肝膽胰的影像學診斷

1、Good morning everyone!,,唐光健,Liver, gallbladder and pancreas: imaging diagnosis,Method for learning,What is image? Image just is contrast!,,Pathologic change? to show the changes?

2、 diagnosis,choice of imaging modality Available, Effectiveness -sensitivity, specificity Cost pathology-imaging (indirectly) Correlate among images of different modalities,,Method for l

3、earning,,,,,,adenoma,metastasis,metastasis,angioma,Angiography,CT,B-sonography,MRI,,,cyst,Method for learning,,,cancer,Mr. Diag,cancer,Imaging modalities,conventional radiology B-mode ultrasound computed tomography CT

4、 pancreatic-cholangiography angiography magnetic resonance imaging MRI,,Liver,,liver,,Characteristics:poor natural X-ray contrast Luminal Structure biliary canal, vessel system -cholagiography, angiography

5、Parenchyma surrounding adipose tissue -TOMOGRAPHIC IMAGING,,liver,?main modalities: BUS ERCP PTC CT Angiography MRI?characteristics of normal liver ? homogeneous with parenchyma ? echo/density/signal of soft-ti

6、ssue ? organized distribution and course of the vessels,,liver,B mode sonography,,t1,t2,t3,It1,It3,It2,,,,liver-normal manifestation,,B mode sonography,liver-normal manifestation,CT,,liver-normal manifestation,CT,,l

7、iver-normal manifestation,Plain scan,Arterial phase,Portal V. phase,angiography,,DSA,Routine,liver-normal manifestation,liver-lesions,Solid lesions malignant~ hepatic cell carcinoma ( HCC ) benign~cavernous angioma

8、 Cystic lesions hepatic cyst abscess of liver cirrhosis of liver,,liver-lesions,Solid lesions malignant~ hepatic cell carcinoma ( HCC ) benign~cavernous angioma Cystic lesions hepatic cyst abscess of liver

9、 cirrhosis of liver,,,liver-HCC,pathologic features correlate to imaging (bulky type) concentrated cellularity, no hepatic plate or sinus structures intracellula lipomicron,edema of the tissue lack of blood suppl

10、y, necrosis tumor vessel, 80% from HA, A-V shunt,,liver-HCC,imaging manifestations B-sonography,,hypo-/moderate/hyper-echogenic, hypoechogenic halo,liver-HCC,,arterial flow,imaging manifestations color-Dopp

11、ler flow imaging,liver-HCC,imaging manifestations CT,,plain scan,contras enhancement,inhomogeneous low density mass, low enhancement,liver-HCC,imaging manifestations CT-double phase enhancement,,plain scan,a. phase,P

12、.V. phase,a. phase enhancing, fast in fast out,liver-HCC,,T1WI,CE T1WI,T2WI,heavy T2WI,long T1 long T2, SI attenuate with heavy T2WI, +Gd enhancing,imaging manifestations-MRI,liver-HCC,,feeding A. thickening, tumor vess

13、els, tumor staining, AVF,imaging manifestations angiography,liver-HCC,liver-lesions,Solid lesions malignant~ hepatic cell carcinoma ( HCC ) benign~cavernous angioma Cystic lesions hepatic cyst abscess of live

14、r cirrhosis of liver,,liver-lesions,Solid lesions malignant~ hepatic cell carcinoma ( HCC ) benign~cavernous angioma Cystic lesions hepatic cyst abscess of liver cirrhosis of liver,,,liver-cavernous angioma,p

15、athologic features correlate to imaging micro-blood sinusoid & interstitial tissue between sinusoids slow blood flow intra-sinusiod,flow from peripheral to central zone no capsule,,liver-cavernous angiom

16、a,,Hyperechogenic mostly,liver-cavernous angioma,imaging manifestations sonography,,vein flow,liver-cavernous angioma,imaging manifestations Doppler color flow imaging,imaging manifestations CT,,plain scan,arterial

17、 ph.,p. vein ph.,balance ph.,low density, tuberculiform enhance peripherally, enhancing zone growing-fast in slow out,liver-cavernous angioma,,blood pool, popcorn like, tumor stain slow,liver-cavernous angioma,imaging ma

18、nifestations angiography,,Long T1, long T2, no attenuation of T2 SI with heavy T2WI,T1,heavy T2,T2,liver-cavernous angioma,imaging manifestations-MRI,liver-lesions,Solid lesions malignant~ hepatic cell carcinoma (

19、HCC ) benign~cavernous angioma Cystic lesions hepatic cyst abscess of liver cirrhosis of liver,,liver-lesions,Solid lesions malignant~ hepatic cell carcinoma ( HCC ) benign~cavernous angioma Cystic lesions

20、 hepatic cyst abscess of liver cirrhosis of liver,,pathologic features correlate to imaging cyst wall uniformly thin clear fluid inside the cyst without blood supply normal adjacent hepatic parenchyma, mass e

21、ffect with large cyst,,liver-cyst,,anechoic, posterior echo-enhance, side-wall “l(fā)ost”,liver-cyst,imaging manifestations-US,,edge sharp & smooth , “no wall”, fluid desity, no enhancement,plain scan,contrast enhance,l

22、iver-cyst,imaging manifestations-CT,,T1WI,T2WI,Heavy T2WI,edge sharp & smooth, “no wall”, long T1 long T2, no SI attenuation with heave T2WI,liver-cyst,imaging manifestations-MRI,liver-lesions,Solid lesions malignan

23、t~ hepatic cell carcinoma ( HCC ) benign~cavernous angioma Cystic lesions hepatic cyst abscess of liver cirrhosis of liver,,liver-lesions,Solid lesions malignant~ hepatic cell carcinoma ( HCC ) benign~cav

24、ernous angioma Cystic lesions hepatic cyst abscess of liver cirrhosis of liver,,,liver-abscess,pathologic features correlate to imaging cystic purulent cavity + inflammatory wall edema of the adjacent tissue

25、 ! Inflammatory process,,liver-abscess,,plain scan,contrast enhancement,fluid density cyst; thick wall lower density, may be enhanced; liver adjacent lesion lower density; intra-cystic gas,liver-abscess,imaging

26、 manifestations-CT,liver-lesions,Solid lesions malignant~ hepatic cell carcinoma ( HCC ) benign~cavernous angioma Cystic lesions hepatic cyst abscess of liver cirrhosis of liver,,liver-lesions,Solid lesions m

27、alignant~ hepatic cell carcinoma ( HCC ) benign~cavernous angioma Cystic lesions hepatic cyst abscess of liver cirrhosis of liver,,pathologic features correlate to imaging regenerative nodules (large style

28、& small style) hepatic fissure widen caudal lobe enlarge portal vein hypertension- thickening of the portal v., collateral circulation, splenomegaly, ascites,,liver-hepatic cirrhosis,,liver-cirrhosis,imaging man

29、ifestations CT,nodule-like edge, collateral shunt,,liver-cirrhosis,imaging manifestations CT,enlargement of caudle lobe, hypotrophy of right lobe,,liver-cirrhosis,imaging manifestations CT,ascitessplenomegaly,bill

30、iary,,system,,Characteristics:poor natural X-ray contrast Luminal Structure biliary tree, gall bladder -cholagiography, sonography very small amount of parenchyma not good for tomographic imaging,Biliary sys

31、tem,Biliary system,,imaging modalities B-mode sonography X-ray: cholangio-, cholecystography endoscopic retrograde cholangiopancreatography, ERCP percutaneous transhepatic cholangiography, PTC CT, 3

32、D reformation – MIP, MPR MRI, hydrography~MRCP,,cholecystography-oral Iopenoic acid,after graphy,before graphy,after fat meal,Biliary system -normal manifestation,,ERCP,Biliary system -normal manifestation,,B-mode sonog

33、raphy,Biliary system -normal manifestation,,CTC & MR hydrography MRCP,CTC,Biliary system -normal manifestation,,MRCP,CTC & MR hydrography MRCP,Biliary system -normal manifestation,,curved MPR,Biliary system -norm

34、al manifestation,MSCT & MPR,Biliary system -lesions,intra-cavity lesions gallstones thickening of the wall benign-cholecystitis：acute/chronic malignant-carcinoma of gallbladder,,Biliary system -lesions,intra-c

35、avity lesions gallstones thickening of the wall benign-cholecystitis：achute/chronic malignant-carcinoma of gallbladder,,,Biliary system –gall stones,,pathologic features correlate to imaging intra the cavity with

36、in bile fluid without calcification/with calcification lack of water,,imaging modalities B-mode sonography first choice X-ray filming: X-ray negative stone: cholecystography ERCP-with therapy X-ray negative s

37、tone undiagnosable detect complicated cholecystitis,Biliary system –gall stones,,imaging manifestations X-ray filming,X-ray positive stone: plain film,Biliary system –gall stones,,imaging manifestations X-ray film

38、ing,Biliary system –gall stones,X-ray nagative stone: cholecystography,,imaging manifestations X-ray filming,Biliary system –gall stones,X-ray nagative stone: trans T-tube cholangiography,,imaging manifestations B-mode

39、 sonography,Biliary system –gall stones,,X-ray negative stone: CT cholangiography,imaging manifestations-CT,Biliary system –gall stones,Biliary system -lesions,intra-cavity lesions gallstones thickening of the wall b

40、enign-cholecystitis：achute/chronic malignant-carcinoma of gallbladder,,Biliary system -lesions,intra-cavity lesions gallstones thickening of the wall benign-cholecystitis：acute/chronic malignant-carcinoma of ga

41、llbladder,,,Biliary system–cholecystitis, acute,,pathologic features correlate to imaging edema & thickening of the wall hyperemia & edema of mucosa and serous membrane commonly complicated with stone,Bi

42、liary system–cholecystitis, acute,,Double counter sign,Biliary system–cholecystitis, acute,imaging manifestations B-mode sonography,,plain scan,contrast enhance,enlargement, thick wall, “sandwich” sign of the bladder,Bi

43、liary system–cholecystitis, acute,imaging manifestations-CT,Biliary system -lesions,intra-cavity lesions gallstones thickening of the wall benign-cholecystitis：achute/chronic malignant-carcinoma of gallbladder,,Bi

44、liary system -lesions,intra-cavity lesions gallstones thickening of the wall benign-cholecystitis：achute/chronic malignant-carcinoma of gallbladder,,,pathologic features correlate to imaging chronic inflammatory

45、thickening of the gall bladder wall-slight, uniformly with gall stone mostly imaging modalities BUS CT oral cholecystography, may be fail to show stones, seldom use,Biliary system–cholecystitis, chronic,,uniformly

46、thickening of the GB wall,Biliary system–cholecystitis, chronic,imaging manifestations B-mode sonography,,wall thickening, enhancing, with gall stone,Biliary system–cholecystitis, chronic,imaging manifestations

47、-CT,plain scan,contrast enhance,Biliary system -lesions,intra-cavity lesions gallstones thickening of the wall benign-cholecystitis：achute/chronic malignant-carcinoma of gallbladder,,Biliary system -lesions,intra-

48、cavity lesions gallstones thickening of the wall benign-cholecystitis：achute/chronic malignant-carcinoma of gallbladder,,,Biliary system–gallbladder carcinoma,pathologic features correlate to imaging polyp lik

49、e thickening or mass neoplastic vascularity consecutive liver invasion,,Biliary system–gallbladder carcinoma,imaging modalities BUS CT oral cholecystography, -low achievement ratio due to occlusion ERCC,

50、,Biliary system–gallbladder carcinoma,retrograde cholecystography ERCC filling defect or no filling,,Biliary system–gallbladder carcinoma,computed tomography CT tubercular type-nodule: soft tissue density, enhancing

51、with CE, adjacent tissue invasion,,Biliary system–gallbladder carcinoma,computed tomography CT tubercular type-nodule: soft tissue density, enhancing with CE, adjacent tissue invasion,,Biliary system–gallbladder carci

52、noma,computed tomography CT wall thickened type-irregular thickened wall, enhancing with CE, adjacent tissue invasion,,Biliary system–gallbladder carcinoma,computed tomography CT massive type-soft tissue density

53、mass, GB disappeared,,Biliary system–gallbladder carcinoma,computed tomography CT massive type-soft tissue density mass, GB disappeared,,pancreas,Pancreas,,Anatomic characteristics:poor natural X-ray contrast re

54、troperitoneal, deep lobelet, interlobular fat adipose tissue around pancreas luminal structure,Pancreas,,imaging modalities upper gastrointestinography: low sensitivity, seldom use BUS：low satisfactory rate of so

55、nography X ray：ERCP CT：high sensitivity, first choice mostly MRI：not routine exam,,ERCP,pancreas-normal manifestation,,US,pancreas-normal manifestation,,CT,pancreas-normal manifestation,,pancreas-pancreatitis, acute,

56、,pathologic features correlate to imagingedema, necrosis, hemorrhage, infection imaging modality: CT,pancreas-pancreatitis, acute,,pancreas-pancreatitis, acute,imaging manifestations-CT,plain scan,contrast

57、enhance,,slight intumesce; homogeneous enhancing; edge blurring; edema of adjacent fat, renal fascia; effusion in anterior pararenal space,pancreas-pancreatitis, acute,imaging manifestations-CT,,pancreas-carcinoma (p. he

58、ad),,pathologic features correlate to imaging local mass micronecrosis & hemorrhage ischemic necrosis of central part obstruction of CBD/pancreatic duct,pancreas-carcinoma (p. head),,反3字征,pancreas-carcinoma

59、(p. head),imaging manifestations-X ray ( upper gastrointestinography),,hypo-echoic mass, hyper-spots inside, echo attenuation posteriorly,pancreas-carcinoma (p. head),imaging manifestations-US,,pancreas-carcinoma (p.

60、head),imaging manifestations-CT,,inhomogeneous density mass, inhomogeneous & lower enhancement, intro- and extro-bile duct dilatation, hypotrophy of pancreas body,pancreas-carcinoma (p. head),imaging manifestations-C

61、T,Questions for thinking of,,A male, 55, obstructive jaundice, upper abdomen pain but the history not clear. How to choice the imaging modalities and what are your evidences for the choise? A hepatic mass was found wit