Clinical Imaging Of Liver, Gallbladder, Biliary

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  

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ULTRASOUND 

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VASCULAR

COMPUTED TOMOGRAPHY SCAN (MDCT) 

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PLAIN CONTRAST

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 & WIIDBURNE

COUINAUD & BISMUTH

CAUDATE

CAUDATE

1

LEFT LATERAL SUP SUBSEGMENT

2

LEFT LATERAL INF SUBSEGMENT

3

LEFT MED SUP SUBSEGMENT

4A

LEFT MED INF SUBSEGMENT

4B

RIGHT ANT INF SUBSEGMENT

5

RIGHT ANT SUP SUBSEGMENT

8

RIGHT POST INF SUBSEGMENT

6

RIGHT POST SUP

7

LEFT LOBE

LEFT LATERAL SEGMENT

LEFT MEDIAL SEGMENT

RIGHT LOBE

RIGHT ANTERIOR SEGMENT

RIGHT POSTERIOR SEGMENT

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)

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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

hepatomegaly/normal gallbladder wall thickening US dec echogenecities 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

CHRONIC US increase liver echogenecity 

coarse echopattern No sound attenuation

NEONATAL HEPATITIS  

1-4 WKS OF AGE US     

M>F

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  

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

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asymmetric enlargement inhomogenous echopatternwith increase echogenecity high level echoes with shadowing behind (scarring and calcification) nodular echoes w/ complex patterns

COMPUTED TOMOGRAPHY  

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rare cause of biliary stricture most common is the porta hepatis level dense chalky liver calcification, periportal, periductal nodal calcifications (suggestive)

SCHISTOSOMIASIS most common cause of portal hypertension in the world periportal pipestem fibrosis 

ULTRASOUND 

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echogenic bands extending into the liver from the porta diamond shaped band of high level echoes + dilated superior mesenteric and splenic veins (portal vein thrombosis)

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CT 

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dense at CT (periportal fibrosis) calcification(suggestive of portal vein occlusion) enhancement of thrombus(suggestive of malignancy)

LIVER ABSCESS 

PYOGENIC    

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centrally located multiple in 50% rim enhancement (86%) gas within abscess (esp Klebsiella) well defined mildly echogenic rim

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AMEBIC   

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peripherally located multiple in 25% nodularity of abscess wall in 60% well defined smooth thin wall in utz

LIVER ABSCESS

CIRRHOSIS 

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chronic liver dse characterized by diffuse liver parenchymal necrosis regeneration and scarring with abnormal reconstruction of preexisting lobular architecture ETIOLOGY 

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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      

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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   

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slight hepatomegaly/normal generalized increase echogenecity fine speckled pattern

LATE   

right liver become small /shrunken (+) regenerating nodules (<2mm) coarse echopattern (heterogenous)

caudate lobe relatively large surface nodularity

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CT 

EARLY  

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low density at CT relatively high attenuationof portal vessels

LATE   

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isodense regenerating nodules irregular outline prominent fissure when liver gets smaller caudate becomes relatively large

CIRRHOSIS & PORTAL HPN

HEPATIC CYST 

CONGENITAL  

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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 

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Iso/hypo/hyperechoic homogenous mass Hyperechoic central scar (18%) Displacement of hepatic vessels

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CT SCAN 

NECT 

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iso to hypoattenuating homogenous mass

CECT 

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transient intense 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 yrs ff up

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CT Scan 

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Well circumscribed spherical ovoid low density mass NECT Peripheral enhancement and complete fill in to isodensity in delayed phase

MALIGNANT TUMOR 

HEPATOCELLAR CARCINOMA    

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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

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LIVER most common metastatic site after REGIONAL LYMPH NODE

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ORGAN OF ORIGIN: colon (42%), stomach (23%), pancreas (21%), breast (14%), lung (13%)

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In CHILDREN: neuroblastoma, Wilms tumor Location: both lobes (77%), right lobe (20%) left lobe (3%)

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LIVER METASTASIS 

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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 

 

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CYSTIC DUCT OBSTRUCTION (HYDROPS, EMPYEMA) CHOLELITHIASIS CHOLECYSTITIS W/ CHOLELITHIASIS COURVOISIER PHENOMENON 

 

Panc CA, ampullary periamp CA

PANCREATITIS INFECTION (LEPTOSPIROSIS,ASCARIASIS, TYPHOID FEVER)

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UNOBSTRUCTED 

MOSTLY NEUROPATHIC    

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s/p vagotomy DM Alcoholism Bedridden patient with prolonged illness Prolonged fasting Sepsis

SMALL GB

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

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Contracted gallbladder <2cm in diameter

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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?

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COMPOSITION: cholesterol (mixed),pigment CHOLEDOCHOLITHIASIS most specific technique is CHOLANGIOGRAPY Differentiate gallstones vs kidney stones

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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

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ASCARIASIS 

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

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 

  

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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 

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

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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     

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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



US   

 



CT

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 PATTERN

US

CT

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  

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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

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“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