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LIVER, BILE DUCTS, AND GALL BLADDER
Neeraj Lalwani, M.D.Assistant Professor, Radiology (Body Imaging)
University of Washington, Seattle, USA
Email: [email protected]
UW Radiology Review Course- 2015
Disclosures
• None
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Case 1: Chronic hepatitis and raised LFTs
What is the diagnosis?A. CirrhosisB. PseudocirrhosisC. Infiltrating MetastasisD. Budd-Chiari Syndrome
Cirrhosis• Hepatic fibrosis + Regenerative nodules• Most common causes:
i. Alcohol (Micronodular)ii. Chronic viral hepatitis (Macronodular)
• Early micro-nodular cirrhosis may be overlooked in up to 30 %
• Inhomogenous echotexture and irregular-nodular liver surface
• Coarse liver pattern secondary to fibrosis• Nodular liver surface (especially using high
frequency transducers) has an excellent positive predictive value
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Gamna-Gandy Bodies (Splenic Siderotic Nodules)
Extensive Peribiliary Varices
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Pseudocirrhosis?
• Treated metastases (lung, breast, colorectal)• Simulates macronodular cirrhosis• Only history and comparison can lead to correct
diagnosis
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Confluent Hepatic Fibrosis
• May occur in the setting of chronic hepatic disease
• Wedge shaped and extends to the porta hepatis• Overlying capsular retraction
Case 2: 32-year-old female with pain RUQ
What is the diagnosis?A. HCCB. AdenomaC. AngiomyolipomaD. FNH
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Hepatic Adenoma
• Young women taking oral contraceptive pills• Glycogen storage disease or anabolic hormones• Presence of intratumoral fat or hemorrhage.• Sharply marginated (85% of cases), nonlobulated
(95%), sometimes encapsulated (30%)• Hyperattenuating areas corresponding to recent
hemorrhage (25% )• Old hemorrhage is seen as a heterogeneous,
hypoattenuating area within the tumor
In-phaseT2w Out-phase T1w fat sat
a b c d
Hepatic Adenoma
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Arterial phase Portal venous phase Equilibrium phaseT2w
Hepatic Adenoma
Fat containing hepatic lesions
• Focal fatty infiltration• Adenoma• Well differentiated HCC• Hepatic AML• Metastatic liposarcoma• Others: Teratoma, Post-operative omental
packing
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T2w: IntermediateDWI: Restricted diffusion on higher b-values
Typical Imaging features of HCC
T1w: Hypo-, iso- or hyperintenseArterial Phase: Typically hypervascular
Equilibrium Phase: Washout and pseudocapsule
Case 3: Young woman with incidental hepatic lesion
What is the most appropriate next step?A. No further action neededB. MR liverC. MR liver with Gd-BOPTA or Gadoxetate
disodium D. Image guided biopsy
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Arterial phase
T2wIn-phase Out-phase
Hepatospecific phaseEquilibrium phase
MR with Gadoxetate Disodium
• Most common benign hepatocellular lesion• Prevalence 1% • Younger asymptomatic women• Regenerative lesion rather than a neoplasm• Reactive response of hepatic parenchyma
around vascular malformation• Gadoxetate disodium/Gd BOPTA
(dimeglumine): Hepatobiliary imaging agent• Specifically taken up by hepatocytes using the
same molecular mechanism as bile acid
FNH
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FibrolamellarHCC
Large solitary lesion
mostly of the left lobe
Prominent central scar
T2 Hypointense
Scar doesn’t show delayed enhancement
Calcification seen.Upper abdominal lymphadenopathy.
Serum tumor markers are usually not elevated
Fibrolamellar HCC
Unenhanced CT Arterial phase Equilibrium phase
Fibrolamellar HCC
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T1w
Arterial phase Equilibrium phase
T2w
Fibrolamellar HCC
Case 4: 49-year-female with raised LFTs
What is the diagnosis?A. Hypervascular metastasesB. Hypovascular metastasesC. Multifocal HCCD. Lymphoma
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Hypervascular Metastasis
• Most common neoplasm in an adult liver• Multiple lesions in otherwise normal liver• T2 intensity corresponding to spleen is always
worrisome• Most of the metastases are hypovascular• DDx hypervascular metastases: Carcinoid
(Neuroendocrine) tumors, RCC, Thyroid Ca, ChorioCa
• Large metastases can outgrow their blood supply leading to central necrosis
Multiple lesions in otherwise normal liver
What is the diagnosis?A. MetastasesB. Multifocal fatty infiltrationC. Hepatic adenomatosisD. Indeterminate lesions
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Multifocal fatty infiltration
Non-FS T2wOpposed phaseIn phase
Case 5: 32-year-old with jaundice
What is the diagnosis?A. Biliary calculiB. Oriental cholangitisC. Primary sclerosing
cholangitisD. Blood clots
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Primary Sclerosing Cholangitis
• Unknown etiology but thought to be auto-immune
• 5% of all patients with UC have PSC• 75% of all patients with PSC will have UC• Men (70%)• Irregular narrowing with saccular dilatation
proximal to strictured ducts leads to beaded (beads-on-a-string) appearance of ducts
• Usually involves intra- and extrahepaticducts simultaneously
Recurrent Pyogenic (Oriental) Cholangitis
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• Oriental Cholangiohepatitis• Biliary sepsis and recurrent episodes of
bacterial cholangitis• Ascaris lumbricoides, Clonorchis sinensis,
Opisthorchis viverrini, Opisthorchis felineus, and Fasciola hepatica
• Imaging hallmark: Biliary obstruction from strictures and intraductal pigmented stones
• Hepatic Abscess +/-
Recurrent Pyogenic Cholangitis
Ascending Cholangitis
• Charcot’s triad: pain, jaundice and fever• Most common causes: impacted stone, neoplastic
obstruction and biliary strictures• Gold standard: ERCP• High mortality rate due to early septicaemia• Tx: emergent decompression with PTC
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Case 6: Young male with suspected nephrolithiasis
What is the diagnosis?A. Primary hemochromatosisB. Secondary hemochromatosisC. Thorotrast therapyD. Gold therapy
80 HU
• Increased attenuation >80HU• Enlarged or cirrhotic liver• Iron deposition: primary or secondary
(excessive oral intake or multiple blood transfusions) hemochromatosis
• Pancreas is involved in primary • Spleen is involved in secondary• Amiodarone therapy• Glycogen storage disease
Hyperdense Liver
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Primary Hemochromatosis
Case 7: Middle aged man with abdominal discomfort
What is the diagnosis?A. Infiltrative HCCB. Infarcted liverC. Budd-Chiari SyndromeD. Primary biliary cirrhosis
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• Acute: Acute thrombosis of the main hepatic veins or the IVC
• Chronic: Fibrosis of the intrahepatic veins• Inhomogeneous mottled liver • Peripheral zones of the liver may appear
hypoattenuating and show delayed enhancement
• Enlarged caudate lobe shows increased contrast enhancement compared with the remainder of the liver
Budd-Chiari Syndrome
Common Causes (Western Population)
• Idiopathic
• Post-hepatobiliary surgery
• Hypercoagulable state
• Infections, hepatic abscess, sepsis
• Malignancies: mets, HCC, RCC, lung, leukemia
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CO2 Venography during TIPSS
“Spider web” appearance (intrahepatic collateral veins)
Case 8: Elderly male with jaundice and weight loss
What is the diagnosis?A. Infiltrative HCCB. LymphomaC. CholangiocarcinomaD. Metastasis
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Hilar and Perihilar CholangioCa
• Delayed enhancement of hilar mass on delayed (10 minutes) imaging is classical and attributed to the presence of excessive fibrous stroma
• Non-union of the dilated right and left ducts sometimes the only sign
• MR: may have increased T2 signal on MR (due to mucin-producing/glandular components)
• Atrophy-hypertrophy complex: Atrophy of affected lobe (with intrahepatic duct dilation) and hypertrophy of the contralateral lobe
• Benign hilar strictures (PSC, post-operative)• Infiltrating carcinoma of the gallbladder• Portal lympadenopathy• Non-Hodgkin lymphoma• Metastasis
DDx
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Case 9: Elderly diabetic male with pain RUQ
What is the diagnosis?A. Emphysematous cholecystitisB. Hemorrhagic cholecystitisC. Perforated gall bladderD. GB carcinoma
Emphysematous Cholecystitis
• Acute infection of GB wall caused by gas-forming organisms
• Unlike other biliary tract disorders, most common in men (65-70%)
• Mostly 50 and 70 years of age and have underlying diabetes mellitus.
• Often insidious and one-third of patients may be afebrile
• CT is the most sensitive and specific imaging modality
• Treatment is emergent surgical intervention
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Case 10: 28-year-woman with increasingly severe episodes of RUQ pain and sepsis
What is the diagnosis?A. Multiple hepatic cystsB. Caroli’s diseaseC. Biliary hamartomaD. Primary sclerosing cholangitis
Caroli’s Disease• Type V choledochal cyst (Todani classification)• “Fibropolycystic disease”• Simple (large bile ducts) and periportal (both
the large bile ducts and smaller peripheral bile ducts) forms
• Simple type: RUQ pain and recurrent attacks of cholangitis with fever and jaundice
• Periportal type: portal hypertension and fibrosis• Central dot sign: dilated intrahepatic bile
ducts, representing portal radicles
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Choledochal Cysts
Choledochal “Cyst” Types
From Todani, et al, Ann Surg 1978
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Type-I
Type-II
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Type-III
Type-IV