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Abdominal Imaging of Liver

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Abdominal Imaging of Liver Chuan Lu School of Radiology Taishan Medical University portal vein invasion (25-48%) HCC- CT sensitivity of 63% in cirrhosis, 80% ... – PowerPoint PPT presentation

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Title: Abdominal Imaging of Liver


1
Abdominal Imaging of Liver
  • Chuan Lu
  • School of Radiology
  • Taishan Medical University

2
  • Anatomy
  • Protocols and Normal Ultrasound Findings
  • Pathology

3
Anatomy of the Liver
  • The Liver occupies all of the right
    hypochondrium, the greater part of the
    epigastrium, and left hypochondrium. The ribs
    cover the greater part of the right lobe .In the
    epigastric region, the liver extends several
    centimeters below the xiphoid process. Most of
    the left lobe of the liver is covered by the rib
    cage.

4
Lobes of the Liver
  • Right lobe The right lobe of the liver is the
    largest of the livers lobes. It extends the left
    lobe by a ratio of 61. It occupies the right
    hypochodrium.
  • Left lobe The left lobe of the liver lies in the
    epigastric and left hypochondriac region.
  • Caudate lobe The caudate lobe is a small lobe
    situated on the posterosuperior surface of the
    left lobe opposite the tenth and eleventh
    thoracic vertebrae .

5
Hepatic Nomenclature
  • Couinauds system of hepatic nomenclature
    provides the anatomic basis for hepatic surgical
    resection. By using this system , the radiologist
    may be able to precisely isolate the location of
    a lesion for the surgical team

6
  • Couinauds hepatic segments divide the liver
    into eight segments . The hepatic veins are the
    longitudinal boundaries . The transverse plane
    is defined by the right and left portal pedicles
    .

7
Hepatic Segmental Anatomy
  • The caudate lobe (segment?) is situated
    posteriorly.
  • Segment ?includes the caudate lobe.
  • Segment ?and ? includes the left superior and
    inferior lateral segment.
  • Segment ?a and ?b includes the medial segment of
    the left lobe.
  • Segment? and ? are caudal to the transverse plane
    .
  • Segments ? and ? are cephalad to the transverse
    plane.

8
Superior anterior segment (right lobe)
Caudate lobe
?
?
Superior lateral segment
Superior posterior segment (left lobe)
?
?
Inferior lateral segment
?
Superior posterior segment (left lobe)
?
Medial segment
?
Inferior anterior segment (right lobe)
9
Ultrasound can allow us to visualize the portal
veins, hepatic veins , intrahepatic bile ducts .
Anatomy of Liver Glisson system
  • The portal veins carry blood from the bowl to the
    liver, whereas the hepatic veins drain the blood
    from the liver into the inferior venal cava . The
    hepatic arteries carry oxygenated blood from the
    aorta to the liver. The bile ducts transport bile
    ,manufactured in the liver , to the duodenum.

10
The portal venous system is a reliable indicator
of various ultrasonic tomographic planes
throughout the liver.Main portal veinRight main
portal veinLeft main portal vein
Vascular Supply Portal veins
  • Intrahepatic Portal Vein Branches
  • Right anterior superior left median superior
  • Right anterior inferior left median
    inferior
  • Right posterior superior left anterior
    inferior
  • Right posterior inferior left lateral
    superior

11

Vascular Supply Hepatic veins The hepatic
veins are divided into three components
right,middle,and left. The right hepatic veins is
the largest and enters the right lateral
12
Distinguishing Characteristics of Hepatic and
Portal Veins
  • The best way to distinguish the hepatic from the
    portal vessels is to trace their points of entry
    to the liver. The hepatic vessels flow into the
    inferior vena cava, whereas the splenic veins and
    superior mesenteric vein join together to form
    the portal venous system.

13
Distinguishing Characteristics of Hepatic and
Portal Veins
  • The walls of hepatic veins are thin-walled ,and
    the walls of portal veins are brightly reflective
    veins

14
  • The hepatic veins are easily differentiated from
    bile ducts and portal veins .
  • They are not surrounded by an echogenic wall
  • They originate close to the diaphragm , and can
    be traced into the inferior vena cava

15
Sonographic Evaluation of the Liver
  • Evaluation of the hepatic structure is one of the
    most important procedures in sonography for many
    reasons. The normal , basiclly homogenerous
    parenchyma of the liver allows imaging of the
    neighboring anatomic structures in the upper
    abdomen.

16
Sonographic Evaluation of The Liver
  • The system gain should be adjusted to adequately
    penetrate the entire right lobe of the liver as a
    smooth ,homogeneous echo-texture pattern
  • The time gain compensation should be adjusted to
  • balance the far-gain and the near-gain echo
    signals.
  • The far time -gain control pods should gradually
    be increased until the posterior aspect of the
    liver is well seen.

17
  • The appropriate transducer depends on the
    patients body habitus and size
  • The average adult abdomen usually requires a
    3.5MHz

18
  • The basic instrumentation should be adjusted in
    the following parameters
  • Time gain compensation
  • Overall gain
  • Transducer frequency and type
  • Depth and focus

19
Longitudinal Scan Plane
  • The longitudinal ,or sagittal, scan offers an
    excellent window to visualize the hepatic
    structure . With the patient in full inspiration
    , the transducer may be swept under the costal
    margin to record the liver parenchyma from the
    anterior abdominal wall to the diaphragm.

20
Longitudinal Scan Plane
  • Scan ?
  • Scan ?
  • Scan ?
  • Scan ?,?,?

21
Longitudinal Scan Plane
  • Scan ?
  • The initial scan should be made slightly to
    the left of the midline to record the left lobe
    of the liver and the abdominal aorta. The left
    hepatic and portal veins may be seen as small
    circular structures in this view.

22
??????????Sagittal image of left
lobe of liver, and aorta
  • The initial scan should be made slightly to the
    left of the midline to record the left lobe of
    the liver and the abdominal aorta. The left
    hepatic and portal veins may be seen as small
    circular structures in this view.

23
Sagital image of tip of left lobe of liver
The initial scan should be made slightly to the
left of the midline to record the left lobe of
the liver and the abdominal aorta. The left
hepatic and portal veins may be seen as small
circular structures in this view.
24
Sagittal image of left lobe of liver, and aorta
  • The initial scan should be made slightly to
    the left of the midline to record the left lobe
    of the liver and the abdominal aorta. The left
    hepatic and portal veins may be seen as small
    circular structures in this view.
  • SMA,CA

25
Longitudinal Scan Plane
  • Scan ?
  • As the sonographer scans at midline or slightly
    to the right of midline , a larger segment of the
    left lobe and the inferior vena cava may be seen
    posteriorly . In this view , it is useful to
    record the inferior vena cana as it is dilated
    near the end of inspiration. The left or
    midline hepatic vein may be imaged as it drain
    into the inferior vena cava near the level of
    the diaghram. The area of the portal hepatis is
    shown anterior to the inferior vena cava as the
    superior mesenteric vein and splenic vein
    converge to form the main portal vein. The common
    bile duct may be seen just anterior to the main
    portal vein. The head of the pancreas may be
    seen just inferior to the right lobe of the
    liver and main portal vein and anterior to the
    inferior vena cava.

26
Sagittal image of left lobe of liver, portal
vein and inferior vena cava
  • The left or midline hepatic vein may be imaged
    as it drain into the inferior vena cava near
    the level of the diaghram. The area of the
    portal hepatis is shown anterior to the inferior
    vena cava

27

Normal IVC and Budd-Charis Syndrome
28
Longitudinal Scan Plane
  • Scan ?
  • The next image should be made slightly lateral
    to this saggital plane to record part of the
    right portal vein and right lobe of liver . The
    caudate lobe is often seen in this view.

29
Sagittal image of gallbladder
30
Gallbladder and Biliary System
  • Normal size of gallbladder
  • 79cm in length
  • 34cm in width
  • Wall thickness 23mm
  • Normal size of bile ducts
  • right /left intrahepatic duct just to
    proximal CHD 2-3mm
  • CBD8mm dilated

31
Longitudinal Scan Plane
  • Scan ?,?,?
  • The nest three scans should be made in small
    increment through the right lobe of the liver .
  • The last scan is usually made to show the
    right kidney and lateral segment of the right
    lobe of the liver. The liver texture is compared
    with the renal parenchyma. The normal liver
    parenchyma should have a softer , more
    homogenerous texture than the dense medulla and
    hypoechoic renal cortex. Liver size may be
    measured from the tip of the liver to the
    diaphragm . Generally this measurement is less
    than 15 cm, with 15 to 20 cm representing the
    upper limits of normal. Hepatomegaly is present
    when the liver measurement exceed 20 cm.

32
????????Sagittal image of
liver /right kidney
  • The normal liver parenchyma should have a
    softer , more homogenerous texture than the
    dense medulla and hypoechoic renal cortex

33
The last scan is usually made to show the right
kidney and lateral segment of the right lobe of
the liver. The liver texture is compared with the
renal parenchyma. The normal liver parenchyma
should have a softer , more homogenerous
texture than the dense medulla and hypoechoic
renal cortex.
34
Transverse Scan Plane
  • Multiple transverse scans are made across the
    upper abdomen to record specific areas of the
    liver. The transducer should be angled in a
    steep cephalic direction to be as parallel to the
    diaphragm as possible.

35
  • The patient should be in full inspiration to
    maintain detail of the liver parenchyma ,
    vascular architecture, and ductal structures

36
Transverse Scan Plane
  • Scan ?
  • Scan ?
  • Scan ?
  • Scan ?
  • Scan ?,?

37
Transverse Scan Plane
  • Scan ?
  • The initial transverse scan is made with the
    transducer under the costal margin at a steep
    angel perpenducular to the diaphragm.
  • The patient should be in deep inspiration to
    adequately record the dome of the liver. The
    sonographer should identify the inferior vena
    cava and three hepatic veins as they drain into
    the cava. This pattern has sometimes been
    referred to as reindeer sign or Playboy bunny
    sign.

38
  • The sonographer should identify the inferior
    vena cava and three hepatic veins as they drain
    into the cava. This pattern has sometimes been
    referred to as reindeer sign or Playboy bunny
    sign.

39
Transverse Scan Plane
  • Scan ?
  • The transducer is then directed slightly inferior
    to the point described in scan ? to record the
    left portal vein as it flows into the left
    lobe of the liver.

40
Transverse Scan Plane
  • Scan ?
  • The porta hepatis is seen as a tubular
    structure within the central part of the liver.
    Sometimes the left or right portal vein can be
    identified . The caudate lobe may be seen just
    superior to the porta hepatis thus , depending
    on the angel , either the caudate lobe is shown
    anterior to the inferior vena cava, or as the
    transducer moves inferior ,the porta hepatis is
    identified anterior to the inferior vena cava.

41
Transverse Scan Plane
  • Scan ?
  • The fourth scan should show the right portal
    vein as it divides into the anterior and
    posterior segments of the right lobe of the
    liver. The gallbladder may be seen in this
    scan as an anechoic structure medial to the
    right lobe and anterior to the right kidney.

42
????????
  • The fourth scan should show the right portal
    vein as it divides into the anterior and
    posterior segments of the right lobe of the
    liver. The gallbladder may be seen in this
    scan as an anechoic structure medial to the
    right lobe and anterior to the right kidney.

43
Transverse Scan Plane
  • Scan ?,?
  • These two scans are made through the lower
    segment of the right lobe of the liver . The
    right kidney is the posterior border. Usually
    intrahepatic vascular structures are not
    identified in these views

44
????????
  • ???????????????????????????????????????
  • ???????????????????????,????? ????
  • ?????12-14cm

45
Lateral Decubitus Scan Plane
  • Left Anterior Oblique
  • The left anterior oblique scan requires that the
    patient roll slightly to the left . A 45-degree
    sponge or pillow may be placed under the right
    hip to support the patient.
  • This view allows better visualization of the
    lower right lobe of the liver, usually diaplacing
    the duodenum and transverse colon to the midline
    of the abdomen , out of the field of view.
    Transverse , oblique, or longitudinal scans may
    be made in this position.

46
Lateral Decubitus Scan Plane

47
Lateral Decubitus Scan Plane
  • Measurement of main portal vein
  • 1.01.5cm

48
Fliying Bird Sign
49
Common bile duct
  • Diameter lt0.8cm

50
Sonographic Evaluation of The Liver
  • Adequate scanning technique demands that each
    patient be examined with the following assessment
  • The size of the liver in the longitudinal plane
  • The attenuation of the liver parenchyma
  • Liver texture
  • The presence of hepatic vascular structures,
    ligaments ,and fissures

51
Pathology of the Live
  • Evaluation of the liver parenchyma includes the
    assessment of its size , configuration,
    homogeneity , and contour.

52
The Normal attenuation of the liver parenchyma
Normal Liver texturehomogeneous Assessment of
its size , configuration, homogeneity , and
contour
53
Abnormal Liver texture-inhomogeneous The
diffuse hepatic lesions Assessment of its size
, configuration, homogeneity , and contour.
54
Assessment of its size , configuration,
homogeneity , and contour
55
  • Assessment of its size , configuration,
    homogeneity , and contour
  • The size of the liver
  • The changes of the size and shape

56
Assessment of its size , configuration,
homogeneity , and contour The changes of the
hepatic contour

57
Assessment of its size , configuration,
homogeneity , and contour The focal hepatic
lesions
  • hyperechoic , hypoechoic, anechioc , mixed
    pattern

58
Assessment of its size , configuration,
homogeneity , and contour The vascular
disorganization
59
Assessment of its size , configuration,
homogeneity , and contour Dilated intrahepatic
bile ducts
60
Pathology of the Live
  • Subsequent sections discuss the pathology of
    liver disease in the following categories
  • Diffuse disease
  • Hepatic Tumors
  • Benign disease
  • Malignant disease
  • Abscess formation
  • Functional disease
  • Tranplantation
  • Vascular problems

61
Pathology of the Live
  • Diffuse Fatty Infiltration
  • US
  • increased sound attenuation poor definition of
    posterior aspect of liver ( bright liver)
  • fine/coarsened hyperechogenicity
  • (compared with kidney)
  • impaired visualization of borders of hepatic
    vessels
  • Attenuation of sound beam

62
Fatty Infiltration
increased sound attenuation poor definition of
posterior aspect of liver ( bright liver)
impaired visualization of borders of hepatic
vessels
63
Diffuse Fatty InfiltrationCT
  • Areas of lower attenuation than normal portal
    vein/IVC density
  • Reversal of liver spleen density relationship
    (liver density is normal 6-12HU greater than
    spleen)
  • Hyperdense intrahepatic vessels

64
Diffuse Fatty InfiltrationCT
  • Areas of lower attenuation than normal portal
    vein/IVC density
  • Hyperdense intrahepatic vessels

65
  • Reversal of liver spleen density relationship
    (liver density is normal 6-12HU greater than
    spleen)

66
Hepatic Cirrhosis
  • Surface irregularity
  • Increased echogenicity
  • Heterogeneous coarse echotexture
  • Ascites

67
Regenerating nodules
68
Regenerating nodules
69
AscitesPortal hypertension
70
Heterogeneous coarse echotextureSurface
irregularityAscitesDecreased definition of
walls of portal venules
71
Heterogeneous coarse echotextureSurface
irregularityAscitesDecreased definition of
walls of portal venules
72

Ascites, even in very small qualities, can
cause a thick gallbladder wall
73
Ascites
74
  • Surface irregularity

75
Pathology of the Live
  • Focal Hepatic Disease
  • Cystic Lesions
  • Hepatic cysts may be congenital or acquired
    ,solitary , or multiple. Patients are often
    asymptomatic, except patients who have large
    cysts , which can compress the hepatic
    vasculature or ductal system.

76
Pathology of the Live
  • Focal Hepatic Disease
  • Cystic Lesions within the liver include the
    following
  • Simple or congenital hepatic cysts
  • Traumatic cysts
  • Parasitic cysts
  • Inflammatory cysts
  • Polycystic disease
  • Pseudo-cysts

77
Ultrasound Findings of Cystic Lesions
  • On ultrasound examination the cyst walls are thin
    , with well-defined borders, and anechoic with
    distal posterior enhancement.

78
  • Sonographic Features
  • Of hepatic cyst
  • No internal echoes
  • Smooth borders
  • Regular /irregular outline
  • Acoustic enhancement
  • Septum may be seen

79
Hepatic cyst 1
80
Hepatic cyst 2
81
Hepatic cyst
  • Second most common benign hepatic lesion(22)
  • Acquired hepatic cyst second to trauma,
    inflammation , parasitic infection
  • Associated
  • tuberous necrosis
  • polycystic kidney disease(25-33have liver
    cyst)
  • polycystic liver disease(50have polycystic
    kidney disease)

82
Polycystic liver disease
83
Hepatic abscess
  • Types
  • pyogenic(88)
  • amebic(10)
  • fungal(2)

84
Hepatic abscess-
  • Hypoechoic round lesion with well-defined
    mildly echogenic rim
  • Distal acoustic enhancement
  • Coarse clumpy debris /low-level
    echoes/fluid-debris level
  • Intensely echogenic reflections with
    reverberations

85
  • Hypoechoic round lesion with well-defined
    mildly echogenic rim
  • Distal acoustic enhancement
  • Coarse clumpy debris /low-level
    echoes/fluid-debris level
  • Intensely echogenic reflections with
    reverberations

86
Hepatic abscess-CT
87
Pathology of the Live
  • Hepatic Tumors
  • Benign disease
  • Malignant disease

88
Pathology of Liver
  • Primary Hepatic Carcinoma (PHC)
  • Metastases to liver
  • Hepatic hemangioma

89
Hepatocellular Carcinoma(HCC) Primary Hepatic
Carcinoma (PHC)
  • Etiology cirrhosis, hepatitis B and C
    infection and carcinogens
  • Solitary,
  • multifocal or
  • more rarely diffusely infiltrating

90
Hepatocellular Carcinoma(HCC)
  • Growth pattern
  • solitary massive (27-59)
  • bulk in one (most often right) lobe with
    satellite nodules
  • multifocal small nodular (15-25)
  • small foci of usually lt2 cm (up to 5 cm) in both
    hepatic lobes
  • diffuse microscopic infiltrating form (10-26)
  • tiny indistinct nodules closely resembling
    cirrhosis
  • Vascular supply hepatic artery, portal vein in 6

91
HCC
  • Metastases to lung (most common 8), adrenal,
    lymph nodes, bone
  • portal vein invasion (25-48)
  • arterioportal shunting (4-63)
  • invasion of hepatic vein (16)/IVC (
    Budd-Chiari
  • syndrome)
  • occasionally invasion of bile ducts
  • calcifications in ordinary HCC (2-25) however,
  • common in fibrolamellar (30-40) and
    sclerosing HCC
  • hepatomegaly and ascites
  • tumor fatty metamorphosis (2-17)

92
Sonographic Features of HCC
  • 86-99 sensitivity
  • 90-93 specificity
  • 65-94 accuracy
  • Hyperechoic HCC(13)due to fatty metamophosis or
    marked dilatation of sinusoids
  • Hypoechoic HCC(26)due to solid tumor
  • HCC of mixed echogenicity (61)due to
    nonliquefactive tumor necrosis

93
  • HCC of mixed echogenicity (61)due to
    nonliquefactive tumor necrosis

94
  • Hypoechoic HCC(26)due to solid tumor

95
  • Hyperechoic HCC(13)due to fatty metamophosis or
    marked dilatation of sinusoids

96
Vascular supply hepatic artery, portal vein in 6
97
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98
portal vein invasion (25-48)
99
HCC- CT
  • sensitivity of 63 in cirrhosis, 80 without
    cirrhosis)
  • hypodense mass/rarely isodense/hyperdense in
    fatty liver
  • dominant mass with satellite nodules
  • mosaic pattern multiple nodular areas with
    differing attenuation on CECT (up to 63)
  • diffusely infiltrating neoplasm
  • encapsulated HCC circular zone of radiolucency
  • surrounding the mass (12-67)
  • False-positive confluent fibrosis, regenerative
    nodule

100
Biphasic CECT
  • enhancement during hepatic arterial phase (80)
  • decreased attenuation during portal venous phase
    with inhomogeneous areas of contrast accumulation
  • isodensity on delayed scans (10)
  • thin contrast-enhancing capsule (50) due to
    rapid washout
  • wedge-shaped areas of decreased attenuation
    (segmental/lobar perfusion defects due portal
    vein occlusion by tumor thrombus)

101
Biphasic CECT
  • enhancement during hepatic arterial phase (80)

102
Biphasic CECT
  • decreased attenuation during portal venous phase
    with inhomogeneous areas of contrast accumulation

103
Biphasic CECT
  • isodensity on delayed scans (10)

104
HCC- CT Unenhanced CT and Contrast enhanced CT
  • Unenhanced CT hypodense mass/rarely
    isodense/hyperdense in fatty liver

105
Biphasic CECT
  • enhancement during hepatic arterial phase (80)

106
Biphasic CECT
  • decreased attenuation during portal venous phase
    with inhomogeneous areas of contrast accumulation

107
Biphasic CECT
  • isodensity on delayed scans (10)

108
After 1st TACE
  • Therapy of HCC Interventional radiology -
    transcatheter arterial chemoembolization(TACE)

109
After 2nd TACE
  • Therapy of HCC Interventional radiology -
    transcatheter arterial chemoembolization(TACE)

110
Metastases to liver
  • Organ of origin
  • colon(42) stomach(23)
  • pancreas(21) breast(14) lung(13)
  • Number multiple(98) solitary(2)
  • BullseyeAn echogenic center with a
  • surrounding echopenic area
  • Echopenic Less echogenic than the
  • surrounding liver
  • Echogenic More echogenic than the
  • surrounding liver

111
BullseyeAn echogenic center with a
surrounding echopenic area ???
112
BullseyeAn echogenic center with a
surrounding echopenic area
113
Metastases to liver
114
Metastases to liver

115
(bulls eye sign)
116
Hepatic hemangioma / Cavernous hemangioma of
liver
  • CH of the liver is composed of blood-filled
    fairly large or tortuous vascular cavities
    divided by thin, often incomplete, fibrous septa
    and lined by a single layer of flat endothelium
  • The blood flow in the vascular spaces is slow and
    nondirectional which is predisposed to thrombosis

117
Ultrasonic features of Hepatic hemangioma
  • Uniformly hyperechoic mass(60-70)
  • Inhomogeneous hypoechoic mass (up to 40)
  • Homogeneous(58-73) /heterogeneous
  • May show acoustic enhancement(37-77)
  • Unchanged in size/appearance(82)on 1-to-6 year
    follow-up
  • No Doppler signals/signals with peak velocity of
    lt50cm/cm

118
?
  • Uniformly hyperechoic mass(60-70)

119
Cavernous hemangioma of liver
Markedly hyperechoic lesion without dorsal
acoustic shadowing.
120
  • A slightly hypoechoic lesion with sharply
    delineated borders, oval shape and no dorsal
    acoustic enhancement.

121
  • hypoechoic mass (up to 40)

122
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123
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124
  • ? ?
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