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Image-guided liver biopsy

Introduction Percutaneous image-guided needle biopsy (PNB) is the cornerstone for diagnosis and treatment of many diseases involving the liver. Minimally invasive, PNB is an effective outpatient procedure with a low complication rate. The success of PNB requires proper patient selection, optimal procedural technique, and optimal postprocedure management. Interventional radiology (IR, which also stands for interventional radiologists) plays a central role in patient management because of the…

Endoscopic ultrasound of the biliary tract and pancreas

Imaging and diagnosis The diagnosis of benign and malignant diseases of the pancreas and biliary tree historically have relied on a detailed history and complete physical examination, with correlation of the results of clinical chemistries. Imaging of the hepatic and pancreatic parenchyma and ductal anatomy has, however, evolved as critical for accurate diagnosis and for guiding therapy. Ultrasonography (US), computed tomography (CT), and magnetic resonance imaging…

Diagnostic angiography in hepatobiliary and pancreatic disease: Indications

Overview Once a mainstay of diagnosis in hepatobiliary and pancreatic diseases, indications for catheter angiography have changed significantly in the past three decades. This is mainly because of the widespread adoption of noninvasive imaging modalities such as multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI). These imaging techniques can accurately demonstrate both vascular and nonvascular structures associated with the hepatobiliary and pancreatic systems without the…

Direct cholangiography: Approaches, techniques, and current role

Direct cholangiography overview Direct cholangiography, the introduction of contrast medium into the biliary system, can be performed under fluoroscopic guidance percutaneously, endoscopically, or intraoperatively via surgically placed catheters. The nonoperative techniques are percutaneous transhepatic cholangiography (PTC) and endoscopic retrograde cholangiopancreatography (ERCP). Magnetic resonance imaging (MRI) and contrast-enhanced computed tomography (CECT), however, have virtually eliminated the need for direct cholangiography (see Chapters 13 and 16 ). Currently,…

Emerging techniques in diagnostic imaging

The field of radiology has undergone tremendous growth over recent decades, with continuous advances in diagnostic imaging that include innovations in medical devices, such as the creation of dual energy–source multidetector computed tomography (CT); innovations in imaging agents, such as new hepatocyte-specific gadolinium (Gd)-binding contrast agents for magnetic resonance imaging (MRI); increases in use of functional imaging, such as for magnetic resonance (MR) diffusion-weighted imaging, and…

The role of nuclear medicine in diagnosis and management of hepatopancreatobiliary diseases

Nuclear medicine uses radioactive pharmaceuticals, or radiopharmaceuticals , for diagnostic imaging and internal radiotherapy of a variety of diseases. This chapter discusses clinical applications of diagnostic nuclear medicine imaging for the care of patients with hepatic, pancreatic, and biliary (hepatopancreatobiliary [HPB]) diseases. Radioembolization of liver tumors with radiolabeled microspheres is discussed more extensively in Chapter 94B . In general, the role of diagnostic nuclear medicine imaging…

Imaging features of benign and malignant pancreatic disease

Introduction to pancreatic imaging Transabdominal ultrasound (US) is a noninvasive, inexpensive, and rapid method of evaluating morphologic changes in the pancreas and may be used as an initial investigation in the setting of abdominal pain or suspected obstructive jaundice. However, considerable limitations reduce its diagnostic utility; these include overlying bowel gas obscuring the pancreas and limitations related to the patient’s body habitus. If a pancreatic mass…

Imaging features of gallbladder and biliary tract disease

In the past decade, the combination of increased computing processing power and technologic improvements in acquisition across all modalities have imparted significant advances in medical imaging, including imaging of the biliary tract and gallbladder. This chapter will review current methods of evaluating the most common abnormalities of the biliary system. As the gallbladder resides in a somewhat anterior right upper quadrant location, ultrasound is ideal for…

Imaging features of metastatic liver cancer

Overview Imaging plays a central role in the characterization of liver lesions and detection of liver metastases in patients at risk. As treatment options for patients with metastatic liver disease have proliferated over the past decade (see Chapter 90, Chapter 91, Chapter 92 ), timely and accurate characterization of liver lesions is increasingly important. Several imaging modalities, such as ultrasonography (US), computed tomography (CT), and magnetic…

Imaging features of benign and malignant liver tumors and cysts

Introduction The increased frequency of cross-sectional imaging with improved imaging techniques has resulted in the increased detection of liver lesions. The majority of incidentally discovered liver lesions are benign, even in the oncologic population. , Although ultrasound (US) can be useful in screening for and detecting liver lesions, lesion characterization is mostly performed using computed tomography (CT) or magnetic resonance imaging (MRI). Contrast-enhanced ultrasound (CEUS) provides…

Cross-sectional imaging of liver, biliary, and pancreatic disease: Introduction and basic principles

Introduction Cross-sectional imaging of the liver, biliary tree, and pancreas can be performed with ultrasound, computed tomography (CT), or magnetic resonance imaging (MRI). Positron emission tomography (PET) is most often performed in combination with CT (PET-CT) and has more recently been performed in conjunction with MRI (PET-MRI). This chapter will emphasize basic principles of ultrasound, CT, and MRI that highlight the strengths and limitations of each…

Clinical investigation of hepatopancreatobiliary and pancreatic disease

Introduction The clinical approach to the patient diagnosed with hepatopancreatobiliary (HPB) disease must be systematic without neglecting clinical elements that could prove illuminating in the diagnostic process. The correct interpretation of symptoms and signs could be challenging, demanding great judgment, because even subtle clinical manifestations may forecast unattended events. A meticulous, detailed history and physical examination, followed by a few laboratory tests, are of great value.…

Infections in hepatic, biliary, and pancreatic surgery

Infections cause significant morbidity and mortality in patients undergoing hepatopancreatobiliary (HPB) surgery. In the era of more extensive resections in elderly comorbid patients with the greater use of perioperative chemoradiotherapy and biliary instrumentation, surgical-site infection (SSI) rates after HPB procedures can be as high as 20% to 40% with an added substantial risk of intraabdominal infections. Infection is associated with increased hospital stay, operative times, transfusions,…

Fundamentals of liver and pancreas immunology

Introduction The immune system manifests two strategies of host defense termed innate and adaptive immunity ( Fig. 10.1 ). Innate immunity refers to the nonspecific first line of defense against danger signals from pathogens or tumor cells. The repertoire of innate immune cells includes natural killer (NK) cells, macrophages, and dendritic cells (DCs). Innate immune cells sense both tissue injury and pathogens through pattern recognition receptors…

Advances in the molecular characterization of biliary tract and gallbladder cancer

Biliary tract cancers First described by Durand-Fardel in 1840, biliary tract tumors arise from cholangiocytes residing in the biliary tree. The biliary tract cancers include intrahepatic cholangiocarcinoma (IHCC, within the liver; see Chapter 50 ), extrahepatic cholangiocarcinoma (EHCC, within the extrahepatic biliary tree; see Chapter 51 ), and gallbladder cancer (GBCA, within the gallbladder; see Chapter 49 ). Recently, it has been recognized that some subtypes…

Advances in the molecular characterization of pancreatic cancer and pre-malignant lesions

Pancreatic cancer overview Pancreatic ductal adenocarcinoma (PDA), commonly referred to as “pancreatic cancer” is the fourth most common cause of cancer in both men and women. PDA remains a devastating diagnosis, with an overall survival rate of no greater than 10%. , In 2020 approximately 57,600 Americans will be diagnosed with PDA, and approximately 47,050 will die of it (see Chapters 61 and 62 ). The…

Advances in the molecular characterization of liver tumors

Overview Tumors of the hepatobiliary (HB) system are among the most challenging tumors to effectively manage in the clinic. At time of diagnosis, only approximately 25% of gallbladder carcinoma (GBC) patients, 30% of cholangiocarcinoma (CCA) patients, and 30% of hepatocellular carcinoma (HCC) patients are eligible for curative therapy through surgical resection (see Chapter 49, Chapter 50, Chapter 51 and 89 ). The direct result of this…

Molecular and cell biology of liver carcinogenesis and hepatitis

Overview of molecular etiology Recent advances in molecular genetics have emphasized the multistep process of tumorigenesis. It is evident that cancer is a genetic disease involving aberrant chromosome rearrangements, genetic mutations, and epigenetic silencing of tumor suppressor genes. Independent of the etiology, hepatocellular carcinoma (HCC) generally develops where sustained hepatocyte turnover occurs in the setting of injury-inflammation-regeneration, which leads to the accumulation of chromosomal aberrations (see…

Molecular and cell biology of hepatopancreatobiliary disease: Introduction and basic principles

Introduction In recent years, there has been an increased understanding of the molecular and cellular processes that govern hepatopancreatobiliary (HPB) diseases. These processes, which include those that are immune-mediated, involve chronic inflammation or processes of neoplastic transformation and are driven by factors such as genomic alterations, epigenetic modification, and dysregulated cell signaling pathways. These principles are integrally intertwined, as evidenced by crosstalk between genetic and epigenetic…

Bile secretion and pathophysiology of biliary tract obstruction

Overview Bile secretion is one of the major functions of the liver, which serves two major purposes: (1) the excretion of hepatic metabolites—including bilirubin, cholesterol, drugs, and toxins—and (2) the facilitation of intestinal absorption of lipids and fat-soluble vitamins. More recently, through their interaction with the gut microbiome, bile acids also have been found to have important signaling functions. Through receptor activation, bile acids regulate lipid,…