X-ray signs of liver and bile duct disease

The recognition of diseases of the liver and bile ducts is currently the result of the collective efforts of therapists, surgeons, ray diagnosticians, laboratory technicians and other specialists. Radiation methods occupy an important place in a complex of diagnostic measures.

Diffusive lesions of the liver. Precise diagnosis of diffuse lesions is based on anamnestic and clinical data, the results of biochemical studies and in some cases puncture liver biopsy. Ray methods usually play only a supporting role. An exception is fatty hepatosis. Fat absorbs X-ray radiation worse than other soft tissues, so the liver shadow with fatty hepatosis on computer tomograms is characterized by low density.

With hepatitis on the X-ray, sonographic and scintigram, a uniform increase in the liver is determined. Both on sonograms and on scintigrams there may be a small image heterogeneity. Moderately increased spleen.

Significantly more pronounced radiation symptoms of cirrhosis of the liver. The liver is enlarged, its edge is uneven. In the future, there may be a decrease and deformation of the right lobe of the liver. There is always a noticeable increase in the spleen. When scintigraphy with colloidal solutions, there is a significant increase in the radioactivity of the spleen, while in the liver the concentration of RFP decreases. Foci of decreased accumulation of RFP in the areas of proliferation of connective tissue and, conversely, increased accumulation in the sites of regeneration are revealed. Especially evident is the variegation of the image of the organ is determined with a layered radionuclide study - emission single-photon tomography. In hepatobiliary scintigraphy, signs of a violation of hepatocyte function are revealed: the liver radioactivity curve reaches a maximum late, after 20-25 minutes after the beginning of the study, the curve of the curve lengthens (a sign of intrahepatic cholestasis), the bile ducts are contrasted late.

Sonograms confirm the heterogeneity of the structure of the liver: in its image reveal multiple foci of different echogenicity - reduced and elevated. MRI and CT allow detection of regeneration areas among cirrhotic fields. The branches of the portal vein in the liver are narrowed, and the portal vein and splenic vein are widened, as cirrhosis leads to portal hypertension. In sonography and CT, the presence of effusion in the abdominal cavity is established. On computer tomograms and angiogrammah, varicose-dilated veins can be detected - a consequence of portal hypertension.

Varicose-dilated veins of the esophagus and stomach are fairly clearly revealed in the X-ray examination of the upper digestive tract with barium sulfate. Against the background of the folds of the mucosa of the esophagus and to a lesser extent the stomach, the varicose nodules form rounded, oval and serpentine bands of enlightenment - filling defects.

Patients with cirrhosis of the liver are always shown X-ray examination of the esophagus and stomach with barium sulfate.

With cirrhosis, all vascular systems of the liver are involved in the process. The hepatic artery and especially its branches are sharply narrowed, whereas the gastric and splenic arteries are enlarged. This clearly demonstrates angiography. In the parenchymal phase of angiography, the liver contrasts unevenly. At most sites, the tissue pattern is depleted, while the zones of hypervascularization are noted at the sites of regeneration. During the return (venous) phase, it is possible to document collateral blood flow pathways, varicose-dilated veins, including in the esophagus and stomach, enlargement of the splenortral trunk and at the same time deformation and narrowing of the intrahepatic portal vessels.

Focal lesions of the liver. To focal (volume) formations of the liver include cysts, abscesses and tumors. Cysts filled with fluid are most surely recognized. On sonograms such a cyst looks like an echo-negative formation of a rounded shape with clear, even contours and a thin wall. There are both single and multiple cysts of different sizes. Cysts with a diameter of less than 0.5-1.0 cm are not detected if there are no lime deposits in their capsule. The marginal annular calcifications are most typical for echinocoy cysts. One of the varieties of cystic liver damage is polycystosis, in which a large part of the organ parenchyma is replaced by fluid-containing cavities. In this disease, cysts can also be in the kidney and pancreas.

On computer and magnetic resonance tomograms, the cyst is reflected as a rounded formation with smooth contours containing the liquid. Especially well visible are cysts on strengthened computer tomograms, i.e. Obtained after the administration of contrast agents. Spatial resolution of CT and MRI is much higher than sonographies. In these studies, it is possible to identify cystic formations with a diameter of only 2-3 mm. Liver scintigraphy is rarely used to detect cysts due to its low spatial resolution.

Asbestos of the liver, like a cyst, on sonograms, scintigrams, computer and magnetic resonance tomograms, causes a limited image defect. In addition to clinical data, additional signs help to distinguish these two lesions. First, an area of the altered tissue is usually located around the abscess. Secondly, the outline of the abscess is less even than the cysts, and the densitometric density on computer tomograms is superior to the cyst. Small pyogenic abscesses are usually located in groups, they often show seals - along the edge or in the center of the cavity.

Most benign liver tumors are hemangiomas, less common are adenoma and nodal hyperplasia. On sonograms they are seen as hyperechogenic formations of round or oval shape with clear contours and homogeneous structure. On computer tomograms, hemangioma causes a limited area of reduced density of a heterogeneous structure with uneven outlines. With enhanced CT, there is an increase in the densitometric density of the affected area. A similar picture on computer tomograms is given by an adenoma, but when the contrast medium intensifies, its shadow turns out to be less intense than the surrounding tissue of the liver. With nodular hyperplasia, computerized tomograms detect multiple small hypodense foci. Hemangioma quite clearly emerges with MRI, especially when combined with a paramagnetic contrast study. As for radionuclide imaging, it is inferior in spatial resolution to all the listed methods of visualization of the liver and is currently rarely used for this purpose.

Hepatocellular carcinoma (hepatoma) causes on the sonograms an area of uneven density with uneven contours. The disintegration of the tumor looks like an echonegative zone of irregular shape, and the swelling around the tumor - like a vague rim, is also echo negative. On computer, magnetic resonance tomograms and scintigrams (emission tomograms) hepatoma causes a defect of irregular shape with uneven outlines.

Radiation picture of metastases of malignant tumors in the liver (and this, unfortunately, frequent lesion) depends on the number and size of the tumor nodes.

Among all means of visualization of metastases, CT has the best spatial resolution, especially when performed by an enhanced technique, followed by an MRI and closes the group named sonography and scintigraphy.

Survey of such patients usually begin with sonography as the most accessible and cheap method. In our country in oncology dispensaries, according to the established tradition, most patients with malignant tumors perform liver scintigraphy in addition to sonography in order to detect metastases. However, gradually, as the development and strengthening of the material base of these medical institutions, CT scan becomes increasingly important in detecting metastases in the liver. We also note that in the presence of metastases, as in other volumetric processes in the liver (primary malignant or benign tumor, abscess), AT and sonography can perform a targeted puncture of pathological formation, take tissue for histological (or cytological) research and, if necessary, The affected area is the required drug.

Under the control of radiation studies, patients with small hepatic-cell malignant tumors and single metastases (in particular, colorectal cancer) are treated. Apply either percutaneous injections of ethanol into the tumor node, or laser irradiation through optical fibers, also transdermally introduced into the tumor. Sonograms and tomograms allow you to evaluate the results of treatment. The intraoperative sonography serves as a valuable aid in operative interventions on the liver. A sterile ultrasound sensor, led to the liver, makes it possible to refine the anatomical variants of the branching of the blood vessels and ducts of the liver and to detect previously unnoticed additional tumor nodules.

Diseases of the biliary tract. In recent years, the frequency of development of cholelithiasis has increased markedly. By composition, cholesterol, pigment, calcareous and mixed (cholesterol-pigment-calcareous) stones are distinguished.

In the diagnosis of gallstones, sonography plays a decisive role. Its sensitivity reaches 95-99%, and the detection limit of stones is 1.5-2 mm. The stone on the sonogram causes hyperechoic formation in the cavity of the gallbladder. Behind the stone, an acoustic shadow is defined - a "sound track".

On ordinary radiographs, gallstones can be recognized only if they contain lime deposits. The remaining stones are identified with cholecystography, if the cystic duct is passed and the contrasted bile enters the bladder. The stones give defects in the shadow of the gallbladder. The number, size and shape of the defects depend on the number, size and shape of the stones. Clearly detected stones with CT. With the development of sonography, cholecystography, which was the main method of detecting stones in the bladder, lost its importance.

Stones in the bile ducts with sonography are rarely detected, since they are usually small; in addition, some part of the common bile duct is covered by the duodenum, which worsens the ultrasound visualization of this part of the bile excretory system. In this regard, the main method of visualizing stones in the bile ducts is CT, and only in the absence of the possibility of its conduct can be assigned to choleography. An indicative picture of stones in the bile ducts on MRI. With mechanical jaundice, important diagnostic data can be obtained with ERCPH-In recent years, interventional methods of treatment of cholelithiasis have become increasingly widespread. Under the control of ultrasound or CT, percutaneous puncture of the gallbladder, its catheterization and subsequent administration of drugs (aliphatic alcohols) that dissolve stones are performed. In practice, extracorporeal shock wave lithotripsy methods were also introduced. Rapidly developing X-ray surgical interventions used in occlusal lesions of the biliary tract. Percutaneous access to the liver is provided by special catheters, and through them the necessary tools for removing the gallstones left behind during surgery, eradication of strictures, placement in the ducts of the drainage tube for the purpose of biliary decompression and external or internal drainage of the biliary tract.

Valuable methods for the clinician are radiation methods in the diagnosis of cholecystitis. First, they allow you to immediately distinguish between calculosis. Secondly, with their help, a group of patients with inflammatory stenosis of the terminal section of the common bile duct is isolated. Thirdly, they make it possible to establish the patency of the cystic duct and the degree of disruption of the concentration and motor functions of the gallbladder, which is very important in planning treatment, especially when deciding on the question of surgical intervention.

In acute cholecystitis, the primary method of investigation is sonography. With it, an increase in the size of the bladder and a thickening of its wall are found. Around the bladder a zone of edema appears. A very frequent finding in sonography is intravesical gallstones; they are observed in 90-95% of patients with acute cholecystitis. All these symptoms are fairly clearly identified with CT, but with positive sonographic and clinical data, it is infrequent. An indirect sign of cholecystitis in sonography can be limited mobility of the right half of the diaphragm during breathing. Note that this symptom is also revealed during X-ray examination of the thoracic cavity organs - fluoroscopy.

Chronic cholecystitis in sonography shows similar signs: the size of the bladder is often enlarged, less often, with shrinkage of the bladder, reduced, the walls are thickened, sometimes uneven, the surrounding liver tissue is usually compacted, often the stones or deposited dense components of bile are visible in the bladder. In a number of cases, the bladder due to sclerosing pericholecystitis is significantly deformed. The last symptom should be evaluated with great care. It should be remembered that in 8% of healthy people there are congenital deformations of the gallbladder, sometimes quite bizarre. All these symptoms can be identified and using other methods of radial imaging - CT and MRI. Hepatobiliary scintigraphy makes it possible to detect dyskinesia of the bladder of varying severity, up to the complete loss of its concentration function and contractility.

Radiation methods and biliary tract surgery are inextricably linked. Ultrasonic surveillance expands the possibilities of laparoscopic surgery. Under the control of ERCPH, papillotomy and sphincterotomy are performed. Percutaneous transhepatic cholangiography is a mandatory preliminary procedure before the percutaneous drainage of the biliary tract and the introduction of various instruments in them, in particular for dilatation of the narrowed sections of the ducts. To detect the gallstones left during the operation, cholangiography is used through the drainage tube. With the help of venoportography, the function of hepatic portal anastomosis, imposed on a patient with cirrhosis of the liver, is evaluated. It is understandable that the main radiation methods - sonography, CT and MRI - are necessary for liver transplantation.

Syndrome of portal hypertension. The term "portal hypertension" means increased pressure in the portal vein system. Distinguish superhepatic blockade, when hypertension is caused by a violation of blood outflow from the liver as a result of compression or thrombosis of the inferior vena cava, thrombophlebitis of the hepatic veins, constrictive pericarditis, intrahepatic blockade, mainly in cirrhosis, and a subhepatic blockade caused by an anomaly of development, thrombosis or compression of the trunk itself portal vein.

With portal hypertension, varicose veins of the esophagus and stomach are observed, which can be complicated by bleeding. To assess the location and severity of varicose veins, X-ray examination of the esophagus and stomach with barium sulfate, endoscopic sonography or angiography (CT or MRI angiography) is used. By transhepatic access, a catheter is made into the portal vein and then embolization of varicose-dilated veins is performed.

Injury of the abdomen. The place and nature of the radiation examination in case of blunt trauma to the abdomen or wounding with gunshot or cold steel depends on the condition of the victim. At a condition of average gravity research spend in branch of radial diagnostics. Clinically unstable patients (severe condition, shock) have to be examined in the intensive care unit. The victims who need urgent surgery are examined directly on the operating table. In all cases, the following scheme is followed.

Radiographic examination of the thoracic cavity is important for the exclusion of combined thoracoabdominal damage; can also be identified fractures of the chest, traumatic collapse of the lung, pneumonia.

Sonography allows you to determine the increase in the affected organ, break its contour, the presence of subcapsular or intraorganic hematomas, the presence of fluid (blood, bile) in the abdominal cavity. CT is more effective than sonography, because the latter is prevented by flatulence, which, as a rule, is observed with a trauma to the abdomen. Damage to the abdominal wall can also interfere with sonography. CT is a "sensitive" method of detecting fluid in the abdominal cavity. The presence of fluid suggests that damage to the intestine or mesentery is suspected. Recently, great opportunities for spiral computed tomography, performed after oral administration of 500 ml of a 2-5% solution of water-soluble contrast medium, are shown. With the help of a series of tomograms, it is possible to recognize bruises and ruptures of the abdominal organs, hematomas and hemoperitoneum, bile accumulations (bilomena), pseudoaneurysms, vein thrombosis, etc. In unclear cases, decisive information is obtained with angiography. It allows you to determine the source of bleeding, the rupture of certain vessels. With its help, you can perform therapeutic activities, such as the introduction of hemostatic drugs or embolization of the bleeding vessel.