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Hepatic imaging


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Hepatic imaging

  1. 1. Abdominal Imaging ABD ALLAH NAZEER..MD Liv er Mamdouh Mahfouz MD
  2. 2. Indications for hepatic CT and MRI imaging • To assess equivocal imaging findings • Staging of hepatic neoplasms • Metastatic workup of primary malignancies • Diagnosis of diffuse hepatic diseases • Assessment of biliary disease and tumour. •Congenital anomalies like Carols disease. • Assessment of suspected post-traumatic injury
  3. 3.  Patient preparation  Patient position  Scanogram….[frontal] No required preparation unless the patient is going to be sedated or injected with contrast material FASTING FOR 4 - 6 HOURS
  4. 4. Rt Ventricle Rt Atrium IVC Lt Ventricle Lt Atrium Espohagus Aorta Azygous
  5. 5. Hepatic Veins Liver IVC Aorta
  6. 6. Lt Portal Vein Lt Lobe Liver Diaphragm Stomach Rt Lobe Liver IVC Falciform Ligament Spleen
  7. 7. Falciform Lig Stomach Rt Portal Vein IVC Spleen
  8. 8. Pylorous Stomach Gallbladder Pancreas Splenic arter Portal Vein Lt Kidney Celiac Artery IVC Crura of diaphragm
  9. 9. Pylorous Stomach Splenic Flexure GB Pancreas Splenic V 2nd part Duodenum IVC SMA Lft Kidney
  10. 10. Hepatic Flexure SMV SMA Splenic flexure Pancreatic Head Spleen IVC Lt Renal V Lt Renal Artery
  11. 11. SMV SMA Jejunum 2nd portion duodenum Pancreatic Head
  12. 12. Tran. colon Mesentery Des. colon Asc. colon 3rd portion duodenum
  13. 13. Ileum Des. Colon Asc. Colon Common Iliac Arteries
  14. 14. Ileum Asc. Colon Desc. Colon Terminal Ileum Lft Iliac Art Lt Iliac V
  15. 15. Small Bowel Ext Iliac Art Iliopsoas Glut. Minimus Ext Iliac V Glut. Medius Glut. Max Internal iliac A. & V. Pyriformis Rectosigmoid
  16. 16. Bladder Prostate Fem Artery Rectum
  17. 17. Ovaries Uterus Rectum Sacrum
  18. 18. Hepatic segmental anatomy
  19. 19. Hepatic pathology Benign lesions Liver cysts.  Hemangioma.  Adenoma. Focal nodular hyperplasia. Malignant lesions Hepatocellular carcinoma.  Fibrolamellar carcinoma.  Hepatoblastoma.  Metastasis. Diffuse lesions Fatty liver  Cirrhosis  Storage diseases
  20. 20. Hepatic pathology Focal lesions Cystic  Simple cyst  Abscess  Hydatid cyst  Hemangioma Rare Biliary cystadenoma
  21. 21. Hepatic cysts      Congenital lesions but detected late Isolated or associated with congenital cystic disease Usually asymptomatic Complications [ rupture or hage ] lead to symptoms Few mms to several cms in size Hepatic
  22. 22. Typical cyst criteria    Sharply defined margin Has no measurable wall. Clear water contents 0-15 HU  NO Septations Calcification Enhancement Mural nodules
  23. 23. Atypical cyst criteria    Thick enhancing margin [ abscess ] Abnormal contents [ hemorrhage ] Presence of Septations Calcification [ hydatid ] Enhancement Mural nodules [ neoplasm ]
  24. 24. Hepatic cysts demonstrated by MRI
  25. 25. Simple hepatic cyst , CT , MRI
  26. 26. Magnetic resonance imaging of hemorrhagic cyst. A, T1-weighted image demonstrates a mass with a hyperintense rim (arrows). B, T2-weighted image demonstrates the mass to be hyperintense, with the rim being hypointense (arrow), consistent with hemorrhage.
  27. 27. Polycystic disease , Liver and kidneys
  28. 28. Hepatic abscess [ Pyogenic ]  Frequently indolent with no signs of infection  May present with profound septicemia  Micro abscesses (>2cm) cluster or scattered  Macro abscesses :Unilocular or multilocular  Marginal enhancement 6% ?!  Gas containing abscesses uncommon
  29. 29. Pyogenic hepatic abscess associated with basal pneumonia and abscess
  30. 30. Pyogenic hepatic abscess
  31. 31. Enhanced MRI of multicystic pyogenic hepatic abscess
  32. 32. Pyogenic hepatic abscess
  33. 33. Hepatic abscess [Amebic ] Entameoba Histolytica  Patients are more often acutely ill  Single or multiple near the liver capsule  Enhancing wall is evident with peripheral zone of edema 10% world wide [ Common in amebic abscess]
  34. 34. Amebic abscess
  35. 35. Hemangioma  The most common benign liver tumour. 20% of hepatic tumors Female: male = 5:1  85% are asymptomatic 50% are multiple  Giant hemangioma More than 5 cm in diameter
  36. 36. Hemangioma  Non contrast well defined hypo dense lesion ,10% of cases shows calcification  Contrast enhancement peripheral nodular enhancement on late imaging
  37. 37. Hemangioma
  38. 38. Hemangioma , MRI T1 WIs T2 WIs Low signal lesion high signal lesion Heavily weighted T2 imaging [TE 100- 160msec]  signal T1+ C nodular marginal enhancement similar to CT
  39. 39. Hemangioma, MRI dynamic contrast enhanced scans
  40. 40. Giant Hemangioma(more than 5 cm
  41. 41. Giant Hemangioma , Serial post contrast
  42. 42. Echinococcal disease [Hydatid cyst]  Larval stage of E. granulosus  Well defined unilocular or multilocular cyst  Central and peripheral calcification  Daughter cysts can be inside the large cyst
  43. 43. Hydatid cyst after treatment with rupture and floating shadows
  44. 44. Hydatid cyst
  45. 45. Imaging features for hydatid cyst diagnosis  Other cysts specially in the lung  Unilocular or multilocular cyst with marginal calcification  Internal floating shadows  Daughter cysts within the large cyst
  46. 46. Gradient-echo T1, T2 -weighted MR image shows a hydatid cyst with a hypointense fibrous pericyst (arrow) Multiple daughter cyst noted.
  47. 47. Hydatid cyst
  48. 48. Malignant cystic lesions Biliary cyst adenoma / carcinoma Cystic deposits Biliary cystadenoma 90% occur intrahepatic With ovarian stroma [seen in females with good prognosis] Without ovarian stroma [males and females with bad prognosis]
  49. 49. Biliary cystadenoma , carcinoma  Large [3 – 40 cm] cystic multilocular tumor with mural nodule [seen better by US]  Distinction between cystadenoma and cystadenocarcinoma may not be possible by imaging and is not clinically critical, both will be excised
  50. 50. Biliary cystadenoma MRI images
  51. 51. The arterial supply is derived from the hepatic artery whereas the venous drainage is into the hepatic veins. FNH does not contain portal venous supply9.
  52. 52. (MRI) of focal nodular hyperplasia. A, T1weighted image demonstrates a mass (arrows) that is isointense to hepatic parenchyma. B, T2weighted image of the liver demonstrates a mass (arrows) that is isointense to hepatic parenchyma.
  53. 53. MRI images of hepatocellular adenoma
  54. 54. CT and MRI images of mesenchymal hamartoma
  55. 55. Hepatocellular carcinoma  The most common primary malignant hepatic neoplasms  3rd – 4th decades Male: female 8:1  80% of HCC occur in cirrhotic liver  Serum AFP and ultrasound [screening]
  56. 56. Hepatocellular carcinoma  Single or multiple masses that are hypo dense to normal liver  Calcification may be seen  After contrast injection [ should be Triphasic study]  Arterial phase : Very early arterial perfusion.  Portal phase : contrast washout
  57. 57. Arterial phase  Detects a greater number of HCC than usual scanning  Detects intravascular thrombosis [ portal vein]  Better delineation of tumour capsule in capsulated lesions  Detects early arteriovenous shunting [ sign of malignancy] CT
  58. 58. Hepatocellular carcinoma
  59. 59. Hepatocellular carcinoma
  60. 60. Delayed Arterial Portal M 59 Y with liver cirhhosis , splenomegaly and suspected focal lesion on US
  61. 61. Hepatocellular carcinoma
  62. 62. CT ,MRI Hepatocellular carcinoma M 60Y
  63. 63. Hepatocellular carcinoma MRI  Dynamic multiphase Gd- DTPA enhanced MRI  0.1 mmol / kgm Gd- DTPA injected as a bolus  Fast low angle shot sequence obtained at 30 - 240 sec  HCC appears as a hyper vascular mass [ similar to CT] Any mass in a cirrhotic liver that does not fulfill the cyst or hemangioma should be criteria of a considered as HCC until proved otherwise
  64. 64. HCC , MRI dynamic
  65. 65. HCC , MRI dynamic
  66. 66. Hepatoblastoma  The most common 1ry hepatic neoplasm in children below 5 years  Usually presents with abdominal mass with elevated AFP  Large diffuse or multifocal hypodense lesion is seen on CT  Matrix calcification and septations may be seen
  67. 67. Hepatoblastoma
  68. 68. Enhanced MRI of hepatoblastoma
  69. 69. Cholangiocarcinoma  The 2nd most common primary malignant tumor  Arise from bile duct epithelium [ 3 TYPES ]  Intrahepatic arises from small ducts  Or the major ducts near the helium  Or at the bifurcation of the CHD [ Klatskin tumor]  HCC: intrahepatic cholangiocarcinoma = 10:1  No strong association with cirrhosis  No specific MR appearance
  70. 70. Cholangiocarcinoma  Hypo dense lesion that shows heterogeneous enhancement  Portal vein invasion is rarely seen  Small dilated ducts around the lesion may be seen CT& MRI
  71. 71. Intra-hepatic cholangiocarcinoma by MRI.
  72. 72. Lymphoma  Primary hepatic lymphoma is rare compared to the 2ry type  AIDS and organ transplant patients have an increased risk  Non specific CT and MR appearance  Diffuse hepatic lymphoma  hypo dense liver similar to fatty infiltration
  73. 73. Lymphoma
  74. 74. Lymphoma
  75. 75. Magnetic resonance imaging findings in primary lymphoma of the liver:
  76. 76. Hepatic deposits  Liver is the 2nd most common site for deposits after nodes  30% - 70% of patients who die of cancer have liver deposits  NCCT hypodense lesions ,calcification in mucin producing metastases  CECT Dynamic bolus contrast injection with helical scanning  Single phase Dual phase ,Triphasic study ,CTHA & CTAP Hypovascular metastasis Hypervascular metastasis
  77. 77. Hepatic deposits  Most of hepatic deposits are hypo vascular  Hepatic neoplasms receive most of their blood supply via hepatic artery  Hyper vascular deposits should be assessed by dual phase CT or dynamic MRI  CTAP and intra operative US are the most sensitive methods for detection of deposits
  78. 78. Hyper vascular deposits
  79. 79. Colorectal carcinoma with multiple hepatic metastasis.
  80. 80. Calcified hepatic metastases in a patient with mucinous adenocarcinoma of the colon
  81. 81. Cancer breast with hepatic metastasis
  82. 82. MR advantages  MR can differentiate focal fatty changes from deposits  In diffuse fatty infiltration hypo dense deposits may be masked by the background of fat  On MR the background is relatively high in T1 WIs while deposits are of low signal .
  83. 83. Hepatic metastases
  84. 84. Hepatic metastases versus multiple HCC
  85. 85. Diffuse Hepatic Disease  Cirrhosis  Fatty Changes  Storage diseases(hemochromatosis &hemosidrosis)  Neoplastic diseases [ HCC , Deposits , Lymphoma ]
  86. 86. Cirrhosis  Repeated episodes of hepatic injury  fibrosis + regeneration  Small fibrotic right lobe with regenerative enlargement of the caudate and left lobe  Caudate/ right lobe ratio = 0.65 or more  Portal vein diameter more that 1.3 cm  Splenomegaly, ascites  Dilated perisplenic collateral venous channels
  87. 87. Liver cirrhosis Regeneration nodules  Without hemosiderin  With hemosiderin mild hyper intense in T1/ mild hypo intense in T2 mild hyper intense in T1/ more hypo intense in T2  Gradient echo images are more sensitive for hemosiderin  MR angiography : Portosystemic shunts and portal vein thrombosis
  88. 88. Liver cirrhosis with multiple regeneration nodules
  89. 89. Regeneration nodules
  90. 90. MDCT in a patient with cirrhosis and portal hypertension CT arterial portography (CTAP) in a patient with cirrhosis
  91. 91. Liver cirrhosis Other imaging findings  Widening of hepatic fissures  Gall bladder and small bowel  Signs of portal hypertension wall thickening (edema)
  92. 92. Fatty infiltration  Alcohol, obesity, diabetes , hepatitis, drugs  Focal, multifocal, diffuse fatty infiltration  Normal hepatic density is 8HU greater than spleen  Fatty liver is 10 HU below the spleen without contrast  Vessels course in the focal areas undisturbed  MR is helpful using the fat suppressed technique and 25 HU after contrast
  93. 93. Fatty infiltration with fat spared area with in phase and out phase sequences
  94. 94. Lipoma
  95. 95. Iron overload  Liver cells or reticuloendothelial iron deposition  Hereditary hemochromatosis, cirrhosis, hemolysis,….. CT Liver signal below that of the muscles is diagnostic, iron is not deposited in the muscles Generalized increase attenuation value of liver parenchyma [seen also in other conditions Wilson’s disease, glycogen storage disease] MRI More specific  diffuse decrease signal intensity of liver parenchyma in T2 and gradient echo images
  96. 96. Diffuse Neoplastic disease Multiple small tumour foci scattered throughout the liver parenchyma  Vascular invasion is common  Increased T2 signal on MR images Diffusely infiltrating Hepatocellular carcinoma with portal vein invasion Diffusely metastasis of the liver
  97. 97. Diffuse Neoplastic disease Lymphoma 35% of patients with secondary hepatic lymphoma show either diffuse or mixed pattern (focal+ diffuse) Imaging findings are non specific
  98. 98. Diffuse lymphoma liver and spleen