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LIVER, BILE DUCTS, AND GALL BLADDER

Neeraj Lalwani, M.D.Assistant Professor, Radiology (Body Imaging)

University of Washington, Seattle, USA

Email: neerajl@uw.edu

UW Radiology Review Course- 2015

Disclosures

• None

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Case 1: Chronic hepatitis and raised LFTs

What is the diagnosis?A. CirrhosisB. PseudocirrhosisC. Infiltrating MetastasisD. Budd-Chiari Syndrome

Cirrhosis• Hepatic fibrosis + Regenerative nodules• Most common causes:

i. Alcohol (Micronodular)ii. Chronic viral hepatitis (Macronodular)

• Early micro-nodular cirrhosis may be overlooked in up to 30 %

• Inhomogenous echotexture and irregular-nodular liver surface

• Coarse liver pattern secondary to fibrosis• Nodular liver surface (especially using high

frequency transducers) has an excellent positive predictive value

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Gamna-Gandy Bodies (Splenic Siderotic Nodules)

Extensive Peribiliary Varices

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Pseudocirrhosis?

• Treated metastases (lung, breast, colorectal)• Simulates macronodular cirrhosis• Only history and comparison can lead to correct

diagnosis

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Confluent Hepatic Fibrosis

• May occur in the setting of chronic hepatic disease

• Wedge shaped and extends to the porta hepatis• Overlying capsular retraction

Case 2: 32-year-old female with pain RUQ

What is the diagnosis?A. HCCB. AdenomaC. AngiomyolipomaD. FNH

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Hepatic Adenoma

• Young women taking oral contraceptive pills• Glycogen storage disease or anabolic hormones• Presence of intratumoral fat or hemorrhage.• Sharply marginated (85% of cases), nonlobulated

(95%), sometimes encapsulated (30%)• Hyperattenuating areas corresponding to recent

hemorrhage (25% )• Old hemorrhage is seen as a heterogeneous,

hypoattenuating area within the tumor

In-phaseT2w Out-phase T1w fat sat

a b c d

Hepatic Adenoma

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Arterial phase Portal venous phase Equilibrium phaseT2w

Hepatic Adenoma

Fat containing hepatic lesions

• Focal fatty infiltration• Adenoma• Well differentiated HCC• Hepatic AML• Metastatic liposarcoma• Others: Teratoma, Post-operative omental

packing

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T2w: IntermediateDWI: Restricted diffusion on higher b-values

Typical Imaging features of HCC

T1w: Hypo-, iso- or hyperintenseArterial Phase: Typically hypervascular

Equilibrium Phase: Washout and pseudocapsule

Case 3: Young woman with incidental hepatic lesion

What is the most appropriate next step?A. No further action neededB. MR liverC. MR liver with Gd-BOPTA or Gadoxetate

disodium D. Image guided biopsy

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Arterial phase

T2wIn-phase Out-phase

Hepatospecific phaseEquilibrium phase

MR with Gadoxetate Disodium

• Most common benign hepatocellular lesion• Prevalence 1% • Younger asymptomatic women• Regenerative lesion rather than a neoplasm• Reactive response of hepatic parenchyma

around vascular malformation• Gadoxetate disodium/Gd BOPTA

(dimeglumine): Hepatobiliary imaging agent• Specifically taken up by hepatocytes using the

same molecular mechanism as bile acid

FNH

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FibrolamellarHCC

Large solitary lesion

mostly of the left lobe

Prominent central scar

T2 Hypointense

Scar doesn’t show delayed enhancement

Calcification seen.Upper abdominal lymphadenopathy.

Serum tumor markers are usually not elevated

Fibrolamellar HCC

Unenhanced CT Arterial phase Equilibrium phase

Fibrolamellar HCC

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T1w

Arterial phase Equilibrium phase

T2w

Fibrolamellar HCC

Case 4: 49-year-female with raised LFTs

What is the diagnosis?A. Hypervascular metastasesB. Hypovascular metastasesC. Multifocal HCCD. Lymphoma

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Hypervascular Metastasis

• Most common neoplasm in an adult liver• Multiple lesions in otherwise normal liver• T2 intensity corresponding to spleen is always

worrisome• Most of the metastases are hypovascular• DDx hypervascular metastases: Carcinoid

(Neuroendocrine) tumors, RCC, Thyroid Ca, ChorioCa

• Large metastases can outgrow their blood supply leading to central necrosis

Multiple lesions in otherwise normal liver

What is the diagnosis?A. MetastasesB. Multifocal fatty infiltrationC. Hepatic adenomatosisD. Indeterminate lesions

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Multifocal fatty infiltration

Non-FS T2wOpposed phaseIn phase

Case 5: 32-year-old with jaundice

What is the diagnosis?A. Biliary calculiB. Oriental cholangitisC. Primary sclerosing

cholangitisD. Blood clots

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Primary Sclerosing Cholangitis

• Unknown etiology but thought to be auto-immune

• 5% of all patients with UC have PSC• 75% of all patients with PSC will have UC• Men (70%)• Irregular narrowing with saccular dilatation

proximal to strictured ducts leads to beaded (beads-on-a-string) appearance of ducts

• Usually involves intra- and extrahepaticducts simultaneously

Recurrent Pyogenic (Oriental) Cholangitis

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• Oriental Cholangiohepatitis• Biliary sepsis and recurrent episodes of

bacterial cholangitis• Ascaris lumbricoides, Clonorchis sinensis,

Opisthorchis viverrini, Opisthorchis felineus, and Fasciola hepatica

• Imaging hallmark: Biliary obstruction from strictures and intraductal pigmented stones

• Hepatic Abscess +/-

Recurrent Pyogenic Cholangitis

Ascending Cholangitis

• Charcot’s triad: pain, jaundice and fever• Most common causes: impacted stone, neoplastic

obstruction and biliary strictures• Gold standard: ERCP• High mortality rate due to early septicaemia• Tx: emergent decompression with PTC

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Case 6: Young male with suspected nephrolithiasis

What is the diagnosis?A. Primary hemochromatosisB. Secondary hemochromatosisC. Thorotrast therapyD. Gold therapy

80 HU

• Increased attenuation >80HU• Enlarged or cirrhotic liver• Iron deposition: primary or secondary

(excessive oral intake or multiple blood transfusions) hemochromatosis

• Pancreas is involved in primary • Spleen is involved in secondary• Amiodarone therapy• Glycogen storage disease

Hyperdense Liver

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Primary Hemochromatosis

Case 7: Middle aged man with abdominal discomfort

What is the diagnosis?A. Infiltrative HCCB. Infarcted liverC. Budd-Chiari SyndromeD. Primary biliary cirrhosis

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• Acute: Acute thrombosis of the main hepatic veins or the IVC

• Chronic: Fibrosis of the intrahepatic veins• Inhomogeneous mottled liver • Peripheral zones of the liver may appear

hypoattenuating and show delayed enhancement

• Enlarged caudate lobe shows increased contrast enhancement compared with the remainder of the liver

Budd-Chiari Syndrome

Common Causes (Western Population)

• Idiopathic

• Post-hepatobiliary surgery

• Hypercoagulable state

• Infections, hepatic abscess, sepsis

• Malignancies: mets, HCC, RCC, lung, leukemia

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CO2 Venography during TIPSS

“Spider web” appearance (intrahepatic collateral veins)

Case 8: Elderly male with jaundice and weight loss

What is the diagnosis?A. Infiltrative HCCB. LymphomaC. CholangiocarcinomaD. Metastasis

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Hilar and Perihilar CholangioCa

• Delayed enhancement of hilar mass on delayed (10 minutes) imaging is classical and attributed to the presence of excessive fibrous stroma

• Non-union of the dilated right and left ducts sometimes the only sign

• MR: may have increased T2 signal on MR (due to mucin-producing/glandular components)

• Atrophy-hypertrophy complex: Atrophy of affected lobe (with intrahepatic duct dilation) and hypertrophy of the contralateral lobe

• Benign hilar strictures (PSC, post-operative)• Infiltrating carcinoma of the gallbladder• Portal lympadenopathy• Non-Hodgkin lymphoma• Metastasis

DDx

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Case 9: Elderly diabetic male with pain RUQ

What is the diagnosis?A. Emphysematous cholecystitisB. Hemorrhagic cholecystitisC. Perforated gall bladderD. GB carcinoma

Emphysematous Cholecystitis

• Acute infection of GB wall caused by gas-forming organisms

• Unlike other biliary tract disorders, most common in men (65-70%)

• Mostly 50 and 70 years of age and have underlying diabetes mellitus.

• Often insidious and one-third of patients may be afebrile

• CT is the most sensitive and specific imaging modality

• Treatment is emergent surgical intervention

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Case 10: 28-year-woman with increasingly severe episodes of RUQ pain and sepsis

What is the diagnosis?A. Multiple hepatic cystsB. Caroli’s diseaseC. Biliary hamartomaD. Primary sclerosing cholangitis

Caroli’s Disease• Type V choledochal cyst (Todani classification)• “Fibropolycystic disease”• Simple (large bile ducts) and periportal (both

the large bile ducts and smaller peripheral bile ducts) forms

• Simple type: RUQ pain and recurrent attacks of cholangitis with fever and jaundice

• Periportal type: portal hypertension and fibrosis• Central dot sign: dilated intrahepatic bile

ducts, representing portal radicles

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Choledochal Cysts

Choledochal “Cyst” Types

From Todani, et al, Ann Surg 1978

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Type-I

Type-II

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Type-III

Type-IV