ct bệnh lý gan mật

Recurrent pyogenic cholangiohepatitis Marked extrahepatic, intrahepatic duct dilatation... recurrent pyogenic cholangiohepatitis Calcified soft intrahepatic stone  Vietnamese Buddhist

Allen J Cohen, Ph.D., M.D.

Department of Radiological Sciences

University of California, Irvine

Liver, Biliary Tree,Gallbladder

U gan lành tính

1 U tuyến (Hepatic adenoma)

2 Tăng sản thể nốt (Focal nodular hyperplasia)

U gan ác tính

1 Ung thư tế bào gan (Hepatocellular carcinoma)

2 Ung thư tế bào xơ dẹt (Fibrolamellar HCG)

3 Ung thư nguyên bào gan (Hepatoblastoma)

4 Ung thư đường mật (Cholangiocarcinoma)

5 Nang ung thư (Cystadenocarcinoma)

6 U máu ác tính (Angiosarcoma)

7 U biểu mô mạch máu (Hemangioendothelioma)

8 U hạch nguyên phát (Primary lymphoma)

9 Di căn (Metastasis)

Chụp cắt lớp vi tính Computed Tomography:

1 Đánh giá giai đoạn và theo dõi di căn.

2 Chẩn đoán các u nguyên phát: hepatoma, adenoma,

I Nang gan

Bẩm sinh, sau nhiễm trùng, sau chấn thương, nhiễm ký sinh trùng.

Bẩm sinh-hay gặp.

CT: Không ngấm thuốc, thành mỏng và đều.

Nhiều nang gan 40%

Nang nhỏ < 1 cm khó phát hiện bằng CT hay US.

Chẩn đoán phân biệt: di căn gan, áp xe nhỏ (metastasis,

micro-abscess).

Nang gan đơn thuần

 Bẩm sinh

Nhiều nang gan

 Trên CT nghĩ đến di căn

Nhiều nang gan

 Gan thận đa nang

Áp xe gan

 A míp

Nguồn: Máu, đường mật, sau chấn

thương, sau phẫu thuật

Áp xe a míp

 Khí bên trong  Thuốc cản quang vòa ổ

áp xe do thông với tá tràng

Sán chó

Echinococcal abscess

 Membranes within cyst

 E granulosis

Echinococcal abscess

 MRI-Large liver abscess-daughter cysts

Áp xe do nấm

 Ổ áp xe nhỏ được phát hiện vớ cửa sổ hẹp

Áp xe gan

 Áp xe lách do nấm  Áp xe do vi khuẩn

Viêm gan do ban xuất huyết

Sau bị mèo cào

U tuyến tế bào gan

 Máu tụ dưới bao gan do vỡ adenoma

1 Dạng nang, vỏ xơ

2 Phụ nữ trẻ, thuốc

3 Đau do u, chảy máu

4 Tiền ung thư

5 Chẩn đoán: CT

U tuyến tế bào gan

 Ngấm thì ĐM

Tăng sản thể nốt (Focal nodular

Focal Nodular Hyperplasia

 Pedunculated FNH with central scar- remnant of AVM

Focal nodular hyperplasia

 Central scar  Tc sulfur colloid avid

Focal nodular hyperplasia

 Focal nodular

hyperplasia

 Central scar

Regenerating Nodules

 Cirrhotic liver-spontaneous spleno-renal shunt

1 Ultrasound: round echogenic focus without hypoechoic halo.

2 CT: precontrast – hypodense mass.

contrast – rim enhancement initially.

delay – centripetal filling in.

3 Tc-labeled RBCs for lesions > 2 cm.

4 T2-weighted MR for lesions < 2cm.

ultrasound finding of hemangioma

 Globular peripheral

enhancement

 Lesion fills in from periphery

 Large hemangiomas may

not be echogenic  Globular peripheral

enhancement

 Contrast filling in from periphery

 Photopenic on Tc

sulfur colloid scan  tagged RBC scan Lesion fills in on Tc

 Hemangioma caused feeling of early satiety

Thrombosed hemangioma

 Same patient as

before-5 years earlier

 Large thrombosed hemangioma

Giant Hemangioma

 Interrupted globular enhancement of periphery is characterisic

Multiple Hemangiomas

 Interrupted globular enhancement of periphery is characterisic

Hepatocellular carcinoma

1 Vascular malignant tumor – solitary or multifocal.

2 Tumor thrombus, hemorrhage, metastases.

3 Elevated alpha-fetoprotein ( 80% of patients.)

4 Associated with hepatitis B, hepatitis C, alcohol

Diagnosis:

1 CT: inhomogeneous enhancement, delayed isoattenuation fibrous capsule – may mimic adenoma.

2 NM: Gallium uptake 90%.

 Enhancing lesion in arterial phase in lateral segment of left lobe.

 SPECT/CT scan shows tumor to be Gallium avid and sulfur colloid cold

 Best seen on portal

venous phase (not

common)

 Different multiple small

patient-hepatomas

 Same patient – other small hepatomas

Tiny Hepatoma

 Examination obtained with cardiac gating

Multiple hepatomas

gastroduodenal artery prior to therasphere embolization

 Large hepatoma  Portal vein thrombosis

 Large hepatoma  Lung metastasis

 Large hepatoma with

portal vein thrombosis

 Cavernous transformation

of portal vein

 Hepatoma adjacent to

thrombosed portal vein

 Gallium 67 citrate avid tumor

 Superior mesenteric

vein thrombosis

 Infarcted pneumatosis intestinalis

 Hepatoma  6 months later after

treatment with Radiofrequency Ablation

Hepatoma chemoembolization

50 mg cisplatin, 50 mg doxyrubicin,

Embogold microparticles 300-500 microns

Suspected hepatoma

 Hep C positive and rising

alpha feto protein

 Pedunculated hepatoma

Fibrolamellar Hepatoma

 Young non cirrhotic patient, normal AFP

Hepatic lymphoma

 Multiple liver lesions  Obstructing left kidney

 Destroying verterbral body

Liver malignancies

 Lymphoma  Cholangiocarcinoma

 Tumor occupies lateral segment of left lobe

 Metastases in right lobe

Hepatic metastases

1 Colon, breast, lung, pancreas –

hepatic artery supply.

2 CT: hyperattenuating,

hypoattenuating or hypoattenuating with rim enhancement.

Hepatic metastases

 metastasis in fatty

liver

metastatic colon Ca

Hepatic Metastases

Initial presentation ,three months,15 months,18 months Initial presentation ,three months,15 months,18 months

Hepatic Metastases

 Colon carcinoma metastatic to lliver and lungs

Hepatic Metastases

 Metastatic breast cancer-note sclerotic veterbral metastasis and absent left breast

Liver segments

Segment characterization

 Liver metastasis  Segmental anatomy better

depicted on MRI –orthogonal planes than single slice CT multislice CT may be best

Liver lesion diagnosis

 CT arterial portography

metastases

 CT arterial thrombosed right portal vein

portography-Carcinoid metastases

 Cystic carcinoid

metastases-unusual

 Classic arterial enhancement of carcinoid metastasis

Carcinoid metastases

Arterial phase images,

narrow and wide windows Portal venous phase imaging

Carcinoid metastases-after treatment with octreotide

Less vascularity

in

Arterial phase

Partially necrotic in portal

venous phase

Fatty liver

 Diffusely fatty liver

DIFFUSE HEPATIC DISEASE

1 Fatty infiltration – focal diffuse.

Chemotherapy,

hyperalimentation, alcohol,

obesity, diabetes,

hyper-triglycerides.

CT: normal liver 5-10 Hounsfield

units > spleen on noncontrast

scan

2 Cirrhosis – alcoholism, viral

hepatitis, cryptogenic cirrhosis,

sclerosing cholangitis.

1 Sequella of chemotherapy, random.

2 CT: normal vascular pattern.

3 MR: fat-suppression.

Focal fatty liver

Focal fatty liver

 Normal vascularity

preserved

 Focal Fat- T1 Fat Sat

Focal Fatty Liver

 Suspected mass on ultrasound

 Focal Fatty Liver on CT

Focal fatty liver

 Focal normal liver in sea of fatty liver-two cases

 Regenerating nodules

 Ascites

 Recanalized periumbilical vein

 Caput Medusa

Cirrhosis-hepatofugal flow

Diffuse hepatic disease

 Dense hemochromatosis

Diffuse hepatic disease

 Post transfusional hemosiderosis in child with leukemia

Budd-Chiari malformation

 Suspected gastric leiomyosarcoma

DIFFUSE HEPATIC DISEASE

Budd-Chiari syndrome:

Chronic hepatic vein congestion.

Tumor, web, phlebitis, blood

Budd-Chiari Syndrome

 Massively enlarged caudate lobe-thought to

be a hepatoma

Budd-Chiari Syndrome

 Portal venous flow  No hepatic venous flow

Portal Vein Thrombosis

Portal vein thrombosis with cavernous transformation

Post transplant evaluation

Hepatic artery patency

Intraoperative ultrasound

1. Focal masses

2. Transplant vascularity

Intraoperative ultrasound

 Needle localization  Probe localization

BILIARY TREE

CONGENITAL ABNORMALITIES

1.Choledochal cyst – marked extra-hepatic

dilation, minimal to no intrahepatic dilation Risk: stones, cholangiocarcinoma

2 Choledochocele – focal dilation of distal

CBD

3 Caroli’s disease – segmental dilatation of intrahepatic bile ducts associated with renal cysts, MSK

Congenital abnormalities

 Choledochal cyst  Choledochocele

Congenital abnormalities

Caroli’s disease

Choledochal cyst

 CT-Choledochal cyst

Choledochal cyst

 Ultrasound  MRI

Choledochal cyst

 CT

 Hepatobiliary scan

Choledochal cyst

 US- thick wall cyst  6 months later - metastatic

cholangiocarcinoma

Biliary tree

 Hamartoma of bile duct

Benign stricture – gradual

tapering

Malignant stricture –

abrupt cutoff

1 Acute cholangitis – biliary gas, wall enhancement

2 Sclerosing cholangitis – association – UC, Crohn

disease, retroperitoneal fibrosis.

Extra (95%) & intrahepatic strictures.

Beaded ducts.

Focal dilatation – suspect cholangiocarcinoma.

3 Recurrent pyogenic cholangiohepatitis

Marked extrahepatic, intrahepatic duct dilatation Numerous stones – cast of biliary tree

4 Choledocholithiasis.

-AIDS-AIDS cholangitis

 Beaded ducts  AIDS gallbladder

AIDS cholangitis

 AIDS gallbladder  CMV cholecystitis

AIDS cholangitis

 Papillary stenosis-AIDS cholangitis

 Sclerosing cholangitis  Periportal

nodes-primary bilary cirrhosis

recurrent pyogenic cholangiohepatitis

 Calcified soft intrahepatic stone

 Vietnamese Buddhist

monk with right upper

quadrant pain

Recurrent cholangiohepatitis

 Soft common duct stone  Stone in left duct

Common bile duct stone

 Subtle distal common

bile duct stone-filling of

intrahepatic radicles, no

 After stone removed

Common bile duct

 Ischemic stricture  CBD entering

diverticulum

Common bile duct obstruction

 Tension from T-Tube  Different

patient-jaundiced-dilated intrahepatic bile ducts

Common bile duct

 No excretion into bile duct

on Tc hepatobiliary scan

 Common duct stone

Common bile duct obstruction

 Dilated intrahepatic

bile ducts

 stone in distal CBD

 Ducts of Luschka-bile

leak

 pancreatitis

Bilary tree: neoplastic disease

1 Cholangiocarcinoma – Klatskin, intrahepatic, extrahepatic.

2 Metastatic to porta hepatis – lymphoma, ovarian, colon,

gallbladder, pancreas, stomach.

Sclerosing cholangitis

 ERCP  Same patient-7 years

later-cholangiocarcinoma

 Klatzkin tumor at confluence of ducts

 ERCP showing stented obstructing stricture

 Obstruction at porta

hepatis

 Stented tumor

 Dilated intrahepatic bile

ducts

 Delayed enhancement of tumor

Ovarian Carcinoma metastatic to porta

hepatis

Biliary dilatation, masses at porta, retroperitoneal

adenopathy, left ovarian cystadenocarcinoma

 MRCP-stone at

ampulla  MRCP-common duct

stones

 Low insertion of cystic duct not appreciated on previous CT scan

 cholesterol polyps

Oral cholecystograms

 Polyps  hypercontractility

 Septated gallbladder

 CT - adenomyosis  US - adenomyosis

 No stone seen on

ultrasound

 Gallstone seen on CT

 Fissured Cholesterol Stones

thrombosis

Acute cholecystitis

 Calcified gallstones  Perforated gallbladder

with pericholecystic

Acute emphysematous cholecystitis

 Usually diabetic patients, need emergency surgery

Gallbladder Cancer

Radiology:

SPREAD OF GALLBLADDER CANCER

Gallbladder Cancer

 Stones on ultrasound  Tumor growing into

liver

Jaundiced patient

 Dilated intrahepatic

ducts

 Nonvisualization of gallbladder

Gallbladder carcinoma

 Gallbladder cancer

growing into liver

 Perforated gallbladder cancer with

pericholecystic abscess

Gallbladder carcinoma

thrombosis-THAD-transient hepatic attenuation

difference-right lobe enhances

before left lobe

cause of right portal vein thrombosis

Leiomyosarcoma of gallbladder

Ultrasound-anechoic

Patient with vomiting

 Large gas collection

in right upper

quadrant

 MR-gallstone in empyema of gallbladder obstructing

stomach, patient also has cystic lesions of kidneys-tuberous

Quiz Case-elderly patient with

severe abdominal pain

Quiz Case

CT scan two years earlier

Perforated Gallbladder

 Gallstones are now in peritoneal cavity