1. Good morning everyone!

2. Liver, gallbladder and pancreas: imaging diagnosis
唐光健

3. What is image? Image just is contrast!
Method for learning
What is image? Image just is contrast!
Pathologic change to show the changes diagnosis

4. Method for learning choice of imaging modality
Available,
Effectiveness
-sensitivity, specificity
Cost
pathology-imaging (indirectly)
Correlate among images of different modalities

5. Method for learning cyst adenoma metastasis cancer cancer CT angioma
Angiography
B-sonography
MRI
Mr. Diag

6. Imaging modalities conventional radiology B-mode ultrasound
computed tomography CT
pancreatic-cholangiography
angiography
magnetic resonance imaging MRI

7. Liver

8. liver Characteristics: poor natural X-ray contrast Luminal Structure
biliary canal, vessel system cholagiography, angiography
Parenchyma
surrounding adipose tissue -TOMOGRAPHIC IMAGING

9. liver

10. main modalities: BUS ERCP PTC CT Angiography MRI
liver
main modalities: BUS ERCP PTC CT Angiography MRI
characteristics of normal liver
 homogeneous with parenchyma
 echo/density/signal of soft-tissue
 organized distribution and course of the vessels

11. liver-normal manifestation
B mode sonography
It1
It2
It3 t1 t2 t3

12. liver-normal manifestation
B mode sonography

13. liver-normal manifestationCT

14. liver-normal manifestationCT
Arterial phase
Portal V. phase
Plain scan

15. liver-normal manifestation
angiography
DSA
Routine

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

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

18. liver-HCC

19. 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 supply, necrosis
tumor vessel, 80% from HA, A-V shunt

20. liver-HCC imaging manifestations B-sonography
hypo-/moderate/hyper-echogenic, hypoechogenic halo

21. liver-HCC imaging manifestations color-Doppler flow imaging
arterial flow

22. liver-HCC imaging manifestations CT
contras enhancement
plain scan
inhomogeneous low density mass, low enhancement

23. liver-HCC imaging manifestations CT-double phase enhancement
a. phase
P.V. phase
a. phase enhancing, fast in fast out
plain scan

24. liver-HCC imaging manifestations-MRI heavy T2WI CE T1WI T1WI T2WI
long T1 long T2, SI attenuate with heavy T2WI, +Gd enhancing

25. liver-HCC imaging manifestations angiography
feeding A. thickening, tumor vessels, tumor staining, AVF

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

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

28. liver-cavernous angioma

29. liver-cavernous angioma
pathologic features correlate to imaging
micro-blood sinusoid & interstitial tissue between sinusoids
slow blood flow intra-sinusiod, flow from peripheral to central zone
no capsule

30. liver-cavernous angioma
imaging manifestations
sonography
Hyperechogenic mostly

31. liver-cavernous angioma
imaging manifestations
Doppler color flow imaging
vein flow

32. liver-cavernous angioma
imaging manifestations CT
plain scan
arterial ph.
p. vein ph.
balance ph.
low density, tuberculiform enhance peripherally, enhancing zone growing-fast in slow out

33. liver-cavernous angioma
imaging manifestations
angiography
blood pool, popcorn like, tumor stain slow

34. liver-cavernous angioma
imaging manifestations-MRI T1 T2
heavy T2
Long T1, long T2, no attenuation of T2 SI with heavy T2WI

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

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

37. liver-cyst pathologic features correlate to imaging
cyst wall uniformly thin
clear fluid inside the cyst without blood supply
normal adjacent hepatic parenchyma, mass effect with large cyst

38. liver-cyst imaging manifestations-US
anechoic, posterior echo-enhance, side-wall “lost”

39. liver-cyst imaging manifestations-CT plain scan contrast enhance
edge sharp & smooth , “no wall”, fluid desity, no enhancement

40. liver-cyst imaging manifestations-MRI T1WI T2WI Heavy T2WI
edge sharp & smooth, “no wall”, long T1 long T2, no SI attenuation with heave T2WI

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

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

43. liver-abscess

44. pathologic features correlate to imaging
liver-abscess
pathologic features correlate to imaging
cystic
purulent cavity + inflammatory wall
edema of the adjacent tissue
! Inflammatory process

45. liver-abscess imaging manifestations-CT
plain scan
contrast enhancement
fluid density cyst; thick wall lower density, may be enhanced; liver adjacent lesion lower density; intra-cystic gas

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

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

48. liver-hepatic cirrhosis
pathologic features correlate to imaging
regenerative nodules (large style & small style)
hepatic fissure widen
caudal lobe enlarge
portal vein hypertension- thickening of the portal v., collateral circulation, splenomegaly, ascites

49. liver-cirrhosis imaging manifestations CT
nodule-like edge, collateral shunt

50. liver-cirrhosis imaging manifestations CT
enlargement of caudle lobe, hypotrophy of right lobe

51. liver-cirrhosis
imaging manifestations CT
ascites
splenomegaly

52. billiary
system

53. Biliary 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

54. Biliary system imaging modalities B-mode sonography
X-ray: cholangio-, cholecystography
endoscopic retrograde cholangiopancreatography, ERCP
percutaneous transhepatic cholangiography, PTC
CT, 3D reformation – MIP, MPR
MRI, hydrography~MRCP

55. Biliary system -normal manifestation
cholecystography-oral Iopenoic acid
before graphy
after graphy
after fat meal

56. Biliary system -normal manifestation
ERCP

57. Biliary system -normal manifestation
B-mode sonography

58. Biliary system -normal manifestation
CTC & MR hydrography MRCP
CTC

59. Biliary system -normal manifestation
CTC & MR hydrography MRCP
MRCP

60. Biliary system -normal manifestation
MSCT & MPR
curved MPR

61. Biliary system -lesions
intra-cavity lesions
gallstones
thickening of the wall
benign-cholecystitis： acute/chronic
malignant-carcinoma of gallbladder

62. Biliary system -lesions
intra-cavity lesions
gallstones
thickening of the wall
benign-cholecystitis： achute/chronic
malignant-carcinoma of gallbladder

63. Biliary system –gall stones
pathologic features correlate to imaging
intra the cavity within bile fluid
without calcification/with calcification
lack of water

64. Biliary system –gall stones
imaging modalities
B-mode sonography first choice
X-ray filming: X-ray negative stone: cholecystography
ERCP-with therapy
X-ray negative stone undiagnosable
detect complicated cholecystitis

65. Biliary system –gall stones
imaging manifestations
X-ray filming
X-ray positive stone: plain film

66. Biliary system –gall stones
imaging manifestations
X-ray filming
X-ray nagative stone: cholecystography

67. Biliary system –gall stones
imaging manifestations
X-ray filming
X-ray nagative stone: trans T-tube cholangiography

68. Biliary system –gall stones
imaging manifestations
B-mode sonography

69. Biliary system –gall stones
imaging manifestations-CT
X-ray negative stone: CT cholangiography

70. Biliary system -lesions
intra-cavity lesions
gallstones
thickening of the wall
benign-cholecystitis： achute/chronic
malignant-carcinoma of gallbladder

71. Biliary system -lesions
intra-cavity lesions
gallstones
thickening of the wall
benign-cholecystitis： acute/chronic
malignant-carcinoma of gallbladder

72. Biliary system–cholecystitis, acute

73. 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

74. Biliary system–cholecystitis, acute
imaging manifestations
B-mode sonography
Double counter sign

75. Biliary system–cholecystitis, acute
imaging manifestations-CT
plain scan
contrast enhance
enlargement, thick wall, “sandwich” sign of the bladder

76. Biliary system -lesions
intra-cavity lesions
gallstones
thickening of the wall
benign-cholecystitis： achute/chronic
malignant-carcinoma of gallbladder

77. Biliary system -lesions
intra-cavity lesions
gallstones
thickening of the wall
benign-cholecystitis： achute/chronic
malignant-carcinoma of gallbladder

78. Biliary system–cholecystitis, chronic
pathologic features correlate to imaging
chronic inflammatory 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

79. Biliary system–cholecystitis, chronic
imaging manifestations
B-mode sonography
uniformly thickening of the GB wall

80. Biliary system–cholecystitis, chronic
imaging manifestations-CT
contrast enhance
plain scan
wall thickening, enhancing, with gall stone

81. Biliary system -lesions
intra-cavity lesions
gallstones
thickening of the wall
benign-cholecystitis： achute/chronic
malignant-carcinoma of gallbladder

82. Biliary system -lesions
intra-cavity lesions
gallstones
thickening of the wall
benign-cholecystitis： achute/chronic
malignant-carcinoma of gallbladder

83. Biliary system–gallbladder carcinoma
pathologic features correlate to imaging
polyp like thickening or mass
neoplastic vascularity
consecutive liver invasion

84. Biliary system–gallbladder carcinoma
imaging modalities
BUS CT
oral cholecystography,
-low achievement ratio due to occlusion
ERCC

85. Biliary system–gallbladder carcinoma
retrograde cholecystography ERCC
filling defect or no filling

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

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

88. Biliary system–gallbladder carcinoma
computed tomography CT
wall thickened type-
irregular thickened wall, enhancing with CE, adjacent tissue invasion

89. Biliary system–gallbladder carcinoma
computed tomography CT
massive type-
soft tissue density mass, GB disappeared

90. Biliary system–gallbladder carcinoma
computed tomography CT
massive type-
soft tissue density mass, GB disappeared

91. pancreas

92. Pancreas retroperitoneal, deep lobelet, interlobular fat
Anatomic characteristics:
poor natural X-ray contrast
retroperitoneal, deep
lobelet, interlobular fat
adipose tissue around pancreas
luminal structure

93. Pancreas imaging modalities
upper gastrointestinography: low sensitivity, seldom use
BUS：low satisfactory rate of sonography
X ray：ERCP
CT：high sensitivity, first choice mostly
MRI：not routine exam

94. pancreas-normal manifestation
ERCP

95. pancreas-normal manifestationUS

96. pancreas-normal manifestationCT

97. pancreas-pancreatitis, acute

98. pancreas-pancreatitis, acute
pathologic features correlate to imaging
edema, necrosis, hemorrhage, infection
imaging modality: CT

99. pancreas-pancreatitis, acute
imaging manifestations-CT
contrast enhance
plain scan

100. pancreas-pancreatitis, acute
imaging manifestations-CT
slight intumesce; homogeneous enhancing; edge blurring; edema of adjacent fat, renal fascia; effusion in anterior pararenal space

101. pancreas-carcinoma (p. head)

102. pancreas-carcinoma (p. head)
pathologic features correlate to imaging
local mass
micronecrosis & hemorrhage
ischemic necrosis of central part
obstruction of CBD /pancreatic duct

103. pancreas-carcinoma (p. head)
imaging manifestations-X ray ( upper gastrointestinography)
反3字征

104. pancreas-carcinoma (p. head)
imaging manifestations-US
hypo-echoic mass, hyper-spots inside, echo attenuation posteriorly

105. pancreas-carcinoma (p. head)
imaging manifestations-CT

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

107. 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 with B-US in other hospital, the manifestations were not clear. Who to choice the imaging modalities?