Liver,bile duct,pancreas and spleen

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Liver,bile duct,pancreas and spleen

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

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