1. Abdominal
Imaging
ABD ALLAH
NAZEER..MD
Liv
er
Mamdouh Mahfouz MD
mamdouh.m5@gmail.com

2. Indications for hepatic
CT and MRI imaging
• To assess equivocal imaging findings
• Staging of hepatic neoplasms
• Metastatic workup of primary malignancies
• Diagnosis of diffuse hepatic diseases
• Assessment of biliary disease and tumour.
•Congenital anomalies like Carols disease.
• Assessment of suspected post-traumatic injury

3.  Patient preparation
 Patient position
 Scanogram….[frontal]
No required preparation unless the patient is going to be
sedated or injected with contrast material
FASTING FOR 4 - 6 HOURS

4. Rt Ventricle
Rt Atrium
IVC
Lt Ventricle
Lt Atrium
Espohagus
Aorta
Azygous

5. Hepatic Veins
Liver
IVC
Aorta

6. Lt Portal Vein
Lt Lobe Liver
Diaphragm
Stomach
Rt Lobe Liver
IVC
Falciform
Ligament
Spleen

7. Falciform Lig
Stomach
Rt Portal
Vein
IVC
Spleen

8. Pylorous
Stomach
Gallbladder
Pancreas
Splenic arter
Portal Vein
Lt Kidney
Celiac Artery
IVC
Crura of
diaphragm

9. Pylorous
Stomach
Splenic Flexure
GB
Pancreas
Splenic V
2nd
part
Duodenum
IVC
SMA
Lft Kidney

10. Hepatic
Flexure
SMV
SMA
Splenic
flexure
Pancreatic
Head
Spleen
IVC
Lt Renal V
Lt Renal
Artery

11. SMV
SMA
Jejunum
2nd portion
duodenum
Pancreatic Head

12. Tran. colon
Mesentery
Des. colon
Asc. colon
3rd portion
duodenum

13. Ileum
Des. Colon
Asc. Colon
Common Iliac
Arteries

14. Ileum
Asc. Colon
Desc. Colon
Terminal Ileum
Lft Iliac Art
Lt Iliac V

15. Small Bowel
Ext Iliac Art
Iliopsoas
Glut. Minimus
Ext Iliac V
Glut. Medius
Glut. Max
Internal iliac A. & V.
Pyriformis
Rectosigmoid

16. Bladder
Prostate
Fem Artery
Rectum

17. Ovaries
Uterus
Rectum
Sacrum

19. Hepatic segmental anatomy

27. Hepatic pathology
Benign lesions
Liver cysts.
 Hemangioma.
 Adenoma.
Focal nodular hyperplasia.
Malignant lesions
Hepatocellular carcinoma.
 Fibrolamellar carcinoma.
 Hepatoblastoma.
 Metastasis.
Diffuse lesions
Fatty liver
 Cirrhosis
 Storage diseases

30. Hepatic pathology
Focal lesions
Cystic
 Simple cyst
 Abscess
 Hydatid cyst
 Hemangioma
Rare
Biliary
cystadenoma

31. Hepatic cysts





Congenital lesions but detected late
Isolated or associated with congenital cystic disease
Usually asymptomatic
Complications [ rupture or hage ] lead to symptoms
Few mms to several cms in size
Hepatic

32. Typical cyst criteria



Sharply defined margin
Has no measurable wall.
Clear water contents 0-15 HU

NO
Septations
Calcification
Enhancement
Mural nodules

33. Atypical cyst criteria



Thick enhancing margin [ abscess ]
Abnormal contents [ hemorrhage ]
Presence of
Septations
Calcification [ hydatid ]
Enhancement
Mural nodules [ neoplasm ]

34. Hepatic cysts demonstrated by MRI

35. Simple hepatic cyst , CT , MRI

36. Magnetic resonance imaging of hemorrhagic cyst. A, T1-weighted image
demonstrates a mass with a hyperintense rim
(arrows). B, T2-weighted image demonstrates
the mass to be hyperintense, with the rim being
hypointense (arrow), consistent with hemorrhage.

37. Polycystic disease , Liver and kidneys

38. Hepatic abscess [ Pyogenic ]
 Frequently indolent with no signs of infection
 May present with profound septicemia
 Micro abscesses (>2cm) cluster or scattered
 Macro abscesses :Unilocular or multilocular
 Marginal enhancement 6% ?!
 Gas containing abscesses uncommon

39. Pyogenic hepatic abscess associated with basal pneumonia and abscess

40. Pyogenic hepatic abscess

41. Enhanced MRI of multicystic pyogenic hepatic abscess

42. Pyogenic hepatic
abscess

43. Hepatic abscess [Amebic ] Entameoba Histolytica
 Patients are more often acutely ill
 Single or multiple near the liver capsule
 Enhancing wall is evident with peripheral zone of edema
10% world wide
[ Common in amebic abscess]

44. Amebic abscess

47. Hemangioma
 The most common benign liver tumour.
20% of hepatic tumors Female: male = 5:1
 85% are asymptomatic 50% are multiple
 Giant hemangioma More than 5 cm in diameter

48. Hemangioma
 Non contrast
well defined hypo dense lesion ,10% of cases shows calcification
 Contrast enhancement
peripheral nodular enhancement on late imaging

49. Hemangioma

50. Hemangioma , MRI
T1 WIs
T2 WIs
Low signal lesion
high signal lesion
Heavily weighted T2 imaging [TE 100- 160msec]  signal
T1+ C nodular marginal enhancement similar to CT

52. Hemangioma, MRI dynamic contrast enhanced scans

54. Giant Hemangioma(more than 5 cm

55. Giant Hemangioma , Serial post contrast

56. Echinococcal disease [Hydatid cyst]
 Larval stage of E. granulosus
 Well defined unilocular or multilocular cyst
 Central and peripheral calcification
 Daughter cysts can be inside the large cyst

57. Hydatid cyst after treatment with rupture and floating shadows

58. Hydatid cyst

59. Imaging features for hydatid cyst diagnosis
 Other cysts specially in the lung
 Unilocular or multilocular cyst with marginal calcification
 Internal floating shadows
 Daughter cysts within the large cyst

60. Gradient-echo T1, T2 -weighted MR image shows a
hydatid cyst with a hypointense fibrous pericyst (arrow)
Multiple daughter cyst noted.

61. Hydatid cyst

62. Malignant cystic lesions
Biliary cyst adenoma / carcinoma
Cystic deposits
Biliary cystadenoma
90% occur intrahepatic
With ovarian stroma [seen in females with good prognosis]
Without ovarian stroma [males and females with bad prognosis]

63. Biliary cystadenoma , carcinoma
 Large [3 – 40 cm] cystic multilocular tumor with mural nodule [seen better by US]
 Distinction between cystadenoma and cystadenocarcinoma may not be
possible by imaging and is not clinically critical, both will be excised

66. Biliary cystadenoma MRI images

70. The arterial supply is derived from the hepatic artery whereas the venous
drainage is into the hepatic veins. FNH does not contain portal venous supply9.

72. (MRI) of focal nodular hyperplasia. A, T1weighted image demonstrates a mass (arrows)
that is isointense to hepatic parenchyma. B, T2weighted image of the liver demonstrates a mass
(arrows) that is isointense to hepatic parenchyma.

78. MRI images of hepatocellular adenoma

79. CT and MRI images of mesenchymal hamartoma

82. Hepatocellular carcinoma
 The most common primary malignant hepatic neoplasms
 3rd – 4th decades Male: female 8:1
 80% of HCC occur in cirrhotic liver
 Serum AFP and ultrasound [screening]

83. Hepatocellular carcinoma
 Single or multiple masses that are hypo dense to normal liver
 Calcification may be seen
 After contrast injection [ should be Triphasic study]
 Arterial phase : Very early arterial perfusion.
 Portal phase : contrast washout

84. Arterial phase
 Detects a greater number of HCC than usual scanning
 Detects intravascular thrombosis [ portal vein]
 Better delineation of tumour capsule in capsulated lesions
 Detects early arteriovenous shunting [ sign of malignancy]
CT

85. Hepatocellular carcinoma

86. Hepatocellular carcinoma

87. Delayed
Arterial
Portal
M 59 Y with liver cirhhosis , splenomegaly and suspected focal lesion on US

88. Hepatocellular carcinoma

89. CT ,MRI
Hepatocellular carcinoma
M 60Y

90. Hepatocellular carcinoma
MRI
 Dynamic multiphase Gd- DTPA enhanced MRI
 0.1 mmol / kgm Gd- DTPA injected as a bolus
 Fast low angle shot sequence obtained at 30 - 240 sec
 HCC appears as a hyper vascular mass [ similar to CT]
Any mass in a cirrhotic liver
that does not fulfill the
cyst or
hemangioma should be
criteria of a
considered as HCC
until proved otherwise

91. HCC , MRI dynamic

93. HCC , MRI dynamic

98. Hepatoblastoma
 The most common 1ry hepatic neoplasm in children below 5 years
 Usually presents with abdominal mass with elevated AFP
 Large diffuse or multifocal hypodense lesion is seen on CT
 Matrix calcification and septations may be seen

99. Hepatoblastoma

100. Enhanced MRI of hepatoblastoma

101. Cholangiocarcinoma
 The 2nd most common primary malignant tumor
 Arise from bile duct epithelium [ 3 TYPES ]
 Intrahepatic arises from small ducts
 Or the major ducts near the helium
 Or at the bifurcation of the CHD [ Klatskin tumor]
 HCC: intrahepatic cholangiocarcinoma = 10:1
 No strong association with cirrhosis
 No specific MR appearance

102. Cholangiocarcinoma
 Hypo dense lesion that shows heterogeneous enhancement
 Portal vein invasion is rarely seen
 Small dilated ducts around the lesion may be seen
CT& MRI

104. Intra-hepatic cholangiocarcinoma by MRI.

105. Lymphoma
 Primary hepatic lymphoma is rare compared to the 2ry type
 AIDS and organ transplant patients have an increased risk
 Non specific CT and MR appearance
 Diffuse hepatic lymphoma  hypo dense liver similar to fatty
infiltration

106. Lymphoma

107. Lymphoma

108. Magnetic resonance imaging findings in
primary lymphoma of the liver:

109. Hepatic deposits
 Liver is the 2nd most common site for deposits after nodes
 30% - 70% of patients who die of cancer have liver deposits
 NCCT hypodense lesions ,calcification in mucin producing metastases
 CECT Dynamic bolus contrast injection with helical scanning
 Single phase Dual phase ,Triphasic study ,CTHA & CTAP
Hypovascular metastasis
Hypervascular metastasis

110. Hepatic deposits
 Most of hepatic deposits are hypo vascular
 Hepatic neoplasms receive most of their blood supply via hepatic artery
 Hyper vascular deposits should be assessed by dual phase CT or dynamic MRI
 CTAP and intra operative US are the most sensitive methods for detection of deposits

111. Hyper vascular deposits

112. Colorectal carcinoma with multiple hepatic metastasis.

113. Calcified hepatic metastases in a patient with
mucinous adenocarcinoma of the colon

115. Cancer breast with hepatic metastasis

118. MR advantages
 MR can differentiate focal fatty changes from deposits
 In diffuse fatty infiltration hypo dense deposits may be masked by the background of fat
 On MR the background is relatively high in T1 WIs while deposits are of low signal .

119. Hepatic metastases

120. Hepatic metastases versus multiple HCC

123. Diffuse Hepatic Disease
 Cirrhosis
 Fatty Changes
 Storage diseases(hemochromatosis &hemosidrosis)
 Neoplastic diseases [ HCC , Deposits , Lymphoma ]

124. Cirrhosis
 Repeated episodes of hepatic injury
 fibrosis + regeneration
 Small fibrotic right lobe with regenerative enlargement of the caudate and left lobe
 Caudate/ right lobe ratio = 0.65 or more
 Portal vein diameter more that 1.3 cm
 Splenomegaly, ascites
 Dilated perisplenic collateral venous channels

125. Liver cirrhosis
Regeneration nodules
 Without hemosiderin
 With hemosiderin
mild hyper intense in T1/ mild hypo intense in T2
mild hyper intense in T1/ more hypo intense in T2
 Gradient echo images are more sensitive for hemosiderin
 MR angiography : Portosystemic shunts and portal vein thrombosis

126. Liver cirrhosis with multiple regeneration nodules

127. Regeneration nodules

128. MDCT in a patient with cirrhosis and portal hypertension
CT arterial portography (CTAP) in a patient with cirrhosis

129. Liver cirrhosis
Other imaging findings
 Widening of hepatic fissures
 Gall bladder and small bowel
 Signs of portal hypertension
wall thickening (edema)

130. Fatty infiltration
 Alcohol, obesity, diabetes , hepatitis, drugs
 Focal, multifocal, diffuse fatty infiltration
 Normal hepatic density is 8HU greater than spleen
 Fatty liver is 10 HU below the spleen without contrast
 Vessels course in the focal areas undisturbed
 MR is helpful using
the fat suppressed
technique
and 25 HU after contrast

131. Fatty infiltration with fat spared area
with in phase and out phase sequences

132. Lipoma

133. Iron overload
 Liver cells or reticuloendothelial iron deposition
 Hereditary hemochromatosis, cirrhosis, hemolysis,…..
CT
Liver signal below that
of the muscles is diagnostic,
iron is not deposited in the muscles
Generalized increase attenuation value
of liver parenchyma [seen also in other
conditions Wilson’s disease, glycogen
storage disease]
MRI
More specific  diffuse decrease
signal intensity of liver parenchyma
in T2 and gradient echo images

134. Diffuse Neoplastic disease
Multiple small tumour foci scattered throughout the liver parenchyma
 Vascular invasion is common
 Increased T2 signal on MR images
Diffusely infiltrating Hepatocellular
carcinoma with portal vein invasion
Diffusely metastasis of the liver

135. Diffuse Neoplastic disease
Lymphoma 35% of patients with secondary hepatic lymphoma show
either diffuse or mixed pattern (focal+ diffuse)
Imaging findings are non specific

136. Diffuse lymphoma liver and spleen