Different Medical Imaging Modalities including CT, MRI, US techniques for evaluation of Liver diseases, a short but comprehensive review

1. In the Name
of God
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2. Liver Imaging
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3. Table of Content
• Introduction
• Anatomy
• Diseases
• Imaging
Modalities
• Imaging
Techniques
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5. An Introduction to Liver Imaging
o Liver :
the largest internal organ in the body, Located in the RUQ , consists of 2 main lobes
o Why different imaging modalities?
• Accurate diagnosis
• Precise staging
• Detecting Lesions
• Assessment of treatment response
• monitor the course of disease
o Liver carries out many functions
• Making bile. Fluid that helps break down fats and gets rid of wastes in the body
• Changing food into energy
• Clearing the blood of drugs and other poisonous substances
• Producing certain proteins for blood plasma
• Regulating blood clotting
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7. Abdominal regions &
quadrants
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8. Liver Lobes & Segments
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9. Liver Vasculature & Ducts
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15. Liver Diseases
o Hepatitis
• Inflammation of the liver, usually caused by viruses, types: A, B, and C. have also non-infectious
causes too, including heavy drinking, drugs, allergic reactions, or obesity.
o Cancer
• The most common type: hepatocellular carcinoma.
o Hemangioma
• Blood-filled vascular space, the most common liver tumor
• are frequent, often asymptomatic, very low rate of complications
o Liver Failure
• Has many causes including infection, genetic diseases, and excessive alcohol.
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16. Liver Diseases (Cont.)
o Ascites
• As cirrhosis results, the liver leaks fluid into the belly.
o Gallstones
• If a gallstone becomes stuck in the bile duct draining the liver, hepatitis and bile duct
infection (cholangitis) can result.
o Hemochromatosis
• Allows iron to deposit in the liver, damaging it.
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17. Liver Diseases (cont.)
o Fatty Liver
• Also known as hepatic steatosis, happens when fat builds up in the liver, can cause
liver inflammation
o Cirrhosis
• Long-term damage, lead to permanent scarring.
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19. Radiography
o Indications:
• RUQ pain ddx
• R/O Hepatomegaly
• …
o Types of Imaging:
• Abdomen upright PA
• Abdomen Supine
• End of expiration
• …
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20. Computed Tomography
o Indications:
• Benign/Malignant Neoplasms
• Pyogenic/fungal Abscess
• Portal Vein Thrombosis
• Fatty Infiltration
• Hepatomegaly
• Hemangioma
• Cirrhosis
• Cysts
• Trauma
• …
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21. Magnetic Resonance Imaging
o Indications:
• Haemochromatosis / Haemasidrosis
• Potential liver donor evaluation
• Iron content determination
• Tumor response to treatment
• Vascular evaluations
• Fatty infiltration
• Hepatic Adenoma
• Metastasis
• Cysts
• Hemangioma
• Gallstones
• Cirrhosis
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22. Ultra Sonography
o Indications:
• Hepatomegaly
• Fatty infiltration
• Abdominal Pain
• Trauma
• Hepatitis
• Hemangiomas
• Cirrhosis
• Gallstones
• Pre/Post transplantation evaluation
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23. Positron Emission Tomography
o Indications:
• Detecting cancer
• Metastasis
• Treatment response evaluations
• Checking cancer recurrence
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25. Multi Phasic CT
o Preparation
• Check pregnancy, allergies to any medicines, Kidney problems, Diabetes
• Fill out informed consent form
• Fasting before exam
o Injection
• Iodine-based contrast media
• 18 or 20 gauge needle, right antecubital vein
• Large amount of contrast material/ small amount of it followed by a saline bolus chaser
• Injection rate should be 2-5 mL/sec.
• Injected volume should be 100-150 cc
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26. Multi Phasic CT (Cont.)
o Acquisition
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Non-enhanced
Early arterial phase
Late arterial phase
Hepatic or late portal phase
Nephrogenic phase
Delayed phase

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Helpful in detecting:
o Calcifications & stones
o fat in tumors/inflammation
o appendicitis
o diverticulitis
o etc.

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o 15-20 sec p.i. or immediately after
bolustracking
o the contrast is still in the arteries
o has not enhanced the organs/other soft
tissues
Helpful in detecting:
o Arterial bleeding
o Dissection of Aorta

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o 35-40 sec p.i. or 15-20 sec after bolustracking
o also called "arterial phase" or "early venous
portal phase“
o Enhancement of hypervascular lesions/
kidney outer cortex/ pancreas parenchyma
Helpful in detecting:
o HCC
o Adenoma
o Ischemia
o FNH

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o 70-80 sec p.i. or 50-60 sec after bolustracking
o liver parenchyma enhances through blood
supply by the portal vein
Helpful in detecting:
o Cysts
o Abcess
o Metastases
o hypervascular lesions

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o 100 sec p.i. or 80 sec after bolustracking
o all of the renal parenchyma including the
medulla enhances.
Helpful in detecting:
o small renal cell carcinomas.

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o 6-10 minutes p.i. or 6-10 minutes after bolustracking
o So called "wash out phase" / "equilibrium phase“
o There is wash out of contrast in all abdominal
structures except for fibrotic tissue
Helpful in detecting:
o Transitional cell carcinoma in kidney
o Cholangiocarcinoma in liver
o Fibrotic metastasis

33. Contrast agent
Injection volume:
o Weight < 75kg : 100cc
o Weight 75-90kg: 120cc
o Weight > 90kg : 150cc
Injection rate:
o 5cc/sec through a 18 gauge i.v. catheter for all indications
o 3-4cc/sec through a 20 gauge pink venflon If 5cc/sec is not possible
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34. Importance of timing
• Hyper vascular tumors (e.g. HCC) are best seen in late arterial phase
• Irregular enhancement Vs. Obvious multiple masses
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35. Lesion Characterization
o Late arterial phase (at 35 sec):
o hypervascular lesions like HCC, FNH, adenoma and
hemangioma wiLl enhance optimally, while the normal
parenchyma shows only minimal enhancement.
o Hepatic phase (at 70 sec p.i. ):
o Hypovascular lesions like metastases, cysts and abscesses
will not enhance and are best seen
o Delayed phase (at 600 sec p.i.):
o Fibrotic lesions like cholangiocarcinoma and fibrotic
metastases hold the contrast much longer than normal
parenchyma. They are best seen in the
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37. Dynamic MRI
o Supine, head first
o Spine coil, Body coil from nipple down to iliac crest
o Laser beam center over xiphoid process of sternum
o Using respiratory trigger device
o Proper breathing instruction
o Navigator and blade sequences (if possible)
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38. Dynamic MRI (cont.)
o Injection
• Gd-based contrast agents
Best liver-to-lesion contrast within 90. sec p.i.
• Hepatocyte targeted contrast agents
Best normal-to-abnormal contrast within 10-
40 min p.i.
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o Suggested Dynamic Protocol:
• Flash 3D sequence
• Consists of 3 flash 3mm 3D scan
• 10s delay between first (arterial) and
second scan (portal venous phase)
• 5min delay after second, for third phase
(equilibrium)

39. Suggested
Sequences
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40. Proper arterial phase
 Marked enhancement of hepatic arteries, pancreas, spleen
 No enhancement of hepatic veins
 Maximum enhancement of tumor and hypervascular lesions
 Guess timing method: Start about 20sec p.i , scan time less than 30 sec
 Care bolus technique: start liver scan immediately after CM reaching the heart
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41. Proper portal phase
 Maximum enhancement of liver parenchyma
 Easily detection of hypo vascular tumor
 Guess timing method: Start about 60 sec p.i , scan time less than 30 sec
 Care bolus technique: 15s scan delay after finishing arterial scan
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42. Proper Equilibrium phase
 Contrast has moved away from liver parenchyma
 2-5 min after injection
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43. Liver MRI
• Precontrast (a)
• Arterial phase (b)
• Portal venous phase (c)
• The arterial phase demonstrates
respiratory motion artifact
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45. Hemangiomas
multi-phasic CT images T1 & T2-w MR images
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46. Fatty Liver
Contrast enhanced CT In/out phase T1-W MR images
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47. Hepatitis
T2-w MR image
Delay CT image
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48. HCC
T2-FS MR image
T1.fl portal phase MR image
Late portal phase CT image
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49. Emergency Imaging of Liver
Trauma:
Lacerations
(large arrow)
Hemoperitoneum
(small arrows)
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50. Take
Care
Of
Your
Liver
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