Abdominal

Imaging
Xian LI
Dept. of Radiology, the Affiliated Hospital
of JiNing Medical College

Section 1
the liver

TEACHING OBJECT
Emphasis
The

characteristic findings of
common diseases of the liver
Comprehend
The liver imaging techniques

 Liver imaging techniques

X-ray examination
Ultrasound (US)
Compute tomography (CT)
Magnetic resonance imaging (MRI)

 X-ray examination
The limited soft tissue contrast and projection acquisition
of plain radiographs
approximately estimate the liver contour and size

Plain film
useless in the diagnosis of
liver diseases.

 Ultrasound

The normal echo texture of

the liver parenchyma is
homogeneous

color Doppler imaging

The vascular systems in the
liver may be studied

 Ultrasound
widely available, easily performed
and has no contraindications.
a noninvasive and excellent screening
tool.

 CT
High

spatial resolution and rapid

acquisition time

The

mainstay for hepatocellular imaging

 CT

CT of the liver can be performed with or without

contrast material.

The vascular structures can be identified by their

location on the unenhanced images and
confirmed by enhancement with intravenous
contrast.

Pre-contrast

Enhance-CT

The liver parenchyma is homogeneous with

attenuation values of 5565 HU, usually 810
HU greater than the spleen.

Precontrast

Enhance-CT

the difference in attenuation between

parenchyma and tumor can be quite subtle
on the precontrast CT. Contrast-enhanced
imaging is widely used for the detection
and characterization of focal lesions.

Dynamic Contrast CT
Arterial

Phase: (delayed time:25-30s)

Portal vein Phase: (delayed time:55-60s)
Delayed Phase: (delayed time:90-200s)

The liver have a dual blood

supply
approximately 75%
originating from the portal
venous system
25% arising from the
hepatic artery.

arterial phase
(when the contrast just
fills up the aorta and the
main hepatic arterial
structures)

Portal vein phase

(when the contrast
disperses into the liver
parenchyma and mixes
with portal blood)

Multiplanar Reconstruction

MPR
True volume acquisition with isotropic voxels
rapid reformatting in other planes

 MRI

the liver is brighter than (hyperintense to) the

spleen on T1-weighted images and darker than
(hypointense to) the spleen on T2-weighted
images.

MRI
multiple sequences
multiplanar capability

T1WI
T2WI

Fat saturation

 MRI
MRI has many advantages over CT
high soft tissue contrast resolution
(can see smaller lesions)
multiple sequences
multiplanar capability
no radiation, no iodinated contrast
etc.

 Common diseases of Liver

Hepatocellular HCC

Cavernous
haemangioma CH

Hepatic metastasis

Hepatic Cyst

Hepatic

cirrhosis

1 Hepatocellular
Carcinoma

Clinical and pathology

the

commonest primary malignant neoplasm of

the liver
Risk factors include: aflatoxin, chronic
hepatitis and cirrhosis
Patients present with abdominal pain and often
have a palpable mass ,jaundice, weight loss,
and fever
the serum alpha-fetoprotein is often elevated.

Hepatocellular Carcinoma
Solitary

mass
Multifocal nodule
Diffuse involvement

CT findings
Unenhanced

an iso-hypodense mass.
Large lesions may show internal heterogeneity,
due to haemorrhage, necrosis, or fat .
Hypodense capsule rim-one of the more specific
signs indicating HCC

CT findings
Enhanced CT

occurs and disappears earlier

arterial phase : an early moderate to
high degree of homogeneous
enhancement
portal vein phase: the lesion becomes
iso-or hypodense
complications portal vein invasion

Focal lesion: Contrast uptake dynamics

Arterial phase
Portal phase

delayed phase

CT

Precontrast

Portal phase

Arterial phase

delayed phase

Tumorextends to portal vein

THROMBUS

CT

NORMA
L

CT
Intrahepatic
bile duct
dilation

NORMAL

CT
Enlargment of
the lymph gland

normal

MRI findings
T1 Weight images
iso-hypointensity
T2Weight images
moderately increased signal

the enhancement patterns with

gadolinium parallel those for enhanced
CT examination

MRI

T1WI

T2WI

T2WI

MRI

Pre-constrast

Arterial phase

Portal vain phase

 HCC

Arterial phase

Portal vain phase

male,44Y

Arterial phase

Portal phase

CT

CT

delayed phase

Same case

T2WI

Arterial phase

MRI

Portal
DWIphase

embolism with Iodinated Oil

CT is frequently the first examination;

however, MRI has superior contrast
resolution and may better detect lesions less
than 1 cm in diameter.

2. Cavernous Hemangioma CH
the

commonest benign hepatic tumors.

the lesions are usually asymptomatic but
large tumors may cause abdominal
discomfort or pain,
Commonly multiple lesions
Focal fibrosis, cystic spaces, necrosis
frequently present in large lesions

CT findings
Unenhanced CT :
Low attenuation (dark)
large lesions the thromboses ,necrotic or
fibrotic areas are lower in attenuation

CT findings
Enhanced
Arterial

images

phase: a peripheral, discontinuous, intense

nodular enhancement
Portal vein phase: later centripetal filling to
uniform enhancement
Foci of no enhancement (focal fibrosis, necrosis,
cyst)

Low attenuation

CT

Peripheral enhancement of one or more

nodular or globular strcture which
encircled the tumor

CT

progressive infilling of the lesion form

the peripheral towards the centre

CT

Complete filling in

CT

Arterial phase

Portal vein phase

Delayed phase

MRI findings

T1WI low signal intensity

T2WI homogeneously marked high signal

light bulb

Gd-DTPA (Gadolinium)
similar to that observed on contrast enhanced
dynamic CT

MRI

T1WI

T2WI-FS

MRI

T2WI

T1WI

MRI

Arterial phase

Portal vein phase

Delayed phase

MRI is now considered the most sensitive

and specific imaging examination for the
diagnosis of haemangioma. This is based
primarily on T2w characteristics but also
using the enhancement pattern on T1w
images following IV Gd-DTPA.

The world is a book, and those

who dont travel read only a page

Interleave Joke

A: Im so glad I wasnt born

in
the United States.
B: Why?
A: Because I cant speak
English.

3. Hepatic metastases
Pathogenesis:

the most common malignant mass in the

liver.

the three most common sources of

metastasis to the liver:

Primary tumors of the GI tract (e.g. tumors

of the colon, pancreas, or stomach)
Breast tumors
Lung tumors

CT
multiple low
attenuation

multiple low attenuation

Contrast CT

Some may have rim enhancement.

Hypervascular masses are enhanced
during the arterial phases. (Many are also
well visualized during the portal venous
phase.)

CT

rim enhancement, the central is

hypodense

insulinoma

Hypervascular

masses are
enhanced during the arterial
phases.

MRI
T1-weighted MRI: mostly hypoisointense, can also be hyperintense.
T2-weighted MRI: Iso-hyperintense.

MRI

T2WI
Target sign:
hyperintense center
surrounded by less
intense rim.

T1WI
Doughnut sign: low
signal rim around
even lower signal
center

4. absess of liver
Causes pyogenic amebic
Clinic fever pain enlargement of liver
Bacteria gain access to liver via the portal or

biliary system.
Most pyogenic abscesses occur in the right lobe.

CT
Round or ovoid
inhomogeneous fluid

attenuation
20% contain gas bubbles.
A surrounding lowdensity halo.
on contrast-enhanced
CT
ring sign

T1WI

MRI
Abscess Liquid
signal areas
T1WI: a slightly low
signal ring surrounding
the lesion
T2WI a slightly
low signal ring

T2WI

5.hepatic cyst

Pathogenesis

The most common liver masses.

May be solitary or multiple.
~40% of patients with polycystic kidney
disease have liver cysts. ~ 60% of
patients with multiple liver cysts have
polycystic kidney disease.

CT

Noncontrast CT:
density

of less than 20 HU

well-defined

margins homogenous

Contrast CT:
no enhancement

MRI
a.T1-weighted: homogeneously hypointense
(arrowhead);
b. T2-weighted: homogeneously hyperintense
(arrow) due to water property

T1WI

T2WI

Note: cysts can be confused with

hemangiomas on T2-weighted MRI.
However, on T1-weighted with Gd-DTPA,
cysts do not enhance whereas hemangiomas
do in a centripetal manner.

6.cirrhosis of liver
Pathogenesis:

Causes of cirrhosis include:

a) alcohol
b) postnecrotic (hepatitis)

metabolic disease.
Cirrhosis pathology consists of hepatocyte necrosis, fibrosis, and
nodular regeneration.
Cirrhosis increases risk of developing hepatocellular carcinoma.
C)

CT

Loss of volume

The increase nodularity

of the liver

The increase in the

caudate lobe/right lobe
ratio

The widing liver fissure

Ascitic fluid

Enlargement of spleen

Esophageal varices

extensive collateral vessels

question

thanks