Imaging of liver and pancreas

Transcription

1 Imaging of liver and pancreas..

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3 Disease of the liver Focal liver disease Diffusion liver disease

4 Focal liver disease Benign Cyst Abscess Hemangioma FNH Hepatic adenoma HCC Malignant Fibrolamellar carcinoma Metastasis Cholangiocarcinoma

5 Diffuse liver disease Cirrhosis Metabolic disease Hemochromatosis Wilson s disease Fatty liver

6 Anatomy of liver

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9 Hemodynamic Blood supply Portal vein (70%) Hepatic artery (30%) Hepatic vein

10 Anatomy of the liver Morphological anatomy 3 lobes Right lobe Left lobe Caudate lobe Functional anatomy 8 segments Base on portal and hepatic vein supply

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12 Morphological anatomy Division between: Right lobe and left lobe: Middle hepatic vein Left lobe and caudate lobe: Ligamentum venosum

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15 Caudate lobe

16 Morphological anatomy

17 Imaging modality Plain film: not useful Ultrasound: good screening test, noninvasive, cheap CT: good modality MRI: the best at present

18 Plain film

19 Ultrasound Pro: Non-invasive method Good screening tool Not expensive Widely available Con: Operator dependent Less specificity than CT and MRI

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21 Hemangioma

22 CT Pro: Good for lesion detection and characterization Widely available in most hospital Con: Radiation hazard Risk of contrast allergy Risk in patient with renal insufficiency

23 Contrast enhanced CT Arterial phase (25-30 sec) Portovenous phase (70 sec) Delay phase (10-20 min) Multiphasic CT scan Iodinated or non-iodinated contrast cc (6%) rate 2-3 cc/sec

24 Blood supply of the liver Blood supply Portal vein (70%) Hepatic artery (30%) Hepatic vein

25 Extracellular contrast agent

26 Non contrast Arterial phase sec Portovenous phase 70 sec

27 Arterial phase Scan at sec. after injection Clearly seen hepatic artery Minimal hepatic parenchymal enhancement Benefit: Good for hypervascular tumor detection Transient hepatic attenuation difference (THAD)

28 Non-contrast Arterial phase Hypervascular tumor Portovenous phase

29 No contrast Arterial phase Portovenous phase

30 Arterial phase Portovenous phase THAD

31 Portovenous phase Scan at 70 sec after injection Clearly seen hepatic vein and portal vein Enhancement of hepatic parenchyma Benefit: Good for Hypovascular tumor Biliary tract dilatation Hepatic injury

32 Non contrast Arterial phase Portovenous phase

33 Arterial phase Portovenous phase THAD

34 Biliary tract dilatation

35 Portovenous phase Pitfall: 35% miss HCC 14% miss hypervascular metastasis (breast, melanoma, choriocarcinoma, pancreatic islet cell tumor, GIST, etc)

36 Delay scan (equilibrium phase) Scan at min after injection Benefit: For confirmation of Hemangioma Intrahepatic cholangiocarcinoma

37 MRI Pro: Good for lesion detection and characterization (better than CT) No radiation hazard No risk for contrast allergy and in patient with renal insufficiency Con: Expensive Not widely available Cannot perform in patient with metal in body

38 Liver cyst Ultrasound Anechoic Thin wall Posterior acoustic enhancement CT Thin wall Clear water content

39 Benign liver cyst MRI 43219

40 US, CT: Sharp margin, no internal septation Clear internal fluid

41 Liver abscess Ultrasound Irregular wall Echogenic content May have acoustic enhancement CT Hypodensity collection with irregular peripheral enhancement

42 Unliquified abscess Liquified abscess

43 Liver abscess

44 Non-contrast Arterial phase 66M RUQ pain, fever with Chill and weight loss Portovenous phase Liver abscess

45 Solid liver mass FNH Hepatic adenoma HCC Fibrolamellar carcinoma Metastasis Cholangiocarcinoma

46 Hemangioma 2 months follow up

47 Hemangioma

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51 Pancreatic mass

52 Pancreatic mass CT is investigation of choice CT with dual phase and thin section at pancreas Staging Local invasion: adjacent structure and vascular Adenopathy Metastasis

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55 Investigation of jaundice

56 Etiology 1. Hemolysis 2. Bilirubin conjugation problem 3. Obstruction of biliary tract

57 Etiology 1. Hemolysis Overproduction of heme High indirect bilirubin Thalassemia

58 Etiology 2. Bilirubin conjugation problem Hepatitis (viral, bacterial) Sepsis Liver failure Diffuse liver disease

59 Etiology 3. Biliary tract obstruction Stone Stricture Tumor: cholangiocarcinoma and pancreatic carcinoma Choledochol cyst

60 Investigation of jaundice US is investigation of choice Follow by CT, ERCP, PTC Or MRCP

61 Ultrasound - NPO 4-6 hrs - Biliary tract dilatation - CBD dilatation - Liver disease

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64 CT Indication Further investigation of site and cause of jaundice. Preparation: oral and IV contrast NPO 4-6 hrs Good in obesity patient

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70 ERCP

71 ERCP Indication Inconclusive ultrasound finding Patient preparation NPO 4-6 hrs Mild sedation Prophylatic antibiotic

72 ERCP Post procedure care Post sedation care Look for infection and pancreatitis Complication Acute pancreatitis

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75 Percutaneous transhepatic Cholangiography (PTC)

76 PTC Indication High level of biliary obstruction Fail ERCP Stent placement Contraindication Bleeding disorder Biliary tract infection

77 PTC Patient preparation Clotting study Prophylactic antibiotic NPO 4-6 hrs Sedation

78 PTC Post procedure care Observe bleeding and infection Complication Hemorrhage Septicemia Bile leak, bile peritonitis

79 T-tube cholangiography Post cholecystectomy with T-tube placement

80 MRCP Indication Preoperative find cause of obstruction fail ERCP Postperative Recurrent jaundice symptom of pancreatitis

81 Portal hypertension

82 Portal hypertension Increase portal venous pressure Cause: Intrahepatic, extrahepatic Intrahepatic: cirrhosis Extraheaptic: hepatic vein obstruction Physiology: splenomegaly, collateral circulation

83 Imaging of portal hypertension Indication Prove portal hypertension Find cause Find complication: collateral circulation, splenomegaly

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87 CT Same indication and finding as ultrasound

88 Liver cirrhosis: enlarged caudate and left lobe liver

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