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

ofascites.

In:

VOL.

123,

No.

Percutaneous

2

Transhepatic

Progress

in Liver Disease. Chapter 16. Edited by H. Popper, and F. Schaffner. Grune & Stratton, Inc., New York, 1972. S. GOLD, R. H., and YOUKER, J. E. Idiopathic intestinal lymphangiectasis (primary proteinlosing enteropathy) : lymphographic verification of enteric and peritoneal leakage of chyle. Radiology,

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6. MORENO, L. M., S. F., raphy: tracts

1973,

109,

315-316.

A. H., RUZICKA, F. R., ROUSSELOT, BURCHELL, A. R., BoNo, R. F., SLAFSKY, and BURKE, J. H. Functional hepatogstudy of hemodynamics of outflow

of human

liver by intraparenchymal

de-

Cholangiography

419

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.

nodes. In: L. Weiss. Company,

Hepatic lymphatics demonstrated by percutaneous transhepatic cholangiography.

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