Imaging In Obstructive Biliopathy.Aizawl

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Imaging In Obstructive Biliopathy.Aizawl

  1. 1. Imaging in Obstructive biliopathy Dr H.S.Das
  2. 2. Hepatic Segments (Couinauds)
  3. 3. Liver masses / nodules <ul><li>Benign : Cysts </li></ul><ul><li> : Abscess </li></ul><ul><li> : Tumors (Haemangioma , FNH, Adenoma etc), </li></ul><ul><li> : Vascular </li></ul><ul><li>Malignant : Primary Tumors </li></ul><ul><li> : Metastatic </li></ul><ul><li>Nodules : Cirrhotic / NRH </li></ul><ul><li> : Dysplastic </li></ul><ul><li>*Misc : Hepatic Steatosis - Focal fatty infiltration </li></ul><ul><li>- Focal fatty sparing </li></ul>
  4. 4. Role of CT/MR in hepatic lesions <ul><li>Confirm lesion </li></ul><ul><li>Differentiate benign from malignant </li></ul><ul><li>Vascular involvement </li></ul><ul><li>Extent & extrahepatic involvement </li></ul><ul><li>Select patients for resectable lesions </li></ul><ul><li>Staging </li></ul><ul><li>Determine response to Treatment </li></ul>
  5. 5. MRI <ul><li>Fast Spin Echo (FSE) Techniques </li></ul><ul><li>Gradient Echo (GRE) Techniques </li></ul><ul><li>Superparamagnetic Iron Oxide (ferrite particles): 3 fold increase in lesion detection </li></ul><ul><li>Mn Phos(DPDP): new MR contrast agent </li></ul><ul><li>* help to differentiate haemangioma & malignant tumors </li></ul><ul><li>* Add to D/D’s in problem cases </li></ul>
  6. 6. CT Techniques <ul><li>CT Arteriography CTA </li></ul><ul><li>CT Arterioportography CTAP </li></ul><ul><li>Iodised Oil CT </li></ul><ul><li>Spiral CT </li></ul><ul><li>MDCT </li></ul>
  7. 7. Spiral CT:Scan Delays & Technique <ul><li>CT Arterial Phase HAP (25-30secs) </li></ul><ul><li>Venous Phase PVP (60-70secs) </li></ul><ul><li>Interstitial Phase Eqbl (5-7mins) </li></ul><ul><li>Optimisation of coverage & section Width: </li></ul><ul><li>Pitch Factor >1.5 </li></ul><ul><li>5/8/4 Protocol </li></ul>
  8. 8. Imaging Plays Crucial Role <ul><li>Diagnosing + distinguishing hyperplastic, dysplastic and malignant hepatocellular masses </li></ul><ul><li>Accurate diagnosis requires: </li></ul><ul><ul><li>Evaluation of lesion in multiphasic CT (+/- MR) </li></ul></ul><ul><ul><li>Evaluation of surrounding liver </li></ul></ul><ul><ul><ul><li>e.g. cirrhosis, Budd-Chiari, hemochromatosis etc. </li></ul></ul></ul>
  9. 9. Cystic Lesions <ul><li>Simple cysts </li></ul><ul><li>VMC </li></ul><ul><li>Biliary Cyst </li></ul><ul><li>Peribiliary cyst </li></ul><ul><li>Parasitic cysts </li></ul>
  10. 10. Biliary Microcystic Hamartoma ( Von Meyenburg Complex ) <ul><li>Primitive and aberrant bile ductules </li></ul><ul><li>Cystic dilatation </li></ul><ul><li>Multiple, < 1cm. </li></ul><ul><li>Spectrum of adult fibropolycystic diseases </li></ul>
  11. 11. Typical Cysts <ul><li>Intrahepatic (simple): Varying size </li></ul><ul><li>: Intrahepatic </li></ul><ul><li>Peribilary : APKD </li></ul><ul><li>: Small size </li></ul><ul><li>: Portal tract location </li></ul>
  12. 12. Atypical Cysts <ul><li>Cyst Mimics : Cystic neoplasm </li></ul><ul><li> : Necrotized tumors( mets, scc) </li></ul><ul><li> : localised biliary dilatation </li></ul><ul><li> : Old abscess / haematoma </li></ul><ul><li> : Biloma </li></ul><ul><li> : Peliosis Hepatis </li></ul><ul><li> : Abnormal vessel </li></ul>
  13. 13. Liver Cyst
  14. 14. Calcified Hydatid Cyst
  15. 15. Fatty Liver <ul><li>: Regular : Focal fatty infiltration </li></ul><ul><li> : Focal Fatty Sparing </li></ul><ul><li>: Irregular : Number : Solitary </li></ul><ul><li> : Multiple </li></ul><ul><li> : Shape - Round Shape </li></ul><ul><li> -Irregular Shape </li></ul>
  16. 16. Fatty Infiltration & Sparing
  17. 17. Fatty liver -THAD
  18. 18. Lipomatous Tumors <ul><li>Lipoma </li></ul><ul><li>Angiomyolipoma </li></ul><ul><li>Myelolipoma </li></ul>
  19. 19. Abscess
  20. 20. METASTASIS TYPICAL CT/MRI APPEARANCE <ul><li>1) Multiple and variable </li></ul><ul><li>2) Hypodense on NCCT </li></ul><ul><li>3) Hypovascular (PVP), thin vascular rim </li></ul><ul><li>4) Hypervascular (HAP) </li></ul><ul><li>5) Six patterns: Doughnut, Target, Amorphous, Halo, Lightbulb </li></ul>
  21. 21. Metastases
  22. 22. Hypovascular Metastasis
  23. 23. Metastases
  24. 24. MRI
  25. 25. Metastases
  26. 26. Metastases
  27. 27. Metastases
  28. 28. Metastases
  29. 29. Hypervascular Mets
  30. 30. Hypervascular metastases
  31. 31. Hypervascular Metastases
  32. 32. Metastases
  33. 33. Metastases- MR
  34. 34. Classification of Hepatocellular Nodules <ul><li>Regenerative nodules </li></ul><ul><ul><li>Monoacinar regenerative nodule </li></ul></ul><ul><ul><li>Multiacinar (large) regenerative nodule </li></ul></ul><ul><ul><li>Lobar or segmental hyperplasia </li></ul></ul><ul><ul><li>Cirrhotic nodule </li></ul></ul><ul><ul><li>Focal nodular hyperplasia </li></ul></ul>
  35. 35. Classification of Hepatocellular Nodules <ul><li>Dysplastic or neoplastic lesions </li></ul><ul><ul><li>Hepatocellular adenoma </li></ul></ul><ul><ul><li>Dysplastic nodule </li></ul></ul><ul><ul><li>Hepatocellular carcinoma </li></ul></ul>
  36. 36. Dysplastic Nodules <ul><li>“ Adenomatous hyperplasia” (old term) </li></ul><ul><li>Are premalignant </li></ul><ul><li>Rarely diagnosed by US or CT </li></ul><ul><li>MR – iso to hyperintense on T1 </li></ul><ul><ul><li>Hypo on T2 (opposite of HCC) </li></ul></ul><ul><ul><li>Should not enhance much on HAP </li></ul></ul><ul><li>Diagnosed correctly 5 – 15% of cases </li></ul><ul><ul><ul><ul><li>Krinsky et al. Radiology 2001; 219: 445-454 </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Dodd et al. AJR 1999; 173: 1185 - 1192 </li></ul></ul></ul></ul>
  37. 37. Cirrhotic Nodules – Classification <ul><li>Based on </li></ul><ul><li>1) hyperplastic or dysplastic </li></ul><ul><li>2) nature of surrounding liver </li></ul><ul><li>All are due to local proliferation of hepatocytes + stroma in response to injury (ischemic or toxic) </li></ul><ul><li>May be indistinguishable histologically </li></ul><ul><ul><li>imaging plays a key role </li></ul></ul>
  38. 38. Cirrhotic Nodule
  39. 39. Regenerating Nodules <ul><li>Usually too small to detect by imaging </li></ul><ul><ul><li>May be surrounded by fibrotic septa </li></ul></ul><ul><ul><li>May contain iron, copper </li></ul></ul><ul><li>Siderotic nodules </li></ul><ul><ul><li>Hyperdense on NCCT, disappear on HAP & PVP </li></ul></ul><ul><ul><li>Hypointense on T2 MR, “bloom” on GRE </li></ul></ul><ul><li>Larger or vascular/enhancing RN </li></ul><ul><ul><li>Can not be distinguished from dysplastic nodule or HCC </li></ul></ul>
  40. 40. Liver Nodules
  41. 41. Nodular Regenerative Hyperplasia <ul><li>Usually results from obstruction of hepatic or portal veins </li></ul><ul><ul><li>Budd-Chiari, leukemia, polycythemia, etc. </li></ul></ul><ul><li>Patients have abnormal LFTs but not cirrhosis </li></ul>
  42. 42. NRH – CT findings <ul><li>Multiple (2-20), small (1-4 cm) </li></ul><ul><li>Homogeneous enhancement, +/- ring </li></ul>
  43. 43. NRH – Problem Solving <ul><li>MR – same features as CT </li></ul><ul><li>usually hyperintense on T1, hypo on T2 </li></ul><ul><li>Unlike HCC, may take up and retain Gd-BOPTA (= benign) </li></ul><ul><li>Recognize associated clinical and liver abnormalities </li></ul><ul><li>May have to biopsy </li></ul>
  44. 44. CLD- dysplastic ,regen nodules
  45. 45. CLD with PHTN
  46. 46. LIVER TUMORS HEPATOCELLULAR ORIGIN <ul><li>-Focal nodular hyperplasia </li></ul><ul><li>-Hepatocellular adenoma </li></ul><ul><li>-Hepatocellular carcinoma </li></ul><ul><li>-Fibrolamelar Carcinoma </li></ul>
  47. 47. LIVER TUMORS NON-HEPATOCELLULAR ORIGIN <ul><li>- Hemangioma </li></ul><ul><li>- Metastasis </li></ul><ul><li>- Biliary microcystic hamartoma </li></ul><ul><li>- Bile duct cyst (simple cyst) </li></ul><ul><li>- Cystadenoma-adenocarcinoma </li></ul><ul><li>- Cholangiocarcinoma </li></ul><ul><li>- Epitheliod hemangioendothelioma </li></ul><ul><li>- Angiosarcoma </li></ul>
  48. 48. Adenoma <ul><li>Well defined, smooth, spherical </li></ul><ul><li>>90% in young women (30-50) on OCP </li></ul><ul><ul><li>rest in glycogen storage disease, anabolic steroids </li></ul></ul><ul><li>Often bleed (25%), rarely have malignant degeneration </li></ul><ul><ul><li>should be resected </li></ul></ul><ul><li>50% solitary </li></ul><ul><ul><li>50% multiple (rarely “adenomatosis”, dozens of lesions) </li></ul></ul><ul><li>Path </li></ul><ul><ul><li>benign hepatocytes, few Kupffer calls, no bile ducts </li></ul></ul><ul><ul><li>excessive glycogen, lipids, hemorrhage, necrosis </li></ul></ul>
  49. 49. Focal Nodular Hyperplasia (FNH) <ul><li>Present in 2-5% of population (F >> M), incidental finding, rarely symptomatic, may simulate tumor </li></ul><ul><li>Size 2-10 cm </li></ul><ul><li>Number: solitary (77%) to numerous </li></ul><ul><li>Path: normal hyperplastic liver tissue with central scar; other vascular lesions (adenoma, hemangioma) </li></ul>
  50. 50. FNH – CT Criteria <ul><li>Homogeneous on all phases </li></ul><ul><li>Almost isodense with liver (noncon., PVP, delayed) </li></ul><ul><li>Uniformly and very hypervascular on HAP (like vessels) </li></ul><ul><li>Non-encapsulated, fuzzy margin, no Ca++, no capsule (pseudocapsule in fatty liver) </li></ul><ul><li>Small scar, 65% of “big” FNH, 35% of small (< 3cm) </li></ul>
  51. 51. FNH vs. Fibrolamellar HCC <ul><li>FL-HCC typically solitary, large tumor (13 cm) </li></ul><ul><li>Typical patient: young to middle age, no predisposition </li></ul>
  52. 52. FNH
  53. 53. Adenoma – CT Findings <ul><li>Usually heterogeneous due to fat (5-10% on CT, 50-75% on MR), necrosis, hemorrhage, calcifications (5%) </li></ul><ul><li>Hypervascular </li></ul><ul><li>Partial capsule (~ 25%) </li></ul>
  54. 54. Adenoma – Problem Solving <ul><li>Hard to distinguish from HCC </li></ul><ul><ul><li>usually resect, especially if hemorrhage </li></ul></ul><ul><li>MR shows fat and blood better than CT </li></ul>
  55. 55. Conventional HCC <ul><li>Solitary (1/2) or multiple (1/2) </li></ul><ul><li>Variable size </li></ul><ul><li>Heterogeneous </li></ul><ul><ul><li>best detected on HAP or delayed </li></ul></ul><ul><li>Capsule, hemorrhage, fat – all < 10% </li></ul><ul><li>HV or PV invasion/obstruction – very common </li></ul><ul><ul><li>may be seen on CT only in large vessels </li></ul></ul><ul><li>Nodes – present in cardiophrenic and porta hepatis </li></ul><ul><li>Typical patient: </li></ul><ul><ul><li>45 – 65 with chronic hep B or C, </li></ul></ul>
  56. 56. HCC in Noncirrhotic Liver <ul><li>HCC typically large tumor (13 cm), solitary or dominant mass (82%) </li></ul><ul><li>Symptomatic 87% </li></ul><ul><li>No identifiable risk factors 62% </li></ul><ul><li>Calcifications 28%, hemorrhage 26%, fat 10% </li></ul><ul><li>Tumors heterogeneous 97% </li></ul><ul><li>Hypoattenuating on NC 87% </li></ul><ul><li>Hyperattenuating on HAP 97% </li></ul><ul><li>Hypoattenuating on PVP 90% </li></ul>
  57. 57. Fibrolamellar HCC – CT Findings <ul><li>Heterogeneous enhancement on all phases (  100%, no hemorrhage or fat) </li></ul><ul><li>Lobulated irregular contour, well defined (75%) </li></ul><ul><li>Large central/eccentric scar (75%) </li></ul><ul><li>+ Radiating fibrous septa, +/- delayed enhancement </li></ul><ul><li>Central calcification (68%) </li></ul><ul><li>Lymph node + other mets (65%) </li></ul><ul><li>Vascular/biliary obstruction – common, invasion rare </li></ul>
  58. 58. HCC-Arterial phase
  59. 59. HCC-Venous phase
  60. 60. HCC
  61. 61. HCC-non cirrhotic liver
  62. 62. Hcc-CT guided FNAC
  63. 63. HCC
  64. 64. HCC
  65. 65. HCC
  66. 66. HCC
  67. 67. HCC
  68. 68. HCC
  69. 69. Multifocal HCC
  70. 70. Large HCC
  71. 71. HCC
  72. 72. Diffuse HCC with Portal Vein Thrombus
  73. 73. HCC
  74. 74. Multifocal HCC
  75. 75. CLD-HCC
  76. 76. HCC( Possibly Fibrolamellar )
  77. 77. HCC
  78. 78. HEMANGIOMA Incidence & Clinical Presentation <ul><li>Most common tumor (1-20% gen.pop.) </li></ul><ul><li>Uniform geographical distribution </li></ul>
  79. 79. Haemangioma <ul><li>Women 5:1 </li></ul><ul><li>Post Menopausal </li></ul><ul><li>Asymptomatic (85%) </li></ul><ul><li>Multiple vascular channels </li></ul><ul><li>Peripheral feeding vessels </li></ul><ul><li>Areas of fibrosis, necrosis </li></ul><ul><li>Normal liver contour </li></ul>
  80. 80. Haemangiomas <ul><li>Solitary ( 90 – 50 %) </li></ul><ul><li>Sharply circumscribed </li></ul><ul><li>Subcapsular ( normal liver contour) </li></ul><ul><li>Cystic areas </li></ul><ul><li>Calcification ( < 10 % ) </li></ul><ul><li>Coarse ( fibrosis ) </li></ul><ul><li>Phleboliths </li></ul>
  81. 81. HEMANGIOMA - CT FINDINGS <ul><li>Low attenuation </li></ul><ul><li>Well defined </li></ul><ul><li>Multiple </li></ul><ul><li>Normal contour </li></ul><ul><li>Early, globular peripheral enhancement </li></ul><ul><li>Isoaortic enhancement </li></ul><ul><li>Slow centripetal “filling in” of contrast </li></ul><ul><li>* Expansion </li></ul>
  82. 82. HEMANGIOMA CT/MRI APPEARANCE <ul><li>1) Single, small (< 3 cm) </li></ul><ul><li>2) Confined within normal liver contour </li></ul><ul><li>3) Peripheral globular filling, arterial </li></ul><ul><li>density, slow flow </li></ul><ul><li>4) Homogeneously hyperintense in T2 </li></ul>
  83. 83. Haemangioma <ul><li>Calcification </li></ul><ul><li>Up to 20 % of cases </li></ul><ul><li>- Large fibrotic areas </li></ul><ul><li>Rapid Enhancement </li></ul><ul><li>In small, capillary hemangiomas </li></ul><ul><li>Uniform, early enhancement </li></ul>
  84. 84. Haemangioma : MR Findings <ul><li>T1: low SI </li></ul><ul><li>T2: - markedly high SI </li></ul><ul><li>Homogeneous </li></ul><ul><li>No halo </li></ul>
  85. 85. Cavernous Haemangioma
  86. 86. Cavernous Haemangioma
  87. 87. Cavernous Haemangioma
  88. 88. Multifocal Cavernous Haemangioma
  89. 89. Cavernous Haemangioma
  90. 90. BILIARY CYSTADENOMA <ul><li>Continual with cystadenocarcinoma </li></ul><ul><li>Women 45 - 55 years </li></ul><ul><li>Symptomatic (RUQ pain, mass) </li></ul>
  91. 91. INTRAHEPATIC CHOLANGIOCARCINOMA <ul><li>2nd most common primary liver malignancy </li></ul><ul><ul><li>10% - 20% of primary malignancies </li></ul></ul><ul><ul><li>Only 10% intrahepatic </li></ul></ul><ul><li>M > F (1.6:1) </li></ul><ul><li>Age: 7th decade </li></ul><ul><ul><li>Older than HCC </li></ul></ul>
  92. 92. I-CAC Pathogenesis/Associations <ul><li>Thorotrast </li></ul><ul><li>Hepatolithiasis (5% - 20%) </li></ul><ul><li>Clonorchis sinensis </li></ul><ul><li>Sclerosing Cholangitis </li></ul><ul><li>Caroli Disease </li></ul><ul><li>Congenital Hepatic Fibrosis </li></ul>
  93. 93. I-CAC CT <ul><li>Hypodense, homogeneous, irregular borders </li></ul><ul><li>Calcification </li></ul><ul><li>Variable enhancement, peripheral </li></ul><ul><ul><li>Central fibrosis, delayed enhancement </li></ul></ul><ul><ul><li>Vascular encasement, no invasion </li></ul></ul><ul><li>Extrahepatic extension </li></ul>
  94. 94. I-CAC MRI <ul><li>Homogenous </li></ul><ul><li>T2 hyperintense, except for </li></ul><ul><ul><li>Central hypointense fibrosis </li></ul></ul><ul><li>Gd-DTPA: peripheral and delayed enhancement </li></ul>
  95. 95. CLD -Icac
  96. 96. DETECTION RATES-MRI <ul><li>Sensitivity & Specificity depends on: </li></ul><ul><li>- Size of lesion : </li></ul><ul><li>100% lesions of >2 cm size on plain MR </li></ul><ul><li>40-50% sens. for lesions between 1-2 cm size </li></ul><ul><li>10% for lesions <1cm size </li></ul><ul><li>- Choosen imaging technique: </li></ul><ul><li> increased rates with VIBE, double echo in & opposed phases, sensitivity encoded sequences.. </li></ul>
  97. 97. DETECTION RATES -CT <ul><li>Overall for biphasic CT exams = 67%-96% </li></ul><ul><li>Increased detection rates (75%-94%) when lesions <1cm are excluded </li></ul><ul><li>>95% rate in lesions of >1cm size </li></ul><ul><li>Hyper vascular mets : PVP only = 84% </li></ul><ul><li>: PVP+ HAP = 96% </li></ul><ul><li>Hypovascular mets : PVP only = 67% </li></ul><ul><li>: PVP+HAP = 75% </li></ul>
  98. 98. Where do we stand? <ul><li>Benign focal liver lesions even in known primary tumors=20%-36% </li></ul><ul><li>In liver Lesions <1.5cm size = 80% benign </li></ul><ul><li>Problem Areas are lesions of <1.5 cm size </li></ul><ul><li>- Small cysts mistaken for hypovascular mets </li></ul><ul><li>- Small haemangiomas for hypervascular met </li></ul><ul><li>- other tumors (FNH, HCC,Adenoma) simulating hypervascular tumors </li></ul>
  99. 99. Take home message : <ul><li>MultiPhasic CT for confirmation & characterization of hepatic masses </li></ul><ul><li>Initial examination: Biphasic exam sufficient </li></ul><ul><li>For tumor resectability : Triphasic scans for diffentiation of small lesions </li></ul><ul><li>For follow up cases: </li></ul><ul><li> - PVP in hypovascular lesions </li></ul><ul><li> - HAP in hypervascular lesions </li></ul>
  100. 100. THANK YOU!!

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