肝、胆、胰、脾肝、胆、胰、脾LLiver, bile duct, pancreas and spleeniver, bile duct, pancreas and spleen

陈少琼（陈少琼（ Chen,Shaoqiong)Chen,Shaoqiong)

Technique and methodsTechnique and methods1.1. Liver angiographyLiver angiography

2.2. CT CT

3.3. MRI MRI

4. Contrast examination of the bile duct ：： OOral cholecystographyral cholecystography

IIntravenous cholecystocholangiographyntravenous cholecystocholangiography

Direct cholangiographyDirect cholangiography

TT-tube Cholangiography-tube Cholangiography

PTCPTC --------Percutancous transhepatic cholangiography --------Percutancous transhepatic cholangiography

ERCPERCP ------Endoscopic retrograde cholangiopancreatography ------Endoscopic retrograde cholangiopancreatography

Technique and methodsTechnique and methods

TT-tube -tube CholangiographyCholangiography

Technique and methodsTechnique and methods

PTC 造影

ERCPERCP

显示胆总管、肝总管及肝内胆管及胰管情况

CTCT1.1. CTCT plain scan ：： （（ 11 ）） Slice thickSlice thick ：： 10MM 10MM ，， 5MM5MM

（（ 22 ）） Region: cover the whole organRegion: cover the whole organ

2. 2. Enhancement scanning:: （（ 11 ）） Purpose ：： resolutionresolution ，， diagnosis. diagnosis.

vesselsvessels

（（ 22 ）） MethodsMethods ：： Arterial phaseArterial phase （（ 20-220-25”5” ），）， portal phaseportal phase （（ 60”60” ），）， delayed phdelayed phasease （（ 5-7’5-7’ ））

Imaging of the hepatic vessels

Artery

Portal vein

Hepatic vein

Hepatic vesselsHepatic vessels

Hepatic arteryHepatic artery ： ： Celiac trunk － － comcommon hepatic A.mon hepatic A. － － Proper

hepatic A － － Lt. and Rt. hepatic A.Lt. and Rt. hepatic A.

Portal vein ： ： left branch 、、 right branright bran

chch Hepatic vein ： leftleft 、、 intermediateintermediate 、、

rightright

Normal anatomy

Proper hepatic A

Gastro-duodenal A.

脾动脉 splenic artery

SMA superior mesenteric artery

门脉主干及其分支清晰显示。

门静脉 CE MRA

3ml/s

20mlGd-DTPA

门静脉 hepatic portal vein

Portal vein and hepatic veinPortal vein and hepatic vein

Hepatic vein

right intermediate left

肝右 V

Celiac trunk

Splenic artery

Common hepatic a.

Hepatic artery

Left branch of hepatic portal vein

Right branch of hepatic portal vein

Hepatic vein

Liver lobesLiver lobes

Lobes Lobes ：： Caudate lobe (S1S1)) ，， Left lobeLeft lobe（（ S2S2 、、 3)3) 、、 Quadrate Quadrate lobelobe （（ S4S4 ），）， Right lobeRight lobe （（ S5S5 、、 66 、、77 、、 88 ））

Liver lobesLiver lobes

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

Quadrate lobe

Left lobe

Caudate lobe

( 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

CTCT

4

8

7

2

2

4

8

7

2

4

8

7

1

2/34

8

7

1

1

34

8/5

7/6

34

5

6

1

34

5

6

5

6

5

6

MRMR

二、二、 MRIMRI1.MRI 1.MRI plain scan ：： SSequence————axialaxial、、 coronal coronal T1WT1W 、、 T2WT2W

FIESTAFIESTA 、、 DWIDWI 、、 double echodouble echo

2. MRI 2. MRI enhancement scanning

3. 3. MRMRAA

4.4. MRCPMRCP Magnetic Resonance Cholangiopancreatography

34

5

6

T2WI

34

5

6

T1WI

ERCP 正常胆道

Bile duct systemBile duct system

Intrahepatic bile duct

MRCP

Pancreas

CTCT

body of pancreas head of pancreas

splenic veinPortal vein

tail of pancreas body of pancreas

head of pancreas

MR T1WI

head of pancreas

T2 T2 FFAT SATAT SAT

胰腺 pancreatic duct

胰头胰头

head of pancreasPortal veingallbladder

23

47 8

6 5

冠状位

GB

78

6 56 5

7 8

6 5

肾上腺

M

76

SP

Disease of the liver

Hepatic cyst

CCongenital diseaseongenital diseaseCT SCANCT SCAN Delicate, round, smooth, thin-walled hypodense Delicate, round, smooth, thin-walled hypodense

lesionlesion Homogeneous,waterdensity(0-15HU)Homogeneous,waterdensity(0-15HU) No enhancement No enhancement MR MR Very low signal intensity on T1WI and very high Very low signal intensity on T1WI and very high

intensity on T2WIintensity on T2WI

CT Appearance Hepatic Cyst

-C venous phase

arterial phase

CT Appearance Hepatic Cyst

Polycystic disease

MR appearance Hepatic cyst

Pyogenic abscess － bacterium or Amoeba

Hepatic AbscessHepatic Abscess

Plain Radiography Plain Radiography

CT Appearance of hepatic abscessCT Appearance of hepatic abscess Hypodense –hyperdenHypodense –hyperdensse –hypodense e –hypodense

necrosis membrane edemanecrosis membrane edema

20-40HU20-40HU

Gas or fluid levelGas or fluid level

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

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

MR Appearance of abscessMR Appearance of abscess

low signal intensity on T1WI and high low signal intensity on T1WI and high intensity on T2WIintensity on T2WI---inside cavity---inside cavity

Intensity is decreased than the center in the Intensity is decreased than the center in the wallwall

肝脓肿

肝右叶两个不规则形异常信号

区， T1WI 脓肿壁信号高于脓腔、

低于正常肝， T2WI 反之。增强扫

描：脓肿壁环形强化，轮廓不光滑，边缘不整

平扫 T1WI

平扫 T2WI

静脉期septum

Common hepatic tumorsCommon hepatic tumors Benign tumor

Cavernous hemangioma

Hepatocellular adenoma

Hamartoma

FFocal nodular hyperplasia （（ FNHFNH ）） Malignant tumour

HHepatocellular carcinoma epatocellular carcinoma

Cholangiocellular carcinoma

Liver metastasis

Hemangiomas of liver

Hemangiomas is the most common benign tumor of the liver-- Cavernous hemangioma

CT appearance of hemangiomas

A. A. Plain scan 11 、、 Low density ，， CT CT vvalue-about alue-about 30HU30HU 22 、、 Homogeneous Homogeneous (In(Inhomogeneoushomogeneous-centrally lower -centrally lower

density in large tumor, Ca or hemorrage) density in large tumor, Ca or hemorrage) B. B. Enhancement scanning

　 　 11 、、 rapidly enhancerapidly enhance

22 、、 filling in centripetally to become filling in centripetally to become isodensity with the adjacent parenchymaisodensity with the adjacent parenchyma

33 、、 The time for complete in-filling has The time for complete in-filling has been been ：　：　　　　 　

>>33’’、、 usually usually 77 ～～ 1515’’、、 most long most long 2020 ～～ 6060’’

Plain scanPlain scanPlain scanPlain scan

PPortal phaseortal phase DDelayed phaseelayed phasePPortal phaseortal phase DDelayed phaseelayed phase

Arterial phaseArterial phase

Plain ScanPlain ScanPlain ScanPlain Scan

EEnhancementnhancementEEnhancementnhancement

Delayed scanDelayed scan

MRI MRI aappearanceppearance 1.1. Round, Clear marginRound, Clear margin

2.2.IntensityIntensity －－ Hypointense on Hypointense on T1WIT1WI、、 Hyperintense on Hyperintense on T2WIT2WI ，， longlongTETE（（≥≥ 120ms120ms）） long T2 valuelong T2 value““lamp bulb”,”,homogeneouslyhomogeneously

InhomogeneousInhomogeneous caused by thrombosis caused by thrombosis and scar in the centerand scar in the center

3. 3. Enhancement scanning

Cavernous hemangioma

Hepatocellular carcinomaHepatocellular carcinoma

Hepatocellular carcinomaHepatocellular carcinoma (HCC (HCC)) VViral iral hepatitidehepatitide infection ( infection (hepatitis Bhepatitis B or or CC) ) CCiirrhosisrrhosis ( (alcoholismalcoholism))

CTCT

On CT, HCC can have three distinct patterns On CT, HCC can have three distinct patterns of growth:of growth:

Massive typeMassive type------A single large tumor A single large tumor ≥≥ 5cm 5cm NNodular typeodular type------ Multiple tumors Multiple tumors<5cm<5cm DDiffuse typeiffuse type ------Poorly defined tumor with an iPoorly defined tumor with an i

nfiltrative growth pattern nfiltrative growth pattern SSmall hepatocellular carcinomamall hepatocellular carcinoma<3cm<3cm

Key pointsKey points

The key characteristics on CT are hypervasThe key characteristics on CT are hypervascularity in the arterial phase scans, washout cularity in the arterial phase scans, washout or de-enhancement in the portal and delayeor de-enhancement in the portal and delayed phase studies, a pseudocapsule and a mod phase studies, a pseudocapsule and a mosaic pattern. Both calcifications and intralesisaic pattern. Both calcifications and intralesional fat may be appreciated.onal fat may be appreciated.

Important features that guide Important features that guide treatment include:treatment include:

size size spread (spread (stagestage) ) involvement of liver vessels involvement of liver vessels and bile ductand bile duct presence of a tumor capsule presence of a tumor capsule presence of extrahepatic metastases presence of extrahepatic metastases presence of daughter nodules presence of daughter nodules vascularity of the tumor vascularity of the tumor

CT appearance of HCCCT appearance of HCC

Shape and marginShape and margin (1) (1) Regular or irregularRegular or irregular (2)(2) Clear margin Clear margin——pseudo-capsulepseudo-capsule

(3) (3) iill-definedll-defined marginmargin——infiltrating infiltrating

growinggrowing

CT appearance of HCCCT appearance of HCC

DensityDensity （（ 11 ）） hypodensehypodense （（ commoncommon ））

（（ 22 ）） isodense or isodense or hyperdensehyperdense （（ rarerare ））

（（ 33 ）） mixed densitymixed density （（ hemorrage, hemorrage, necrosis, calcification and fatty degenerationnecrosis, calcification and fatty degeneration ））

低密度低密度低密度低密度 高密度高密度高密度高密度

稍低密度稍低密度稍低密度稍低密度 混杂密度混杂密度混杂密度混杂密度

CT appearance of HCCCT appearance of HCC

CT enhancementCT enhancement

Blood supplyBlood supply

11 ）） normal tissuenormal tissue ：： 25% 25% ffrom hepatic rom hepatic arteryartery

75%75% from portal vein from portal vein22 ）） HCCHCC ： ： 90% 90% ffrom hepatic arteryrom hepatic artery 10% 10% from portal veinfrom portal vein

EnhancementEnhancement hypervascularity in the arterial phase scans, washout hypervascularity in the arterial phase scans, washout

or de-enhancement in the portal and delayed phaseor de-enhancement in the portal and delayed phase

CT appearance of HCCCT appearance of HCC

巨块型肝癌、肝内子灶、IVC

癌

栓

CT appearance of HCCCT appearance of HCC

Massive type

肝硬化合并原发性结节型肝癌 nodular type

CT appearance of HCCCT appearance of HCC

CT appearance of HCCCT appearance of HCC

原发型肝细胞癌合并门静脉、下腔静脉癌栓

Diffuse type

IVC

MR appearance of HCCMR appearance of HCC

Low signal intensity on T1WI and high Low signal intensity on T1WI and high intensity on T2WIintensity on T2WI

Low signal capsule on T1WILow signal capsule on T1WI

MR appearance of HCCMR appearance of HCC

time

CT Value

HCC

Hemangioma

CT-HCT-Hepatic metastasisepatic metastasis

Hypodense lesion, round, multiple Hypodense lesion, round, multiple Central necrosis and rim enhancementCentral necrosis and rim enhancement bull's-eye configuration

CT-HCT-Hepatic metastasisepatic metastasis

CT-HCT-Hepatic metastasisepatic metastasis

– CholesterolCholesterol stones stones, , Pigment stonesPigment stones, , Mixed stoMixed sto

nesnes

– 2020 ～～ 3030% of gallstones are radio-opaque% of gallstones are radio-opaque

CCholelithiasisholelithiasis

• X-ray ： Radio-opaque stones, round or irregularRadio-opaque stones, round or irregular

• Cholecystography: Filling defect• CT ： Ringlike calcification, CT value -60 ～ 140HU• MR ： Hypointense

------ Complicating with cholangiectasis and cholangitis

CCholelithiasis-radiologic findingsholelithiasis-radiologic findings

CCholelithiasisholelithiasis

平 片

CCholelithiasisholelithiasis

CCholelithiasisholelithiasis

Cholecystography----radioparent calculus

CCholelithiasisholelithiasis

TT-tube -tube CholangiographyCholangiography

CCholelithiasisholelithiasis

PTC 造影

CTCT

cholecystolithiasis

CCholelithiasisholelithiasis

CCholelithiasisholelithiasis

cholecystographyCT 检查

CCholelithiasisholelithiasis

CCholelithiasisholelithiasis

MRCP

Imaging findingsImaging findings ：：– CTCT ：：

Thickening of the wallThickening of the wall>>33 mmmm Acute stageAcute stage ：： edema edema Chronic stageChronic stage ：： shrink,shrink,calcification of the

wall cholelithiasis

Cholecystitis

cholecystitis

Chronic cholecystitis ： shrink of the gallbladder and thickening wall

CalcificationCalcification

Pancreatitis

Acute pancreatitisAcute pancreatitis Excessive swelling of the pancreas, Excessive swelling of the pancreas,

surrounded by isodense or slightly surrounded by isodense or slightly hypodense exudative zones.hypodense exudative zones.

Perirenal fasciae are visible and thickenedPerirenal fasciae are visible and thickened Hemorrhagic and necrosis Hemorrhagic and necrosis

Acute pancreatitisAcute pancreatitis

Excessive swelling of the pancreas

Acute pancreatitisAcute pancreatitis

Acute Acute pancreatitispancreatitis

Chronic Pancreatitis

Calcification Calcification Pancreatic atrophy or swellingPancreatic atrophy or swelling Dilatation of the pancreatic duct Dilatation of the pancreatic duct Pseudocysts 30%Pseudocysts 30%

PseudocystsPseudocysts

Chronic Pancreatitis

慢性胰腺炎慢性胰腺炎– 胰管串珠样增粗胰管串珠样增粗– 合并胆总管结石合并胆总管结石– 慢性胆囊炎慢性胆囊炎

Chronic Pancreatitis

Chronic Pancreatitis

CalcificationCalcification

临床与病理临床与病理– 上段上段胆管占胆管占 5050 ％以上％以上– 早期出现早期出现胆道梗阻症状胆道梗阻症状– 分型：浸润型、结节型、乳头型分型：浸润型、结节型、乳头型

肝胆胰脾肝胆胰脾 ------ 胆管癌胆管癌

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

肝胆胰脾肝胆胰脾 ------ 胆管癌胆管癌

肝胆胰脾肝胆胰脾 ------ 胆管癌胆管癌

肝胆胰脾肝胆胰脾 ------ 胆管癌胆管癌