RADIOLOGICAL ANATOMY OF

LIVER, GALLBLADDER, BILIARY

TREE, PANCREAS AND SPLEEN

TALAT H.SHARIF MD
 Objective
 To identify abdominal structures such
as liver, gallbladder, pancreas and
spleen on X-Rays, Contrast Studies,
CT Scan , Ultrasound and MRI
 To be able to understand the
relationship of these organ with the
structures around them.
 Imaging Modalities
 X-RAYS
 ULTRASOUND
 CT SCAN
 MRI
 T-TUBE CHOLANGIOGRAM
 MRCP
 ORAL CHOLECYSTOGRAM
 ENODSCOPIC RETROGRADE
CHOLANGIOPANCREATICOGRAPHY (ERCP)
 CHOLESCINTEGRAPHY
 Radiographic anatomy on
Supine abdominal film
 Standard plain abdominal film is taken with the
patient in the supine position.
 It may help us to make a specific diagnosis.

 It may also provide useful information for

determining if any subsequent or more
specialized, examinations are needed.
 Radiographic anatomy on
Supine abdominal film
 Plain abdomen film may also help us
 To evaluate the normal soft-tissue
densities /organs, and abnormal
masses
 To find any calcifications in the
abdomen if any.
 Radiographic anatomy on
Supine abdominal film
– To evaluate any gaseous lucencies , their
distribution and the amount of
intraluminal gas, the presence of any
abnormal intraluminal collections, and
any evidence of extraluminal gas
– To evaluate the visualized bones and the
lung bases.
Plain Abdominal film(supine)
Supine view shows
normal liver, kidneys,
and psoas muscles.
In plain-film estimation of
liver size is not very
reliable and does not
correlate well with
clinical estimations of
liver size.
 Normal soft tissue densities
– The normal soft-tissue structures that can
usually be identified on plain films of the
abdomen include the liver, kidneys, psoas
muscles, and bladder .
– The normal spleen and the uterus may also
be identified. (not always).
– These structures are of water density
and are visible because they are
largely surrounded by fat.
Normal soft tissue densities
 A supine view
of the abdomen
shows normal
(L), spleen (S),
kidneys (K), and
psoas muscles (
Psm). The right
kidney is lower
than left
Liver
Anatomic diagram of abdominal
organs
 Liver
 The largest organ in the abdominal
cavity and the most complex.
 Liver occupies most of the right
upper quadrant.
 upper surface of the liver is almost
always adjacent to the inferior
surface of the right hemidiaphragm.
 Liver
 Located between the fifth intercostal
space in the midclavicular line
downward and along the right costal
margin.
 Weighs approximately 1800 grams in
men and 1400 grams in women.
 Surfaces of the liver are smooth and
convex in the superior, anterior and
right lateral regions.
Liver
 Inferior margin of the
liver is defined by
extraperitoneal fat
posteriorly and by gas
in the hepatic flexure
and transverse colon
anteriorly.
 Right lateral margin of
the liver can also be
seen because of
adjacent fat.
 Liver
 The physical
examination defines
the anterior margin of
the liver.
 It is the posterior
margin of the liver,
which is surrounded
by retroperitoneal fat,
that is consistently
visible on radiographs
 Liver

 Liver size is< 13 cm (Normal)

 > 15.5 cm is considered hepatomegaly

Hepatomegaly may be detected by:

– Elevation of the right hemidiaphragm
anteriorly
– Inferior displacement of the hepatic flexure
– Left lateral displacement of the stomach.
surfaces of the liver are smooth and convex in the superior,
anterior and right lateral regions.
Portal Triad
CT Scan (Porta Hepatis)
 Abdominal Ultrasound

RIGHT LOBE
LIVER

DIAPHRGAM

COSTOPHRENIC
SULCUS SAGITTAL PLANE
Abdominal Ultrasound
CT Scan of abdomen
 Liver
 The liver is divided into two lobes of
unequal size and shape.
– Right lobe
Occupies the right upper
quadrant
Right hepatic vein divides right
lobe into anterior and posterior
segments
 Liver
–Left lobe

–Left hepatic vein divides left lobe

into medial and lateral segments
–Left lobe is much smaller and has a
different blood supply and portal
drainage from the right lobe
 Liver
– Caudate lobe
Functionally is part of both right and
left lobes because it receives its blood
supply from both right and left hepatic
arteries
– Quadrate lobe
Receives its blood supply from the left
hepatic artery and is therefore
functionally part of the left lobe.
Middle hepatic vein divides right from
left lobe of liver
 Blood supply of the Liver
 It is important to understand the complex
blood flow through the liver
 Liver receives blood from two sources-

– Portal vein – 80%

– Hepatic artery – 20%
 It drains into the hepatic veins
 The hepatic artery, portal vein and bile
ducts travel together as portal triad and is
covered by connective tissue
 Liver
 The hepatic artery arises from the celiac axis
and courses through the upper portion of the
pancreas toward the liver.
 The hepatic artery gives rise to the
gastroduodenal artery posterior and superior
to the duodenum. It divides to right and left
hepatic branches and then into smaller
branches. In many cases, a third artery
supplies portions of segment IV and the right
lobe of the liver.
 Liver
 The Couinaud classification accepted
internationally and is used in UTZ, CT,
MRI. It divides the liver into 8
independent segments each of which
has its own vascular inflow, outflow,
and biliary drainage
 Because of this division into self-
contained units, each can be resected
without damaging the remaining
 Liver
View of the
liver
showing
plane of
right hepatic
vein as it
courses to
the IVC.
 Liver
Shaded-Surface
projection
showing how the
plane of the right
hepatic vein
provides the
vertical division of
the right liver lobe
into anterior and
posterior segments
 Posterior shaded surface view of the liver
magnified to show the relation of the caudate
lobe with the IVC medially and the fissure for
the ligamentum venosum laterally.
 CT Scan of Liver

 COUINAD’S Segments
Middle Left hepatic vein
hepatic
vein

right hepatic
vein

Axis of
intrahepatic Umbilical
portal vein fissure
• I) Caudate lobe
• II) Left posterolateral
segment
• III) Left anterolateral
segment
• IVa) Left superomedial
segment
• IVb) Left inferomedial
segment
• V) Right anteroinferior
segment
• VI) Right posteroinferior
segment
• VII) Right postero-superior
segment
• VIII) Right anterosuperior
segment
 Shaded surface view showing that the course of
the middle hepatic vein falls roughly along a plane
extending from the gallbladder fossa and the IVC.
This plane divides the right hepatic lobe from the
left hepatic lobe
 MIP and shaded-surface views showing that
the plane of the umbilical fissure divides the
left lobe into medial and lateral portions which
need to be further divided to qualify as
independent Couinaud segments.
 Left hepatic lobe: MIP and shaded-surface
views showing that the plane of the left
hepatic vein subdivides the lateral portion of
the left hepatic lobe
 MIP and shaded surface views showing the
plane of the main intrahepatic portal vein
Note this plane (arrow on surface view) is
roughly horizontal but in some cases may be
angled
The dotted line indicates how this plane is
sometimes used to divide segment IV into
superior (IVa) and inferior (IVb) divisions.
Ultrasonographic view of the portal vein
branches to the Couinaud segments 5, 6,
7, and 8
 Ultrasonographic view of the portal
vessels locating the central portions of
the Couinaud segments of the left liver
lobe
 Ultrasonographic view of the
confluence of the right (rhv), middle
(mhv), and left (lhv) hepatic veins with
the IVC
Doppler Study of Liver
CT Scan of the Liver
Gall Bladder & Biliary Tree
 Gallbladder
 Small pear-shaped sac
 Sits in between the right and quadrate lobes
of the liver
 30-50 cc in capacity
 Connected to the liver by connective tissue
 Parts of the gall bladder:

– Fundus
– Body
– Neck
 RIGHT AND LEFT HEPATIC DUCTS
LIVER

COMMON
HEPATIC
DUCT

CYSTIC DUCT

PANCREATIC DUCTS

GALLBLADDER

AMPULLA OF VATER
COMMON BILE DUCT
DUODENUM
 Biliary Drainage System

 Hepatic ducts
 Cystic duct

 Pancreatic duct

 Common bile duct

 Ampulla of Vater
 Gallbladder
 Relationship to other structures:
–Anterior
Anterior abdominal wall

–Posterior
Transverse colon
Duodenum

–Superior
Under surface of liver
 Ultrasound of GB and Biliary

tree
– Painless, non-invasive procedure.
– does not require special preparation, although
it is technically easier in patients with at least
six hours of fasting.
– Usually recommended as the first imaging
modality for the investigation of patients with
suspected cholangiocarcinoma.
– In hilar cholangiocarcinoma, ultrasound
demonstrates bilateral dilation of intrahepatic
ducts, and right and left hepatic ducts
Ultrasound of GB and Biliary tree
 The best noninvasive test for detecting
gallstones in the gallbladder is abdominal
ultrasonography because of its high specificity
and sensitivity (90–95%)
 Does not employ ionizing radiation, and
provides accurate anatomical information.
 May also indicate distal obstruction by the
finding of dilated intrahepatic or extrahepatic
bile ducts.
 Less useful for excluding gallstones
obstructing the common bile duct.
Ultrasound of GB and Biliary
tree
 GALLBLADDER ON
ULTRASOUND
Common Bile Duct

Gall
If transverse Bladder
diameter of
gallbladder is
more than 5 cm
with round
configuration
instead of ovoid
it means that it
is hydropic

Portal Transverse diameter less than 2 cm

Vein inspite of adequate fasting means it is
abnormally contracted
Ultrasound of Gallbladder and
Biliary tree
Acute cholecystitis
Acute cholecystitis
 Computed Tomography (CT)
of GB and Biliary Tree
 May detect lesions like low-density mass
or stone in GB or in dilated biliary ducts .
 Produces different pictures depending on
location of the tumor and the level and
degree of obstruction.
 Clearly show hilar masses causing bilateral
dilation of intrahepatic biliary ducts.
 May detect tumors causing dilatation of
intra- and extrahepatic bile ducts and
gallbladder.
 Computed Tomography (CT)
of GB and Biliary Tree
 Useful in demonstrating masses and dilated
biliary ducts, although they are not as reliable
for the diagnosis of calculous disease.
 Principal use is detection of the complications
of gallstones such as pericholecystic fluid, gas
in the gallbladder wall, gallbladder
perforations, and abscesses.
 May help determine which patients will require
urgent surgical intervention .
Computed Tomography (CT)
of Gallbladder
Computed Tomography (CT)
of Gallbladder and Biliary Tree
 Magnetic Resonance Imaging (MRI)

 Slightly superior to computed tomography in

visualization of body structures and tumors.
 Allows visualization of both dilated biliary ducts
proximal to the tumor and normal-sized
extrahepatic ducts distal to the level of occlusion.
 Images obtained from the newest diagnostic
equipment are comparable in quality to those
obtained with Endoscopic Retrograde
Cholangiopancreatography (ERCP) and
percutaneous transhepatic cholangiography.
 Ductal or intravenous injection of contrast
medium is not necessary and the patient is not
exposed to irradiation.
MRI Abdomen
 Endoscopic Retrograde
Cholangiopancreatography (ERCP)
Endoscopic Ultrasound (EUS)
 The patient is placed in the supine or tilted towards
left.
 During this procedure, pharyngeal topical anesthetic
agent are administered to prevent gagging. Pain
medication and a sedative may also be given prior to
the procedure.
 Allows physician to visualize and biopsy the mucosa
of the upper gastrointestinal tract.
 Endoscopy permits visualization of the esophagus,
stomach and duodenum.
 Enteroscope allows visualization of at least 50% of
the small intestine, including most of the jejunum
and part of the ileum.
 Endoscopic Retrograde
Cholangiopancreatography (ERCP)
ERCP
 Endoscopic Retrograde
Cholangiopancreatography (ERCP)
 Endoscopic procedure involves the use of
fiberoptic endoscopes .
 The side-viewing endoscope is introduced into
the second portion of duodenum, and contrast
material is injected into the bile ducts via major
duodenal papilla under fluoroscopic guidance .
 Multiple x-ray pictures are taken to visualize the
distribution of the contrast in the biliary tree.
ERCP can demonstrate normal size & structure
of the extrahepatic ducts distal to occlusion and
dilated intrahepatic ducts proximal to occlusion .
ERCP
Percutaneous Transhepatic
Cholangiography
 Percutaneous Transhepatic
Cholangiography
 Another invasive procedure
performed by a radiologist under
fluoroscopic guidance. A small needle
is introduced through the liver into
one of the peripheral biliary ducts.
Contrast material is injected through
the needle and x-ray pictures
obtained to document the biliary tree
anatomy.
 Percutaneous Transhepatic
Cholangiography
 For tumors of the middle third of
extrahepatic duct, surgical options include
resection of the mass with possible
primary end-to-end bile duct anastomosis
(for early small tumors) or
hepatojejunostomy (if large portion of
extrahepatic ducts should be removed).
For tumors located in distal common bile
duct, as inWhipple procedure
 MRI and MRCP
 These are relatively new applications that
utilizes MRI imaging with special software.
 Capable of producing images similar to
ERCP without the accompanying risks of
sedation, pancreatitis, or perforation.
 Helpful in assessing biliary obstruction and
pancreatic ductal anatomy.
 Effective in detecting gallstones and to
evaluate the gallbladder for the presence
of cholecystitis.
 Major shortcoming of MRCP lies in the
experience of the interpreting physician.
 Oral Cholecystography
 Considered cheap and noninvasive test.
 Patient must ingest a dose of an oral contrast agent on
the evening before the test. This contrast is absorbed
and secreted into the bile. The iodine in the contrast
produces opacification of the gallbladder lumen on a plain
radiograph the next day. Gallstones appear as filling
defects.
 Main use of oral cholecystography is to establish patency
of the cystic duct. This information is required before
attempting lithotripsy or medical methods to dissolve
gallstones.
 A major drawback of oral cholecystography is that it
takes 48 hours to perform, which limits its usefulness in
patients with acute cholecystitis and gallstone
complications and increase risk of toxicity by the
contrast- not popular.
 Cholescintigraphy
 Employs the use of an intravenous radioactive
iminodiacetic acid derivative which is rapidly
absorbed by the liver and excreted into the bile.
 Serial scans demonstrate the radioactivity in the
gallbladder, common bile duct, and small bowel
within 30–60 minutes.
 A nonfunctioning gallbladder is diagnostic of
acute cholecystitis.
 May be useful in determining whether
cholecystectomy will benefit a patient with
chronic biliary pain without gallstones.
 Cholangiogram
RIGHT
AND LEFT
HEPATIC
DUCTS
COMMON
HEPATIC
DUCT

COMMON
CYSTIC
BILE
DUCT
DUCT
CT Scan with Contrast
Pancreas
 Pancreas
 Total length – 12.5 to 15.0 cm
 Head measures approx. 1.5- 2.0 cm

 Neck measures approx. 1.0 cm

 Body measures approx. 2.0 cm

 Tail measures approx. 2.0-3.0 cm

 Normal pancreatic duct 2 mm

 The head & body are retroperitoneal structures

while tail is intraperitoneal
 Pancreas
 The pancreas is 12-15 cm long and is located in
the epigastrium
 Has four parts:

– Head
Uncinate process

– Neck
– Body and tail
 The head and body lie outside peritoneum
 The head of the pancreas is surrounded by the
duodenum as it makes a C-loop around the
pancreas
Imaging of Pancreas- CT scan
Acute pancreatitis
Ultrasound of Pancreas
 Pancreas
 The pancreas lies behind the peritoneum of the
posterior abdominal wall and is oblique in its
orientation.
 The head of the pancreas is on the right side and lies
within the “C” curve of the duodenum at the second
vertebral level (L2).
 The tip of the pancreas extends across the abdominal
cavity almost to the spleen.
 Collecting ducts empty digestive juices into the
pancreatic duct, which runs from the head to the tail
of the organ.
 Pancreas
 The pancreatic duct empties into the
duodenum at the duodenal papilla,
alongside the common bile duct.
 Smooth circular muscle surrounding the
end of the common bile duct (biliary
sphincter) and main pancreatic duct
(pancreatic sphincter) fuses at the level of
the ampulla of Vater is called the
sphincter of Oddi.
 The distal end of the
common bile duct can
be found behind the
upper border of the
head of the pancreas.
This duct courses the
posterior aspect of the
pancreatic head before
passing through the
head to reach the
ampulla of Vater (major
papilla).
 The pancreas may be divided
into five major regions—the
head, neck, body, tail and
uncinate process.
 The uncinate process is the
segment of pancreatic tissue
that extends from the
posterior of the head. The
neck of the pancreas, a part
of the gland 3–4 cm wide,
joins the head and body. The
pancreatic body lies
anteriorly in contact with the
antrum of the stomach.
 The Duct of Wirsung is the main pancreatic duct
extending from the tail of the organ to the major
duodenal papilla or Ampulla of Vater . The widest part
of the duct is in the head of the pancreas (4 mm),
tapering to 2 mm at the tail in adults. The duct of
Wirsung is close, and almost parallel, to the distal
common bile duct before combining to form a common
duct channel prior to approaching the duodenum. In
approximately 70% of people, an accessory pancreatic
duct of Santorini (dorsal pancreatic duct) is present.
This duct may communicate with the main pancreatic
duct. The degree of communication of the dorsal and
ventral duct varies from patient to patient.
 Pancreas
 The common bile duct traverses
through the head of the pancreas
and joins with the pancreatic duct at
the ampulla of Vater to empty bile
into the second or descending part of
the duodenum
 Both the pancreatic ducts of
Santorini and Wirsung drain the
exocrine pancreas
 Relationship of Pancreas
– Head
Posterior

–SMV
–Splenic vein
–IVC
–Terminal portion of renal vein
–Right crus of diaphragm
Anterior

–Transverse colon
–Uncinate process passes in front of
aorta
 Relationship to Surrounding
Structures
Lateral
Bile duct
–Bile
– Neck
Anterior
Pylorus
–Pylorus
Omental bursa
–Omental
Posterior
SMV
–SMV
Beginning of portal vein
–Beginning
 Relationship to Surrounding
Structures
– Body
 Anterior
– Stomach separated by omental bursa
 Posterior
– Aorta
– SMA
– Left crus of diaphragm
– Left adrenal
– Left kidney
– Left renal vein
– Splenic vein
 Relationship to Surrounding
Structures
Inferior
Transverse mesocolon
–Transverse
Duodeno-jejunal junction
–Duodeno-jejunal
Left colic flexure
–Left
Superior border
Splenic artery
–Splenic
– Tail
The tail of the pancreas lies in the
splenorenal ligament and enters the hilum
of the spleen with splenic vessels.
Ultrasound of Pancreas
Ultrasound of Pancreas
CT Scan of Pancreas
Spleen
Spleen on Plain X-ray
 Recognizable as a
soft-tissue density
measuring 8 cm to
12 cm in length,
high under the left
hemidiaphragm and
lateral to the
stomach.
 Spleen
 Size may vary considerably(< 15 cm in adult &
50% decrease in old age).
 When enlarged, the spleen frequently displaces
the gas-filled splenic flexure of the colon in an
inferomedial direction and may also displace the
stomach medially.
 Significant splenomegaly may be diagnosed
quite accurately on plain abdominal films.
Ultrasound of Spleen
CT Scan of Spleen
Adrenal Glands
 Adrenal Glands

 Anatomically, the adrenal glands

are located in the abdomen,
situated on the anterosuperior
aspect of the kidneys
 They are found at the level of the
12th thoracic vertebra
 Adrenal Glands
 Arterial supply –
– Superior suprarenal artery
– Middle suprarenal artery
– Inferior suprarenal artery
 Venous supply
– Suprarenal veins only
– Among all imaging modalities CT is considered
the first line of investigations, UTZ preferred in
children
 Adrenal Glands
 Normal adrenal in adults weighs about
3 to 6 grams each. Average size is 3 to
5 cm (L) X 2 to 3 cm (W)
 Right is triangular in shape lying
adjacent to the upper pole of kideny
behind IVC.
 Left is semilunar in shape and lies
anteromedial to the upper pole of left
kidney.
 Imaging of Adrenal Glands

The adrenal glands are located in the

perirenal space near the upper pole of each
kidney
 Normal left
adrenal
gland

Right
adrenal mass

 Late
phase of contrast enhanced Ct shows a right
adrenal mass with central area of necrosis
Normal right
adrenal gland
Contrast-enhanced axial CT scan showing
a right adrenal mass enlarging the gland
and giving it a bulbous appearance
Thank You