Hepatic imaging
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This document provides an overview of abdominal imaging with a focus on hepatic CT and MRI imaging. It discusses indications for hepatic imaging including assessing equivocal findings, staging neoplasms, metastatic workup, and evaluating diffuse hepatic diseases and biliary abnormalities. It then covers patient preparation, positioning, and protocols for hepatic CT and MRI. The remainder of the document details normal hepatic anatomy and vasculature as well as descriptions of benign and malignant focal and diffuse hepatic lesions with accompanying imaging examples.
![ 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](https://image.slidesharecdn.com/hepaticimaging-140213194114-phpapp02/85/Hepatic-imaging-3-320.jpg)
![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](https://image.slidesharecdn.com/hepaticimaging-140213194114-phpapp02/85/Hepatic-imaging-31-320.jpg)
![Atypical cyst criteria
Thick enhancing margin [ abscess ]
Abnormal contents [ hemorrhage ]
Presence of
Septations
Calcification [ hydatid ]
Enhancement
Mural nodules [ neoplasm ]](https://image.slidesharecdn.com/hepaticimaging-140213194114-phpapp02/85/Hepatic-imaging-33-320.jpg)
![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](https://image.slidesharecdn.com/hepaticimaging-140213194114-phpapp02/85/Hepatic-imaging-38-320.jpg)
![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]](https://image.slidesharecdn.com/hepaticimaging-140213194114-phpapp02/85/Hepatic-imaging-43-320.jpg)
![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](https://image.slidesharecdn.com/hepaticimaging-140213194114-phpapp02/85/Hepatic-imaging-50-320.jpg)
![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](https://image.slidesharecdn.com/hepaticimaging-140213194114-phpapp02/85/Hepatic-imaging-56-320.jpg)
![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]](https://image.slidesharecdn.com/hepaticimaging-140213194114-phpapp02/85/Hepatic-imaging-62-320.jpg)
![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](https://image.slidesharecdn.com/hepaticimaging-140213194114-phpapp02/85/Hepatic-imaging-63-320.jpg)
![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]](https://image.slidesharecdn.com/hepaticimaging-140213194114-phpapp02/85/Hepatic-imaging-82-320.jpg)
![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](https://image.slidesharecdn.com/hepaticimaging-140213194114-phpapp02/85/Hepatic-imaging-83-320.jpg)
![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](https://image.slidesharecdn.com/hepaticimaging-140213194114-phpapp02/85/Hepatic-imaging-84-320.jpg)
![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](https://image.slidesharecdn.com/hepaticimaging-140213194114-phpapp02/85/Hepatic-imaging-90-320.jpg)
![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](https://image.slidesharecdn.com/hepaticimaging-140213194114-phpapp02/85/Hepatic-imaging-101-320.jpg)
![Diffuse Hepatic Disease
Cirrhosis
Fatty Changes
Storage diseases(hemochromatosis &hemosidrosis)
Neoplastic diseases [ HCC , Deposits , Lymphoma ]](https://image.slidesharecdn.com/hepaticimaging-140213194114-phpapp02/85/Hepatic-imaging-123-320.jpg)
![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](https://image.slidesharecdn.com/hepaticimaging-140213194114-phpapp02/85/Hepatic-imaging-133-320.jpg)
Hepatic imaging
- 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. 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. Rt Ventricle Rt Atrium IVC Lt Ventricle Lt Atrium Espohagus Aorta Azygous
- 6. Lt Portal Vein Lt Lobe Liver Diaphragm Stomach Rt Lobe Liver IVC Falciform Ligament Spleen
- 8. Pylorous Stomach Gallbladder Pancreas Splenic arter Portal Vein Lt Kidney Celiac Artery IVC Crura of diaphragm
- 12. Tran. colon Mesentery Des. colon Asc. colon 3rd portion duodenum
- 13. Ileum Des. Colon Asc. Colon Common Iliac Arteries
- 14. Ileum Asc. Colon Desc. Colon Terminal Ileum Lft Iliac Art Lt Iliac V
- 15. Small Bowel Ext Iliac Art Iliopsoas Glut. Minimus Ext Iliac V Glut. Medius Glut. Max Internal iliac A. & V. Pyriformis Rectosigmoid
- 27. 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
- 30. Hepatic pathology Focal lesions Cystic Simple cyst Abscess Hydatid cyst Hemangioma Rare Biliary cystadenoma
- 31. 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
- 32. Typical cyst criteria Sharply defined margin Has no measurable wall. Clear water contents 0-15 HU NO Septations Calcification Enhancement Mural nodules
- 33. Atypical cyst criteria Thick enhancing margin [ abscess ] Abnormal contents [ hemorrhage ] Presence of Septations Calcification [ hydatid ] Enhancement Mural nodules [ neoplasm ]
- 34. Hepatic cysts demonstrated by MRI
- 35. Simple hepatic cyst , CT , MRI
- 36. 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.
- 37. Polycystic disease , Liver and kidneys
- 38. 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
- 39. Pyogenic hepatic abscess associated with basal pneumonia and abscess
- 41. Enhanced MRI of multicystic pyogenic hepatic abscess
- 43. 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]
- 44. Amebic abscess
- 47. 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
- 48. Hemangioma Non contrast well defined hypo dense lesion ,10% of cases shows calcification Contrast enhancement peripheral nodular enhancement on late imaging
- 49. Hemangioma
- 50. 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
- 52. Hemangioma, MRI dynamic contrast enhanced scans
- 54. Giant Hemangioma(more than 5 cm
- 55. Giant Hemangioma , Serial post contrast
- 56. 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
- 57. Hydatid cyst after treatment with rupture and floating shadows
- 58. Hydatid cyst
- 59. 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
- 60. Gradient-echo T1, T2 -weighted MR image shows a hydatid cyst with a hypointense fibrous pericyst (arrow) Multiple daughter cyst noted.
- 61. Hydatid cyst
- 62. 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]
- 63. 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
- 66. Biliary cystadenoma MRI images
- 70. 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.
- 72. (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.
- 78. MRI images of hepatocellular adenoma
- 79. CT and MRI images of mesenchymal hamartoma
- 82. 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]
- 83. 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
- 84. 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
- 87. Delayed Arterial Portal M 59 Y with liver cirhhosis , splenomegaly and suspected focal lesion on US
- 90. 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
- 91. HCC , MRI dynamic
- 93. HCC , MRI dynamic
- 98. 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
- 99. Hepatoblastoma
- 100. Enhanced MRI of hepatoblastoma
- 101. 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
- 102. 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
- 104. Intra-hepatic cholangiocarcinoma by MRI.
- 105. 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
- 106. Lymphoma
- 107. Lymphoma
- 108. Magnetic resonance imaging findings in primary lymphoma of the liver:
- 109. 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
- 110. 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
- 112. Colorectal carcinoma with multiple hepatic metastasis.
- 113. Calcified hepatic metastases in a patient with mucinous adenocarcinoma of the colon
- 115. Cancer breast with hepatic metastasis
- 118. 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 .
- 119. Hepatic metastases
- 120. Hepatic metastases versus multiple HCC
- 123. Diffuse Hepatic Disease Cirrhosis Fatty Changes Storage diseases(hemochromatosis &hemosidrosis) Neoplastic diseases [ HCC , Deposits , Lymphoma ]
- 124. 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
- 125. 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
- 126. Liver cirrhosis with multiple regeneration nodules
- 127. Regeneration nodules
- 128. MDCT in a patient with cirrhosis and portal hypertension CT arterial portography (CTAP) in a patient with cirrhosis
- 129. Liver cirrhosis Other imaging findings Widening of hepatic fissures Gall bladder and small bowel Signs of portal hypertension wall thickening (edema)
- 130. 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
- 131. Fatty infiltration with fat spared area with in phase and out phase sequences
- 132. Lipoma
- 133. 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
- 134. 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
- 135. Diffuse Neoplastic disease Lymphoma 35% of patients with secondary hepatic lymphoma show either diffuse or mixed pattern (focal+ diffuse) Imaging findings are non specific
- 136. Diffuse lymphoma liver and spleen