GALLBLADDER portions of the duodenum are labeled in

white.
 functions as a reservoir for bile produced
by the liver. It is 7-10 cm long, 3 cm wide
at its broadest measure, and has a
capacity of 30-50 mL
 at the head of the pancreas, the common
bile duct meets the pancreatic duct, and
they exit into the second part of the
duodenum, forming the hepatopancreatic
ampulla (ampulla of Vater)

 divided into 3 regions: fundus, body, and

neck

 bile produced by the left and right portions

of the liver travel through the right and
left hepatic ducts (1-2 mm in diameter).
These two ducts join to form the common
hepatic duct
 the common hepatic duct lies anterior to
the portal vein and to the right of hepatic
artery
 the common hepatic duct descends
roughly 3 cm before the cystic duct (3-4
cm long) from the gallbladder joins it from
the right

 the common bile duct passes posterior to
the first portion of the duodenum. It then
descends via a groove on the
superolateral portions of the posterior
head of the pancreas sometimes traveling
through the pancreas head. The four
Adenomyomatosis
 one of the many causes for gallbladder
wall thickening
 pathologically, it is identified by
proliferation of the gallbladder mucosa
with diverticular outpuochings known as
Rokitansky-Aschoff sinuses
 typically cholesterol deposits are seen
within the gallbladder wall and cause a
comet tail artifact
Causes of GB wall thickening
 biliary causes include:
-acute cholecystitis, gall bladder
carcinoma, polyps, as well as adenomyomatosis
  nonbiliary causes include:
-CHF, hepatitis, pancreatitis as well as
AIDs cholangiopathy
Acute Acalculous Cholecystitis
 represents inflammation of the gallbladder
in the absence of demonstrated calculi
 the disease process is distinct from the
calculous variety, in which the primary
initiating event is believed to be
obstruction of the cystic duct
 typically occurs as a secondary event in
patients who are hospitalized and acutely
ill from another cause
Pathophysiology
 at least 3 mechanisms
a. systemic mediators of inflammation and
trauma
b. biliary stasis
c. generalized or localized ischemia
 in turn, the mechanisms often result in
functional or secondary mechanical
obstruction of the cystic duct from
inflammation and bile viscosity
Sonographic signs compatible with acalculous
cholecystitis
 gallbladder wall thickening
 sonographically localized tenderness over
the GB
 subserosal edema
 pericholecystic fluid
 gallbladder distention
 biliary sludge
 presence of gas
CT findings
 gallbladder wall thickening
 mucosal irregularity
 luminal distention
 increased bile density (biliary sludge)
 intramural or intraluminal gas
 intraluminal hemorrhage
 localized pericholecystic fluid collections
 inflammatory infiltration of pericholecystic
fat
 indistinctiveness of the liver-gallbladder
interface
Acute Cholecystitis
 sonographic criteria for acute cholecystitis
-a thickened gallbladder wall (normal GB
wall- <3 mm)
 other sonographic findings
-gallstones
-positive Murphy’s sign
-pericholecystic fluid as well as
sonolucencies within the gallbladder wall
(indicates gallbladder wall edema)
Complications
 empyema
 gangrene
 perforation
Epigastric Pain
Chronic Cholecystitis with GB polyps
 chronic inflammation of the gallbladder
results from recurrent attacks of acute
cholecystitis
 fibrotic reaction usually causes the
gallbladder to become small and
contracted
Diffuse Wall Thickening
  most frequent gallbladder wall
abnormality detected by ultrasound
 the wall is >3mm thick
 this appearance is neither sensitive nor
specific for an inflammatory process
Case
-patient is a 72-year old woman who presents
with nausea and vomiting
Porcelain Gallbladder
 has been termed calcifying cholecystitis,
cholecystopathia chronic calcaria, or
calcified gallbladder
 are 5 times more common in women than
in men
 most often considered a sequel of low-
grade chronic inflammation
 some have postulated that it is secondary
to intramural hemorrhage or an imbalance
in calcium metabolism
Cholelithiasis
 is the pathologic state of stones or calculi
within the gallbladder lumen
 75-80% of gallstones are of the cholesterol
type
 10-25% of gallstones are bilirubinate of
either black or brown pigment
 in Asia, pigmented stones predominate,
although recent studies have shown an
increase in cholesterol stones in the Far
East
Complications
 biliary colic- 56 %
 acute cholecystitis- 36 %
 acute pancreatitis- 4 %
 choledocholithiasis- 3 %
 gall bladder cancer- 0.3 %
 cholangitis- 0.2 %
Gall Stones
 appear as single or multiple filling defects
within the gallbladder and are densely
calcified, rim calcified, laminated, or have
a central nidus of calcification

 stones also may present as a soft-tissue
density or a lucent filling defect within the
bile. Some stones may contain air
 most gallstones have no signal on MRI and
present as signal void-filling defects within
the gallbladder
 on T2-weighted sequences where signal-
void stones are contrasted against high-
signal bile
 on T1 weighted sequences, bile usually
shows a homogenous low signal
 signal-void stones also may be apparent
on T1-weighted images
 high signal may be seen occasionally on
T2-weighted images within stones that
contain bile within clefts
 stones with high fatty acid content may
demonstrate high signal on T1-weighted
images
Porcelain gallbladder along with
distention and filled with sludge and
calculi
 associated with chronic gallbladder
inflammation and gall stones in 95 % of
cases
 it appears as an echogenic arc with dense
posterior shadowing
Carcinoma of the Gallbladder
 the most common primary hepatobiliary
carcinoma
 the fifth most common malignancy of the
GI tract
 predominantly affects older persons with
long-standing cholecystolithiasis
 GB epithelial tumors tend to behave
similarly to other GI adenocarcinomas
 GB tumors occur in the fundus in 60 % of
patients, in the body in 30 %, and neck 10
%
 early lymphatic spread occurs to the
retroperitoneal, right celiac, and
pancreaticoduodenal nodes
 direct invasion of the liver, extrahepatic
biliary ducts, and duodenum, and colon
occurs
 intraperitoneal seeding may occur
Ultrasound findings
 GB wall thickening
 single or multiple intraluminal mass
 extraluminal mass extending to the liver
 polyps larger than 1 cm in diameter
Extraluminal mass extending to the liver
 this often is accompanied by a large mass
replacing the GB fossa
 the mass often is complex with areas of
necrosis visible
 this is the most common manifestation of
GB carcinoma, accounting for 40-65 % of
GB carcinomas
 US shows echogenic mass adherent to
gallbladder fundus (arrows). CT shows
enhancing mass within the gallbladder
(arrows) with involvement of the liver
(arrow head)
 3-Left inferior lateral subsegment
4a-Left superior medial subsegment
4b-Left inferior medial subsegment
5-Right inferior anterior subsegment
6-Right inferior posterior subsegment
7-Right superior posterior subsegment
8-Right superior anterior subsegment

Bacterial (Pyogenic) Abscess

 80-85 % of all abscesses are bacterial in
origin
 bacteria gain access to liver via the portal
LIVER or biliary system. Possible causes are
iatrogenic, biliary disease, diverticular
disease, trauma, and inflammatory bowel
disease
 E. coli and anaerobes are the two most
common offending agents in pyogenic
abscess
 most pyogenic abscesses occur in the
right lobe

Radiogrpahic Findings (US)

 unique in having a dual blood supply
- 75 % originating from the portal venous
system and
-25 % arising from the hepatic artery
 the hepatic veins are responsible for
drainage of filtered blood from the liver
into the IVC
 heterogenous, rounded masses with
irregular, thickened walls and poor
peripheral definition
 fluid and debris inside the abscess can
create internal echoes
 gas-containing lesion also has acoustic
shadowing
CT

3 Functional Lobes
 right
 left
 caudate

 the right and left lobes are further divided

into 2 segments each:
-the anterior and posterior
segments of the right lobe
-the medial and lateral segments of  heterogenous lesion with irregular margin
the left lobe (arrowhead) and possible peripheral
enhancement
Segments  internal septations or papillary projections
 20 % contain gas

Amebic Abscess
 trnasmitted by fecal-oral route
 the organism, E. histolytica, first infects
the colon, then gains access to the liver
via portal venous system
 patients generally present with right upper
quadrant pain

Radiographic Findings (US & CT)

1-Caudate lobe  indistinguishable from bacterial abscess.
2-Left superior lateral subsegment Tends to be peripheral in location
 Diffuse Hepatic Disease
CT Findings
Cirrhosis

Causes
 alcohol
 alpha 1-antitrypsin
 postnecrotic (hepatitis)
 metabolic disease: Wilson,
hemochromatosis, glycogen storage
disease
 congestive heart failure

Pathology
 hepatocyte necrosis
 fibrosis
 nodular regeneration

Radiographic Findings

Signsof advanced necrosis

 generally non specific including:  liver surface nodularity
 a peripherally based, round or oval low  contracted liver with ascites
density lesion which often demonstrates a
 atrophy of the posterior segments (VI, VII)
peripheral rim of slightly higher of the right lobe
attenuation
 enlarged caudate lobe (I) and lateral
 the peripheral rim will often enhance with segments (II, III) of the left lobe
contrast administration
 prominent umbilical vein
 irregular enhancement
Echinococcal Abscess
 dogs are the main intermediate hosts of
hydatid disease
 eggs get ingested, hatch in the stomach
and duodenum, travel to the liver via
portal venous drainage, encyst in the liver
and grow slowly
 the cysts can exert mass effect on the
surrounding liver and biliary system. The
right lobe of the liver is most frequently
involved
 the cysts can rupture into the pleural  US- advanced cirrhotic liver appears to be
cavity, peritoneal cavity, alimentary canal, nodular, irregular, and contracted with
or biliary tree, causing profound shock, relatively enlarged caudate lobe (C) and
peritonitis, and anaphylaxis lateral segment (L) of the left lobe. Fatty
infiltration and fibrosis give a coarse
Radiographic Findings (US) echotexture of the liver parenchyma

 double-layered cyst, “classic” double-line

sign, water lily sign, racemose
 Diffuse Fatty Infiltration
 Contrast CT: areas of fibrosis and
 a reversible process in which triglyceride
regeneration may become isodense to
accumulates diffusely in hepatocytes
parenchyma. The surface of the liver may
causing abnormal appearance on imaging
be very nodular in cirrhosis
 normally, less than 5 % of the liver is
composed of fat. In diffuse fatty infiltrated
liver, fat can make up to 50 % of the liver
tissue
 commonly seen in acute or chronic alcohol
abuse (most common), obesity, diabetes,
cystic fibrosis, tetracycline, steroids,
chemotherapy, malnutrition, and
hyperalimentation
 clinically, patients are asymptomatic. Liver
can be enlarged but without splenomegaly

 development of collateral vessels in portal Radiographic Findings (US)

hypertension
 splenomegaly and the presence of ascites

 the liver has increased focal or diffuse

echogenicity when compared to the
surrounding organs such as the kidneys

 Noncontrast CT- the liver looks hypodense

to the spleen due to fatty infiltration,
making the hepatic vasculature more
prominent

Hemochromatosis
  iron overload leads to deposition in the
liver. The liver can be enlarged
 primary hemochromatosis: an autosomal
recessive disease that has abnormal
absorption of iron in the intestine and thus
causes iron to be deposited in
hepatocytes, spleen, pancreas, and the
myocardium
 secondary hemochromatosis: caused by
multiple transfusions with deposition of
iron in the reticuloendothelial cells of the
liver and the spleen. However, the
pancreas is not usually involved. If the
pancreas is involved, the
hemochromatosis is usually of the primary
type
idiopathic, usually asymptomatic and
variable in size. They cannot be
distinguished from cysts that arise from
prior hematomas or abscesses
 they can be associated with other disease
processes such as tuberous sclerosis and
polycystic kidney disease
 40 % of patients with polycystic kidney
diseae have liver cysts
 60 % of patients with multiple liver cysts
have polycystic kidney disease
Radiographic Findings

US (95-99 % accurate)
 anechoic
 posterior enhancement (increased
transmitted sound)
 well-defined or imperceptible walls
 CT: hyperdense liver (>75 HU). There are
similar findings in Wilson’s disease,
amiodarone toxicity, and previous
thorotrast exposure

 Non-contrast CT: density of less than 20

HU, well-defined margins, no perceptible
wall (arrow)
 T1 and T2 weighted MRI: liver and spleen
are hyperintense (very dark liver)  Contrast CT: no enhancement after
compared with adjacent muscles owing to contrast administration
paramagnetic effect. Normally, the signal
intensity of the liver parenchyma is equal MRI
to or slightly greater than that of muscle

Simple Cysts
 the most common liver masses
 may be solitary or multiple
 cysts are found in 2-10 % of population,
has increased frequency with age and is
more common in females aged 50-70
 true hepatic cysts have bile duct origin
and cuboidal epithelial lining. They are
  US: hyperechoic and well-defined
 T1 weighted- homogeneously hypointense
(arrowhead)

 T2 weighted- homogeneously
hyperintense (arrow) due to water
property (comparable to the intensity of
CSF or gallbladder bile

Differential Diagnosis
 cystic liver mass with internal echoes,
thick septations, or a perceptible wall  T1 weighted MRI- hypointense to liver
noted on US include (arrows). If gadolinium-diethylenetriamine
-hemorrhagic cyst penta-acetic acid (Gd-DTPA) is used,
-abscess peripheral enhancement is seen initially
-echinococcal cyst with central enhancement within 15-30
-biliary cystadenoma minutes. Enhancement is persistent
-cystic metastasis (e.g. ovarian)
-HCC with necrosis

Hemangioma
 is a benign proliferation of vascular tissue
lined with endothelium which has slow
hepatic arterial blood flow
 two types are capillary (more common)
and cavernous
 occurs in the right lobe
 can easily be confused with metastases or  T2-weighted MRI- hyperinetense to the
hepatoma liver (just like a cyst; arrows). Looks as
bright as a light bulb! Intensity is as high
 the most common cause of a hyperechoic
as that of pure fluid (CSF or bile)
liver mass on US
 large hemangioma may appear
heterogenous. There may be thrombosis
Focal Nodular Hyperplasia
or a central stellate scar with a giant  most likely seen in young women (3 %)
hemangioma
Pathology
 a non-capsulated nodular mass
 was thought to be a
vascular/hamartomatous malformation
 is composed of normal hepatocytes,
Kupffer cells, and bile ducts but arranged
abnormally
 is less than 5 cm in diameter, most
commonly found peripherally in the right
lobe
 classic appearance: solitary, well-
circumscibed mass with a central stellate
scar of fibrosis even though the central
scar is seen in only 20 % of the cases

Hepatocellular Carcinoma (HCC)

• the most common primary hepatic tumor

 Non-contrast- the lesion has low
attenuation (arrows) compared with the
normal liver. The central stellate scar may
also show low attenuation
3 Growth Patterns of HCC
 Contrast CT: the lesion shows homogenous
enhancement early in arterial phase
(arrows) with prompt wash out. The
central stellate scar will not enhance.
and
• one of the most common cancers
worldwide
• a primary malignancy of hepatocyte origin
• Solitary mass – often large
• Multifocal or Nodular Pattern – multiple
nodules
• Diffuse – multiple, small foci scattered
diffusely throughout liver

US Findings

• Small HCCs can be homogenously

hyperechoic and can mimic hemangioma.
This can result when a large proportion of
fat is present in the tumor
• Small HCCs can appear hypoehcoic with
larger HCCs frequency mixed in
echogenicity.

 T1-weighted MRI: The lesion is hypo-

isointense to the normal liver. The central
scar enhances with Gd-DTPA.

 T2-weighted MRI: The lesion is isointense

to slightly hyperintense to liver. The
central scar is hyperintense to the liver
(arrows). (In contrast to hypointense
appearance of the central scar in large
hemangioma)

In the Portal Venous Phases

• Small lesions may be isodense or

hypodense and difficult to see, since the
remainder of the liver increases in
attenuation.
 • Larger lesions with necrotic regions remain
hypodense.
Contrast CT: dense diffuse non-uniform
enhancement in arterial phase; some lesions are
hypervascular
MRI
• T1-weighted: usually hypointense to
normal liver. When fatty change, fibrosis,
or copper is present, variable signal can
be seen.
• With Gd-DTPA, hypervascular lesions
enhance early in the arterial phase.
Liver Metastasis
• The liver is the most commonly involved
organ by metastatic disease, after the
lymph nodes.
• The most common primary sites are the
eye, colon, stomach, pancreas, breast and
lung.
• In children the most common liver
metastases are from a neuroblastoma,
Wilm’s tumor or leukemia.
Causes of Echogenic Metastases
• Mucinous adenocarcinoma of the colon,
Pancreatic carcinoma (usually hypoechoic
but possibly becoming echogenic as
calcification occurs), Gastric carcinoma
(usually hypoechoic), HCC,
Neuroblastoma, Cholangiocarcinoma,
Treated Breast Carcinoma, Renal cell
Carcinoma, Carcinoid, Choriocarcinoma,
Pancreatic Islet Cell tumors, Wilm’s Tumor
(usually spread to the lungs), Kaposi
sarcoma, Myeloma deposit, Hepatic
chloroma
Causes of Hypoechoic Metastases
• Lymphoma (especially AIDS related), HCC,
Pancreatic carcinoma, Lung (particularly
adenocarcinoma), Cervix, Melanoma,
Nasopharyngeal carcinoma, Kaposi
sarcoma (rare, most are hyperechoic),
Myeloma deposits, Cystic liver
metastases, Mucinous
cystadenocarcinoma colon,
Cystadenocarcinoma ovary.
Cystadenocarcinoma pancreas,
Leiomyosarcoma, Squamous cell
carcinoma, Testicular CA, Carcinoid,
Graunulosa cell ovarian tumor.
Cystic metastases
Two groups of patients tend to get cystic
metastases:

(1) Patients who have a primary neoplasm

with a cystic component such as a
mucinous cystadenocarcinoma of the
colon, stomach, pancreas, or ovary and,
(2) Patients with metastases that are
undergoing central necrosis, when low-
level echoes and wall irregularity is seen.
Squamous cell carcinoma,
leiomyosarcoma, melanoma, and Portal Vein Thrombosis
testicular carcinoma, have a propensity to
undergo extensive central necrosis. Five causes of portal vein thrombosis:
Causes of Bull’s Eye or Target, Metastases 1. Pancreatitis
2. Cirrhosis
• The halo is most probably related 3. Hepatic or biliary surgery
to a combination of compressed 4. Hepatoma with tumor thrombus
normal hepatic parenchyma around 5. Hypercoagulable states
the mass and a zone of cancer cell
proliferation CT: example of carcinoma in the hepatic vein
• The presence of a halo usually
suggests aggressive behavior
• Bronchogenic carcinoma
• Breast and colon as well as
• Primary malignant liver neoplasms
(eg. HCC) and
• Benign liver neoplasms (eg.
Adenoma in glycogen storage
disease)

Causes of heterogeneously Echogenic Liver

Metastases

• Breast, colon and/or rectum, stomach

(especially anaplastic lesions) and cervix
• Other causes of heterogeneously liver
metastases include the ff: HCC (especially
when complicated with hemorrhage),
carcinoid, melanoma, and bronchogenic
carcinoma.
PANCREAS
Acute Pancreatitis
• Common cause of pancreatitis include
alcohol abuse, choledolithiasis,
hypergylceridemia and hypercalcemia.
Acute pancreatitis usually presents as an
acute episode of upper abdominal pain,
with or without accompanying GI
symptoms.

• Other symptoms may include fever,

hypotension, pulmonary edema or shock.
Laboratory values reveal elevated WBC,
serum amylase and pancreatic lipase.
Initial treatment of pancreatitis includes
NPO, NG suction, analgesics, parenteral or
jejunal feeding. Prophylactic antibiotics
may also be of benefit.
Ranson’s score estimates the life threatening associated with associated with
complications or death in patients with acute pancreatic fat acute pancreatitis
pancreatitis using several factors at the time of infiltration
admission and during the first 48 hours
thereafter. Grad Single fluid
eD collection
Ranson’s Score
Grad Two or more fluid
Values at Admission First 48 Hours eE collections.

Age>55 Hct fall >10%

WBC >16,000/ml Ca >8mEq/L

Glucose >200mg/dl BUN rise > 5mg/dl

LDH>350 U/L PaO2 < 60mmHg

AST > 250 U/L Base defect > 4 mEq/L

Fluid sequestration > Nausea, vomiting with abdominal pain that

6L radiates to the back

Number of Criteria Mortality

0-2 <5%

3-4 15-20%

5-6 40%
Acute Necrotizing Pancreatitis
≥7 >99%
• Pancreatic necrosis is a known
complication of acute pancreatitis.
• Areas of necrosis are usually multifocal
Balthazar et al developed a classification system and rarely involve the entire gland.
for patients with acute pancreatitis based on • Necrosis develops earl in severe
radiologic findings pancreatitis and is usually established
within 96 hours of the onset of clinical
symptoms.

Balthazar et al Radiographic Grading of

Acute Pancreatitis

G Radiographic Prognosis
rade Findings

Grad Normal appearing

eA pancreas
Pancreatic Pseudocysts
Grad Focal or diffuse Mild,
eB enlargement of the uncomplicated • The most common cystic lesions of the
pancreas accounting for 75-80% of such
pancreas course
masses
Grad Pancreatic gland High risk of • A collection of amylase-rich, lipase-rich,
eC abnormalities complications and enterokinase-rich fluid
 • Most frequently located in the lesser
peritoneal sac in proximity to the pancreas
• Large pseudocysts can extend to the
paracolic gutters; pelvis; mediastinum
• Some are loculated
Most Common Etiologies
• Chronic pancreatitis
• Acute pancreatitis and
• Pancreatic trauma
• In addition, pseudocysts are associated
with pancreatic ductal obstruction and
pancreatic neoplasms
US Findings
• An anechoic structures associated with
acoustic enhancement
• Well defined and round or oval, and they
are contained within a smooth wall
• During the early phases, the more
complex, with varying degrees of internal
echoes
• Usually, this appearance results from the
presence of necrotic pancreatic and
peripancreatic debris and is more common
in pseudocysts that form as a result of
acute necrotizing pancreatitis than in
others. The debris is cleared over time.
• The pseudocysts can appear more
complex in 2 other instances: when
hemorrhage occurs in the cyst or when
infection of the cyst complicates the
clinical course
• Color Doppler or duplex scanning should
always be performed in cystic lesions to
ensure that the lesion in question is not a
giant pseudoaneurysm
• Abdominal CT is an excellent choice for
imaging acute fluid collections and
pancreatic pseudocysts
• CT characteristics of an acute fluid
collection include low attenuation and a
homogenous appearance
• CT attenuation values may measure
greater than 20-30 HU because of the
presence of necrotic pancreatic or
peripancreatic debris or blood within the
confines of the acute fluid collection.
Pancreatic Cancer
• The findings of an invasive hypodense
mass in the had of the pancreas which
involves the SMV and SMA along with
enlarged lymph nodes are most
suggestive of pancreatic CA
• The 5th most common cause of cancer
deaths
• It is approximately twice as common in
males compared to females
• Patients are usually greater than 50
years old
• Greater than 90% of pancreatic
cancers are ductal adenocarcinoma
and its variants
• Most of the remaining 5-10% are islet
cell tumors
• Arises in the head of the pancreas 70%
of the time, in the body 20%, and in
the tail 10%.
• Abdominal pain and weight loss are
present in greater than 75% of
patients with pancreatic cancer, and
jaundice is present in greater than
80% of patients with pancreatic heat
tumors secondary to biliary obstruction
CT
• The best modality for imaging the
pancreas
• A mass deforming the size and contour of
the pancreas is the most common finding
for ductal cell carcinomas occurring in
96% of the cases
• A central zone of decreased attenuation is
present in 83% of pancreatic head and
60% of pancreatic body carcinomas
• CT can be used for staging purposes with
the findings of the retroperitoneal
extension, major vascular involvement,
invasion of contiguous organs, ascites, LN
and distant metastases suggesting
unresectability.
Adenocarcinoma
• The fourth most common cancer
• The prognosis of the disease is poor and
very few patients survive longer than one
year
• Major role of imaging once the primary
diagnosis has been made is to “stage” the
disease to determine operability
• The loss of the fat plane indicates
encasement of the artery making the
patient uncurable
CT Findings of Pancreatic CA
• Alteration in the morphology of the gland
with abnormalities of CT attenuation
values
• Obliteration of peripancreatic fat
• Loss of sharp margins with surrounding
structures
• Involvement of adjacent vessels and
regional lymph nodes
• Pancreatic ductal dilatation
• Pancreatic atrophy and,
• Obstruction of the common bile duct
(CBD)
Mucinous Cystic Neoplasm
US Features
Mucinous Cystic Tumors
• So called macrocystic cystadenomas or,
cystadenocarcinomas.
• Predominate in the body and tail of
pancreas, have a strong female
predilection
• Most common of cystic pancreatic tumors,
accounting for 45-50% of tumors
• Multiloculated tumors with a characteristic
smooth glistening surface
• Arise from oversecretion of the mucus of
the hyperplastic columnar lining of the
ducts. The cysts contain thickened viscous
material, which can also be hemorrhagic
• Nonenhanced CT scans show a well-
defined unilocular or multilocular,
externally smooth, round-to-ovoid mass
with fluid attenuation
• The attenuation values of the multilocular
cysts vary according to the degree of
hemorrhage or protein in the mucoid cysts
• Larger cysts may demonstrate small
daughter cysts along its internal surface.
Typically, they show a well defined,
multilocular cystic mass with thick internal
mass septae separating the separating the
different cystic cavities of varying sizes.
The cysts are 2-26cm.
• Visualization of the nodule with irregular
borders of the septae and calcification
which is curvilinear or punctate and
confined to the cyst wall or septa
• CECT show enhancement of the cyst wall,
internal septations, mural nodules, and
other intracavitary projections
• CT may also allow the identification of
solid components associated with cystic
elements, which are features of borderline
or malignant tumors but not benign
variants. MCN’s develop predominantly in
the tail of the pancreas (>90%)
• CT more clearly demonstrates
enhancement of the cystic walls and septa
• Usually larger than 5cm
• The walls are composed of thick, fibrous
stroma sometimes containing dystrophic
calcification
• A large cystic mass sometimes with
numerous septa and debris
• The tumor may be 2-23cm, and they
usually have sharply marginated walls and
smooth borders
• Typically show a multilocular, fluid-
containing mass with good transmission
and strong acoustic enhancement
• Compared with serous cystic tumors, the
cysts in MCNs are larger (>20mm in
diameter) and less numerous (usually
<6). CT-guided aspiration of the cyst can
provide further diagnostic clues and
enable their differentiation from other
pancreatic cystic masses (eg, pseudocyst,
serous cystadenoma, and solid and
pseudopapillary neoplasm)
• MCN cyst fluid typically has a high
viscosity, low amylase levels, and high
CEA and carbohydrate antigen (CA) 72-4
levels, and they may show malignant
cytology in patients with mucinous
cystadenocarcinomas. Periodic Acid-Schiff
(PAS) and May Grunwald/Giemsa (MGG)
stains are usually positive for extracellular
as well as intracellular mucin.
Mucinous Cystic Neoplasm

Intraductal Papillary Mucous Neoplasm

• Papillary neoplasm that arises within the

MPD or its branches
• The tumor hypersecretes mucin, which
often leads to duct dilatation and/or
chronic obstructive pancreatitis
• Are premalignant and may histologically
demonstrate areas ranging from
hyperplasia to carcinoma within in a single
tumor
• The tumors generally show intraluminal,
longitudinal growth but is usually slow to
invade periductal tissues radially and slow
to metastasize.
• Most commonly localized to the head of
the pancreas, but they may occur at any
site along the pancreatic ductal system
• Ductal dilatation is often impressive any
may mimic MCNs on CT scans
• Is recognized as predominantly a solid Hypervascular tumor in the pancreatic tail with
tumor with a central cyst. The cystic sunburst calcification. Note the Swiss-cheese
variety consists microscopically of cyst like enhancement.
spaces with papillary protrusions.

Intraductal Papillary Mucinous Tumor

SPLEEN
Accessory Spleens

• Or splenculi, are relatively commonly

In these cases, the findings on ERCP may be
diagnostic. Rarely, segmental pancreatic duct
dilatation may acquire a cystic appearance,
whereas the MPD and the rest of the pancreas
appears normal.
Microcystic Adenoma
• Cystic mass in the region of the tail of the
pancreas.
CT Findings
encountered “normal” anatomic variants
• Estimated to be present in approximately
10% of the population
• May be single or multiple in occurrence
• Are most frequently discovered in the
vicinity of the splenic hilum or elsewhere
within the gastrosplenic ligament
• They may, however, be found along the
omentum, or anywhere else within the
peritoneal cavity
 • Attenuation and contrast-enhancement
characteristics that are identical to those
of normal spleen
• Measures approximately 1.0-1.5cm in
diameter, but may range in size a few
millimeters to several centimeters (2.3)
• Resection of all accessory spleens is
recommended at the time of the
splenectomy, as cases of accessory-
splenic hypertrophy have been described
subsequent to removal of the “main” • An example of calcified splenic cyst shown
spleen first on plain radiograph (left) with a
coronal CT construction (right). Note the
clear demarcation of the calcified cyst
capsule.

Accessory Spleen (s)

Metastases: the axial CT images demonstrates

multiple hypoenhancing lesions in the spleen
consistent with metastatic CLL.

Splenic Cysts

Images of splenic metastasis visualized on US.

• The differential diagnosis of large splenic Careful ultrasound examination can determine if
cysts should include posttraumatic cysts these are cysts with increased through
(most common), epidermoid cysts, transmission of echoes versus solid metastatic
abscess, pancreatic pseudocyst, lesions.
echinococcal cysts, lymphoma, infarction
or cystic lymphangiomas (less common).
Splenic cyst shown below as imaged on
US.

Lymphoma
• Lymphomas is the most common
malignant tumor of the spleen. Typically,
lymphatic drainage to the spleen serves
as the primary mechanism by which
extranodal lymphomas of varying types by
which extranodal lymphomas of varying
types disseminates to the spleen. Of the
two broad types of lymphoma (B vs. T
cell), B cell lymphomas Hodgkin’s and non
Hodgkin’s disease are often diagnosed
from splenic imaging. Primary splenic
lymphoma (PSL) is a rare malignancy with
a reported incidence of less than 1% of all
lymphomas.
Case
Twenty-three year old woman with non-Hodgkin’s
lymphoma.
Splenic Calcifications
• Infectious
o Previous granulomatous disease
(tuberculosis, histoplasmosis)
o Opportunistic infection in AIDS
patients (Pneumocystis carinii)
• Traumatic
• Vascular
o “phleboliths”
o Post-ischemic/infarction
The plain film shown demonstrates numerous
round calcifications diffusely distributed
specifically within the spleen. The likely etiology
of the calcified granulomata is Histoplasmosis,
which have this characteristic appearance in
comparison to microabscess.
Case
33-year old woman with fever of unknown origin.
Patient is HIV +.
Pneumocystis carinii infection in the
spleen
• Important cause of pneumonia in an
immunocmporomised host
• Common sites of dissemination include
lymph nodes, liver, bone marrow, and
spleen.
• Splenic pneumocystic carninii infections
have been described typically as low
attenuation lesion which may contain
internal calcifications.
Differential diagnosis of cystic lesions
 • Post traumatic
• Epidermoid
• Epithelial and
• Echinococcal cyst
• Abscess
• Lymphoma and
• Metastatic lesions may also appear as
regions of decreased attenuation in the
spleen that may mimic cystic lesions

Splenomegaly

• lymphoma
• leukemia
• cirrhosis
• portal hypertension