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Liver MRI Teaching Case

Submitted by G. Jerry Trotti, MD Body Imager and Imaging Directed Interventionalist Riverside Radiological Associates

Clinical History
• Obese female found to have an abnormal appearance of the liver on an outside abdominal CT and ultrasound with elevated liver function test.

Outside Ultrasound .

Middle hepatic vein Left hepatic vein Right hepatic vein Hypoechogenic area Outside Ultrasound .

MRI of the Liver: T1 Flash in Phase .

T1 Flash out of Phase .

T1 Flash in Phase T1 Flash out of Phase .

T1 Flash in Phase T1 Flash out of Phase Liver high in signal Liver drops in signal .

T1 Flash in Phase .

T1 Flash with Fat saturation .

T1 Flash out of Phase .

Next Slide for Diagnosis .

Diagnosis • Multifocal Fatty Infiltration of the Liver .

– Although this diagnosis can sometimes be made with ultrasound it is sometimes difficult especially if the patient is obese. . Given that most neoplastic tumors of the liver are hypoechoic by ultrasound there was concern. Given that the outside inconclusive CT was not available an MRI was preformed. Therefore the entire fatty infiltrated liver was brighter then normal and the normal fatty spared liver appeared hypoechoic (dark).Discussion • Hypoechogenic area on outside ultrasound – Fatty elements are hyperechoic (bright) on ultrasound. – Both CT and MRI can be used to make the Diagnosis.

Middle hepatic vein Left hepatic vein Right hepatic vein Normal Fatty spared Liver Outside Ultrasound .

.Discussion • MRI is a great modality to diagnose a fatty liver. Two types of sequences work best: – T1 FLASH with and without fat saturation pulse or – T1 FLASH in and out of phase – Fat has a high signal on T1 and you are looking for a signal drop (dark area) on the fat saturation or out of phase sequence.

T1 Flash in Phase T1 Flash out of Phase Fatty Liver high in signal Fatty Liver drops in signal .

• Some of the more common Insults: – Alcohol Abuse – Obesity – Hyperalimentation – DM – Hepatitis – Steroids / Cushing’s syndrome – Chemotherapy .Discussion • Fatty liver represents an excess of triglycerides within hepatocytes due to a nonspecific response to certain metabolic insults.

without bulging the contour. Typically extends to the liver capsule.Discussion Continued • 3 Common Hepatic Patterns: • Diffuse – The entire liver involved. near falciform lig and fissure for lig teres . • Focal – Fan shaped or geographic (non-spherical) portions of the liver. – Usually at the medial segment. Most common and easiest to recognize.

The hypoechogenic area was normal liver.Discussion Continued • Multifocal – Multiple Patchy (geographic) areas of fatty infiltration through the liver. – Common focal sparring • periphery of the liver • Abutting porta hepatis and gallbladder fossa . – Focal areas of fatty sparring my simulate a tumor as demonstrated on outside ultrasound.

Fatty infiltration can be seen within 3 wks following an insult and can resolve 6 days after removing an insult.Discussion Continued • Differentiating focal fatty liver from malignancy – Angulated geometric margins – Interdigitating margins with fingers of normal tissue – Absence of mass effect or vessel displacement – Rapid change over time. .