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Presentation on theme: "Good morning everyone!."— Presentation transcript:

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 manifestation
CT

14 liver-normal manifestation
CT 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 manifestation
US

96 pancreas-normal manifestation
CT

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?


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