VOL.
123,
No.
2
HEPATIC LYMPHATICS BY PERCUTANEOUS
DEMONSTRATED TRANSHEPATIC
CHOLANGIOGRAPHY* By
HENRY
I. GOLDBERG, EDWARD
T.
M.D.,t WYLIE J. DODDS, M.D., STEWART, M.D.4 and ALBERT SAN
FRANCISCO,
American Journal of Roentgenology 1975.123:415-419.
L. LAWSON, M.D.t
M.D.,*
CALIFORNIA
I
NTRAHEPATIC and extrahepatic lymphatic vessels were demonstrated by the intraparenchymal injection of contrast material into the liver during percutaneous transhepatic cholangiography in patients with liver disease. Six cases are presented to draw attention to this unusual occurrence and to aid the roentgenologist in identifying hepatic lymphatics. Moreno and colleagues6 were first to describe hepatic lymphatic opacification after the intraparenchymal injection of sodium diatrizoate dun ng percutaneous transhepatic cholangiography. Their observation was made in patients with alcoholic cirrhosis accompanied by abdominal ascites; filling of lymphatics was not noted
in cirrhotic patients without ascites. Since their study in 1963, hepatic lymphatics have been demonstrated during percutaneous transhepatic cholangiography in only 9 other reported cases.2’7 It is not clear in these last 9 cases if ascites was present. CLINICAL
AND
ROENTOENOGRAPHIC FINDINGS
The age of the patients in our series and the type ofliver disease varied. One patient had chronic, active hepatitis: the other 5 had some form of nonalcoholic biliary cirrhosis (Table i). Two of these patients (Cases III and iv) had primary biliary cirrhosis, while the other 3 had cholestasis with cirrhosis secondary to obstruction.
TABLE SUMMARY
THOMAS A. MOSS,
OF
I FINDINGS
Case
Age,sex Ascites Esophagealvarices Totalserumbilirubin (mg./’oo mL) Dilatcdbileductsonpercutaneous cholangiogram Diagnosis by liver biopsy
Clinical
diagnosis
B From Milwaukee4 Supported
the
Departments and George in part by
I
II
S4yr..F o
6mo.,F + o
44yr.,F o o
48yr.,F o o
11.0
9.4
8.2
10.0
19.5
15.0
o
o
o
+
o
0
+ Secondary biliary cirrhosis with chronic pencholangitis
Secondary biliary cirrhosis due to biliary atresia
Recurrent cholangitis due to common bile duct stricture resulting from surgical esploration during cholecystectomy
Biliary atresia with Kiebsiella and Pseudo mesas septicemia
III
Primary biliary cirrhosis with portal scarring, diffuse lympho’ cyte infiltrate, and proliferation of small bile ducts Sclerosing cholangitis and chronic ulcerative colitis
IV
V
8iyr.,M o o
Primary biliary cirrhosis
Nonspecific ob-’ structive cholestasis with bile lakes; secondary biliary cirrhosis
Chronic. active hepatitis
Idiopathic jaundice; previous liver biopsy specimen show’ ing biliary cirrhosis
Carcinoma of head of pancreas with obstructive jaundice
Hepatitis
of Radiology, University of california School of Medicine, San Francisco,t Washington University Medical Center, Washington, D.C. National Institutes of Health Career Development Award KO GM 70582-02.
4’S
VI
#{243}iyr,,M o o
Medical
College
of Wisconsin,
Goldberg,
416
Dodds,
Lawson,
Stewart same
and
Moss
orientation
ducts vessels
I,
and
zi
in
gastrohepatic
appearance
were
instances,
arranged
...1
ducts. terial
the the
water-soluble,
day
no
was
noted
persistence
of
to
over
the
biliary
material
was
residual
contrast
ma-
in
lymph
nodes
vessels
contrast
in
minutes
to the injected
on
the
and
material
several
tradistinction trast material
the
contrast
after each study. The filling of lymphatic
channels
from
perpendicular
Because
bile these
were irregular and to have valves channels extended the area overlying of T12, along the (Fig. 3; ; and ). lymphatic channels
ligament
In some
197$
the intrahepatic B). However,
as
(Fig. varied
bile ducts in that they beaded; some appeared (Fig. 2). The lymphatic beyond the hilus towards the spine in the region
‘I
American Journal of Roentgenology 1975.123:415-419.
FEBRUARY,
were
rapid outflow into hepatic
the these
in conof
conveins.
Hepatic venous channels were oriented in a direction toward the heart, and remained opacified only a few seconds. In cases, contrast material was also injected into the biliary
tree
seen
to
was
not
and
the
Intraparenchymal injection of conresulted in opacification of a deep lymphatic channel. (A) The lymphatic channel divides into 2 branches in the region of the gastrohepatic ligament and courses medially to the region of L. A ls’mph node is faintly opacified (arrow) by a small lymphatic branch. (B) Further intraparenchvmal injection led to opacification of several I vmphatic branches coursi ng horizontally to the region ofthe L, vertebral body. I.
FIG.
trast
Only
channels
were
Case vi. material
patient
I
had
infant,
In
biliary
In Case vi, the biliary tree opacified. Of interest was that in
opacify.
each
(Case
case,
6 month
a
ii),
abdominal
,i
-
-
old
ascites.
intraparenchymal
injec-
tions were
of sodium diatrizoate (o made during percutaneous
per
cent) trans-
hepati
c
injections
‘-
resulted nels wards
cholangiographv.
The
in demonstration that
the
filled
hiltis
from
of the
ofirregular the
site
liver,
of injection
generally
chanto-
in the
11G.
2.
tion,
Case iv. In the right irregular, serpiginous
beaded in appearance, the region of the celiac
posterior lymphatic
may be seen lymphatics.
oblique projecvessels, some
converging
in
VOL.
No.
123,
Percutaneous
2
Transhepatic
only 2 patients (Cases i and v) were biliary ducts actually seen to be dilated.
Cholangiography
417
the
DISCUSSION
The i ng
hepatic
percu
lymphatic
taneous
raphy
was
et al.,6
in
opacification
transhepatic
dur-
cholangiog-
a fortuitous occurrence. Moreno the lymphatic filling from parenchymal hepatic injection, described the beaded irregular appearance that we saw in our cases; but all of their patients with hepatic lymphatic opacification had ascites. Also, the opacified lymphatics noting
rapidly
emptied
American Journal of Roentgenology 1975.123:415-419.
posed
to
in
their
patients,
as
op-
in whom the contrast material remained in the lymphatic vessels for several minutes. Moreno a al.6 postulated that dilated lymphatics, which carry increased flow in patients with cirrhosis and ascites, permit enough contrast medium to be removed from the extravascular parenchymal spaces of the liver to allow roentgenographic opacification. This explanation found basis because all of their patients had ascites. Ascites was present in only I of our patients, a 6 month old infant with biliary cirrhosis and septicemia secondary to biliary
ours,
atresia.
Lymphatics
were
opacified
I Ftc.
Case
.
v. Lymphatic
traparenchymal contrast material the
liver
to the
(black
arrows).
system
has
normal was
biopsy
in-
of of
area
overlying
fill from
the
‘I’,,-L,
of the
left
interspace
biliary
duct
filled.
but,
produced flow was
when
from
inflammation
biliary
cirrhosis
(Case present primary
II).
hepatic
inflamma-
experimentally, seen to increase.
specimens
active
channels
A branch
dogs,
tion phatic
an
collection (open white arrows) and extend beyond the margin
our
patients
in
i
secondary
lymLiver showed
with
patient
to biliary
atresia
The chronic, active hepatitis in Case vi is the only example of inflammatory liver disease.
other 5 patients who had no ascites. Moreno et al.6 also mentioned that they were not able to demonstrate lymphatics in in
our
FIG. are
3. Case
opacified
i.
The
as
right
is
(black arrow). Hepatic are also opacified.
and
the
left
hepatic
bile
ducts
choledochojelunostomy
lymphatics
(white
arrows)
FIG.
5. Case
phatic of the patient
in. vessels
porta
with
Irregular, in great
hepatis sclerosing
beaded, numbers
and
celiac
cholangitis.
serpentine, crowd the
lymph
nodes
lymregion
in a
American Journal of Roentgenology 1975.123:415-419.
418
Goldberg,
Dodds,
Lawson,
The major features that distinguish lymphatic channels from irregular biliary ducts are the undulating pattern of dilatation, which produces a beaded appearance (Fig. 5), and the presence of fine, lucent bands caused by valves. Lymphatic channels follow a serpiginous course in contrast to biliary ducts. In addition, the lymphatic vessels extend well beyond the region of the liver hilus into the gastrohepatic ligaments. They do not parallel the course of the common bile duct but extend horizontally towards the level of the T12 vertebral body. The appearance and distribution of hepatic drainage have been verified by lymphangiography.5 There are lymphatic systems in the liver: a superficial system beneath the capsule which is connected by lymphatic channels to a deep lymphatic system which courses with the portal channels. The deep lymphatic plexuses follow the portal vein, bile duct, and hepatic artery to the edge of each lobule of the liver. The 2 systems join together as larger collecting vessels that leave the liver at the hilus. These vessels enter lymph nodes in the region of the hilus and gastrohepatic ligament where they are joined by lymphatics from the extrahepatic biliary tract. These larger channels, in turn, course horizontally towards the celiac lymph nodes and, from there, empty into the cisterna chyli. Some deep lymphatics follow hepatic veins to the inferior vena cava as it passes through the diaphragm. One conspicuous feature of normal hepatic lymphatics is the presence of valves in the larger collecting vessels and main lymphatic channels. No valves are apparent in the lymphatic capillary vessels.8 The occurrence of increased hepatic lymph flow in patients with cirrhosis and ascites is a well-known phenomenon.”4’6 Distended hilar lymphatics have also been seen, however, in cases of extrahepatic biliary obstruction.3 Extrahepatic biliary obstruction, due to carcinoma of the head of the pancreas, was associated with dilated
Stewart
and
Moss
FEBRUARY,
1975
lymphatics in Case v (Fig. 4). In primary biliary cirrhosis or primary intrahepatic cholestasis, large lymphatics and hilar lymph nodes have been noted (Cases III and iv).3 Percutaneous transhepatic cholangiography is not performed specifically to demonstrate hepatic lymphatics; it is important, however, to recognize the characteristic roentgenographic features of hepatic lymphatics so that they may be differentiated from biliary ducts and hepatic vascular channels. hepatic
SUMMARY
Intrahepatic and extrahepatic lymphatic vessels were opacified by the intraparenchymal injection of contrast material during percutaneous transhepatic cholangiography in 5 patients with cirrhosis and I patient with chronic, active hepatitis. The lymphatic channels had a beaded, irregular appearance. They converged in the region of the liver hilus and extended outside the boundaries of the liver to the region of the T12 vertebral body. The location and the roentgenographic appearance of these lymphatic channels should distinguish them from biliary ducts and hepatic vessels. Henry I. Goldberg, M.D. Department of Radiology University of California San Francisco, California
94143
REFERENCES A. H., and CAIN, J. C. Further studies on lymphatic vessels at hilus of liver of man : their relation to asci tes. Proc. Staff Meet. Mayo C/in., 1957,32, 615-627.
1.
BAGGENSTOSS,
2.
B#{246}TTGER,
E., BURGHARD, A., DITTMAR, F., and MANEGOLD, B. Die perkutane transhepatische Cholangiographie-neue Erfahrungen und sdtene Befunde. Fortschr. a. d. Geb. d. R#{246}ntgenstrah/en u. d. Nuk/earmedizin, 1973, ii8, 405412.
3. CAMERON, R., and PAO-CHANG, H. Editors. Biliary Cirrhosis. Oliver & Boyd, Ltd., London, 1962, pp. 85; 143. 4.
CONN,
H. 0.
Rational
management
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In:
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position of contrast medium, with attempts at functional evaluation of outflow block concept of cirrhotic ascites and accessory outflow role of portal vein. Radiology, 1963,81, 65-79. 7. OKUDA, K., TANIKAWA, K., and EMURA, ‘I’. Nonsurgical percutaneous transhepatic cholangiography: diagnostic significance in medical prob.. lems of liver. Am. 7. Digest. Dis., 1974, 19, 21-
36. 8. WEISS, L. Lymphatic vesselsand lymph Histology. By R. 0. Greep, and Third edition. McGraw-Hill Book Inc., New York, 1973, pp. 423-443.
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