Liver,bile duct,pancreas and spleen

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  • 1. 肝、胆、胰、脾 Liver, bile duct, pancreas and spleen 陈少琼( Chen,Shaoqiong)
  • 2.  
  • 3. Technique and methods
    • Liver angiography
    • CT
    • MRI
    • C ontrast examination of the bile duct :
    • O ral cholecystography
    • I ntravenous cholecystocholangiography
    • Direct cholangiography
    • T -tube Cholangiography
    PTC --------Percutancous transhepatic cholangiography ERCP ------Endoscopic retrograde cholangiopancreatography
  • 4. Technique and methods T -tube Cholangiography
  • 5. Technique and methods PTC 造影
  • 6. ERCP 显示胆总管、肝总管及肝内胆管及胰管情况
  • 7. CT
    • 1. CT plain scan :
    • ( 1 ) Slice thick : 10MM , 5MM
    • ( 2 ) Region: cover the whole organ
    • 2. E nhancement scanning :
    • ( 1 ) P urpose : resolution , diagnosis.
    • vessels
    • ( 2 ) Methods : Arterial phase ( 20-25” ), portal phase ( 60” ), delayed phase ( 5-7’ )
  • 8. Imaging of the hepatic vessels Artery Portal vein Hepatic vein
  • 9. Hepatic vessels
    • Hepatic artery : Celiac trunk - common hepatic A. - Proper
    • hepatic A - Lt. and Rt. hepatic A.
    • Portal vein : left branch 、 right branch
    • Hepatic vein : left 、 intermediate 、 right
  • 10. Normal anatomy
  • 11. Proper hepatic A Gastro-duodenal A. 脾动脉 splenic artery SMA superior mesenteric artery
  • 12.  
  • 13. 门脉主干及其分支清晰显示。
  • 14. 门静脉 CE MRA 3ml/s 20mlGd-DTPA
  • 15. 门静脉 hepatic portal vein
  • 16. Portal vein and hepatic vein
  • 17. Hepatic vein right intermediate left
  • 18.  
  • 19. 肝右 V
  • 20. Celiac trunk Splenic artery Common hepatic a .
  • 21. Hepatic artery
  • 22. Left branch of hepatic portal vein
  • 23. Right branch of hepatic portal vein
  • 24. Hepatic vein
  • 25. Liver lobes
    • Lobes : C audate lobe ( S1 ) , Left lobe ( S2 、 3) 、 Quadrate lobe ( S4 ), Right lobe ( S5 、 6 、 7 、 8 )
  • 26. Liver lobes Quadrate lobe Left lobe Caudate lobe Quadrate lobe 上段 下段 Left lobe Right lobe 右后叶 上段 下段 1 上段 下段 左外叶 尾状叶 方叶 左内叶 Right lobe 右后叶 上段 下段
  • 27. ( 二 ) Couinaud 肝段划分法 ( 8 段划分法 ) 肝门静脉 肝圆韧带 肝左静脉 下腔静脉 肝中静脉 肝右静脉
  • 28. CT
  • 29. 4 8 7 2
  • 30. 2 4 8 7
  • 31. 2 4 8 7 1
  • 32. 2/3 4 8 7 1
  • 33. 1 3 4 8/5 7/6
  • 34. 3 4 5 6 1
  • 35. 3 4 5 6
  • 36. 5 6
  • 37. 5 6
  • 38. MR
  • 39.
    • 二、 MRI
    • 1.MRI plain scan :
    • S equence —— axial 、 coronal T1W 、 T2W
    • FIESTA 、 DWI 、 double echo
    • 2. MRI enhancement scanning
    • 3. MR A
    • 4. MRCP Magnetic Resonance Cholangiopancreatography
  • 40. 3 4 5 6 T2WI
  • 41. 3 4 5 6 T1WI
  • 42. ERCP 正常胆道 Bile duct system
  • 43. Intrahepatic bile duct
  • 44. MRCP
  • 45. P ancreas
  • 46. CT body of pancreas head of pancreas splenic vein Portal vein
  • 47. tail of pancreas body of pancreas head of pancreas MR T1WI
  • 48. head of pancreas
  • 49. T2 FAT SAT 胰腺 pancreatic duct
  • 50. 胰头 head of pancreas Portal vein gallbladder
  • 51. 23 4 7 8 6 5 冠状位 GB
  • 52. 7 8 6 5 6 5
  • 53. 7 8 6 5 肾上腺 M
  • 54.  
  • 55. 76 SP
  • 56. Disease of the liver
  • 57. Hepatic cyst
    • C ongenital disease
    • CT SCAN
    • Delicate, round, smooth, thin-walled hypodense lesion
    • Homogeneous,waterdensity(0-15HU)
    • No enhancement
    • MR
    • Very low signal intensity on T1WI and very high intensity on T2WI
  • 58. CT Appearance Hepatic C yst -C venous phase arterial phase
  • 59. CT Appearance Hepatic C yst Polycystic disease
  • 60. MR appearance Hepatic cyst
  • 61. Hepatic Abscess P yogenic abscess - bacterium or Amoeba
  • 62. Plain Radiography
  • 63. CT Appearance of hepatic abscess
    • Hypodense –hyperden s e –hypodense
    • necrosis membrane edema
    • 20-40HU
    • Gas or fluid level
  • 64. 肝脓肿 肝右叶圆形低密度区,脓肿壁密度高于脓腔、低于正常肝。增强扫描:脓肿壁环形强化,轮廓光滑,厚度均匀,外围可见低密度水肿带
  • 65. 肝脓肿 肝右叶椭圆形低密度区,增强扫描脓肿壁环形强化,轮廓光滑,厚度均匀,外围可见低密度水肿带
  • 66. MR Appearance of abscess
    • low signal intensity on T1WI and high intensity on T2WI ---inside cavity
    • Intensity is decreased than the center in the wall
  • 67. 平扫 T 1 WI 平扫 T 2 WI 静脉期 septum 肝脓肿 肝右叶两个不规则形异常信号区, T 1 WI 脓肿壁信号高于脓腔、低于正常肝, T 2 WI 反之。增强扫描:脓肿壁环形强化,轮廓不光滑,边缘不整
  • 68. Common hepatic tumors
    • Benign tumor
    • Cavernous hemangioma
    • Hepatocellular adenoma
    • Hamartoma
    • F ocal nodular hyperplasia ( FNH )
    • Malignant tumour
    • H epatocellular carcinoma
    • C holangiocellular carcinoma
    • Liver metastasis
  • 69. H emangiomas of liver
    • H emangiomas is the most common benign tumor of the liver-- C avernous hemangioma
  • 70.
    • CT appearance of h emangiomas
    • A. P lain scan
    • 1 、 L ow density , CT value-about 30HU
    • 2 、 Homogeneous (In homogeneous -centrally lower density in large tumor, Ca or hemorrage)
    • B. E nhancement scanning
    •   1 、 rapidly enhance
    • 2 、 filling in centripetally to become isodensity with the adjacent parenchyma
    • 3 、 The time for complete in-filling has been :     
    • > 3 ’ 、 usually 7 ~ 15 ’ 、 most long 20 ~ 60 ’
  • 71. Plain scan P ortal phase D elayed phase A rterial phase
  • 72.  
  • 73.  
  • 74.  
  • 75. Plain Scan E nhancement D elayed scan
  • 76.
    • MRI appearance
    • 1. Round, Clear margin 2. Intensity - Hypointense on T1WI 、 Hyperintense on T2WI , long TE ( ≥ 120ms ) long T2 value “ lamp b ulb ”, homogeneously
    • Inhomogeneous caused by thrombosis and scar in the center
    • 3. E nhancement scanning
  • 77.  
  • 78.  
  • 79. C avernous hemangioma
  • 80. Hepatocellular carcinoma
    • Hepatocellular carcinoma (HCC )
    • V iral hepatitide infection ( hepatitis B or C )
    • C i rrhosis ( alcoholism )
  • 81. CT
    • On CT, HCC can have three distinct patterns of growth:
    • Massive type --- A single large tumor ≥ 5cm
    • N odular type --- Multiple tumors <5cm
    • D iffuse type --- Poorly defined tumor with an infiltrative growth pattern
    • S mall hepatocellular carcinoma <3cm
  • 82. Key points
    • The key characteristics on CT are hypervascularity in the arterial phase scans, washout or de-enhancement in the portal and delayed phase studies, a pseudocapsule and a mosaic pattern. Both calcifications and intralesional fat may be appreciated.
  • 83. Important features that guide treatment include:
    • size
    • spread ( stage )
    • involvement of liver vessels and bile duct
    • presence of a tumor capsule
    • presence of extrahepatic metastases
    • presence of daughter nodules
    • vascularity of the tumor
  • 84. CT appearance of HCC
      • Shape and margin (1) Regular or irregular (2) Clear margin — pseudo-capsule
      • (3) i ll-defined margin — infiltrating growing
  • 85. CT appearance of HCC
    • Density ( 1 ) hypodense ( common )
    • ( 2 ) isodense or hyperdense ( rare )
    • ( 3 ) mixed density ( hemorrage, necrosis, calcification and fatty degeneration )
  • 86. 低密度 高密度 稍低密度 混杂密度
  • 87. CT appearance of HCC
  • 88. CT enhancement
    • Blood supply
    • 1 ) normal tissue : 25% from hepatic artery
    • 75% from portal vein
    • 2 ) HCC : 90% from hepatic artery
    • 10% from portal vein
    • Enhancement
    • hypervascularity in the arterial phase scans, washout or de-enhancement in the portal and delayed phase
  • 89. CT appearance of HCC
  • 90. 巨块型肝癌、肝内子灶、 IVC 癌栓 CT appearance of HCC Massive type
  • 91. 肝硬化合并原发性结节型肝癌 nodular type CT appearance of HCC
  • 92. CT appearance of HCC 原发型肝细胞癌合并 门静脉、下腔静脉癌栓 Diffuse type IVC
  • 93. MR appearance of HCC
    • Low signal intensity on T1WI and high intensity on T2WI
    • Low signal capsule on T1WI
  • 94. MR appearance of HCC
  • 95.  
  • 96.  
  • 97. time CT Value HCC Hemangioma
  • 98. CT-H epatic metastasis
    • Hypodense lesion, round, multiple
    • Central necrosis and rim enhancement
    • bull's-eye configuration
  • 99. CT-H epatic metastasis
  • 100. CT-H epatic metastasis
  • 101.  
  • 102.
      • Cholesterol stones , Pigment stones , Mixed stones
      • 20 ~ 30 % of gallstones are radio-opaque
    C holelithiasis
  • 103.
      • X-ray : Radio-opaque stones, round or irregular
      • C holecystography: Filling defect
      • CT : Ringlike calcification, CT value -60 ~ 140HU
      • MR : Hypointense
      • ------ Complicating with cholangiectasis and cholangitis
    C holelithiasis-radiologic findings
  • 104. C holelithiasis 平 片
  • 105. C holelithiasis
  • 106. C holelithiasis Cholecystography----radioparent calculus
  • 107. C holelithiasis T -tube Cholangiography
  • 108. C holelithiasis PTC 造影
  • 109.
    • CT
    • cholecystolithiasis
    C holelithiasis
  • 110. C holelithiasis cholecystography CT 检查
  • 111. C holelithiasis
  • 112. C holelithiasis MRCP
  • 113.
    • Imaging findings :
      • CT :
        • Thickening of the wall > 3 mm
        • Acute stage : edema
        • Chronic stage : shrink, calcification of the wall cholelithiasis
    C holecystitis
  • 114. cholecystitis
  • 115. Chronic cholecystitis : shrink of the gallbladder and thickening wall
  • 116. Calcification
  • 117. P ancreatitis
    • Acute pancreatitis
    • Excessive swelling of the pancreas, surrounded by isodense or slightly hypodense exudative zones.
    • Perirenal fasciae are visible and thickened
    • Hemorrhagic and necrosis
  • 118. Acute pancreatitis Excessive swelling of the pancreas
  • 119. Acute pancreatitis
  • 120. Acute pancreatitis
  • 121. Chronic P ancreatitis
    • Calcification
    • Pancreatic atrophy or swelling
    • Dilatation of the pancreatic duct
    • Pseudocysts 30%
  • 122.
    • Pseudocysts
    Chronic P ancreatitis
  • 123.
    • 慢性胰腺炎
      • 胰管串珠样增粗
      • 合并胆总管结石
      • 慢性胆囊炎
    Chronic P ancreatitis
  • 124. Chronic P ancreatitis
    • Calcification
  • 125.
    • 临床与病理
      • 上段 胆管占 50 %以上
      • 早期出现 胆道梗阻症状
      • 分型:浸润型、结节型、乳头型
    肝胆胰脾 --- 胆管癌
  • 126.
    • 影像学表现:
    • PTC 或 MRCP :胆管局限性狭窄或息肉样充盈缺损,
    • 近段胆管扩张,呈“软藤征”。
    • CT :近段胆管扩张
      • 远侧可见低密度肿瘤影(浸润型见不到肿块)
    • MRI :近段胆管扩张,远侧可见肿瘤影
    肝胆胰脾 --- 胆管癌
  • 127. 肝胆胰脾 --- 胆管癌
  • 128. 肝胆胰脾 --- 胆管癌