CLINICAL IMAGING OF LIVER,

GALLBLADDER, BILIARY
TRACT,PANCREAS AND
SPLEEN
ABELARDO P. ESGUERRA MD FPCR, FUSP
RADIOLOGIST/SONOLOGIST
DEPARTMENT OF RADIOLOGY
DE LA SALLE UNIVERSITY HEALTH SCIENCES INSTITUTE -
COLLLEGE OF MEDICINE
SBO

 NORMAL ANATOMY
 IMAGING INDICATIONS
 POSSIBLE CONTRAINDICATIONS
 TYPICAL/EXPECTED FINDINGS
 INTERPRET RESULTS OF DIAGNOSTIC
TESTS
IMAGING STUDIES
 X-RAYS
 PLAIN
 CONTRAST
 ULTRASOUND
 VASCULAR
 COMPUTED TOMOGRAPHY SCAN (MDCT)
 PLAIN
 CONTRAST- dynamic bolus contrast enhanced MDCT
 MAGNETIC RESONANCE IMAGING
 RADIONUCLEIDE IMAGING
PLAIN X-RAY
CALCIFICATIONS
CONTRAST EXAMINATION
ULTRASOUND
ULTRASOUND
CT SCAN
MAGNETIC RESONANCE IMAGING
NUCLEAR MEDICINE
LIVER ANATOMY

 COUINAUD SEGMENTS
 BASED ON 3 LONGITUDINAL PLANE
 MHV,IVC, GBFOSSA = RL/LL
 RHV = VIII/V (RT LOBE)
 LHV = IVA,IVB/II,III (LEFT LOBE, MEDIAL/LATERAL)
 2 TRANVERSE PLANE
 LEFT PORTAL VEIN = IVA, II (SUP), IVB,III(INF)
 RIGHT PORTAL (OBL TRANSV) RL = VIII/VII (SUP),
V/VI (INF)
FUNCTIONAL SEGMENTAL LIVER ANATOMY
GOLDSMITH & COUINAUD &
WIIDBURNE BISMUTH
CAUDATE CAUDATE 1

LEFT LOBE LEFT LATERAL LEFT LATERAL SUP 2

SEGMENT SUBSEGMENT
LEFT LATERAL INF 3
SUBSEGMENT
LEFT MEDIAL LEFT MED SUP 4A
SEGMENT SUBSEGMENT
LEFT MED INF 4B
SUBSEGMENT
RIGHT LOBE RIGHT ANTERIOR RIGHT ANT INF 5
SEGMENT SUBSEGMENT
RIGHT ANT SUP 8
SUBSEGMENT
RIGHT POSTERIOR RIGHT POST INF 6
SEGMENT SUBSEGMENT
RIGHT POST SUP 7
COMPUTED TOMOGRAPHY SCAN
LIVER SIZE

 YOUNG INFANT
 SHOULD NOT EXTEND >1 CM BELOW RIGHT
COSTAL MARGIN
 CHILD
 SHOULD NOT EXTEND BELOW RIGHT
COSTAL MARGIN
ADULT

 MIDCLAVICULAR LINE
(VERTICAL/CRANIOCAUDAD AXIS)
<13 CM = NORMAL
13 – 15.5 CM = INDETERMINATE
>15.5 CM = HEPATOMEGALY (87% ACC)
 PREAORTIC LINE < 10 CM
 PRERENAL LINE <14 CM
PEDIATRIC SIZE

 LIVER
 correlation between the body length in cm and
hepatic length at midclavicular line (modified from
weitzel), at 55cm:3.3 to 6.7 mean of 5.0 cm HL,
>150 cm: 7.5 to 12.7 mean of 9.5 cm.
 At first 6 months, liver parenchyma = renal
parenchyma
ECHOGENECITY/ATTENUATION

 UTZ: PANCREAS>HEPATIC>RENAL
 CT: 40-70 HU (PRE CONTRAST)
 CECT:
 early arterial phase 20 sec
 late arterial phase 30-40 secs
 portal venous phase 60-70 secs
 Maximal enhancement 45-60
 Hemochromatosis (liver>spleen)
 Fatty Infiltration of the liver (liver<spleen)
FATTY INFILTRATION

 DIFFUSE VS FOCAL
 Focal – adjacent to falciform ligament, gallbladder
 and porta hepatis
 FOCAL FATTY SPARRING
 Spared area = normal parenhcyma (tumor ?)
 Segment IV
HEPATITIS
 ACUTE  CHRONIC
hepatomegaly/normal US increase liver echogenecity
gallbladder wall thickening coarse echopattern
US dec echogenecities No sound attenuation
starry sky pattern (increase
brightness of portal triads)
edema gb fossa

CT low periportal attenuation

(lymph edema)

 increase AST + ALT, increase in

serum conjugated bilirubin
NEONATAL HEPATITIS

 1-4 WKS OF AGE M>F

 US
 normal/enlarged liver
 Inc parenchymal echogenecities
 Dec visualization of peripheral portal veins
 Normal bile duct system
 Decrease in gb size after milk feeding
(ddx: biliary atresia)
 TUBERCULOSIS (TB) OF THE LIVER
ddx: granulomatous dses
multiple small vs curvilinear
 ULTRASOUND  COMPUTED TOMOGRAPHY
 asymmetric enlargement  rare cause of biliary stricture
 inhomogenous  most common is the porta hepatis
echopatternwith increase level
echogenecity  dense chalky liver calcification,
 high level echoes with periportal, periductal nodal
shadowing behind (scarring calcifications (suggestive)
and calcification)
 nodular echoes w/ complex
patterns
 SCHISTOSOMIASIS
most common cause of portal hypertension in the world
periportal pipestem fibrosis
 ULTRASOUND  CT
 echogenic bands
extending into the liver
 dense at CT (periportal
from the porta fibrosis)
 diamond shaped band
 calcification(suggestive
of high level echoes + of portal vein occlusion)
dilated superior  enhancement of
mesenteric and splenic thrombus(suggestive of
veins (portal vein malignancy)
thrombosis)
LIVER ABSCESS
 PYOGENIC
 centrally located
 multiple in 50%
 rim enhancement (86%)
 gas within abscess (esp
Klebsiella)
 well defined mildly
echogenic rim
 AMEBIC
 peripherally located
 multiple in 25%
 nodularity of abscess wall
in 60%
 well defined smooth thin
wall in utz
LIVER ABSCESS
CIRRHOSIS
 chronic liver dse characterized by diffuse liver parenchymal
necrosis regeneration and scarring with abnormal reconstruction
of preexisting lobular architecture
 ETIOLOGY
 TOXIC alcohol, drug methotrex, methyldopa, inh, iron;
INFLAMMATION viral hep, schisto; BILIARY OBSTRUCTION,
VASCULAR prolonged chf, NUTRITIONAL, HEREDITARY, ETC.
 MORPHOLOGY
micronodular (<3mm) = alcoholism, biliary obstruction
macronodular (3-15mm)= chronic viral hepatitis
mixed cirrhosis
FINDINGS
 SURFACE NODULARITY + INDENTATION
 SIGNS OF PORTAL HYPERTENSION
 SPLENOMEGALY
 ASCITIS
 ASSOCIATED WITH FATTY INFILTRATION (in early cirrhosis)
 HEPATIC SIGNS: hepatomegaly, hypertrophy of caudate lobe
(ratio of >0.65), surface nodularity,increase parenchymal
echogenecity, coarse echotexture,
 EXTRAHEPATIC SIGNS: splenomegaly, ascitis, signs of portal
hypertension
 CIRRHOSIS
 most common cause in alcohol liver disease
 may progress to portal HPN, liver failure and hepatoma (5%)
 Morphology: micronodular vs. macronodular

ULTRASOUND
 EARLY

 slight hepatomegaly/normal
 generalized increase echogenecity
 fine speckled pattern
 LATE
 right liver become small /shrunken caudate lobe relatively large
 (+) regenerating nodules (<2mm) surface nodularity
 coarse echopattern (heterogenous)
 CT
 EARLY
 low density at CT
 relatively high attenuationof portal
vessels
 LATE
 isodense regenerating nodules
 irregular outline
 prominent fissure when liver gets
smaller
 caudate becomes relatively large
CIRRHOSIS & PORTAL HPN
HEPATIC CYST

 CONGENITAL
 Simple Congenital Cyst
 Polycystic Kidney Disease
 ACQUIRED
 Echinococcal Cyst
BENIGN TUMORS

 HEPATOCELLULAR ADENOMAS
 most common tumor in young women after use of
contraceptive steroids
 usually in subcapsular location, right lobe with
average size of 8 – 10 cm
 DDX: FNH, hemangioma, HCC
 CX: spontaneous hemorrhage, subcapsular
hematoma, hemoperitoneum, recurrence,
malignant transformation
FOCAL NODULAR HYPERPLASIA
(FNH)
 rare benign congenital hamartomatous
malformation, SPECIFIC DIAGNOSIS
RARELY POSSIBLE
 3RD TO 4TH decade M:F = 1:2-4
 R:L = 2:1
 Less than 5 cm (in 85%)
FNH FINDINGS
 UTZ  CT SCAN
 Iso/hypo/hyperechoic  NECT
homogenous mass  iso to hypoattenuating
 Hyperechoic central scar homogenous mass
(18%)  CECT
 Displacement of hepatic  transient intense
vessels hyperdensity (30-60 sec
after bolus injection
followed by isodensity
 Hypodense mass during
peak portal venous;
isodense mass during
equilibrium phase
HEPATIC HEMANGIOMA
 CAVERNOUS HEMANGIOMA
 Most common benign liver tumor (78%)
 2nd most common liver tumor after metastasis
 M:F = 1:5
 Frequently peripheral/subcapsular in post right lobe of liver
 Size: <4 cm (90%) if greater than 4-6-12 cm giant
cavernous hemagioma
 ANGIOGRAPHY: historical gold standard
 MRI: light bulb (as bright as CSF) on heavily T2
HEPATIC HEMANGIOMA
 UTZ
 Uniformly hyperechoic
 In larger hemagiomas,
well define thick/thin
echogenic border due to
hemorrhagic necrosis,
scarring (inhomogenous
hypoechoic mass (40%)
 Unchanged in size on 1-6
 CT Scan
 Well circumscribed
spherical ovoid low
density mass NECT
 Peripheral enhancement
and complete fill in to
isodensity in delayed
phase


yrs ff up
MALIGNANT TUMOR
 HEPATOCELLAR CARCINOMA
 most frequent primary visceral malignancy
 80 – 90 % of all primary liver malignancy
 2nd in hepatic tumor in children
 most commonly metastasize to lung (8%), adrenal, lymph
node, bone
 Growth pattern: solitary massive up to 60% most often in
the right, multicentric small nodular <2cm up to 5 cm,
diffusely microscopic
 M>F (5:1)
HEPATOCELLULAR CANCER
LIVER METASTASIS
 most common malignant lesion of the liver
 LIVER most common metastatic site after REGIONAL
LYMPH NODE
 ORGAN OF ORIGIN: colon (42%), stomach (23%), pancreas
(21%), breast (14%), lung (13%)
 In CHILDREN: neuroblastoma, Wilms tumor
 Location: both lobes (77%), right lobe (20%)
left lobe (3%)
LIVER METASTASIS

CALCIFIED: mucinous GI tract (colon,rectum, stomach), pancreatic
CA, leiomyosarc, osteosarc, malignant melanoma
 HYPERVASCULAR: renal cell CA, Carcinoid tumor, pancreatic islet cell
tumor, thyroid CA, chorioCA, sarcoma
 HYPOVASCULAR: stomach, colon, pancreas, lung, breast
 HEMORRHAGIC: colon CA, Thyroid CA, breast CA, chorioCA,
Melanoma, Renal Cell CA
 ECHOGENIC: colonic CA, hepatoma, breast CA
 MIXED ECHOGENECITY: breast CA, Rectal CA, Lung CA, Stomach
CA
 CYSTIC : mucinous ovarian CA, colonic, sarcoma, melanoma, lung CA,
carcinoid tumor
 ECHOPENIC: lymphoma, pancreas, cervical CA, AdenoCa Lung,
NPCA,
 STOMACH
BREAST

TESTIS (TERATOMA)
GALLBLADDER

 SIZE, CAPACITY AND WALL THICKNESS

 LENGTH
 Infant < 1 year old: 1.5 – 3.0 cm
 Older child: 3 – 7 cm
 Adult: 7-10 cm (L); 2-3.5 cm (W)
 CAPACITY: 30 – 50 cm
 WALL THICKNESS: 2 – 3 mm
 PHRYGIAN CAP , JUNCTIONAL FOLD
ENLARGED GB
(CHOLECYSTOMEGALY/HYDROPS)
 OBSTRUCTION  UNOBSTRUCTED
CYSTIC DUCT OBSTRUCTION
MOSTLY


(HYDROPS, EMPYEMA)
 CHOLELITHIASIS NEUROPATHIC
 CHOLECYSTITIS W/  s/p vagotomy
CHOLELITHIASIS
 COURVOISIER PHENOMENON
 DM
 Panc CA, ampullary periamp CA  Alcoholism
 PANCREATITIS  Bedridden patient with
 INFECTION
(LEPTOSPIROSIS,ASCARIASIS, prolonged illness
TYPHOID FEVER)  Prolonged fasting
 Sepsis
SMALL GB

 Chronic cholecystitis
 Post prandial
 Congenital hypoplasia/multiseptated gb
 Intrahepatic cholestasis (viral drug related)
 Cystic fibrosis

 Contracted gallbladder <2cm in diameter

CHOLECYSTITIS
 ACUTE
 CHRONIC
 CALCULOUS (CYSTIC DUCT CALCULUS)
 ACALCULOUS
 GB WALL THICKENING

INTRINSIC VS EXTRINSIC
SHADOWING GB FOSSA
WES, GAS IN DUODENUM,
EMPHYSEMATOUS CHOLECYSTITIS
PORCELAIN GB
CHOLESCINTIGRAPHY = Tech 99m- IDA is more
sensitive in US in ACUTE CHOLECYSTITIS
ACUTE CALCULOUS
CHOLECYSTITIS
 Cystic duct obstruction by impacted calculus (80-95%)
 Acalculous Cholecystitis (10%)
 Assoc w/ CHOLEDOCHOLITHIASIS (15-25%)
 “halo sign”
 GB hydrops = >5cm in diameter
 + sonographic Murphy sign
 COMPLICATIONS:
 GANGRENE OF GB

 GB PERFORATION - most commonly at fundus

 EMPYEMA GB – intraluminal echoes w/out shadowing, layering

gravity dependence (purulent exudate/debris)

CHRONIC CHOLECYSTITIS

 Most common form of gallbladder

inflammation
 Gallstones
 Smooth/irregular gb wall thickening
 Mean volume of 42 ml
 EMPHYSEMATOUS CHOLECYSTITIS
 Complication: gangrene (75&), perforation (20%)
GALLBLADDER AND BILIARY
TREE
 CHOLELITHIASIS
 PREDISPOSING FACTORS= 4Fs + 2F
What are they?
 COMPOSITION: cholesterol (mixed),pigment
 CHOLEDOCHOLITHIASIS most specific
technique is CHOLANGIOGRAPY
 Differentiate gallstones vs kidney stones
 CBD
OBSTRUCTION
GALLSTONES
 BILE DUCT STRICTURES
 BENIGN
 pancreatitis
 recurrent cholangitis
 passage of stone
 MALIGNANT
 Cholangion CA
 Pancreatic CA
 Portal lymphadenopathy
 ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREATOGRAPHY (ERCP)
CHOLANGITIS

BILIARY DUCT OBSTRUCTION associated with

biliary infection
best seen in ERCP/PTC
Acute Obstructive/ Ascending Cholangitis (SSC)
CHARCOT TRIAD
Primary Sclerosing Cholangitis (PSC)
Recurrent Pyogenic Cholangitis
Secondary Sclerosing Cholangitis
BILIARY ASCARIASIS

 tubular echogenic filling defect with central

sonolucent line within dilated common bile
duct
 ASCARIASIS
 is seen as a
single highly
reflective line
 or as double
parallel reflective
lines with a
central echo free
region
 bulls eye or
target sign
MALIGNANT TUMORS
 GALLBLADDER CARCINOMA
 CHOLANGIOCARCINOMA
 50-70 y/o;assoc with ulcerative colitis
 INTRAHEPATIC VS EXTRAHEPATIC
 KLATSKIN TUMOR (50%) bifur of rt and left HD
 15% in primary sclerosing cholangitis (PTC)
 AMPULLARY CARCINOMA
 endoscopic US is the most sensitive technique
PEDIATRICS
 CHOLESTATIC JAUNDICE
 NEONATAL HEPATITIS
 BILIARY ATRESIA
 Jaundice beyond 4 weeks
 Liver UTZ findings: PATHOGNOMONIC (+) of triangular
cord= tubular echogenic structure in porta hepatis
 GB findings: non-visualized GB, small GB (<1.5 cm;
DDX hepatitis, normal GB (>1.5 cm in 19%)
 VIRAL HEPATITIS
BILIARY SCINTIGRAPHY
CHOLESCINTIGRAPHY
 Preparation of px: 5ng/kg/day of phenobarb 2x/day
for 3-7 days
 90-97% sensitive
 NO visualization of bowel on delayed images at 6
and 24 hours, NO excretion of radionuclide into GIT

 RX:
 Roun-en Y= choledochojejunostomy
 Kasai procedure = portoenterostomy (80%)
 Success rate 91% at child <60 days of age
PANCREAS
 ADULT SIZES
 10-12 CM in LENGTH
 HEAD: 3.0 CM
 BODY: 2.5 CM
 PANCREATIC TAIL: 2.0 CM
 Pancreatic duct 3-4 MM
 PEDIATRICS
 Pediatric head, body and tail diameter is
dependent on the age
 <1mon,1-12mons, 1-5 yrs, 5-10 yrs and 10-19 yrs
ULTRASOUND
PANCREATITIS

 DIAGNOSE CLINICALLY
 ROLE OF IMAGING
 Clarify the diagnosis
 Assess severity
 Determine prognosis
 Detect complication
 PANCREATITIS
 ACUTE  CT
 US  best imaging technique for
pancreas,peripancreatic tissues
 normal in 30%  pancreatic enlargement
 ultrasonic 12 -24 hrs  dec attenuation
 maybe focal or generalized 
indistinct outline
enlargement
 phlegmon low density (5 -20)
 reflectivity is lower than normal
 hemorhage
 dilated CBD
 fluid collection

 abscess, inflammation, free fluid

CHRONIC PANCREATITIS
US CT
PATTERN uneven echoes irregular density
CALCIFICATION echogenic foci with multiple dense foci
acoustic shadows
OUTLINE irregular, ill-defined irregular loss of
fascial plains
PANCREATIC dilated chain of lakes
DUCT wall echoes increased
CBD dilated dilated
CALCIFICATIONS
COMPLICATIONS

 PSEUDOCYST
 develop in >4wks, and mature in 6-8 wks
 2/3 within the pancreas, 1/3 in atypical location
(others like intra/retroperitoneal)
 PANCREATIC FISTULA
 PANCREATIC ASCITIS
MALIGNANT TUMORS

 99 % EXOCRINE DUCTAL EPITH

 1% ACINAR CELL CA
 OTHERS: ENDOCRINE NEOPLASM, NON
EPITHELIUM (PRIMARY LYMPHOMA,
METASTASIS ETC)
PANCREATIC CA
 Adenocarcinoma 75%
 location: 60% head, 25 % body, 15% tail)
 tail best demonstrated in CT
 US
 focal bulge to the pancreatic outline- early
 irregular lobulated mass of low or mixed echogenecity
 distal chronic pancreatitis
 dilated CBD
 signs of spread ( hypoechoic liver mets,
portal/peripancreatic nodes, invasion of retroperitoneal
fat, occlusion of splenic/portal veins
METASTASIZE (?)

 REGIONAL LYMPH NODE BONE (>2cm)

 LUNGS(pulmonary nodules, lymphangitic)
 BONE
 PLEURA
 PERITONEAL CARCINOMATOSIS(ascitis)
 LIVER
AMPULLARY CA
(PERIPANCREATIC)
SPLEEN
 Body largest lymphoid organ
 Adult size by 15 y/o
 Adult diameter = 12 cm L, 7cm W, 3-4cm T
 SPLENOMEGALY = >14 cm
 LYMPHOMA= most common malignant tumor
(leukemia, IM, HA, Myelofibrosis)
 HEMANGIOMA = most common primary neoplasm
 SPLENOMEGALY + GENERALIZED LYMPHOID
HYPERPLASIA = AIDS
SPLEEN
 ADULT: 12 cm (L), 7-8(AP), 3-4(T)
 Splenic index: <480 (LxWxH)
 IN CHILDREN: 5.7 +0.31 X AGE (YRS)
 IN INFANTS: (0-3 mons of age):<6 cm (L)
 ESTIMATED WEIGHT : SI x 0.55
 At birth: 15 grams
 In adult: 150 (150-265)

IN CT: 40-60 HU; 5-10 HU less than LIVER

TRAUMA FACTS
 CT scan is the single best imaging technique.
 LIVER
– is the most common injury in penetrating injury
 Hepatic laceration focal hypodense, RL>LL associated

findings are RLL pulmonary contusion,right pleural effusion

and right renal injury
 SPLEEN
 – is the most common injury in blunt intraabdominal injury
 CT is 100% sensitive, IV contrast is essential

 PANCREAS
 Blunt trauma is most common cause of pancreatitis in

children

FAST PROTOCOL
HEPATIC LACERATION SPLENIC LACERATION
“Radiology is internal medicine with
pictures. It is an integral part in the
diagnosis and therapy of all medical and
surgical diseases. Evaluation of the image
is only a part of the total information
input in the interpretation of the result.
Essential informations like history & PE,
recent imaging studies as well as other
laboratory work-up done when provided,
IMAGE INTERPRETATION will be
optimized.” THANK YOU AND GOD
BLESS
POST LECTURE EXAM (10
PTS)
GIVE THE DIAGNOSIS AND IMAGING
MODALITY
1. WALL ECHO SHADOW
2. STARRY SKY PATTERN
3. LIGHT BULB FINDING
4. SPLENOMEGALY AND GEN LYMPHOID
HYPERPLASIA
5. CHAIN OF LAKES

GOOD LUCK AND HAVE A NICE DAY