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Abdominal Imaging. Deng-Bin WANG, MD, PhD Dept. of Radiology, Rui Jin Hospital SJTU. The Biliary Tract Liver Pancreas Spleen. Imaging of the Biliary Tract. Methods of examination Normal anatomy and X-ray findings Common diseases. Methods of examination (I). - PowerPoint PPT Presentation
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Deng-Bin WANG, MD, PhDDeng-Bin WANG, MD, PhD
Dept. of Radiology, Rui Jin Hospital SJTUDept. of Radiology, Rui Jin Hospital SJTU
Abdominal ImagingAbdominal Imaging
I.I. The Biliary TractThe Biliary TractII.II. LiverLiverIII.III. PancreasPancreasIV.IV. Spleen Spleen
Imaging of the Biliary TractImaging of the Biliary TractImaging of the Biliary TractImaging of the Biliary Tract
Methods of examination
Normal anatomy and X-ray findings
Common diseases
Methods of examination (I)Methods of examination (I)
Plain film: calcium (10~20%)Plain film: calcium (10~20%)
Oral cholecystographyOral cholecystography
Intravenous cholangiographyIntravenous cholangiography
T tube cholangiographyT tube cholangiography
Endoscopic retrograde cholangio- Endoscopic retrograde cholangio-
pancreatography, ERCPpancreatography, ERCP
percutaneous transhepatic percutaneous transhepatic
cholangiography, PTCcholangiography, PTC
Plain film — gallstone
Oral cholecystography
T tube cholangiography
ERCP
PTC
Method of examination (II)
Ultrasonography (US)Ultrasonography (US)
AngiographyAngiography
Computed tomography (CT)Computed tomography (CT)
spiral CT cholangiography (SCTC)spiral CT cholangiography (SCTC)
Magnetic resonance imaging (MRI)Magnetic resonance imaging (MRI)
MR cholangiopancreatography (MRCP)MR cholangiopancreatography (MRCP)
MRCP
Normal gallbladder anatomy
right 12th rib level Round, oval or pear-shaped 7~10cm in length, 3~4cm in wid
th four parts: funds, body, infu
ndibulum, neck cystic duct: 3cm in length, 2~3cm in widt
h
Normal biliary tract findings
Intrahepatic bile duct
left 、 right hepatic duct
common hepatic duct (3~4cm in length, 4~6mm in width)
cystic duct
common bile duct (6~10cm in length, 4~8mm in width)
Normal gallbladder and biliary tract anatomy
Position: between the left and r
ight lobes of liver, at the porta s
ection or below it.
Shape: oval
Size: 4 × 5cm
Density: lower, a little higher t
han water, homogeneous
Common bile duct : 1/3 is visualiz
ed
Intrahepatic ducts are not visualiz
ed
Normal CT finding of gallbladder
Common diseases of biliary tract
Gallstone
Cholecystitis
Gallbladder cancer
Gallstones (I)
composition: cholesterol, bile pigment, calcium shape: round, multi-facet, shell-like location:
gallbladder, intra- or extra-hepatic bile duct
Gallstones (II)
opaque stone (+): 10~20%
plain film (differentiate: renal stone)
non-opaque stone (-): 80~90%
contrast study: filling defect
Gallstones – Gallstones – non-opacifyingnon-opacifying
Gallstones – non-opaque stone
Gallstones – opaque stone
Gallstones – opaque stone
Stones in common bile duct
Stones in common bile duct
Hepatic bile duct stone
Gallstones and hepatic duct stones
Differentiation of calculi
Ureteral calculi
Calcification ofLymph node
Gallstones
Acute cholecystitis Causes: bile duct stone 、 infection 、 reflux of pancreatic sec
retion Pathology:c congestion and edema of gallbladder mucosa, gall
bladder enlarged and its wall thichened X-ray finding: gallbladder enlarged, gas in the gallbladder lu
men or wall. CT: thickening , irregular and wall(>4mm) , vague margin.
Chronic cholecystitis
Non-opacifying gallbladder
(excluding: inadequate absorption or excr
etion)
Faint opacifying with vague margin
slower rate of emptying
Chronic cholecystitis
Gallbladder CarcinomaGallbladder Carcinoma
Hepatic Hilar Cholangiocarcinoma
Biliary Biliary ductal ductal systemsystem
23 sec Breath-hold
BiliaryBiliary ductalductal systemsystem SSFSE & 3D FRFSE
Sl. thickness: 3 mm. Matrix: 512 x 192
2D SSFSE
3D FRSFSE
2D Fast GRE T1 w. Fat Sat
Sl. thickness: 5 mm. Matrix: 512 x 256
Sl. thickness: 2 mm. Matrix: 384x224
Sl. thickness: 7 mm. Matrix: 512 x 256
Sl. thickness: 20 mm. Matrix: 512 x 384
High spatial resolution of the entire pancreaticobiliary tract
and of the adjacent soft tissue
After Contrast Media Injection
FGRE T1 w. Fat Sat
FGRE T1 w. Fat Sat
Biliary ductal systemBiliary ductal systemSSFSE & 3D FRFSE 3D FRSFSE
3D FRSFSE
2D SSFSE
2D SSFSE
2D SSFSE
Biliary ductal systemBiliary ductal system 2D FIESTA Fat Sat
Sl. thickness: 3 mmMatrix 224x224
Zip 5121 sec / slice
FS FIESTA FS FIESTA
SSFSE long TE SSFSE long TE
Hepatobiliary system
Biliary ductal systemBiliary ductal system LAVA after mangafodipir trisodium administration (Teslascan )
Sl. Thickness 3 mm (ov -0.8 mm)Matrix: 256x224 – ZIP 512
Acq. time: 18 sec
High Resolution T1 w. 3D MRCP - Functional information -
Liver Imaging
Plain filmUS, CT, MRIcontrast study
GI double contrast ERCP / PTC DSA
Plain film
Angiography
CTCT
CT
Torso coil4 elements phase-array coil
-> huge anatomical coverage-> high SNR-> Asset compatible
Patient preparation
MRI
Liver and Pancreas:Dynamic Contrast- enhanced Scanning Protocol for CT or MRI
Early Phase: (delayed time:25-30s)Portal Phase: (delayed time:55-60s)Delayed Phase: (delayed time:90-200s)
Common diseases of Liver
Abscess
Hemangioma
Cancer
Cyst
Cirrhosis
Abscess Causes : pyogenic 、 amebic Clinic : fever 、 pain 、 enlargement of liver CT finding : low-density or cystic mass , 20 – 40Hu , with c
ontrastcnhancement of the wall, A surrounding low-density halo.
Abscess - MRI
Hemangioma Well-defined, low-density lesion. Dynamic scans after a bolus of intravenous c
ontrast show dense peripheral enhancement at 15’s, with gradual infilling so
that the lesion becomes isodense.
Hemangioma-angiography
Cancer – primary HCC
Pathology : Hepatocellular carcinoma ( 90% ) , cholangiocarcinoma and mixed form.
Categories : solitary mass 、 multifocal nodule 、 diffuse involvement.
CT findings : Plain scan reveals well or poor defined, low-density mas
s with irregular margin. Enhancement occurs and disappears earlier.
Hepatocellular carcinoma
Hepatocellular carcinoma —diffuse involvement
Vascular mapping:Portal system
Vascular mapping:Portal system & vena cava
Liver Volumetry
Arterial phase Portal phase Equilibrium phase
Focal lesion: Contrast uptake dynamics
Washout
Arterial perfusion
Portal systemc
Liver veins
Liver parenchymaLiver parenchyma
Extra cellular Imaging
Presurgical topography information & vessel assessment
Arterial phase Portal phase
Arterial phase Portal phase
Focal lesion characterization &
3D presurgical topography information
Arterial phase
Arterial phase: MIP
Portal phase
Portal phase: MIP
Arterial phasePortal phase
Arterial phase
Arterial phase
Portal phase
Portal phase
High sensitivity to detect small lesions (less than 0.5 mm)
Early arterial phase Late arterial phase Portal phase
2 acquisitions – 1 single breath-hold
1 single breath-hold
Focal lesion: Double hepatic arterial phase MRI
From the From the morphology morphology to the functionto the function
“Today, the contribution of MRI to Body application is decisive not only for the accuracy of the diagnosis but also for the follow up and the monitoring of treatment.”
Pr D. RégentUniversity hospital, Nancy
Brownian motion
Angiogenesis
From the morphology to the functionFrom the morphology to the function
DW Imaging
METS
FNH
Bachir Taouli, MD, et al. Evaluation of Liver Diffusion Isotropy and Characterization of Focal Hepatic Lesions with Two Single-Shot Echo-planar MR Imaging Sequences: Prospective Study in 66 Patients – Radioligy 2003; 226:71–78
HCC
DW-EPI B 600 s/mm²
8 mm slices / gap 0Matrix: 128x1605 slices / 20 sec
• 3 D FSGPR3 D FSGPR
• 容积内插技术容积内插技术• 优点优点
• 层面更薄层面更薄• 成像更快成像更快• 内插技术有利于内插技术有利于 MPRMPR
• 可同时进行肝脏动态增强和可同时进行肝脏动态增强和 CE-MRACE-MRA
• 缺点缺点• T1T1 对比略差于对比略差于 2D FSPGR T1WI2D FSPGR T1WI
FAME (Fast Acquisition with Multiphase Efgre3d)
VIBE VIBE (( VVolume olume IInterpolated nterpolated BBody ody EExaminationxamination ))
Liver metastases
FAMEFast Acquisition with Multiphase Efgre3d
结肠癌肝脏多发转移结肠癌肝脏多发转移
三维梯度回波三维梯度回波 T1WIT1WI
Hepatocellular carcinoma — angiography
Cyst
Well-defined, nonenhancing lesion of low density(0-20Hu).
Cyst — MRI
Low signal on T1WI and high signal on T2WI with smooth and round margin.
Cirrhosis The liver becomes small, particularly the right lobe,
outline is irregular and the fissures more prominent. Isodense regenerating nodules can appear. Ascites can be seen.
Interleave Joke
A: I’m so glad I wasn’t born in
the United States.
B: Why?
A: Because I can’t speak English.
Pancreas: Methods of examination
X-ray plain film
G-I double contrast
ERCP
PTC
Angiography
T1W T1W 脂肪抑制T2W
正常胰腺 MR 动态增强T1W T2W 抑脂
FSPGR 动脉期 FSPGR 门脉期
SA SV
MRA
胰体尾部癌
MRI with the combination of MRA and MRCP technique has the unique capability of allowing a noninvasive comprehensive examination within a single diagnostic modality for evaluation of the full range of pancreatic diseases.PANCREASPANCREAS
Multi–detector row helical CT
PancreasPancreas SSFSE & 2D FGRE
Slice thickness: 5 mm Matrix 512x224
No In-Plane interpolation
SSFSE
2D Fast GRE
2D Fast GRE
After Contrast Media Injection
High contrast resolution pancreatic examination
Internal septa
PancreasPancreas SSFSE & 2D FIESTA Fat Sat
2D FIESTA Fat sat
Resp. TriggerSlice thickness: 5 mm Matri
x 224x224Zip 512
1 sec / slice
SSFSE Fat Sat
2D SSFSE
PancreasPancreas LAVA
Sl. thickness: 1.6 mm (ov -0.8 mm)Matrix: 256x256 – ZIP 512
Acq. time: 23 sec
Comprehensive Pancreatic examination - Parenchyma & adjacent soft tissue
- Intra and extra pancreatic ducts
- Abdominal arteries & veins 2D SSFSE
Arterial MIP Portal & veins MIP
LAVA: Arterial phase (MinIP)
LAVA: Portal phase (MIP)
LAVA: Venous phase
PancreasPancreas LAVA
2.6 mm (ov-1,3)Matrix: 256x256 Acq. time: 16 sec
Common diseases of Pancreas
Pancreatitis
(acute, chronic)
pancreatic cyst
pancreatic carcinoma
Acute pancreatitis
Causes : Gallstones 、 Alcohol 、 Metabolism drugs 、 infecti
on 、 trauma
Pathology : acute interstitial edema 、 necrosis 、 bleeding 、suppuration
X-ray finding : local G-I dilated with gas accumulating, oblitera
ted left psoas outline,
CT Findings in AP
Acute Fluid Collections
– Acute fluid collections are seen on CT sans as low-a
ttenuation, poorly defined collections of fluid with
no recognizable capusle or wall.
– 40% occurs in acute pancreatitis.
– 50% resolve spontaneously
CT Findings in AP
Extrapancreatic fluid collection– anterior pararenal space– Posterior pararenal space– Lesser sac– Paracolic gutters
Free peritoneal fluid Pleural effusion Gallstone
Pathophysiology of acute pancreatitis
Intra-pancreatic fluid collection
Groove Pancreatitis
APAPAPAP
Simple type Necrotic type
Department of RadiologyDepartment of Radiology
APAP
Department of RadiologyDepartment of Radiology
SIMPLE TYPESIMPLE TYPESIMPLE TYPESIMPLE TYPE
急性坏死性胰腺炎的急性坏死性胰腺炎的 CTCT 表现表现急性坏死性胰腺炎的急性坏死性胰腺炎的 CTCT 表现表现
Department of RadiologyDepartment of RadiologyNecrotic p
Acute necrotic pancreatitisAcute necrotic pancreatitis
Department of RadiologyDepartment of Radiology
Retroperitoneal collection of Retroperitoneal collection of fluidfluid
左肾旁间隙→左结肠旁沟→盆腔Department of RadiologyDepartment of Radiology
Department of RadiologyDepartment of Radiology
Serious APSerious APSerious APSerious AP
Department of RadiologyDepartment of Radiology
hemorrhagehemorrhagehemorrhagehemorrhage
Department of RadiologyDepartment of Radiology
Department of RadiologyDepartment of Radiology
pseudocystpseudocystpseudocystpseudocyst
abscess
Department of RadiologyDepartment of RadiologyChronic PChronic PChronic PChronic P
Chronic pancreatitis
Chronic pancreatitis
The tragedy of life is not so much
what men suffer, but what they
miss.
-----T. Carlyle
Pancreatic carcinomaX-ray finding : widening of the deodenal loop,inverted
3 sign, nodular mucosal filling defectsERCP : occluded or narrowed pancreatic ductPTC : CBD dilated and distal obstruction
Pancreatic carcinomaCT:low density mass with infiltrating growth
manners,easy to involve the retroperitoneal nerve plexus and vessels nearby
PancreasPancreas Comprehensive Pancreatic examination - Vascular presurgical mapping +++
2D SSFSE: Portal phase (MinIP)
: Portal phase (MinIP)
: Portal phase (MIP)
Porto-systemic derivations
Anatomical variation of the left gastric artery
Pancreatic carcinoma
Cancer
Cancer
Department of RadiologyDepartment of Radiology
Portal Vein Invaded by Portal Vein Invaded by Pancreatic CarcinomaPancreatic Carcinoma(( MPR and CTAMPR and CTA ))
Ca of the body and tail of Ca of the body and tail of pancreaspancreas
CT dynamic enhancement
Department of RadiologyDepartment of Radiology
Pancreatic carcinomaPancreatic carcinoma
MSCTMSCT thin scanning
Department of RadiologyDepartment of Radiology
Double tube sign
MPRMPR
MSCTMSCT
Portal vein involvedPortal vein involved
MPR MPR 、、 CTACTA
Department of RadiologyDepartment of Radiology
Department of RadiologyDepartment of Radiology
Cystic adenocarcinomaCystic adenocarcinomaCystic adenocarcinomaCystic adenocarcinoma
VIP瘤
Rare tumorRare tumorRare tumorRare tumor
“Political power grows out of the barrel of a gun”
--MAO TSE-TUNG
Language is the dress of thought
The world is a book, and those who don’t travel read only a page
Well, remember that you took a wrong way to a place, and you can have a smooth trip
home
Imaging of spleen
Exam methodsUS
CT
MRI
Common diseasesenlargement
rupture
tumor
cyst
Tumor
Cavernous hemangioma
lympangioma
lymphoma
海绵状血管瘤海绵状血管瘤
淋巴管瘤淋巴管瘤
脾淋巴瘤合并出血脾淋巴瘤合并出血
Upright MR Scanner