetic (IRM) i

colangiopancreatografia RM (CPRM); Colangiografia transhepatic; Colangiopancreatografia endoscopic retrograd

(ERCP); Studiile radioizotopice: 99mTc-HIDA; Radiografia abdominal simpl: calcificri, acumulri

aerice; Colecistografia oral; Colangiografia:

(- oral, - intravenoasa, - percutanata, - intraoperatorie i postoperatorie petub Kher).

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Ecografia

- Metoda de primintenie

- diagnostic pozitiv i diferenial;- orientare spre o altmetodde explorare;

- Avantaje:- accesibilitate,- cost sczut,- repetabilitatemonitorizare;

- Sensibilitate diagnosticlimitatpentru:

- leziunile mici, de CBP distal,- litiaza de ci biliare nedilatate;

Operator i pacient dependent!

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Ecografia

- Sonde de 3,5-5 MHz;- n decubit dorsal, decubit lateral stng, curealizarea de seciuni axiale, oblice i sagitale,extremitatea cefalic pancreatic reprezint

fereastra acustic pentru coledoc;- Pacienii cu distensie aeric500 ml de apa reducerea gazelorvizualizarea capuluipancreatic si a CBP (95%);

- Poziia de Trendelenburgdecelarea calculului,prin migrarea acestuia din coledocul distal.

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Ecografia- Ecografie + adm. unui prnz grasevidenierea

calculilor prin creterea calibrului cii biliare n amontede obstacol;- Non vizualizarea colecistului n ecografie:status postcolecistectomie; mascat de grilajul costal;anomalii de poziie ( poziie subcostal/ intrahepatic);carcinom VB; perforaie VB; absen congenital;VBcontractat postprandrial.

Ecoendoscopia:

- Sonda de inalta frecventa7,5-12 MHz;- Aplicare sistematic dificil;- Explorare transduodenala capului de pancreas;CBP segment distal; regiunii ampulare; a raporturilor

vasculare.

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Ecografia
http://radiographics.rsnajnls.org/cgi/content/full/23/2/447/F6Ahttp://radiographics.rsnajnls.org/cgi/content/full/23/2/447/F3A

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Computer tomografia Mod secvenial nativ i cu contrast nonionic injectat iv;

La nivelul zonelor de decalibrare se realizeaza seciunifine de 2-3mm, contiguen vederea evidenieriiobstacolului.

Mod spiral + contrast iv - colimare: 3-6 mm; pitch: 1-1,5;

increment: 1,5-3 mm; reconstrucii MPR, MIP, 3D.

Bilancomplet: CB, pancreas, vase, leziuni asociate.

Colangio-CT: achiziia spiral post colangiografietransparietal.

Contrastul biliar oral sau n perfuzie iv este contraindicat

la pacienii cu bilirubin peste 2 mg%.

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Computer tomografia
http://radiographics.rsnajnls.org/cgi/content/full/23/2/447/F5Chttp://radiographics.rsnajnls.org/cgi/content/full/23/2/447/F5Bhttp://radiographics.rsnajnls.org/cgi/content/full/23/2/447/F4B

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IRM i CPRM

Evaluare neinvaziva arborelui biliar;parenchimului hepatic i pancreatic;structurilor vasculare intra/extrahepatice;

Permite o evaluare fiziologica a arboreluibiliar in opozitie cu ERCP in carecontrastul injectat poate modifica situatiaanatomofiziologica normala;

Antena body sau phased array;Intensitate magnet peste 0,5 T.

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IRM i CPRM

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Colecistografia oral Actualmente n majoritatea centrelor

abandonat; rol limitat n evaluarea anatomiei ifunciei VB; Doz: 6x0,5g Razebil la 2 ore dup mas de

sear. Ex se realizeaz la 14-16 ore

postadministrare de contrast, cu VB n repleie idup administrarea prnzului Boyden (prnzulcolecistochinetic). Selecia pacienilor: bilirubinsub 5 mg%;

Contraindicaie relativ: pacieni cu hepatopatiigrave. Contraindicaie absolut: peritonit, ileuspostoperator, pancreatit acut. Toxicitate:grea, vrsturi; reacie anafilactic imediat;

reacie hipotensiv tardiv; insuficien renal.

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Colecistografia oral

Non vizualizarea colecistului n colecistografia oral Vrful de opacifiere a VB: la 14- 19 ore;

1. Cauze extrabiliare: absena ingestiei contrastului;absorbie intestinal deficitar; vrsturi, obstrucie

esofagian, obstrucie gastric; hernie inghinal, hiatal,ombilical; diverticuli: Zencker, epifrenic, gastric,duodenal, jejunal; ulcer gastric; fistul gastro-colic;diaree, malabsorbie; ileus postoperator; traumatismsever; inflamaii: pancreatit acut; peritonit: patologiehepatic: colestaz intra/ extrahepatic; fistule bilio-enterice, anastomoze chirurgicale; pancreatita acut;

2. Cauze intrinseci VB: colecistectomie; anomalii depoziie; obstrucie duct cistic; colecistit cronic

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Colangiocolecistografia iv Inlocuit de CPRM i ERCP;

Indicaie izolat: bilan nainte de colecistectomiacelioscopicdiagnostic de litiaz CBP i evaluareavariantelor anatomice;

Contrast: Pobilan/Biligrafin/Endocistobil, injectat iv lent(6-10 min) n doz de 20-40 ml in funcie de greutateacorpului. Cantiti mai mari de contrast introduse iv nurealizeaz o opacifiere mai bun a CB, excesul deprodus fiind eliminat pe cale renal. Examenulcolangiocolecistografic iv cuprinde dou etape: timpulcoledocian i timpul vezicular; pentru apreciereafunciei VB se poate administra prnzul Boyden;

Rezoluie mic n comparaie cu ERCP;

Reacii de hipersensibilitate: mortalitate 1/ 7000.

C l i fi

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Colangiografia

percutanat (CPT) Injectarea de substan de contrast iodat direct n

arborele biliar intrahepatic; Tehnic: ac Chiba 22G; PCI minim 300 mgI/ml; bolnav n

decubit dorsal premedicat;Reperaj fluoroscopic/ecografic- arbore biliar drept peLMA n plan orizontal, ac cu direcie uor ascendent nplanul arcului costal XIXII;

CTH are indicaie n special n bilanul icterelorobstructive de CBP proximalsau n cazurile n careERCP nu se poate realiza;

n obstacolul hilar este uneori necesar opacifiereaseparata arborelui biliar drept i stng;

Incidene oblice, opacifieri multiple; CPT ofero alternativdiagnosticsi terapeutic.

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COLANGIOGRAFIETRANSHEPATICA PERCUTANA(CPT)

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ERCP Pe cale endoscopic prin cateterizare papilei i

opacifierea CBP, a CBIH i a Wirsungului;

Avantajele ERCP:- Posibilitatea efecturii i la bolnavii cu tulburri de

coagulabilitate, evaluarea papilei, a regiunii ampulare,a CBP i a CBIH,

- Evitarea producerii pneumotoraxului,hemoperitoneului sau a coleperitoneului prin injectareacontrastului iodat direct n CBP;

ERCP este o metod diagnostic i terapeuticpermind drenajul biliar endoscopic, extragereacalculilor coledocieni transendoscopic, dilatareastenozelor biliare benigne sau maligne saupapilosfincterotomia endoscopic.

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ERCP

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Algoritmul de explorarea a CBIH, VB

i CBP Ecografia-examen iniialsistematic,-uneori suficientdiagnostic pozitiv,-alegerea strategiei de explorare suplimentar; Colangio-IRM-Inlocuiete tehnicile de opaciefiere,-Confirm sindromul obstructiv,-Diagnostic etiologic - stenoz malign/ benign, litiaz, etc;

CT spiral-Explorare canalar i parenchimatoas leziuni tumorale; Ecoendoscopiecazuri complexe; ERCP i CPTaproape exclusiv n scop terapeutic.

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Patologia cailor biliare de tip benign

I. Anomalii de dezvoltare a CB

Apare probabil secundar unor procese de tip inflamator

tip hepatit neonatal la care se adaug fenomene decolangit sclerozant i tulburri vasculare locale; Incidena de 10 cazuri/ 100.000 nou nscui, M/F- 2:1;

Clasificare :

tipul I (A):rar, afectare multifocal a arborelui biliar(injurii vasculare n viaa intrauterin);tipul II (B):atrezie de CBIH;tipul III (C):atrezie de CBP extrahepatic cu respectareaCBIH.

I.A.Atrezia congenitala de cai biliare

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Atrezia congenitala de caibiliareEco: creterea dimensiunilor ficatului/ ecogenitate

crescut; absena vizualizrii structurilor portaleperiferice datorit fibrozei; absena vizualizriiVB/ VB mic; absena vizualizrii CBIH; dilataiechistic CBP;

Colescint igraf ia:absena excreiei biliare;CPRM:VB atrofic; absena vizualizrii CBP;

ngroarea spaiilor periportale;Colangiografia (endoscopic/ intraoperatorie);Biopsia hepatic:acuratee: 60-97%.

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Atrezia congenitala de caibiliare

I B Chi t l d l d
http://radiographics.rsnajnls.org/cgi/content/full/20/1/173/F4Bhttp://radiographics.rsnajnls.org/cgi/content/full/20/1/173/F1http://radiographics.rsnajnls.org/cgi/content/full/20/1/173/F4A

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I.B.Chistul de coledocDilataie chistic a cii biliare extrahepatice

reprezentnd 50-80% din totalitatea leziunilorchistice localizate la nivelul CB; Raport F/B de3/1.

- Asocieri lezionale: dilatri, stenoze sauatrezii parcelare de arbore biliar, anomalii aleveziculei biliare, boal polichistic hepatic,carcinom de vezicul biliar;

- Clinic triada: icter intermitent febril, durericolicative hepatobiliare, tumefaciela nivelulhipocondrului drept.

C

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Chistul de coledoc

Complicaii: litiaza coledocian (8-70% din

cazuri), colangitele (20% din cazuri),degenerescena malign(3-28% din cazuri),ciroza biliar(1-13% cazuri), ruptura chistului cuperitonit biliar.

Eco:dilataie fuziform de CBP cu decalibrarebrusc;Scint igraf ia cu HIDA ;CPRM :confirm diagnosticul: dilataie marcat

de CBP extrahepatic, de obicei de tip sacular;CBIH- de aspect normal sau pot fi discretdilatate; decalibrarea dilataiei chistice de CBPse produce brusc.

Chi t l d l d

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Chistul de coledocClasificarea chisturilor de ci biliare:

(Clasificarea Todani)

Tip Ia.Chist coledocian pur; b.Dilataiesegmentar a cii biliare principale; c.Dilataie

fusiform difuz a cii biliare principale;Tip IIDiverticul coledocian;Tip IIIColedococel;Tip IVa.Dilataie chistic a cilor biliare

intrahepatice i a cii biliare principale; b.Chisturimultiple de cale biliar principal;

Tip VBoal Caroli.

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Chistul coledocian -Tipul I
http://radiographics.rsnajnls.org/cgi/content/full/26/3/715/F16Bhttp://radiographics.rsnajnls.org/cgi/content/full/26/3/715/F16A

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Chistul coledocian-Tipul I

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Chistul de coledoc

-Tipul I

Aspect tomografic, la un copil de 3,4ani, evideniid dilataia chistic a cii

biliare principale

Aspect intraoperator.Se remarc vascularizarea bogat ifenomene inflamatorii perichisticeintense.Acestea au determinat realizarea unuiabord intern al chistului.

colangiografie intraoperatorie

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Chistul de coledocTipul I
http://radiographics.rsnajnls.org/cgi/content/full/20/1/173/F10Chttp://radiographics.rsnajnls.org/cgi/content/full/20/1/173/F10Ahttp://radiographics.rsnajnls.org/cgi/content/full/19/1/25/F23

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Chistul de coledocTipul I

colangiocarcinom asociat
http://radiographics.rsnajnls.org/cgi/content/full/20/2/353/F3Dhttp://radiographics.rsnajnls.org/cgi/content/full/20/2/353/F3Chttp://radiographics.rsnajnls.org/cgi/content/full/20/2/353/F3Bhttp://radiographics.rsnajnls.org/cgi/content/full/20/2/353/F3Ahttp://radiographics.rsnajnls.org/cgi/content/full/21/suppl_1/S97/F13Bhttp://radiographics.rsnajnls.org/cgi/content/full/21/suppl_1/S97/F13A

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Diverticul -Tipul II
http://radiographics.rsnajnls.org/cgi/content/full/26/3/715/F16Dhttp://radiographics.rsnajnls.org/cgi/content/full/26/3/715/F16C

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Diverticul
http://radiographics.rsnajnls.org/cgi/content/full/19/1/25/F13

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Chistul de coledoc

-Tipul IV

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Chistul de coledoc

-Tipul V (Boala Caroli)

Boala Caroli
http://radiographics.rsnajnls.org/cgi/content/full/26/3/715/F17Ehttp://radiographics.rsnajnls.org/cgi/content/full/26/3/715/F17Dhttp://radiographics.rsnajnls.org/cgi/content/full/26/3/715/F17C

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Boala Caroli

Afeciune autosomal recesiv; ectazii localizate lanivelul canaliculelor biliare ce comunic cu multipledilataii neobstructive de tip sacular;

Incidena: rar; mai frecvent ntlnit la copii i ndecada a 2-a /a-3-a de vrst;

Asocieri lezionale: fibroz hepatic, chisturi de coledoc,boal polichistic renal; IRM: multiple dilataii de tip sacular ale CBIH cu

dimensiuni variate i distribuie n general difuz nntreg parenchimul hepatic.

Central dot signpozitiv, corespunde unui ram portalnconjurat complet de canaliculul biliar dilatat; Colangiografia transhepatic-afirmarea diagnosticului; Complicaii: litiaz biliar n 34% cazuri, cu leziuni de

tip inflamator (colangite, abcese), grefarea unui

colangiocarcinom sau fenomene de HTP

Boala Caroli

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Boala Caroli

Boala Caroli
http://radiographics.rsnajnls.org/cgi/content/full/20/1/173/F12http://radiographics.rsnajnls.org/cgi/content/full/21/4/895/F8

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Boala Caroli

Monolobara

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I D V i t t i

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I.D.Variante anatomice

ale CB

Inciden: 2-4% la autopsie; 13-18% ncolangiografia intraoperatorie;

Ducte aberante intrahepatice: nproximitatea VB, CHC, CBP, CC, DHD;

CC cu vrsare n DHD; duplicaia CC;

fistula congenital traheobiliar(comunicare ntre carin i DHS).

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DUCTE HEPATICE ACCESORII A.DUCT HEPATIC ACCESORIU CARE SE

VARSA IN DUCTUL HEPATIC DREPT IN

FISURA TRANSVERSALA (porta hepatis); B. DISTANTA INTRE DUCTUL CISTIC SI

DUCTUL ACCESOR ESTE MAI MICA. DUCTULACCESORIU SE DESPRINDE SUBCAREFOUR-UL BILIAR;

C.DUCTUL CISTIC SE VARSA INTR-UN DUCTACCESORIU LANGA JONCTIUNEA CU

DUCTUL HEPATIC COMUN. DUCTULHEPATIC ACCESORIU ARE APROXIMATIVACELASI DIAMETRU CU CEL AL DUCTULUIHEPATIC COMUN;

D.ACELEASI CARACTERISTICI CA LAPUNCTUL C. DAR CU O DISTANTA MAI MICADE LA JONCTIUNEA DUCTULUI ACCESORIU

PANA LA CAREFOUR-UL BILIAR; E, F, I, J, H.DUCTURI ACCESORII CARE SE

VARSA IN CANALUL HEPATIC COMUN LADIFERITE NIVELURI;

G.DUCTUL CISTIC SE VARSA IN DUCTULHEPATIC DREPT LA 1 CM DISTANTA DEHILUL HEPATIC SI ARE ACELASI DIAMETRU

CU DUCTUL HEPATIC COMUN.

DUCTE HEPATICE

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DUCTE HEPATICE

ACCESORII
http://radiographics.rsnajnls.org/cgi/content/full/26/6/1603/F15http://radiographics.rsnajnls.org/cgi/content/full/19/1/25/F21B

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Duplicatie de duct hepaticcomun FICAT, DUODEN SI DUPLICATIE

DE DUCT HEPATIC COMUN:

-DUCT HEPATIC COMUN;-DUCT HEPATOENTERIC(SEVARSA IN PORTIUNEASUPERIOARA A DUODENULUI

LA 1,5 CM DE PILOR);-SEGMENT ANASTOMOTICINTREDUCTUL HEPATIC COMUN SIDUCTUL CISTIC ;-DUCTUL COLEDOC(SE VARSAMULT MAI JOS IN PARTEA

DESCENDENTA A DUODENULUIIMPREUNA CU DUCTULPANCREATIC LA 8 CM DE PILORLA NIVELUL PAPILEIDUODENALE).

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INSERTII ALE DUCTELORBILIARE ABERANTE Locurile de insertie ale

ductelor biliare seimpart in doua marigrupuri generale:

-(grupa A)cele care sedeschid deasuprapilorului in stomac si

-(grupa B)situate la

nivelul duodenului panala ampula Vater.


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extrahepatice-Duct cistic.

Variante ale inseriei

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Variante ale inserieicanalului cistic (CC)

Inciden:18-23%Direcie.1. Craniocaudal

Inserie: proximal n regiunea hilar;n 1/3 medie a CBP extrahepatice (75% cazuri);

n 1/3 distal a CBP extrahepatice (10%);

2. MediolateralInserie: lateral dreapt; anterioar n spiral;posterioar n spiral; proximal; lateral joas;medial joas (n proximitatea ampulei Vater);

3. Inserie ntr-un duct biliar intrahepatic;

4. Absena CC: VB dreneaz direct n DHC.

V i t d i i l

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Variante de inserieale

canalului cistic (CC)

Variante anatomice:-insertie laterala dreapta (A ),-insertie anterioara spirala (B),-insertie posterioara spirala (C),

-insertie inferioara joasa lateralacu traiect paralel cu ductulheptic comun (D),-insertie proximala(E),

-sau insertie joasa mediala (F).

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II A C l it l t

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II. A. Colangita sclerozant

primitiv (CSP)

II.A. Colangita sclerozant
http://radiographics.rsnajnls.org/cgi/content/full/20/4/959/F8Bhttp://radiographics.rsnajnls.org/cgi/content/full/20/4/959/F8Ahttp://radiographics.rsnajnls.org/cgi/content/full/20/4/959/F7Bhttp://radiographics.rsnajnls.org/cgi/content/full/20/4/959/F7Ahttp://radiographics.rsnajnls.org/cgi/content/full/20/4/959/F6Bhttp://radiographics.rsnajnls.org/cgi/content/full/20/4/959/F6Ahttp://radiographics.rsnajnls.org/cgi/content/full/20/4/959/F4

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primitiv (CSP)

Clinic: icter intermitent i prurit;Complicaiile: ciroza biliar, litiaza intrahepatic i de CBP,colangitele bacteriene, grefarea unui colangiocarcinom;

Eco:creterea ecogenitii triadei portale, dilataiimoniliforme;

CT: alternarea dilataiilor cu zone de stenoz; aspectde arbore iarna; atrofie lobar n zonele afectate;

IRM, CPRM:infiltraie inflamatorie periportal(hipersemnal T2), aspect monilifom CB;

Scint igraf iacu Tc-99m.IDA; Colangiograf ia.

II A Colangita sclerozant

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primitiv (CSP)

II B C l it l t d
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II.B. Colangite sclerozante secundare Cauze: colangite bacteriene cronice secundare

stricturilor biliare / coledocolitiazei; modificri CBpostischemice; colangita infecioas n SIDA; anomaliicongenitale arbore biliar; neoplasme CB; modificripostoperatorii CB;

Colangita oriental Sinonime: colangita piogen recurent, boala Hong

Kong, litiaza intrahepatic pigmentar; Reprezint o infecie cronic sau recurent a CB, ce

asociaz procese de tip inflamator n parenchimulhepatic adiacent, leziuni fibrotice periportale, inflamaii ifibroz a complexului sfincterian vaterian, litiaz biliarpigmentar (calculi bilirubinici).

Colangita secundara-bacteriana

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Colangita secundara-bacteriana(secundara unui colangiocarcinom)

Colangita secundara
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g( -la 6 luni postcolecistectomie,

-colangita infectioasa in SIDA)

C
http://radiographics.rsnajnls.org/cgi/content/full/19/1/25/F15Ahttp://radiographics.rsnajnls.org/cgi/content/full/20/4/959/F23http://radiographics.rsnajnls.org/cgi/content/full/20/4/959/F22http://radiographics.rsnajnls.org/cgi/content/full/20/4/959/F20

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Colangita secundara(posttransplant hepatic)

Colangita oriental
http://radiographics.rsnajnls.org/cgi/content/full/26/6/1603/F24Bhttp://radiographics.rsnajnls.org/cgi/content/full/26/6/1603/F24Ahttp://radiographics.rsnajnls.org/cgi/content/full/20/4/959/F25Bhttp://radiographics.rsnajnls.org/cgi/content/full/20/4/959/F25A

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Colangita oriental

Complicaiile: abcesele (18% cazuri), atrofiesegmentar sau lobar, splenomegalie, biliom,colangiocarcinom;CT:priz de contrast la nivelul pereilor CB;

calculi hiperdeni;IRM:dilataie important a CBIH mari; stenozela nivelul ductelor hepatice; amputarea itergerea vizibilitii cilor biliare periferice;

imagini lacunare n hiposemnal T2 n lumenulCB (calculi bilirubinici sau sludge); atrofiehepatic segmentar; abcese;ERCP.

Colangita oriental

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Colangita oriental

(+ colangiocarcinom)
http://radiographics.rsnajnls.org/cgi/content/full/20/4/959/F21Chttp://radiographics.rsnajnls.org/cgi/content/full/20/4/959/F21Bhttp://radiographics.rsnajnls.org/cgi/content/full/20/4/959/F21Ahttp://radiographics.rsnajnls.org/cgi/content/full/21/suppl_1/S97/F22A

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Imagini lacunare n CBP

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Imagini lacunare n CBP Pseudocalcul: contracia sfincterului Oddi; Aer: seciuni axiale/ sagital; Cheaguri sanguine; Calculi biliari; Sindrom Mirizzi; Tumori

- maligne: colangiocarcinom, hepatom, rabdomiosarcomembrionar, hamartom, carcinoid, tumori metastatice(tract GI, pancreas, sn, melanom, limfom);- benigne: adenom, papilom, fibrom, lipom, sarcom,

mieloblastom; Parazii: ascarizi, schistosoma japonicum, chist hidatic.Material ecogen n CB: calculi; aer; snge; tumori; parazii.

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Litiaza biliar

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Litiaza biliar

Compoziia calculilor:

-colesterol (70%): transpareni (93%),calcificai (7%); discret hipodeni fa de bil;calculi de colesterol pur (transpareni); calculimicti (colesterol+bilirubin+calciu) radioopaci n15-20% din cazuri- vizibili radiografic;

-pigmentari (30%): conin biulirubin, calciu imic cantitate de colesterol; faetai; radioopaci;CT- hiperdeni.

Litiaza biliar

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Litiaza biliar Calculi opaci/transpareni:

- transpareni: 84%- colesterol (85%); pigmentari (15%)- calcificai: pigmentari (67%); colesterol (33%)

. vizibili radiografic: 15-20%

. vizibili CT: 60%Calcificri centrale: fosfat de calciu/ n calculii micticolesterinici.Calcificri radiare sau periferice: calciu carbonat ncalculii micti pigmentari.

Sludge (noroi biliar)apare n staza biliar i

corespunde unor granule de bilirubinat de calciu icolesterol. Eco: material ecogen dispus decliv, structurat sub

forma unui nivel orizontal fluid-sludge.

III.A.Litiaza intrahepatic

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p

Litiaza intrahepatic este rar ntlnit ca entitate de sine

stttoare; Dintre factorii predispozaniamintim: colangitele primare

i secundare, boala Caroli i ascarizii biliari; Complicaii: colangite, abcese hepatice, fistule;

Clinic: dureri n hipocondrul drept; icter intermitent;Ecograf iapoate evidenia dilataie de CBIH cu miciimagini ecogene n lumen cu sau fr con de umbrposterioar;CPRMCalculii- imagini lacunare n hiposemnal accentuat

T2, hiposemnal T1, contur net delimitat; Diag. dif.: aerobilia. Cantiti mici de aer n CBIH duc la

neomogeniti de semnal fiind dificil de diagnosticat prinIRM, CT fiind metoda de elecie n aceste cazuri.

III A Litiaza intrahepatic

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III.A.Litiaza intrahepatic

III.B.Litiaza de cale

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biliar principal (CBP) Este cea mai frecvent cauz de obstrucie biliar;

Incidena este de 12-15% la pacieniicolecistectomizai; de 3-4% la pacieniipostcolecistectomie; de 75%n obstruciile biliare

cronice; Factorii predispozani: litiaz de colecist, stenoza

CBP, colangitele sau disfuncia complexuluivaterian;

Complicaii: pancreatite acute, de stricturi CBP,fistule biliare, colangite sau abcese hepatice;

Clinic: dureri n hipocondrul drept, icter de apariie

recent.


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biliar principal (CBP)

Eco.Sb: 22-82%- calcul vizibil n 13-75% (ncondiii de dilataie CBP i bun vizualizare acapului pancreatic;

CT. Sensibilitate (Sb): 88%, specificitate:97%,acuratee: 94%; calcul vizibil n 75-88% dincazuri (calcul mixt, cu calcificare inelarperiferic, calcul n tras la int);

CPRM.Sb 81-100%; Sp 85-100% (calculii

trebuie s fie mai mari de 2mm); Colangiograf ia.Calculii sunt vizibili n 92%; Colang iograf ia int raoperator ie.Fali negativi:

4%. Fali pozitivi: 4-10%.

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III B Litiaza de cale

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Calcul i in coledocul d istal .


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ERCP. Calcul impactat in ductul biliarcomun distal.

Imaginea fluoroscopica-multipliicalculi in ductul hepatic comun vazuti

in timpul ERCP-ului.

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III.C.Litiaza veziculei biliare

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Clinic- colici biliare n 30-35% din cazuri; asimptomatic n 60-65% dincazuri;

Complicaii: colecistita acut (30%c), coledocolitiaza, colangite,pancreatite, duodenite, ileus biliar, sindrom Mirizzi, neoplasm VB;

Rg abdominal simpl-Sb: 10-16% (calculii calcificai);Colecistografia oral-Sb: 65-90%; imagine lacunar unic/

multipl; aspectul ductului cistic; contractilitatea VB dupprnzul gras;

Eco -Sb: 91-98%; fali negativi n 5% cazuri. Imaginehiperecogen, mobil, cu con de umbr posterioar i artefactde reverberaie; calcificrile sub 2 mm pot s nu aib con de

umbr posterioar.Nevizualizarea VB cu prezena uneiacumulri ecogene cu con de umbr posterioar;

CT-Sb: 80%; calculi hiperdeni/ calcari-60%c; hipodeni -colesterinici; izodeni cu bila, nedetectabili CT n 21-24% dincazuri.

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III.C.Litiaza

veziculeibiliare

Calculi de colesterol in VB

Colelitiaza pe o colangiograma.Multiplii calculi radiotransparenti in VB

-PTCACalculi in VB formati in 4 ani

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Litiaza veziculei biliare

III C Litiaza biliar
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III.C.Litiaza biliar

III.D.Sindromul Mirizzi

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- Determinat de compresia lateral dreapt a ductului

hepatic comun prin calcul voluminos inclavat n canalulcistic/n reginunea infundibular VB/n bontul cisticnsoit de o reacie inflamatorie cronic;- Frecvent asociat cu apariia unei fistule ntre veziculabiliar i ductul hepatic comun;

- Sindromul Mirizzi apare mai frecvent la pacienii cuinserie anormal joas a canalului cistic n ductulhepatic comun sau la pacienii cu un cistic paralel cutraiectul ductului hepatic comun;- Triad: calcul inclavat n infundibulul VB; dilataie de

CB n amonte de abuarea cisticului n CBP; amprent istenoz excentric DHC;Colangiografie i CPRM:obstrucie parial DHC prin

compresie extrinsec.- Diag. dif: adenopatii, neoplasm de DHC i VB.

III D Si d l Mi i i

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III.D.Sindromul Mirizzi

PATOLOGIA VB
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Bil hiperdens Colecistit hemoragic; hemobilie; bilcalcica;

Contrast: ageniurografici/colecistoopaci/ paramagnetici(Multihance).

Deplasarea VB-Impresiune normal dat de duoden/ colon-Mase hepatice: hepatom, hemangiom, noduli de regenerare,

chist biliar, chist hidatic, abcese, granuloame

-Mase extrahepatice: tumori retroperitoneale; boalpolichistic renal; limfom; adenopatii hilare hepatice;pseudochist pancreatic.

PATOLOGIA VB

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VB mareHidrops vezicular- colecistomegalie

Dimensiune-copii sub 1 an L>3 cm; - copii L>7 cm; - aduli L > 10 cm

Obstrucie- obstrucie duct cistic; - litiaz; - colecistit culitiaza; - semnul Courvoisier pozitiv (tum pancreatic,

duodenal, papilar, ampulara, duct hepatic comun); -pancreatit; - infecii: leptospiroz, ascaridoz, febrtifoid, febr mediteranean

Nonobstrucie (neuropatic)

- vagotomie- diabet/ alcoolism/ apendicit/ analgezie /hiperalimentaie/acromegalie/ sdr Kawasaki /anticolinergice/ SIDA/deshidratare/ nutriie parenteral/ sepsis

Normal (2%)

PATOLOGIA VB

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VB mic: colecistit cronic; fibroz chistic: n 25% dinpacieni; hipoplazie congenital/ colecist multiseptat;postprandrial; colestaz intrahepaticVB cu perete ngroat difuzgrosime >3 mmCauze intrinseci: colecistit acut; colecistit cronic;colecistit xantogranulomatoas; colecistozhiperplazic; perforaie VB; sepsis; carcinom VB(41%difuz); SIDA; colangit sclerozant; varice VB; ischemie

Cauze extrinseci: hepatit; hipoalbuminemie; insuficienrenal; insuficien cardiac dreapt; hipertensiunevenoas sistemic; obstrucie vv hepatice; ascit;mielom multiplu; ciroz; leucemie mielogenic acut;brucelozFiziologic- postprandrial

PATOLOGIA VB

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VB cu perete ngroat focalizat Metabolic Tumori benigne: adenom, papilom, fibroadenom,

chistadenom, neurinom, hemangiom, carcinoid Tumori maligne: carcinom, leiomiosarcom,

metastaze (melanom, neoplasm bronhopulmonar,

renal, esofag, sn, carcinoid, sarcom Kaposi, limfom,leucemie). Inflamaii: polip inflamator; granulom parazitar, chist

epitelial intramural, colecistitxantogranulomatoas).

Calculi adereni la perete Hipertrofie de mucoas: esut pancreatic ectopic;

glande gastrice ectopice, glande intestinale ectopice,esut hepatic ectopic, esut prostatic ectopic.

Ad d VB

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Adenoame de VB

PATOLOGIA VB
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Imagini lacunare n VB Fixe: polipi; adenomiomatoz; neurinom;

tumori primare/ secundare; calculi aderenila peretele VB;

Mobile: sludge; cheaguri de snge; calculi;

Pneumobilia; hamartoame multiple;

VB: sinus Rokitansky-Aschoff; calculiintramurali; colesteroloz VB.

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Polipi colesterolici

IV. Patologie benigna veziculara asociatasau nu cu litiaza biliara Colecistita acut
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Vrst: decada a 5-a- a 6-a; B/F- 1:3.

a. Litiazic- inciden 80-95% secundarunui calcul inclavat n canalul cistic

b. Alitiazic- inciden 10% cazuri.

Eco.Sb-81-100%; Sp-60-100%. PereteVB>3mm (Sb- 45-72%; Sp-76-88%); aspectstratificat al peretelui; hidrops VB (diam

ax>5 cm); semnul Murphy ecografic pozitiv(Sb:63-94%; Sp:85-93%); fluidpericolecistic; calculi intraveziculari, n

canalul cistic; sludge

IV.A.Colecistita acut

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CT cu contrast iv:VB destins; perete cu grosime peste3mm, hiperdens; coninut VB densificat; fluid

pericolecistic; modificri de perfuzie hepatic n fazprecoce cu iodofilie tranzitorie n parenchimulpericolecistic;CPRM(Sb mare). Hiposemnal T2 inelar nconjurandhipersemnalul lichidului biliar.

Complicaii: abcesul pericolecistic; sindromul Mirizzi;gangrena; colecistita emfizematoas; sindromBouveret (calcul ce a erodat peretele VB, migrat nlumenul duodenal pe care-l obstrueaz); ileusul biliar(migrarea calculului VB n tractul gastrointestinalsecundar fistulei bilio-digestive i inclavarea acestuia

n zonele de ngustare ale tractului digestiv-unghiulTreitz, valv ileocecal, colon sigmoid).

IV A C l i tit t

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IV.A.Colecistita acut

IV.A.Colecistita acutalitiazica(asociata cu adenomiomatoza)
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(asociata cu adenomiomatoza)

Colecistita acut
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C l i tit t liti i
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Colecistita acutlitiazica

Colecistita acutlitiazica (calcul

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(

inclavat in colul VB)

Colecistita acut-complicatii

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Colecistita acut complicatii(colecistita gangrenoasa, calcul inclavat)

Colecistita acut

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(gangrenoasa) si duodenita

Colecistita acut- (perforatie

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veziculara asociata cu colecistita

gangrenoasa)

Colecistita acut- perforatie cu

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Colecistita acut perforatie cuabces hepatic

Colecistita acut

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hemoragica

IV.B.Colecistita acut emfizematoas
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Asocierea ischemiei peretelui VB cu infecia

determinat de microorganisme productoare de gaz(Costridium perfringens, E coli, Staphylococus,Streptococus);

Factori predispozani: diabetul, obstrucie litiazic/alitiazic de canal cistic; boli debilitante;

Rg abdominal simpl: acumulrihipertransparente pe aria de proiecie a VB la 24-48 de ore de puseul acut; nivel hidroaeric n

lumenul VB, n peretele VB; pneumobilie;Eco:litiaz VB (50% c); imagini hiperecogene

arcuate ce contureaz peretele VB;

IV.B.Colecistita acutemfi ematoas

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emfizematoas

Complicaie: gangrena; perforaia; Diag.dif.: fistula enteric; incompeten sfincter

Oddi; abces periduodenal; abces periapendicularn ectopia apendicelui;

Colecistita gangrenoas-apare la imunodeprimai;evolueaz spre necroz parietal i perforaie;

Perforaia vezicular se poate face intraperitoneal,

n tubul digestiv (duoden,colon) cu apariia uneiaerobilii sau se poate colecta n patul VB subforma unui abces perivezicular.

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Colecistita acut

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emfizematoas

IV. C.Fistula colecistoenteric

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Etiologie: litiaz biliar (90%) acut/ cronic; colecistit; neoplasmCBP; diverticulit; boli inflamatorii de intestin subire; ulcer peptic;traumatisme; comunicare congenital; iatrogen;

Comunicare cu: duodenul (70%), colonul (26%), stomacul (4%),jejunul, artera hepatic, vena port, arborele bronic, pericardul,bazinetul, ureterul, vezica urinar, ovarul, vaginul;

Fistul: colecistoduodenal (50-80%); colecistocolic (13-21%);coledocoduodenal (13-19%); fistule multiple (7%);

Aspecte imagist ice: pneumobilie- imagini transparente tubulare cepredomin n poriunea central a ficatului; opacifierea CB de ctrebariu/ Gastrografin;VB mic mimnd un diverticul de bulb duodenal;imagini multiple hiperecogene cu umbr posterioar vag.

Triada diagnostic: sindrom ocluziv, aerobilie si opacitate litiazic.Rg abdominal simpl i mai ales CTevideniaz cu sensibilitatecrescut aceste modificri.

IV.D.Ileusul biliar

Fistula biliara

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Ileus biliar

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IV.E.Colecistita cronic

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Este o inflamaie cronic a pereilor veziculeibiliare;

Anatomopatologic procesul inflamator cronicintereseaz toate tunicile parietale, pereteledevenind gros i fibros;

Reprezint cea mai frecvent inflamaie acolecistului;

Cauzele ce duc la apariia colecistitei cronicesunt litiaza veziculei biliare i obstrucia de

canal cistic; Peretele VB este cu grosime crescut n medie

de 5 mm cu contur regulat sau neregulat.

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IV.F.Colecistitaxantogranulomatoas

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xantogranulomatoas

Este ncadrat n inflamaiile cronice aleveziculei biliare simulnd att clinic ct iimagistic un carcinom vezicular. Inciden: 1-2%.Vrst: decada 7-8.n 11% din cazuri este

asociat cu neoplasmul VB;Eco.VB cu perete ngroat neregulat; nodulihipoecogeni intraparietali;CT.Noduli hipodeni intraparietali (5-20 mm);

priz de contrast heterogen; Diag.dif: neoplasmul VB (59% focal, 41% difuz).

Colecistita

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xantogranulomatoas
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Vezicula de porelan

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Reprezint depunerea de carbonat de calciu nperetele VB. Inciden de 0,6-0,8% la pacienii

colecistectomizai; B/F- 1:5. Asociat cu litiaza VB n 90% din cazuri.

Eco:imagine hiperecogen cu umbrposterioar n patul colecistic.CT:imagini calcare n peretele VB; coninuthiperdens.Colecistografia oral:VB exclus.

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Colesteroloza Corespunde unor depozite anormale de colesterol n macrofagele

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Corespunde unor depozite anormale de colesterol n macrofageledin lamina propria. Exist dou forme: vezicula frag(ngroaredifuz a pereilor VB i litiaza colesterinic n 50-70%c); polipul

colesterolic: imagine lacunar unic/ multipl fixat la peretele VB.

Adenomiomatoza focal i difuz a VB. Inciden-5% din pacienii

colecistectomizai; vrsta peste 35 de ani; M/F-1:3. Exist 4 tipuri:difuz (adenomiomatoza)- ingrosare difuza si pseudodiverticuli;segmentar (infundibul);localizat n regiunea fundic(adenomioma)- ingrosare focalizata ce asociaza imaginidiverticulare; inelar septat; Se poate asocia cu calculiintraveziculari si in 33% din cazuri cu colesteroloza.

Eco.Aspect de coad de comet- artefact produs ntre cristalele decolesterol n sinusul Rokitansky- Aschoff.

Adenomiomatoza focaldifuz a VB

Adenomiomatoza focal

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difuz a VB

Adenomiomatoza focalf

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difuz a VB

Adenomiomatoza focaldif VB
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difuz a VB

Stenoz CBP

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Benign(44%): Sunt rezultatul complicatiilor

chirurgicala iatrogene in 90-95%. Restulcazurilor fiind reprezentate de stricturi aparuteposttraumatisme penetrante, in chistul decoledoc; colangit sclerozant; colangitrecurent cu piogeni; pancreatit acut/ cronic;pseudochist pancreatic; ulcer duodenal perforat;colecistit litiazic; abces; postradioterapie;stenoz papilar; SIDA; fibroza retroperitoneala;adenopatii compresive; pancreas ectopic; tumori

benigne (adenoame, hamartoame); varice inperetele CBP.

Adenoame de CBP

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Adenoame de CBP

Papilomatoza biliara

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Pancreatita cronica
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Stenoza papilara

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Adenopatie compresiva

Patologia cilor biliare de tip

li C l i i l

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malign- Colangiocarcinomul

Colangiocarcinomul intrahepatic cu originea nepiteliul CBIH mici; vrsta: 50-60 ani; B>F.Extensie de-a lungul CB, n parenchimul hepatic; meta ggl (15%). Masde 5-20 cm, cu noduli satelii, calcificri punctiforme (18%).

Eco.Mas omogen/ heterogen hiperecogen(75%), izo/hipo (14%);dilataie de CBIHn periferia tumorii. Uneori mas chistic. CT.Mas omogen rotund, hipodens cu margini neregulate;

hipocaptant; iodofilie mic, fugage, precoce, n periferie cu progresiancrcrii spre centrul tumorii, periferia splndu-se (semnul splriiperiferice).ncrcareomogen tardiv(74%).

IRM.Mas heterogen cu hiposemnal T2 central- fibroz, hipersemnalperiferic (tumor viabil), hiposemnal T1, hiperfixant postGadolinium.

Angio.Mas avascular/ hipo/ hipervascular.

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Colangiocarcinomul (CC) centrohilar(tumora Klatskin)

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( )

Clasificarea Bismuthcuprinde 4 tipuri de CC:-Tipu l I:tumor la nivelul ductului hepatic comun curespectarea bifurcaiei.-Tipu l II:tumora infiltreaz ductul hepatic comunextinzndu-se la nivelul bifurcaiei.-Tipu l IIIa:afectarea ductului hepatic comun, a bifurcaieicu extensie la nivelul hepaticului drept i ramificaiilor deordinul doi ale acestuia.-Tipu l IIIb :afectarea ductului hepatic comun, a bifurcaiei,tumora extinzndu-se la nivelul hepaticului stng iramificaiilor biliare stngi.-Tipu l IV:extensia tumorii de la nivelul ductului hepaticcomun, la nivelul hepaticului drept, stng i a ramificaiilorde ordinul doi.

Colangiocarcinomul extrahepaticCC de CBP (DHC i coledoc)

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CC de CBP (DHC i coledoc)

Exist forma:-obstructivcu amputaie n U sau V (70-85%)-stenozant(10-25%), margini neregulate,aspect rigid; dilataie CB n amonte.

-vegetant (polipoid)(5-6%).

Extensie limfatic (48%), infiltraie nparenchimul hepatic (23%);determinri

peritoneale (9%); nsmnri hematogene-rare (ficat, plmn, peritoneu).

Colangiocarcinomul

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Colangiocarcinomul

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Fig- 4 tipuri de colangiocarcinom:Tipul Exofitic;Tipul Infiltrativ;Tipul Polipoid;Tipul Mixt (intra si extracanalar).

Colangiocarcinomul
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Co a g oca c o u

Colangiocarcinomul (CC)

intrahepatic centrohilar
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(tumora Klatskin)

Colangiocarcinomul (CC)

intrahepatic centrohilar

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Colangiocarcinomul

extrahepatic

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extrahepatic

Colangiocarcinomul

extrahepatic

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extrahepatic

ChistadenocarcinomulTumor malign chistic multilocular cu originea n CB;

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Tumor malign chistic multilocular cu originea n CB;Se poate supraaduga hemoragia intratumoral; exist

multiple neregulariti de tip nodular la nivelul pereilor;calcificri grosieretumor rar, chistic, multilocular cupunct de plecare n CBIH. Inciden maxim: decada a 5a.

Eco:mas anecogen/ hipoecogen cu septuri ecogenen interior, delimitat de un perete gros ecogen (mimeazCHH).

CT:se prezint sub forma unei leziuni circumscrise cuperei groi,cu coninut fluid sau parafluid (mucinos/gelatinos) ce conine in interior septuri ce delimiteazmultiple caviti chistice. Iodofilie prezent la nivelulpereilor i septurilor.

IRM:aspectul componentelor chistice variaz funcie decantitatea de proteine coninut.

Ang io:mas avascular, deplasarea structurilorvasculare din vecintate.

Complicaii: ruptura tumorii intra sau retroperitoneal.

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Patologia cilor biliare de

tip malign

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tip malign Carcinomul hepatocelular (CHC)

Invazia de ci biliare este rar ntlnit n CHC.CPRM:stenoze neregulate n formele infiltrative saumase polipoide procidente intralumenal.

- cea mai frecvent tumor hepatic primar (80-90%) - 60-90% din CHC apar pe un ficat cirotic.

- factori de risc: ciroza (alcoolic); hepatita cronic;carcinogeni (hormoni, aflatoxin, thorotrast).

- mas solid unic/ multipl/ form difuz.

- 24% incapsulat; calcificri (10-20%c); invazie vascular(48%).- meta: pulmonare; suprarenale; osoase; ganglioni.- fetoproteina crescut la 90% din pacieni.

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Carcinomul hepatocelular(CHC)

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(CHC)

IRM:caracterizarea superioar a structurii intratumorale;hiposemnal/ hipersemnal T1 (Cu, snge, grsime),hipersemnal T2; capsula hiposemnal T1 i hipo/hipersemnal T2; comportare similar post contrast

paramagnetic cu ex CT. SPIO amelioreaz detecianodulilor de mici dimensiuni.Scint igraf iacu Tc-HIDA, Gallium.Angiograf ia:vase de neoformaie, unturi arterio-

venoase.Metastazelepot determina : zone de stenoz,obstrucie, deplasri, amputri, tergereaarborizaiei biliare normale

Carcinomul hepatocelular

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(diagnostic diferentialcolangiocarcinomulperiferic exofitic)

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Metastazele recurenta tumorala

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dupa adenocarcinom pancreatic)

CTiIRM-bilan preterapeutic.Inciden: 0 4-4 6 din pacienii supui interv chir pe CB;

Carcinomul veziculei biliare

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Inciden: 0,4-4,6 din pacienii supui interv. chir. pe CB;cel mai comun neo. biliar.

Vrsta medie : 73 ani. Asociat cu litiaza biliar, veziculade porelan, colecistita cronic, polipii VB;colangitasclerozant primitiv chistul de coledoc. Sediul deelecie- regiunea fundic (60%c).

Eco:mas ce nlocuiete VB, heterogen; tumor

inseparabil de ficat; mici imagini ecogene (calculi/calcificri). CT i IRM:stadializarea exact :ngroarea focal sau

difuz asimetric a peretelui vezicular; masa tumoralpericolecistic hipocaptant cu zone de necroz incluse;

n 90% din cazuri litiaza vezicular asociat. Contraindicaiile unei rezecii chirurgicale: atingerea

parenchimului hepatic (segmentele IV si V) n contact cupatul vezicular; infiltrarea CB este frecvent (60-90%dincazuri); prezena adenopatiilor celiace si pediculare;

nglobarea venei porte si a arterei hepatice

Adenocarcinomul

veziculei biliare

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veziculei biliare

Adenocarcinomul

veziculei biliare
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veziculei biliare

Carcinomul veziculei

biliare

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biliare
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Patologia cilor biliare de tipmalign

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Metastazele veziculare: apar n- cancerul de ovar,melanoame i rar n alte tipuri de tumori primare. Suntasociate cu metastaze hepatice. O forma particulareste hidrocolecistul secundar unei metastaze culocalizare la nivelul cisticului. Imagistica estenespecific

Neoplasme extrabiliare,extrahepatice cuinvazie de ci biliare

Tumorile periampulare(cefalice pancreatice, de regiuneampular, duodenale invazive) evaluate CT i mai alesIRM i CPMR pot prezenta, fie aspectul de stop total alCBP la contactul cu procesul tumoral, fie semnuldublului duct, adic dilataie de coledoc i ductpancreatic.

Metastazele veziculare

(melanom)

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(melanom)

Tumorile periampulare

(adenocarcinom pancreatic)

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(adenocarcinom pancreatic)

Carcinom pancreatic

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Carcinomul ampular

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Carcinom duodenal
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periampular

Patologia cilor biliare de cauztraumatic, iatrogen,

postoperatorie

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postoperatorie Incidena leziunilor de CB posttraumatisme

abdominale este rar (sub 0,1%).Mecanismul: dilacerare hepatic extins la

nivelul DH.

Complicaii: obstrucia biliar; biliom;extravazarea de bil; atrofia parial de ficat .

Eco, CT: colecie fluid (biliom).IRM: stenoze,amputaie de cale biliar; colecie cu semnal

lichidian dezvoltatn contiguitate cu un ram biliar(biliom).Colangiografie iv: extravazarea substanei de

contrast din CB.


postoperatorie

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postoperatorie Complicaii biliare dup proceduri percutanate

- Colangiografia transhepatic percutanatcu acChiba, incidena complicaiilor: de aproximativ 1,8%.Complicaii postCTH: bacteriemia, hematomulsubcapsular, fistula biliar, biliomul, peritonita, fistula

arteriovenoas, fistula vasculobiliar.CPRMpoate evidenia, n anumite cazuri, imaginiadiionale cilor biliare ce caracterizeaz fistulelebiliare iatrogene.Fistule arteriovenoase sau vasculobiliare: explorate

prin CTS cu contrast sau angio-RM.- Drenajul biliar externincidena complicaiilor: 10-15% din cazuri.- Biopsia hepaticrata complicaiilor: sub 1% .

Leziuni posttraumatice deCBIH (laceratie LD dupa

t ti )

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traumatism)

Leziuni posttraumatice deCBIH (bilioame hepatice

tt ti )
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posttraumatice)

Leziuni de VB posttraumatice

(laceratia VB)

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( )

Complicaii biliare dupproceduri percutanate (biopsie

hepatica-hematom)
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p )


postoperatorie

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postoperatorie Complicaii dup colecistectomie

- Stenoza ductului hepatic comun. Incidena dup colecistectomiaconvenional este de aproximativ 0,1%; 0,6% dup colecistectomialaparoscopic.- Extravazarea de bilpostcolecistectomie se produce fie de lanivelul bontului restant de canal cistic, fie prin leziunile parietale decanal hepatic comun sau canal hepatic drept. Extravazarea de bilpoate duce la apariia unei peritonite biliare, unui biliom sau unuiabces.- Sindromul postcolecistectomie, reprezint persistena/ recurenasimptomatologiei de tip biliar dup colecistectomie.Cauzele : -biliare : chirurgie incomplet (calculi restani n bontulcistic sau migrai la nivelul CBP), stenoze iatrogene de duct hepaticcomun, extravazare de bil, patologie de coledoc (fibrozacomplexului sfincterian vaterian, dischinezie biliar);- extrabiliare:pancreatite, hepatite cronice.- Calculii biliari migrai n CBP sau restani n bontul cistic

Complicaii dupcolecistectomie (calculi

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reziduali)

Complicaii dup colecistectomie(hematom in fosa VB;

duct hepatic drept aberant cu anastomoza

bili t i )
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bilioenterica)

Complicaii dup colecistectomieBiliom
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postoperatorie
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postoperatorie Stenoza postanastomoz hepaticojejunal

Stenozele cicatriciale postchirurgicale sunt scurte; aspect nespecific.20-23% din pacienii cu hepaticojejunostomie dezvolt stenoze cufenomene de colangit sau litiaz. Mecanismele ce duc la apariia

stenozelor anastomotice sunt reprezentate de procesele de fibroz ineoplasmele recurente.Semne imagistice (CPRM, CTH): dilataii de CBIH; stenoz de la nivelulgurii de anastomoz.Fibroza: stenoz scurt, limitat zonei de anastomoz, limite nete dedemarcaie.

Recidiv tumoral: mas tisular neregulat ce amputeaz i tergevizibilitatea anastomozei.n comparaie cu CTH, CPRM supraestimeaz zonele de stenoz, ERCPeste n majoritatea acestor cazuri imposibil de realizat.

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ColedocojejunostomieHepaticojejunostomie

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postoperatorie

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p p

Complicaii biliare posttransplant hepatic:stenoza gurii de anastomozanastomoza coledococoledocian incidenastenozei: 5%,

anastomoza coledocojejunal inciden: 27%dincazuri. Cauze: fibroz sau sutur anastomoticfoarte strns.IRM:evideniaz existena unei stenoze scurte, lanivelul anastomozei, cu limite net trasate.CTH:tratament percutanat.

Complicaii biliare

posttransplant hepatic

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p p p
http://radiographics.rsnajnls.org/cgi/content/full/26/6/1603/F9Chttp://radiographics.rsnajnls.org/cgi/content/full/26/6/1603/F23http://radiographics.rsnajnls.org/cgi/content/full/26/6/1603/F22http://radiographics.rsnajnls.org/cgi/content/full/26/6/1603/F11

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Hemobilie

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Pneumobilie dupasfincterotomie
http://radiographics.rsnajnls.org/cgi/content/full/27/2/477/F12Ahttp://radiographics.rsnajnls.org/cgi/content/full/26/6/1603/F9Bhttp://radiographics.rsnajnls.org/cgi/content/full/26/6/1603/F9Ahttp://radiographics.rsnajnls.org/cgi/content/full/26/6/1603/F29A

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Lrgirea ductului hepatic comun decauze neobstructive

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Pasajul unui calcul (revenire la normal dup zile/sptmni) Postchirurgical (revenire la normal dup 30-60 de

zile)

Postcolecistectomie Hipomotilitate intestinal Variant de normal la vrstnici Ecografie + prnz gras cuplat permite

diferenierea de procesele obstructive prinmsurarea diam DHC nainte i la 45, 60 de mindup stimulare. Sb: 74%; Sp: 100%.

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Va multumesc.

Date post:	04-Jun-2018
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