deng-bin wang, md, phd dept. of radiology, rui jin hospital sjtu

Deng-Bin WANG, MD, PhDDeng-Bin WANG, MD, PhD

Dept. of Radiology, Rui Jin Hospital SJTUDept. of Radiology, Rui Jin Hospital SJTU

Abdominal ImagingAbdominal Imaging

I.I. The Biliary TractThe Biliary TractII.II. LiverLiverIII.III. PancreasPancreasIV.IV. Spleen Spleen

Imaging of the Biliary TractImaging of the Biliary TractImaging of the Biliary TractImaging of the Biliary Tract

Methods of examination

Normal anatomy and X-ray findings

Common diseases

Methods of examination (I)Methods of examination (I)

Plain film: calcium (10~20%)Plain film: calcium (10~20%)

Oral cholecystographyOral cholecystography

Intravenous cholangiographyIntravenous cholangiography

T tube cholangiographyT tube cholangiography

Endoscopic retrograde cholangio- Endoscopic retrograde cholangio-

pancreatography, ERCPpancreatography, ERCP

percutaneous transhepatic percutaneous transhepatic

cholangiography, PTCcholangiography, PTC

Plain film — gallstone

Oral cholecystography

T tube cholangiography

Method of examination (II)

Ultrasonography (US)Ultrasonography (US)

AngiographyAngiography

Computed tomography (CT)Computed tomography (CT)

spiral CT cholangiography (SCTC)spiral CT cholangiography (SCTC)

Magnetic resonance imaging (MRI)Magnetic resonance imaging (MRI)

MR cholangiopancreatography (MRCP)MR cholangiopancreatography (MRCP)

Normal gallbladder anatomy

right 12th rib level Round, oval or pear-shaped 7~10cm in length, 3~4cm in wid

th four parts: funds, body, infu

ndibulum, neck cystic duct: 3cm in length, 2~3cm in widt

h

Normal biliary tract findings

Intrahepatic bile duct

left 、 right hepatic duct

common hepatic duct (3~4cm in length, 4~6mm in width)

cystic duct

common bile duct (6~10cm in length, 4~8mm in width)

Normal gallbladder and biliary tract anatomy

Position: between the left and r

ight lobes of liver, at the porta s

ection or below it.

Shape: oval

Size: 4 × 5cm

Density: lower, a little higher t

han water, homogeneous

Common bile duct : 1/3 is visualiz

ed

Intrahepatic ducts are not visualiz

ed

Normal CT finding of gallbladder

Common diseases of biliary tract

Gallstone

Cholecystitis

Gallbladder cancer

Gallstones (I)

composition: cholesterol, bile pigment, calcium shape: round, multi-facet, shell-like location:

gallbladder, intra- or extra-hepatic bile duct

Gallstones (II)

opaque stone (+): 10~20%

plain film (differentiate: renal stone)

non-opaque stone (-): 80~90%

contrast study: filling defect

Gallstones – Gallstones – non-opacifyingnon-opacifying

Gallstones – non-opaque stone

Gallstones – opaque stone

Stones in common bile duct

Hepatic bile duct stone

Gallstones and hepatic duct stones

Differentiation of calculi

Ureteral calculi

Calcification ofLymph node

Gallstones

Acute cholecystitis Causes: bile duct stone 、 infection 、 reflux of pancreatic sec

retion Pathology:c congestion and edema of gallbladder mucosa, gall

bladder enlarged and its wall thichened X-ray finding: gallbladder enlarged, gas in the gallbladder lu

men or wall. CT: thickening , irregular and wall(>4mm) ， vague margin.

Chronic cholecystitis

Non-opacifying gallbladder

(excluding: inadequate absorption or excr

etion)

Faint opacifying with vague margin

slower rate of emptying

Chronic cholecystitis

Gallbladder CarcinomaGallbladder Carcinoma

Hepatic Hilar Cholangiocarcinoma

Biliary Biliary ductal ductal systemsystem

23 sec Breath-hold

BiliaryBiliary ductalductal systemsystem SSFSE & 3D FRFSE

Sl. thickness: 3 mm. Matrix: 512 x 192

2D SSFSE

3D FRSFSE

2D Fast GRE T1 w. Fat Sat


Sl. thickness: 2 mm. Matrix: 384x224



High spatial resolution of the entire pancreaticobiliary tract

and of the adjacent soft tissue

After Contrast Media Injection

FGRE T1 w. Fat Sat

FGRE T1 w. Fat Sat

Biliary ductal systemBiliary ductal systemSSFSE & 3D FRFSE 3D FRSFSE

3D FRSFSE

2D SSFSE

2D SSFSE

2D SSFSE

Biliary ductal systemBiliary ductal system 2D FIESTA Fat Sat

Sl. thickness: 3 mmMatrix 224x224

Zip 5121 sec / slice

FS FIESTA FS FIESTA

SSFSE long TE SSFSE long TE

Hepatobiliary system

Biliary ductal systemBiliary ductal system LAVA after mangafodipir trisodium administration (Teslascan )

Sl. Thickness 3 mm (ov -0.8 mm)Matrix: 256x224 – ZIP 512

Acq. time: 18 sec

High Resolution T1 w. 3D MRCP - Functional information -

Liver Imaging

Plain filmUS, CT, MRIcontrast study

GI double contrast ERCP / PTC DSA

Plain film

Angiography

Torso coil4 elements phase-array coil

-> huge anatomical coverage-> high SNR-> Asset compatible

Patient preparation

Liver and Pancreas:Dynamic Contrast- enhanced Scanning Protocol for CT or MRI

Early Phase: (delayed time:25-30s)Portal Phase: (delayed time:55-60s)Delayed Phase: (delayed time:90-200s)

Common diseases of Liver

Abscess

Hemangioma

Cancer

Cyst

Cirrhosis

Abscess Causes ： pyogenic 、 amebic Clinic ： fever 、 pain 、 enlargement of liver CT finding ： low-density or cystic mass ， 20 – 40Hu ， with c

ontrastcnhancement of the wall, A surrounding low-density halo.

Abscess - MRI

Hemangioma Well-defined, low-density lesion. Dynamic scans after a bolus of intravenous c

ontrast show dense peripheral enhancement at 15’s, with gradual infilling so

that the lesion becomes isodense.

Hemangioma-angiography

Cancer – primary HCC

Pathology ： Hepatocellular carcinoma （ 90% ） , cholangiocarcinoma and mixed form.

Categories ： solitary mass 、 multifocal nodule 、 diffuse involvement.

CT findings ： Plain scan reveals well or poor defined, low-density mas

s with irregular margin. Enhancement occurs and disappears earlier.

Hepatocellular carcinoma

Hepatocellular carcinoma —diffuse involvement

Vascular mapping:Portal system

Vascular mapping:Portal system & vena cava

Liver Volumetry

Arterial phase Portal phase Equilibrium phase

Focal lesion: Contrast uptake dynamics

Washout

Arterial perfusion

Portal systemc

Liver veins

Liver parenchymaLiver parenchyma

Extra cellular Imaging

Presurgical topography information & vessel assessment

Arterial phase Portal phase

Arterial phase Portal phase

Focal lesion characterization &

3D presurgical topography information

Arterial phase

Arterial phase: MIP

Portal phase

Portal phase: MIP

Arterial phasePortal phase

Arterial phase

Arterial phase

Portal phase

Portal phase

High sensitivity to detect small lesions (less than 0.5 mm)

Early arterial phase Late arterial phase Portal phase

2 acquisitions – 1 single breath-hold

1 single breath-hold

Focal lesion: Double hepatic arterial phase MRI

From the From the morphology morphology to the functionto the function

“Today, the contribution of MRI to Body application is decisive not only for the accuracy of the diagnosis but also for the follow up and the monitoring of treatment.”

Pr D. RégentUniversity hospital, Nancy

Brownian motion

Angiogenesis

From the morphology to the functionFrom the morphology to the function

DW Imaging

METS

FNH

Bachir Taouli, MD, et al. Evaluation of Liver Diffusion Isotropy and Characterization of Focal Hepatic Lesions with Two Single-Shot Echo-planar MR Imaging Sequences: Prospective Study in 66 Patients – Radioligy 2003; 226:71–78

HCC

DW-EPI B 600 s/mm²

8 mm slices / gap 0Matrix: 128x1605 slices / 20 sec

• 3 D FSGPR3 D FSGPR

• 容积内插技术容积内插技术• 优点优点

• 层面更薄层面更薄• 成像更快成像更快• 内插技术有利于内插技术有利于 MPRMPR

• 可同时进行肝脏动态增强和可同时进行肝脏动态增强和 CE-MRACE-MRA

• 缺点缺点• T1T1 对比略差于对比略差于 2D FSPGR T1WI2D FSPGR T1WI

FAME (Fast Acquisition with Multiphase Efgre3d)

VIBE VIBE （（ VVolume olume IInterpolated nterpolated BBody ody EExaminationxamination ））

Liver metastases

FAMEFast Acquisition with Multiphase Efgre3d

结肠癌肝脏多发转移结肠癌肝脏多发转移

三维梯度回波三维梯度回波 T1WIT1WI

Hepatocellular carcinoma — angiography

Cyst

Well-defined, nonenhancing lesion of low density(0-20Hu).

Cyst — MRI

Low signal on T1WI and high signal on T2WI with smooth and round margin.

Cirrhosis The liver becomes small, particularly the right lobe,

outline is irregular and the fissures more prominent. Isodense regenerating nodules can appear. Ascites can be seen.

Interleave Joke

A: I’m so glad I wasn’t born in

the United States.

B: Why?

A: Because I can’t speak English.

Pancreas: Methods of examination

X-ray plain film

G-I double contrast

ERCP

PTC

Angiography

T1W T1W 脂肪抑制T2W

正常胰腺 MR 动态增强T1W T2W 抑脂

FSPGR 动脉期 FSPGR 门脉期

SA SV

MRA

胰体尾部癌

MRI with the combination of MRA and MRCP technique has the unique capability of allowing a noninvasive comprehensive examination within a single diagnostic modality for evaluation of the full range of pancreatic diseases.PANCREASPANCREAS

Multi–detector row helical CT

PancreasPancreas SSFSE & 2D FGRE

Slice thickness: 5 mm Matrix 512x224

No In-Plane interpolation

SSFSE

2D Fast GRE

2D Fast GRE

After Contrast Media Injection

High contrast resolution pancreatic examination

Internal septa

PancreasPancreas SSFSE & 2D FIESTA Fat Sat

2D FIESTA Fat sat

Resp. TriggerSlice thickness: 5 mm Matri

x 224x224Zip 512

1 sec / slice

SSFSE Fat Sat

2D SSFSE

PancreasPancreas LAVA

Sl. thickness: 1.6 mm (ov -0.8 mm)Matrix: 256x256 – ZIP 512

Acq. time: 23 sec

Comprehensive Pancreatic examination - Parenchyma & adjacent soft tissue

- Intra and extra pancreatic ducts

- Abdominal arteries & veins 2D SSFSE

Arterial MIP Portal & veins MIP

LAVA: Arterial phase (MinIP)

LAVA: Portal phase (MIP)

LAVA: Venous phase

PancreasPancreas LAVA

2.6 mm (ov-1,3)Matrix: 256x256 Acq. time: 16 sec

Common diseases of Pancreas

Pancreatitis

(acute, chronic)

pancreatic cyst

pancreatic carcinoma

Acute pancreatitis

Causes ： Gallstones 、 Alcohol 、 Metabolism drugs 、 infecti

on 、 trauma

Pathology ： acute interstitial edema 、 necrosis 、 bleeding 、suppuration

X-ray finding ： local G-I dilated with gas accumulating, oblitera

ted left psoas outline,

CT Findings in AP

Acute Fluid Collections

– Acute fluid collections are seen on CT sans as low-a

ttenuation, poorly defined collections of fluid with

no recognizable capusle or wall.

– 40% occurs in acute pancreatitis.

– 50% resolve spontaneously

CT Findings in AP

Extrapancreatic fluid collection– anterior pararenal space– Posterior pararenal space– Lesser sac– Paracolic gutters

Free peritoneal fluid Pleural effusion Gallstone

Pathophysiology of acute pancreatitis

Intra-pancreatic fluid collection

Groove Pancreatitis

APAPAPAP

Simple type Necrotic type

Department of RadiologyDepartment of Radiology


SIMPLE TYPESIMPLE TYPESIMPLE TYPESIMPLE TYPE

急性坏死性胰腺炎的急性坏死性胰腺炎的 CTCT 表现表现急性坏死性胰腺炎的急性坏死性胰腺炎的 CTCT 表现表现

Department of RadiologyDepartment of RadiologyNecrotic p

Acute necrotic pancreatitisAcute necrotic pancreatitis


Retroperitoneal collection of Retroperitoneal collection of fluidfluid

左肾旁间隙→左结肠旁沟→盆腔Department of RadiologyDepartment of Radiology


Serious APSerious APSerious APSerious AP


hemorrhagehemorrhagehemorrhagehemorrhage


pseudocystpseudocystpseudocystpseudocyst

abscess

Department of RadiologyDepartment of RadiologyChronic PChronic PChronic PChronic P

Chronic pancreatitis

The tragedy of life is not so much

what men suffer, but what they

miss.

-----T. Carlyle

Pancreatic carcinomaX-ray finding ： widening of the deodenal loop,inverted

3 sign, nodular mucosal filling defectsERCP ： occluded or narrowed pancreatic ductPTC ： CBD dilated and distal obstruction

Pancreatic carcinomaCT:low density mass with infiltrating growth

manners,easy to involve the retroperitoneal nerve plexus and vessels nearby

PancreasPancreas Comprehensive Pancreatic examination - Vascular presurgical mapping +++

2D SSFSE: Portal phase (MinIP)

: Portal phase (MinIP)

: Portal phase (MIP)

Porto-systemic derivations

Anatomical variation of the left gastric artery

Pancreatic carcinoma

Cancer


Portal Vein Invaded by Portal Vein Invaded by Pancreatic CarcinomaPancreatic Carcinoma（（ MPR and CTAMPR and CTA ））

Ca of the body and tail of Ca of the body and tail of pancreaspancreas

CT dynamic enhancement


Pancreatic carcinomaPancreatic carcinoma

MSCTMSCT thin scanning


Double tube sign

MPRMPR

MSCTMSCT

Portal vein involvedPortal vein involved

MPR MPR 、、 CTACTA



Cystic adenocarcinomaCystic adenocarcinomaCystic adenocarcinomaCystic adenocarcinoma

VIP瘤

Rare tumorRare tumorRare tumorRare tumor

“Political power grows out of the barrel of a gun”

--MAO TSE-TUNG

Language is the dress of thought

The world is a book, and those who don’t travel read only a page

Well, remember that you took a wrong way to a place, and you can have a smooth trip

home

Imaging of spleen

Exam methodsUS

CT

MRI

Common diseasesenlargement

rupture

tumor

cyst

Tumor

Cavernous hemangioma

lympangioma

lymphoma

海绵状血管瘤海绵状血管瘤

淋巴管瘤淋巴管瘤

脾淋巴瘤合并出血脾淋巴瘤合并出血

Upright MR Scanner

deng-bin wang, md, phd dept. of radiology, rui jin hospital sjtu

Documents

homogeneous common bile

neckcystic duct

bile pigment

common bile ductstones

width normal gallbladder

gallbladder lumen

normal ct

d fiesta fat