Diagnostic Imaging of the Liver

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2 S. Sakuma T. Ishigaki T. Takeuchi Diagnostic Imaging of the Liver Biliary Tract and Pancreas Data Analysis and Diagnostic Procedures With 312 Figures in 932 Separate Illustrations Springer-Verlag Berlin Heidelberg New York London Paris Tokyo

3 Sadayuki Sakuma, 11.D. Professor and Chairman Nagoya University School of 11edicine 65 Tsurumai-Cho, Showa-Ku Nagoya, Japan Takeo Ishigaki, 11.D. Associate Professor Nagoya University School of 11edicine 65 Tsurumai-Cho, Showa-Ku Nagoya, Japan Toshihiko Takeuchi, 11.D. Professor and Chairman Department of 1 st Internal 11edicine Nagoya City University 11edical School 1 Kawasumi-cho, Showa-Ku Nagoya, Japan First published in Japan by Shujunsha Co., Ltd. All rights reserved Shujunsha Co., Ltd. ISBN-13: e-isbn-13: DOl: / Library of Congress Cataloging in Publication Data Diagonstic imaging of the liver, biliary tract, and pancreas. Translated from the Japanese orginal. Includes index. 1. Diagnostic imaging. 2. Liver-Diseases-Diagnosis. 3. Biliary tract-diseases-diagnosis. 4. Pancreas-Diseases-Diagnosis. I. Sakuma. Sadayuki. II. Ishigaki. Takeo III. Takeuchi, Toshihiko, [DNLM: 1. Biliary Tract Diseases-diagnosis. 2. Liver Diseases-diagnosis. 3. Pancreatic Diseases-diagnosis. WI 700 D5346] RC847.D ' ISBN X (U. S.) This work is subjected to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, re-use of illustrations, recitation, broadcasting, reproduction on microfilms or in other ways, and storage in data banks. Duplication of this publication or parts thereof is only permitted under the provisions of the German Copyright Law of September 9, 1965, in its version of June 24, and a copyright fee must always be paid. Violations fall under the prosecution act of the German Copyright Law. Springer-Verlag Berlin Heidelberg 1987 Softcover reprint of the hardcover I st edition 1987 The use of general descriptive names, trademarks, etc. in this publication, even if the former are not especially identified, is not to be taken as a sign that such names, as understood by the Trade Marks and Merchandise Marks Act, may accordingly by used freely by anyone. Product Liability: The publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check its accuracy by consulting other phalmaceutical literature. 2121/

4 Preface The development and the widespread clinical application of various diagnostic imaging modalities, such as diagnostic ultrasonography, X-ray computed tomography, single photon emission computed tomography, and magnetic resonance imaging, have been beyond all expectation. In particular, ultrasonography and X-ray computed tomography have become major diagnostic tools for diseases of the liver, the biliary tract, and the pancreas. They often have virtually replaced other conventional imaging modalities including invasive angiography and percutaneous trans hepatic cholangiography. One modality may complement or conflict with another or other modalities. Each modality should be carefully selected with due regard for its diagnostic efficacy. In this book, the first section contains nine chapters dealing with current techniques of each diagnostic modality applicable to the liver, the biliary tract, and the pancreas. The second section deals with diseases of the liver, the biliary tract, and the pancreas and takes the form of case presentation with discussion of the significance of diagnostic imagings and diagnostic procedure. Preparation of the manuscript was made possible by the help of Dr. S. Fujita, who prepared the photographs, and Mrs. Sobajima, who typed the original manuscript. Dr. S. Miura and Miss Y. Shimizu undertook the labor of translating our manuscript from Japanese into English. I would like to express my deep appreciation to all these persons, as well as to the contributors to this book, and also to the publishers, Shujunsha, Japan and Springer-Verlag. Nagoya, January 1987 Sadayuki Sakuma

5 Table of Contents Part I General Considerations A Main Imaging Modalities 1 Plain Abdominal Radiography Positioning and Roentgenographic Conditions Roentgenographic Findings in the Normal Liver Abnormal Roentgenographic Findings in the Liver Abnormal Roentgenographic Findings in the Biliary Tract Abnormal Roentgenographic Findings in the Pancreas 11 2 Ultrasonography Instrumentation Examination Procedures Liver Gallbladder and Bile Duct Pancreas Nuclear Examination Colloid Liver Scintigraphy Radioisotope Angiography of the Liver Hepatobiliary Scintigraphy X-ray Computed Tomography Equipment Premedication Examination Procedures Contrast Medium Administration Viewing of the Images CT Images of the Normal Liver, Biliary Tract, and Pancreas CT Images of the Diseased Liver CT Images of Gallbladder and Biliary Tract Diseases CT Images of Diseases of the Pancreas Angiography Examination Procedures Hepatic Vasculature and Its Findings Angiographic Findings in Diseases of the Liver Vessels of the Biliary Tract and Gallbladder and Their Angiograms Angiographic Findings in the Pancreas.. 115

6 VIII Table of Contents B Other Imaging Modalities 6 Hypotonic Duodenography Application Roentgenographic Anatomy of the Duodenal Loop Hypotonic Duodenography in Diseases of the Biliary Tract and Pancreas Excretory Cholecystocholangiography Oral Cholecystography Intravenous Cholangiography Examination Procedures Side Effects Roentgenographic Findings Endoscopic Retrograde Cholangiopancreatography (ERCP) Examination Procedures Findings from Opacification of the Pancreas Findings from Opacification of the Bile Duct Percutaneous Transhepatic Cholangiography (PTC) Opacification Procedure Roentgenographic Anatomy of the Biliary Tract PTC Images of Diseases of the Pancreas and Biliary Tract 151 Part II Clinical Presentation Introductory Remarks A Diagnostic Imaging in Diseases of the Liver j Procedure Cases.... Liver Cyst.... Parenchymal Hamartoma Chronic Active Hepatitis (Lupoid Hepatitis) Liver Cirrhosis Liver Cirrhosis Fatty Liver.. Hemochromatosis Liver Abscess.. Hemangioma of the Liver Hepatoblastoma.... Hepatocellular Carcinoma Hepatocellular Carcinoma. Cholangiocarcinoma... Liver Metastasis (Carcinoma of the Rectum). Hepatic Injury

7 Table of Contents IX B Diagnostic Imaging of Diseases of the Biliary Tract 1 Procedure 2 Cases 2.1 Hepatolithiasis and Choledocholithiasis 2.2 Congenital Dilatation of the Bile Duct 2.3 Primary Sclerosing Cholangitis Carcinoma of the Gallbladder Carcinoma of the Common Bile Duct. 2.6 Carcinoma of the Common Hepatic Duct C Diagnostic Imaging of Diseases of the Pancreas 1 Procedure Cases Acute Pancreatitis Chronic Pancreatitis Chronic Pancreatitis (Pancreatolithiasis, Pseudocyst of the Pancreas Cyst of the Pancreas (Pseudocyst) Carcinoma of the Pancreas (Body and Tail) Carcinoma of the Pancreas (Head) Cystadenocarcinoma of the Pancreas Insulinoma of the Pancreas Nonfunctioning Islet Cell Tumor Appendix, Methods of Measurement and Normal Values for Laboratory Data Subjed Index

8 Contributors Ishigaki, Takeo, M.D., Associate Professor Nagoya University, School of Medicine Ishiguchi, Tsuneo, M.D., Nagoya University, School of Medicine Ito, Makoto, M.D., Associate Professor Department of 1st Internal Medicine Nagoya City University Matsuyama, Koji, M.D., Chief Department of 3rd Pediatrics 1st Nagoya Red Cross Hospital Miyaji, Makoto, M.D., Associate Professor Division of Medical Information Nagoya City University Hospital Sakuma, Sadayuki, M.D., Professor, Chairman Nagoya University, School of Medicine Takeuchi, Toshihiko, M.D., Professor, Chairman Department of 1st Internal Medicine Nagoya City University