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IMAGING OF THE HEPATO
BILIARY SYSTEM
Dr Maryam Alam Khan
TMO Surgical E Ward KTH
BLOOD SUPPLY OF LIVER
THE PORTAL VEIN
THE BILIARY TREE
THE MAJOR ARTERIES
• On a non enhanced CT-scan (NECT) liver tumors usually are not visible
• Only a minority of tumors contain calcifications...
THE CONTRAST PHASES
• Optimal timing and speed of contrast injection are very important for good
arterial phase imaging. 
• Hypervascular tumo...
• Portal venous phase imaging works on the opposite idea. 
We image the liver when it is loaded with contrast through the ...
• The equilibrium phase is when contrast is moving away from the liver and the
liver starts to decrease in density. 
• Thi...
NORMAL LIVER ON CT SCAN
COMMON LIVER LESIONS ON CT
SCAN
Hemangioma
Focal nodular hyperplasia
Adenoma
Liver cysts
Primary liver cancers
Hepatocellularcarcinoma
Cholangio carcinoma...
BENIGN LIVER LESIONS
Hepatic Hemangiomas
• Benign vascular lesions of liver.
• The commonest liver tumor
• Autopsy studies : 0.4-20 percent
• 3...
Hepatic Hemangiomas
Hemangiomas are
composed of many
endothelium-lined
vascular spaces
separated by fibrous
septa
Cavernou...
Hepatic Hemangiomas
US: well-defined, uniformly hyperechoic liver mass with peripheral feeder
vessels that are characteris...
Ultrasound
At ultrasonography,
hemangiomas appear
as
well-circumscribed,well-circumscribed,
uniformlyuniformly
hyperechoic...
Hepatic Hemangiomas
CT: The pathognomic features of caverneous hemangioma: peripheral
nodular and discontinuous enhancemen...
The pattern of a peripheral,
discontinuous, intense
nodular enhancementnodular enhancement
during the arterial-dominant
ph...
Hepatic Hemangiomas
Diagnosis
CT: venous enhancement from periphery to center
Hepatic Hemangiomas
Diagnosis
Hepatic Hemangiomas
Diagnosis
MRI:
. Hypointense and well defined in T1
. Marked hyperintensity that increases with echo t...
MRI Findings:
• MRI is more sensitive and specific than other imaging modalities in the diagnosis of
hemangiomas.
• Hemang...
Hepatic Hemangiomas
Diagnosis
MRI:
Focal Nodular Hyperplasia (FNH)
. Benign nodule formation of normal liver tissue
. 2nd most common benign hepatic lesion
....
Focal nodular hyperplasia (FNH) is the second most commonFocal nodular hyperplasia (FNH) is the second most common
tumor o...
Focal Nodular Hyperplasia (FNH)
Rarely- encapsulated and pedunculated.
usually less than 5 cm in diameter
located in the s...
Although FNH usually has no clinical significance, recognition ofAlthough FNH usually has no clinical significance, recogn...
Focal Nodular Hyperplasia (FNH)
Diagnosis:
US: Nodule with varying echogenicity
Color Doppler imaging may show central ves...
Ultrasound
Doppler ultrasound shows centrifugal arterial flowcentrifugal arterial flow originating from the
central portio...
Focal Nodular Hyperplasia (FNH)
Diagnosis: CT
. Central scar
. Brisk homogeneous enhancement
. Well defined
. Early homoge...
Focal Nodular Hyperplasia (FNH)
Diagnosis: CT
HAP
PVP
DP
IV-
Focal Nodular Hyperplasia (FNH)
Diagnosis: CT
CT Findings: Typical CT finding of a FNH:
• In the native scan this benign
tumor appears to be almost
isodense to the surr...
Focal Nodular Hyperplasia (FNH)
Diagnosis:MRI typical finding
. Isointense to hypointense on T1-weighted images
. Slightly...
Focal Nodular HyperplasiaFocal Nodular Hyperplasia
MRI Findings:
T1-weighted sequence.
A focal lesion (arrow) with a
diame...
Hepatic Adenoma
. Rare hepatic tumor
. Women aged 20 to 40 years
. Association with oral contraceptive use
. Solitary (70%...
Hepatocellular AdenomaHepatocellular Adenoma
Ultrasound
• On US, HAs demonstrate variable echogenicity.
• The most adenoma...
•Well circumscribed without lobulation
•Heterogeneous because of their mixed components of fat, hemorrhage,
and necrosis
•...
Hepatocellular AdenomaHepatocellular Adenoma
CT Findings:
Arterial-phase CT scan shows multiple
hypervascular lesions (arr...
Hepatic Adenoma
• Hyper to isointense on T1
(hemorrhage) and slightly
hyperintense on T2 weighted
images
Liver cysts:
. May be single or multiple
. May be part of polycystic kidney disease
. Patients often asymptomatic
. No spe...
Liver cysts:
Liver cysts: HYDATID CYST
• Hyper to isointense on T1 (hemorrhage) and
slightly hyperintense on T2 weighted images
• Same ...
a typical case of a echinococcus cyst with 'daughter cysts' within the large cyst.
Most cases of echinococcus cysts howeve...
LIVER ABSCESS
MALIGNANT LIVER
LESIONS
Hepatocellular Carcinoma (HCC)
•The fifth most common tumor
•Rarely occurs before age of 40 and peaks at 70 years
•Male to...
Several morphological forms
Massive(>3cms)
Nodular (<3cms)
Diffuse
Hepatocellular Carcinoma (HCC)
AFP (Alfa feto protein)
...
Hepatocellular Carcinoma (HCC)
US : hyperechoic, smaller tumors are hypoechoic.
Heterogeneous, hypervascular
US sensitivit...
Arterial Phase:
liver(30-35 sec)
HCC as supplied by arterial branch/neovascularization
Hepatocellular Carcinoma (HCC)
Veno...
Hepatocellular Carcinoma (HCC)
Delayed Phase :
Wash -out phenomenan persists and often exaggerated in smaller
lesions.
The...
Hepatocellular Carcinoma (HCC)
• MRI
• Variable intensity of HCC on T1
• 35% hyper, 25% iso-, 40 % hypo
• Hyperintense (T1) often well-differentiated, co...
Hepatocellular Carcinoma (HCC)
MRI
Hepatocellular Carcinoma (HCC)
Hypovascular HCC +/- 30%
Metastatic disease
• Most common malignant hepatic tumor
• Presence of extrahepatic malignancy should be sought in patient...
Metastatic disease
Variable US features+++
Iso, hyper or hypo echoic++
Contrast-enhanced US (CEUS) (84%
accuracy)
Intraope...
Metastatic disease
• Most liver metastases are hypovascular and are best imaged during the
portal venous phase (colon, sto...
Metastatic disease
. On MRI, metastases are variable but are usually hypo- to isointense on T WI and
iso- to hyperintense ...
Metastatic disease
Metastatic disease
LIVER TRAUMA
CT GRADING SYSTEM
•Green arrow: oval shaped hypodense area
consistent with hematoma
•Yellow arrow: linear shaped hypodense area
consistent w...
• Complete devascularization of the
right lobe (i.e. grade 4) .
• Contrast blush within the
intraparenchymal region, but a...
• Subcapsular hematoma greater
than 10 cm (i.e. grade 4 injury)
• Contrast blush
• No associated hemoperitoneum
Lacerations can be stellate, like the
example on the left or branching like
the one on the right.
THANK YOU
Dr maryam
Dr maryam
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  1. 1. IMAGING OF THE HEPATO BILIARY SYSTEM Dr Maryam Alam Khan TMO Surgical E Ward KTH
  2. 2. BLOOD SUPPLY OF LIVER
  3. 3. THE PORTAL VEIN
  4. 4. THE BILIARY TREE
  5. 5. THE MAJOR ARTERIES
  6. 6. • On a non enhanced CT-scan (NECT) liver tumors usually are not visible • Only a minority of tumors contain calcifications, cystic components, fat or hemorrhage and will be detected on a NECT. • I/V contrast is needed to increase the conspicuity of lesions. • Normal parenchyma is supplied for 80% by the portal vein and only for 20% by the hepatic artery, so it will enhance in the portal venous phase. • All liver tumors however get 100% of their blood supply from the hepatic artery, so when they enhance it will be in the arterial phase. • This difference in blood supply results in different enhancement patterns between liver tumors and normal liver parenchyma in the various phases of contrast enhancement. THE CONTRAST PHASES OF LIVER
  7. 7. THE CONTRAST PHASES
  8. 8. • Optimal timing and speed of contrast injection are very important for good arterial phase imaging.  • Hypervascular tumors will enhance optimally at 35 sec after contrast injection.  • This time is needed for the contrast to get from the peripheral vein to the hepatic artery and to diffuse into the liver tumor • For arterial phase imaging the best results are with an injection rate of 5ml/sec.  THE ARTERIAL PHASE
  9. 9. • Portal venous phase imaging works on the opposite idea.  We image the liver when it is loaded with contrast through the portal vein to detect hypo vascular tumors.  The best moment to start scanning is at about 75 seconds. •  This late portal venous phase is also called the hepatic phase because there already must be enhancement of the hepatic veins. • If you only do portal venous imaging, for instance if you are only looking for hypo vascular metastases in colorectal cancer, fast contrast injection is not needed, because in this phase the total amount of contrast is more important and 3ml/sec will be sufficient. THE PORTAL VENOUS PHASE
  10. 10. • The equilibrium phase is when contrast is moving away from the liver and the liver starts to decrease in density.  • This phase begins at about 3-4 minutes after contrast injection and imaging is best done at 10 minutes after contrast injection.  THE DELAYED/EQUILIBRIUM STAGE
  11. 11. NORMAL LIVER ON CT SCAN
  12. 12. COMMON LIVER LESIONS ON CT SCAN
  13. 13. Hemangioma Focal nodular hyperplasia Adenoma Liver cysts Primary liver cancers Hepatocellularcarcinoma Cholangio carcinoma Metastases Benign Malignant Classification:
  14. 14. BENIGN LIVER LESIONS
  15. 15. Hepatic Hemangiomas • Benign vascular lesions of liver. • The commonest liver tumor • Autopsy studies : 0.4-20 percent • 3-5 decades • Thought to arise from congenital hamartomas (abnormal growth of normal tissue), it can also develop from dilatation of blood vessels in a normal tissue • Usually asymptomatic • Incidental discovery: US++
  16. 16. Hepatic Hemangiomas Hemangiomas are composed of many endothelium-lined vascular spaces separated by fibrous septa Cavernous angiomas
  17. 17. Hepatic Hemangiomas US: well-defined, uniformly hyperechoic liver mass with peripheral feeder vessels that are characteristic of a hemangioma. Cavernous angiomas
  18. 18. Ultrasound At ultrasonography, hemangiomas appear as well-circumscribed,well-circumscribed, uniformlyuniformly hyperechoic lesionshyperechoic lesions Hemangiomas may appear hypoechoic in fatty livers Cavernous HemangiomaCavernous Hemangioma
  19. 19. Hepatic Hemangiomas CT: The pathognomic features of caverneous hemangioma: peripheral nodular and discontinuous enhancement and progressive centripetal fill- in IV- HAP PVP DP
  20. 20. The pattern of a peripheral, discontinuous, intense nodular enhancementnodular enhancement during the arterial-dominant phase with progressive centripetal fill-incentripetal fill-in is considered pathognomic for hemangiomas CT Findings: Contrast-enhanced CT scans reveal the pathognomic features of a hemangioma, namely, peripheral nodular enhancement and progressive centripetal fill-in (arrow). 0’’ 15’1’ 30’’ Cavernous HemangiomaCavernous Hemangioma
  21. 21. Hepatic Hemangiomas Diagnosis CT: venous enhancement from periphery to center
  22. 22. Hepatic Hemangiomas Diagnosis
  23. 23. Hepatic Hemangiomas Diagnosis MRI: . Hypointense and well defined in T1 . Marked hyperintensity that increases with echo time on T2 . The same caracteristic pattern of enhacement as is seen at CT
  24. 24. MRI Findings: • MRI is more sensitive and specific than other imaging modalities in the diagnosis of hemangiomas. • Hemangiomas appear as smooth, lobulated, homogeneous, hypointense lesions on T1- weighted images. • On T2-weighted images, they appear hyperintense relative to liver. The high signal intensity on T2-weighted images is due to the extremely long T2 relaxation time of the free fluid (slowly moving blood) Cavernous HemangiomaCavernous Hemangioma
  25. 25. Hepatic Hemangiomas Diagnosis MRI:
  26. 26. Focal Nodular Hyperplasia (FNH) . Benign nodule formation of normal liver tissue . 2nd most common benign hepatic lesion . More common in young and middle age women . Male to female :5-17 . Usually asymptomatic . A small minority (10-15%) may present with vague abdominal symptoms from mass effect, a palpable mass, or hepatomegaly. . Response of parenchyma to a vascular malformation or portal duct injury.
  27. 27. Focal nodular hyperplasia (FNH) is the second most commonFocal nodular hyperplasia (FNH) is the second most common tumor of the liver and constitutes 8% of all liver tumorstumor of the liver and constitutes 8% of all liver tumors • FNH occurs predominantly in women (80 - 90%) during the third to fifth decade. • FNH is not a true neoplasm, and it is believed to represent a hyperplastic response to increased blood flow in an intrahepatic arteriovenous malformation. • Kupffer cells are usually present in the lesion • Most cases of FNH occur as a solitary lesion (80-95%) FOCAL NODULAR HYPERPLASIA (FNH)
  28. 28. Focal Nodular Hyperplasia (FNH) Rarely- encapsulated and pedunculated. usually less than 5 cm in diameter located in the subcapsular areas A classic focal nodular hyperplasia, paler than the surrounding liver, and with a distinct central stellate scar.
  29. 29. Although FNH usually has no clinical significance, recognition ofAlthough FNH usually has no clinical significance, recognition of the radiological characteristics of FNH is important to avoidthe radiological characteristics of FNH is important to avoid unnecessary surgery, biopsy, and follow-up imaging.unnecessary surgery, biopsy, and follow-up imaging.
  30. 30. Focal Nodular Hyperplasia (FNH) Diagnosis: US: Nodule with varying echogenicity Color Doppler imaging may show central vessels
  31. 31. Ultrasound Doppler ultrasound shows centrifugal arterial flowcentrifugal arterial flow originating from the central portion of the lesion or sometimes from a central vessel with a stellate configuration. Focal Nodular HyperplasiaFocal Nodular Hyperplasia
  32. 32. Focal Nodular Hyperplasia (FNH) Diagnosis: CT . Central scar . Brisk homogeneous enhancement . Well defined . Early homogenesation . Hypodense fibrous bands and septa that arise from the scar . On delayed phase images the central scar may remain hyperattenuating . Without capsule
  33. 33. Focal Nodular Hyperplasia (FNH) Diagnosis: CT HAP PVP DP IV-
  34. 34. Focal Nodular Hyperplasia (FNH) Diagnosis: CT
  35. 35. CT Findings: Typical CT finding of a FNH: • In the native scan this benign tumor appears to be almost isodense to the surrounding liver tissue; in its center a "scar" of lower density can be seen distinctly (top left image). • 25 secs after contrast agent application, enhancement starts (top middle image), reaching its maximum after 30-40 secs (top right image). Note the typical delicate structure of the hypodense septae, which appear in a radial order. • After 45-60 secs, homogenous contrasting is reached (bottom left image); this is followed by a gradual decay in contrasting. Focal Nodular HyperplasiaFocal Nodular Hyperplasia
  36. 36. Focal Nodular Hyperplasia (FNH) Diagnosis:MRI typical finding . Isointense to hypointense on T1-weighted images . Slightly hyperintense to isointense on T2-weighted images . Brisk homogeneous enhancement . Delayed enhancement of the central scar
  37. 37. Focal Nodular HyperplasiaFocal Nodular Hyperplasia MRI Findings: T1-weighted sequence. A focal lesion (arrow) with a diameter of 2.5 cm is hypointense relative to the liver parenchyma. T2-weighted sequence. The lesion is slightly and inhomogeneously hyperintense.
  38. 38. Hepatic Adenoma . Rare hepatic tumor . Women aged 20 to 40 years . Association with oral contraceptive use . Solitary (70%–80%) . Can be associated with right upper-quadrant pain . Risk of rupture, hemorrhage, or malignant transformation . 5-10cm . Benign neoplasm composed of normal hepatocytes no portal tract, central veins, or bile ducts . Surrounded by a capsule . Surgical resection is generally advised
  39. 39. Hepatocellular AdenomaHepatocellular Adenoma Ultrasound • On US, HAs demonstrate variable echogenicity. • The most adenomas are not specifically diagnosed at US and are usually further evaluated with CT or other imaging modalities. From: Luigi Grazioli et al. Hepatic Adenomas: Imaging and Pathologic Findings Radiographics. 2001;21:877-892. Transverse US scan of the liver shows a hypoechoic lesion (cursors) with a hyperechoic center (arrow) due to recent hemorrhage. Sagittal US scan of the liver shows a well- defined, homogeneous, hyperechoic lesion in the right lobe (arrow).
  40. 40. •Well circumscribed without lobulation •Heterogeneous because of their mixed components of fat, hemorrhage, and necrosis •Diffuse heterogeneous arterial enhancement and iso attenuated on delayed scan •MRI: CT SCAN
  41. 41. Hepatocellular AdenomaHepatocellular Adenoma CT Findings: Arterial-phase CT scan shows multiple hypervascular lesions (arrows). On a portal venous-phase CT scan, the adenomas are isoattenuating relative to the surrounding parenchyma. From: Luigi Grazioli et al. Hepatic Adenomas: Imaging and Pathologic Findings Radiographics. 2001;21:877-892.
  42. 42. Hepatic Adenoma • Hyper to isointense on T1 (hemorrhage) and slightly hyperintense on T2 weighted images
  43. 43. Liver cysts: . May be single or multiple . May be part of polycystic kidney disease . Patients often asymptomatic . No specific management required
  44. 44. Liver cysts:
  45. 45. Liver cysts: HYDATID CYST • Hyper to isointense on T1 (hemorrhage) and slightly hyperintense on T2 weighted images • Same appearance on contrast-enhanced image as CT scan
  46. 46. a typical case of a echinococcus cyst with 'daughter cysts' within the large cyst. Most cases of echinococcus cysts however are not that typical. LIVER CYSTS
  47. 47. LIVER ABSCESS
  48. 48. MALIGNANT LIVER LESIONS
  49. 49. Hepatocellular Carcinoma (HCC) •The fifth most common tumor •Rarely occurs before age of 40 and peaks at 70 years •Male to female: 4/1 •Cirrhosis is the strongest predisposing factor for HCC •80% of cases of HCC developing in a cirrhotic liver •Causes of cirrhosis: hepatitis (B and C virus infection), alcohol, Hemochromatosis and biliary cirrhosis Most HCCs develop by means of a multistep progression: from a low-grade dysplastic nodule to a high-grade dysplastic nodule, to a dysplastic nodule with a focus of HCC, and finally to overt carcinoma. Willatt et al Radiology: Volume 247: Number 2—May 2008
  50. 50. Several morphological forms Massive(>3cms) Nodular (<3cms) Diffuse Hepatocellular Carcinoma (HCC) AFP (Alfa feto protein) Is an HCC tumor marker Values more than 100ng/ml are highly suggestive of HCC Elevation seen in more than 70%
  51. 51. Hepatocellular Carcinoma (HCC) US : hyperechoic, smaller tumors are hypoechoic. Heterogeneous, hypervascular US sensitivity about 75%.
  52. 52. Arterial Phase: liver(30-35 sec) HCC as supplied by arterial branch/neovascularization Hepatocellular Carcinoma (HCC) Venous Phase: HCC which is enhanced during arterial phase has lost its contrast, hence no enhancement of the tumor but rest of the liver enhances. Contrast in brightness of the lesion with respect to surrounding liver. Enhancement Wash out phenomenan CT or MR
  53. 53. Hepatocellular Carcinoma (HCC) Delayed Phase : Wash -out phenomenan persists and often exaggerated in smaller lesions. The tumor capsule IV- HAP PVP DP capsule
  54. 54. Hepatocellular Carcinoma (HCC)
  55. 55. • MRI • Variable intensity of HCC on T1 • 35% hyper, 25% iso-, 40 % hypo • Hyperintense (T1) often well-differentiated, contain fat, copper, glycogen • Almost always hyperintense on T2 MR • The tumor capsule is hypointense on both T1- and T2- weighted images in most cases Hepatocellular Carcinoma (HCC)
  56. 56. Hepatocellular Carcinoma (HCC) MRI
  57. 57. Hepatocellular Carcinoma (HCC) Hypovascular HCC +/- 30%
  58. 58. Metastatic disease • Most common malignant hepatic tumor • Presence of extrahepatic malignancy should be sought in patients with characteristic liver lesions per imaging studies. • Common primaries : colon, breast, lung, stomach, pancreases, and melanoma • Mild cholestatic picture (ALP, LDH) with preserved liver function • CT or US guided biopsy provides definitive diagnosis but not always required.
  59. 59. Metastatic disease Variable US features+++ Iso, hyper or hypo echoic++ Contrast-enhanced US (CEUS) (84% accuracy) Intraoperative US (IOUS) (96% accuracy) Typical feature
  60. 60. Metastatic disease • Most liver metastases are hypovascular and are best imaged during the portal venous phase (colon, stomach and pancreas) • Hypervascular metastases enhancing on the arterial phase (neuroendocrine tumors, renal cell, breast, melanoma, thyroid) • Calcification may be present with metastases from mucinous gastrointestinal tract tumors and from primary ovarian, breast, lung, renal, and thyroid cancer • Other features : Hemorrhagic or cystic metastases
  61. 61. Metastatic disease . On MRI, metastases are variable but are usually hypo- to isointense on T WI and iso- to hyperintense on T2 WI . Metastatic tumors with liquefactive necrosis or cystic neoplasms show higher signal intensity on T2 WI . Metastases may show central hypointensity on T2WI (coagulative necrosis, fibrin, and mucin) . High T1 signal intensity can be seen with metastases from melanoma, colonic adenocarcinoma, ovarian adenocarcinoma, multiple myeloma and pancreatic mucinous cystic tumor . Comparing T2-weighted (TE 90) and T2-weighted (TE 160) sequences, metastases become less intense Characterization . T1-weighted 3D dynamic contrast-enhanced MRI Detection
  62. 62. Metastatic disease
  63. 63. Metastatic disease
  64. 64. LIVER TRAUMA
  65. 65. CT GRADING SYSTEM
  66. 66. •Green arrow: oval shaped hypodense area consistent with hematoma •Yellow arrow: linear shaped hypodense area consistent with laceration •Blue arrow: vague ill defined hypodense area consistent with contusion •Fluid around the liver •There is almost a transsection of the liver, but both lobes do enhance so there is still normal vascular supply.
  67. 67. • Complete devascularization of the right lobe (i.e. grade 4) . • Contrast blush within the intraparenchymal region, but also extention beyond the lateral margin of the liver. • Hemoperitoneum. • A second contrast blush at a lower level
  68. 68. • Subcapsular hematoma greater than 10 cm (i.e. grade 4 injury) • Contrast blush • No associated hemoperitoneum
  69. 69. Lacerations can be stellate, like the example on the left or branching like the one on the right.
  70. 70. THANK YOU
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imaging of the hepato biliary system

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