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Good morning everyone!
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Liver, gallbladder and pancreas: imaging diagnosis
唐光健
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What is image? Image just is contrast!
Method for learning What is image? Image just is contrast! Pathologic change to show the changes diagnosis
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Method for learning choice of imaging modality
Available, Effectiveness -sensitivity, specificity Cost pathology-imaging (indirectly) Correlate among images of different modalities
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Method for learning cyst adenoma metastasis cancer cancer CT angioma
Angiography B-sonography MRI Mr. Diag
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Imaging modalities conventional radiology B-mode ultrasound
computed tomography CT pancreatic-cholangiography angiography magnetic resonance imaging MRI
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Liver
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liver Characteristics: poor natural X-ray contrast Luminal Structure
biliary canal, vessel system cholagiography, angiography Parenchyma surrounding adipose tissue -TOMOGRAPHIC IMAGING
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liver
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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
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liver-normal manifestation
B mode sonography It1 It2 It3 t1 t2 t3
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liver-normal manifestation
B mode sonography
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liver-normal manifestation
CT
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liver-normal manifestation
CT Arterial phase Portal V. phase Plain scan
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liver-normal manifestation
angiography DSA Routine
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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
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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
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liver-HCC
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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
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liver-HCC imaging manifestations B-sonography
hypo-/moderate/hyper-echogenic, hypoechogenic halo
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liver-HCC imaging manifestations color-Doppler flow imaging
arterial flow
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liver-HCC imaging manifestations CT
contras enhancement plain scan inhomogeneous low density mass, low enhancement
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liver-HCC imaging manifestations CT-double phase enhancement
a. phase P.V. phase a. phase enhancing, fast in fast out plain scan
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liver-HCC imaging manifestations-MRI heavy T2WI CE T1WI T1WI T2WI
long T1 long T2, SI attenuate with heavy T2WI, +Gd enhancing
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liver-HCC imaging manifestations angiography
feeding A. thickening, tumor vessels, tumor staining, AVF
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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
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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
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liver-cavernous angioma
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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
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liver-cavernous angioma
imaging manifestations sonography Hyperechogenic mostly
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liver-cavernous angioma
imaging manifestations Doppler color flow imaging vein flow
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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
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liver-cavernous angioma
imaging manifestations angiography blood pool, popcorn like, tumor stain slow
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liver-cavernous angioma
imaging manifestations-MRI T1 T2 heavy T2 Long T1, long T2, no attenuation of T2 SI with heavy T2WI
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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
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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
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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
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liver-cyst imaging manifestations-US
anechoic, posterior echo-enhance, side-wall “lost”
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liver-cyst imaging manifestations-CT plain scan contrast enhance
edge sharp & smooth , “no wall”, fluid desity, no enhancement
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liver-cyst imaging manifestations-MRI T1WI T2WI Heavy T2WI
edge sharp & smooth, “no wall”, long T1 long T2, no SI attenuation with heave T2WI
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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
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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
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liver-abscess
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pathologic features correlate to imaging
liver-abscess pathologic features correlate to imaging cystic purulent cavity + inflammatory wall edema of the adjacent tissue ! Inflammatory process
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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
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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
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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
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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
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liver-cirrhosis imaging manifestations CT
nodule-like edge, collateral shunt
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liver-cirrhosis imaging manifestations CT
enlargement of caudle lobe, hypotrophy of right lobe
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liver-cirrhosis imaging manifestations CT ascites splenomegaly
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billiary system
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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
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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
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Biliary system -normal manifestation
cholecystography-oral Iopenoic acid before graphy after graphy after fat meal
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Biliary system -normal manifestation
ERCP
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Biliary system -normal manifestation
B-mode sonography
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Biliary system -normal manifestation
CTC & MR hydrography MRCP CTC
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Biliary system -normal manifestation
CTC & MR hydrography MRCP MRCP
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Biliary system -normal manifestation
MSCT & MPR curved MPR
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Biliary system -lesions
intra-cavity lesions gallstones thickening of the wall benign-cholecystitis: acute/chronic malignant-carcinoma of gallbladder
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Biliary system -lesions
intra-cavity lesions gallstones thickening of the wall benign-cholecystitis: achute/chronic malignant-carcinoma of gallbladder
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Biliary system –gall stones
pathologic features correlate to imaging intra the cavity within bile fluid without calcification/with calcification lack of water
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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
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Biliary system –gall stones
imaging manifestations X-ray filming X-ray positive stone: plain film
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Biliary system –gall stones
imaging manifestations X-ray filming X-ray nagative stone: cholecystography
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Biliary system –gall stones
imaging manifestations X-ray filming X-ray nagative stone: trans T-tube cholangiography
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Biliary system –gall stones
imaging manifestations B-mode sonography
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Biliary system –gall stones
imaging manifestations-CT X-ray negative stone: CT cholangiography
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Biliary system -lesions
intra-cavity lesions gallstones thickening of the wall benign-cholecystitis: achute/chronic malignant-carcinoma of gallbladder
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Biliary system -lesions
intra-cavity lesions gallstones thickening of the wall benign-cholecystitis: acute/chronic malignant-carcinoma of gallbladder
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Biliary system–cholecystitis, acute
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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
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Biliary system–cholecystitis, acute
imaging manifestations B-mode sonography Double counter sign
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Biliary system–cholecystitis, acute
imaging manifestations-CT plain scan contrast enhance enlargement, thick wall, “sandwich” sign of the bladder
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Biliary system -lesions
intra-cavity lesions gallstones thickening of the wall benign-cholecystitis: achute/chronic malignant-carcinoma of gallbladder
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Biliary system -lesions
intra-cavity lesions gallstones thickening of the wall benign-cholecystitis: achute/chronic malignant-carcinoma of gallbladder
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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
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Biliary system–cholecystitis, chronic
imaging manifestations B-mode sonography uniformly thickening of the GB wall
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Biliary system–cholecystitis, chronic
imaging manifestations-CT contrast enhance plain scan wall thickening, enhancing, with gall stone
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Biliary system -lesions
intra-cavity lesions gallstones thickening of the wall benign-cholecystitis: achute/chronic malignant-carcinoma of gallbladder
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Biliary system -lesions
intra-cavity lesions gallstones thickening of the wall benign-cholecystitis: achute/chronic malignant-carcinoma of gallbladder
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Biliary system–gallbladder carcinoma
pathologic features correlate to imaging polyp like thickening or mass neoplastic vascularity consecutive liver invasion
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Biliary system–gallbladder carcinoma
imaging modalities BUS CT oral cholecystography, -low achievement ratio due to occlusion ERCC
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Biliary system–gallbladder carcinoma
retrograde cholecystography ERCC filling defect or no filling
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Biliary system–gallbladder carcinoma
computed tomography CT tubercular type- nodule: soft tissue density, enhancing with CE, adjacent tissue invasion
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Biliary system–gallbladder carcinoma
computed tomography CT tubercular type- nodule: soft tissue density, enhancing with CE, adjacent tissue invasion
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Biliary system–gallbladder carcinoma
computed tomography CT wall thickened type- irregular thickened wall, enhancing with CE, adjacent tissue invasion
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Biliary system–gallbladder carcinoma
computed tomography CT massive type- soft tissue density mass, GB disappeared
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Biliary system–gallbladder carcinoma
computed tomography CT massive type- soft tissue density mass, GB disappeared
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pancreas
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Pancreas retroperitoneal, deep lobelet, interlobular fat
Anatomic characteristics: poor natural X-ray contrast retroperitoneal, deep lobelet, interlobular fat adipose tissue around pancreas luminal structure
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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
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pancreas-normal manifestation
ERCP
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pancreas-normal manifestation
US
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pancreas-normal manifestation
CT
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pancreas-pancreatitis, acute
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pancreas-pancreatitis, acute
pathologic features correlate to imaging edema, necrosis, hemorrhage, infection imaging modality: CT
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pancreas-pancreatitis, acute
imaging manifestations-CT contrast enhance plain scan
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pancreas-pancreatitis, acute
imaging manifestations-CT slight intumesce; homogeneous enhancing; edge blurring; edema of adjacent fat, renal fascia; effusion in anterior pararenal space
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pancreas-carcinoma (p. head)
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pancreas-carcinoma (p. head)
pathologic features correlate to imaging local mass micronecrosis & hemorrhage ischemic necrosis of central part obstruction of CBD /pancreatic duct
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pancreas-carcinoma (p. head)
imaging manifestations-X ray ( upper gastrointestinography) 反3字征
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pancreas-carcinoma (p. head)
imaging manifestations-US hypo-echoic mass, hyper-spots inside, echo attenuation posteriorly
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pancreas-carcinoma (p. head)
imaging manifestations-CT
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pancreas-carcinoma (p. head)
imaging manifestations-CT inhomogeneous density mass, inhomogeneous & lower enhancement, intro- and extro-bile duct dilatation, hypotrophy of pancreas body
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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?
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