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Fatty Liver Remedy

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1 Techniques for Liver MR Imaging 1

1.1 Introduction 1

1.2 MR Imaging Techniques and Concepts 2

1.2.1 T1 - Weighted Sequences 5

1.2.1.1 Spoiled Gradient-Echo (SGE) Sequences 6

1.2.1.2 Out-of-Phase SGE Sequences 7

1.2.1.3 Fat Suppressed SGE Sequences 7

1.2.1.4 3D SGE Sequences 7

1.2.1.5 Motion-Insensitive SGE 9

1.2.1.6 Contrast-Enhanced SGE 9

1.2.2 T2-Weighted Sequences 11

1.2.2.1 Standard Spin-Echo and Fast Spin-Echo Sequences 11

1.2.2.2 Echo-Train Spin-Echo Sequences 11

1.2.3 The Uncooperative Patient Examination 13

1.3 Technical Factors 13

1.3.1 Surface Coils 13

1.3.2 Magnetic Field Strength 13

1.3.2.1 SAR and RF Power Deposition 14

1.3.2.2 Magnetic Field Distortions 14

1.3.2.3 Field-of-View 14

1.3.2.4 Motion 14

1.3.2.5 Contrast 14

1.3.2.6 Signal-to-Noise Ratio 14

1.3.2.7 Dielectric Effect 14

1.4 Summary 14

References 15

2 Histopathologic Classification of Liver Pathologies 17

2.1 Benign and Malignant Nodular Hepatocellular Lesions 18

2.1.1 Regenerative Lesions 18

2.1.1.1 Monoacinar Regenerative Nodule 18

2.1.1.2 Multiacinar Regenerative Nodule 19

2.1.1.3 Lobar or Segmental Hyperplasia 19

2.1.1.4 Cirrhotic Nodule (Monoacinar Cirrhotic Nodule / Multiacinar Cirrhotic Nodule). . . 19

2.1.1.5 Focal Nodular Hyperplasia (FNH) 19

2.1.2 Dysplastic or Neoplastic Lesions 21

2.1.2.1 Hepatocellular Adenoma 21

2.1.2.2 Dysplastic Focus 22

2.1.2.3 Dysplastic Nodule 22

2.1.2.4 Hepatocellular Carcinoma (HCC) 23

2.1.2.5 Fibrolamellar Carcinoma (FLC) 25

2.2 Benign and Malignant Tumors of the Biliary Tract 26

2.2.1 Bile Duct Adenoma 26

2.2.2 Bile Duct Cystadenoma 26

2.2.3 Biliary Papillomatosis 26

2.2.4 Bile Duct Carcinoma (Cholangiocarcinoma, CCC) 26

2.2.5 Bile Duct Cystadenocarcinoma 27

2.2.6 Gallbladder Carcinoma 28

2.3 Benign Non-Epithelial Tumors 28

2.3.1 Hemangioma 28

2.3.2 Infantile Hemangioendothelioma (IHE) 28

2.3.3 Lymphangioma 29

2.3.4 Angiomyolipoma 29

2.4 Malignant Non-Epithelial Tumors 29

2.4.1 Angiosarcoma 29

2.4.2 Malignant Epithelioid Hemangioendothelioma (EHE) 29

2.4.3 Undifferentiated (Embryonal) Sarcoma 30

2.4.4 Rhabdomyosarcoma (Sarcoma Botryoides) 30

2.4.5 Other Primary Sarcomas 30

2.4.6 Primary Lymphoma of the Liver 30

2.5 Hepatoblastoma 31

2.6 Tumor-like Lesions 31

2.6.1 Cysts 31

2.6.1.1 Non-Parasitic Cysts 31

2.6.2 Mesenchymal Hamartoma 32

2.6.3 Biliary Hamartoma 32

2.6.4 Inflammatory Pseudotumor (IPT) 32

2.6.5 Other Tumor-like Lesions: Peliosis Hepatis 32

2.7 Infectious Diseases of the Liver 33

2.7.1 Liver Abscess 33

2.7.1.1 Abscess Formation in Bile Ducts 34

2.7.2 Helminthic Infections 34

2.7.2.1 Nematodes (Ascariasis) 34

2.7.2.2 Cestodes (Echinococcus) 34

2.7.2.3 Trematodes (Schistosomiasis) 34

2.8 Parenchymal Disease 34

2.8.1 Hemochromatosis 34

2.8.2 Transfusional Iron Overload (Hemosiderosis) 35

2.8.3 Fatty Liver 35

2.8.4 Wilson's Disease 35

2.8.5 Primary Sclerosing Cholangitis 36

2.8.6 Cirrhosis 36

2.8.7 Primary Biliary Cirrhosis 37

2.8.8 Secondary Biliary Cirrhosis 37

2.8.9 Reye's Syndrome 38

2.8.10 Caroli's Syndrome 38

2.8.11 Liver Disease in Patients with Cystic Kidneys 38

2.8.11.1 Cystic Liver Disease in Combination with Cystic Kidney Disease 38

2.8.11.2 Congenital Hepatic Fibrosis and Cystic Kidneys 38

2.8.12 Langerhans' Cell Histiocytosis 39

2.8.13 Storage Diseases 39

2.8.13.1 Glycogen Storage Disease 39

2.8.13.2 Galactosemia 39

2.8.13.3 Hereditary Intolerance of Fructose 40

2.8.13.4 Mucopolysaccharidosis 40

2.8.14 Viral Hepatitis 40

2.8.14.1 Acute Hepatitis 40

2.8.14.2 Chronic Hepatitis 40

2.8.15 Liver Disease in Congestive Heart Disease 40

2.9 Vascular Changes 41

2.9.1 Thrombosis of the Portal Vein 41

2.9.2 Obstruction of Smaller Portal Branches 41

2.9.3 Budd-Chiari Syndrome 41

2.9.4 Veno-Occlusive Disease (VOD) 42

2.9.5 Lobular or Segmental Atrophy 42

2.9.6 Infarction / Ischemia 42

2.10 HIV-associated Liver Diseases 43

2.10.1 Kaposi's Sarcoma 43

2.10.2 Primary Lymphoma of the Liver 43

2.10.3 Cholangitis 43

2.10.4 Fungal Infections 43

2.10.5 Protozoal Infections 43

2.10.6 Bacterial Infections 43

2.11 Hepatic Trauma 44

2.12 Metastases 44

2.12.1 Metastases of Colorectal Adenocarcinoma 45

2.12.2 Liver Metastases of Breast Carcinoma 45

2.12.3 Carcinoid Metastases 45

2.13 Infiltration of the Liver in Hematologic Diseases 46

2.13.1 Non-Hodgkin's Lymphoma (NHL) 46

2.13.2 Hepatic Hodgkin's Lymphoma 46

References 46

3 Contrast Agents for Liver MR Imaging 53

3. 1 Introduction 53

3.1.1 Non-Specific Gadolinium Chelates 54

3.1.2 Hepatocyte-Targeted Contrast Agents 58

3.1.3 Agents with Combined Extracellular and Hepatocyte-Specific Distribution 60

3.1.4 RES-Specific Contrast Agents 62

3.2 Injection Schemes for Liver MRI with Different Contrast Agents 72

3.3 Radiologic Classification of Focal Liver Lesions on Unenhanced and Contrast-Enhanced MRI 73

3.4 Summary 74

References 82

4 Imaging of Benign Focal Liver Lesions 89

4.1 Primary Benign Liver Lesions 89

4.1.1 Hemangioma 89

4.1.2 Focal Nodular Hyperplasia 97

4.1.3 Hepatocellular Adenoma 113

4.1.4 Nodular Regenerative Hyperplasia 123

4.1.5 Cysts 130

4.1.6 Miscellaneous Tumors 135

4.1.6.1 Lipomatous Tumors 135

4.1.6.2 Leiomyoma 137

4.2 Secondary Benign Liver Lesions 137

4.2.1 Pyogenic Abscess 137

4.2.2 Amebic Abscess 141

4.2.3 Candidiasis Infection 143

4.2.4 Echinococcal Cyst 143

References 146

5 Hepatic Pseudolesions 151

5.1 Pathophysiologic Background 151

5.1.1 Anatomic Variants of the Hepatic Circulation 152

5.1.2 Vascular Abnormalities 152

5.1.2.1 Portal Vein Compromise 152

5.1.2.2 Hepatic Artery Compromise 153

5.1.2.3 Hepatic Vein Compromise 153

5.2 Parenchymal Pseudolesions 153

5.2.1 Focal Fatty Liver 153

5.2.2 Focal Spared Areas in Fatty Liver 161

5.2.3 Inflammatory Pseudotumors 161

5.2.4 Peliosis Hepatis 168

5.2.5 Confluent Hepatic Fibrosis 170

5.2.6 Segmental Hypertrophy 172

5.2.7 Parenchymal Compression 172

5.3 Vascular Pseudolesions 174

5.3.1 Transient Hepatic Attenuation Differences (THAD) 174

5.3.2 Vascular Malformations 174

5.3.2.1 Arteriovenous Malformations (AVMs) 174

5.3.2.2 Arterioportal Fistulas 181

5.3.2.3 Hereditary Hemorrhagic Teleangiectasia (HHT) 181

References 185

6 Imaging of Malignant Focal Liver Lesions 187

6.1 Primary Malignant Liver Lesions 187

6.1.1 Hepatocellular Carcinoma 187

6.1.2 Fibrolamellar Hepatocellular Carcinoma 206

6.1.3 Epithelioid Hemangioendothelioma 211

6.1.4 Hepatic Sarcomas 214

6.1.4.1 Angiosarcoma 214

6.1.4.2 Undifferentiated Embryonal Sarcoma 215

6.1.4.3 Hepatobiliary Rhabdomyosarcoma 215

6.1.4.4 Leiomyosarcoma, Malignant Fibrous Histiocytoma and Fibrosarcoma 215

6.2 Secondary Malignant Liver Lesions 217

6.2.1 Non-Hodgkin's Lymphoma and Hodgkin's Disease 217

6.2.2 Metastases 218

References 233

7 Imaging of the Biliary Tree and Gallbladder Diseases 237

7.1 Introduction - Imaging Technique 237

7.2 Anatomy 238

7.2.1 Normal Anatomy 238

7.2.2 Biliary Tree and Gallbladder Anomalies 239

7.2.2.1 Choledochal Cyst and Cystic Dilatation of the Bile Duct 239

7.2.2.2 Caroli's Disease 241

7.2.2.3 Biliary Atresia 245

7.2.2.4 Agenesis of the Gallbladder 248

7.2.2.5 Duplication of the Gallbladder 248

7.2.2.6 Anomalies of Gallbladder Shape 248

7.3 Benign Biliary Neoplasms 249

7.3.1 Biliary Cystadenoma 249

7.3.2 Bile Duct Adenoma 252

7.3.3 Biliary Hamartoma 252

7.3.4 Biliary Papillomatosis 252

7.4 Malignant Biliary Neoplasms 253

7.4.1 Cholangiocellular Carcinoma 253

7.4.2 Biliary Cystadenocarcinoma 256

7.5 Benign Neoplasms of the Gallbladder 261

7.5.1 Gallbladder Adenoma 261

7.6 Malignant Neoplasms of the Gallbladder 261

7.6.1 Gallbladder Carcinoma 261

7.6.2 Gallbladder Carcinoid 263

References 264

8 Comparison of Available Contrast Agents for the Imaging of Specific

Liver Lesions 267

8.1 Introduction 267

8.2 Benign Focal Liver Lesions of Hepatocellular Origin 268

8.2.1 Focal Nodular Hyperplasia (FNH) 268

8.2.2 Nodular Regenerative Hyperplasia (NRH) 271

8.2.3 Hepatocellular Adenoma (HA) 271

8.3 Malignant Focal Liver Lesions of Hepatocellular Origin 282

8.3.1 From Regenerative Nodules to Hepatocellular Carcinoma (HCC) 282

8.4 Benign Focal Liver Lesions of non-Hepatocellular Origin 293

8.4.1 Cavernous and Capillary Hemangioma 293

8.5 Malignant Focal Liver Lesions of non-Hepatocellular Origin 295

8.5.1 Hypervascular Metastases 295

8.5.2 Hypovascular Metastases 295

8.5.3 Cholangiocellular Carcinoma (CCC) 300

8.6 Summary 303

References 303

9 Imaging of Diffuse Liver Disease 305

9.1 Steatosis Hepatis 305

9.2 Inflammatory Disease 308

9.2.1 Viral Hepatitis 308

9.2.2 Sclerosing Cholangitis 308

9.2.3 Radiation-Induced Hepatitis 308

9.3 Cirrhosis 311

9.3.1 Regenerative Nodules 311

9.3.2 Portal Hypertension 312

9.4 Iron Overload 313

9.4.1 Hemochromatosis 313

9.4.2 Siderosis 315

9.4.3 Iron Overload in Liver Cirrhosis 317

9.4.4 Hemolysis 317

9.5 Vascular Pathologies 318

9.5.1 Portal Vein Thrombosis 318

9.5.2 Budd-Chiari Syndrome (Acute, Chronic) 318

9.5.3 Arteriovenous Malformations 328

References 332

10 MR Imaging of the Liver in Pediatric Patients 335

10.1 Introduction 335

10.2 Techniques in Pediatric Liver Imaging 336

10.3 Benign Liver Lesions in Pediatric Patients 337

10.3.1 Infantile Hemangioendothelioma (IHE) 337

10.3.2 Focal Nodular Hyperplasia (FNH) 338

10.3.3 Hepatocellular Adenoma (HA) 338

10.3.4 Hemangioma 338

10.3.5 Mesenchymal Hamartoma 338

10.3.6 Choledochal Cyst and Cystic Dilatation of the Bile Duct 343

10.3.7 Inflammatory Pseudotumor 343

10.4 Malignant Liver Lesions in Pediatric Patients 346

10.4.1 Hepatoblastoma (HB) 346

10.4.2 Hepatocellular Carcinoma (HCC) 349

10.4.3 Fibrolamellar Carcinoma (FLC) 352

10.4.4 Undifferentiated Embryonal Sarcoma (UES) 352

10.4.5 Hepatobiliary Rhabdomyosarcoma (RMS) 353

10.4.6 Hepatic Angiosarcoma (HAS) 355

10.4.7 Hodgkin' and Non-Hodgkin's Lymphoma (NHL), Burkitt Lymphoma 357

10.4.8 Metastases 357

10.5 Diffuse Liver Disease in Pediatric Patients 362

10.5.1 Steatosis 362

10.5.2 Biliary Atresia 362

10.5.3 Liver Fibrosis 365

10.5.4 Storage Disease, Metabolic Diseases 365

References 366

11 Imaging of the Liver Post-Surgery and/or Post-Ablative Therapy 371

11.1 Introduction 371

11.2 Surgical Resection 371

11.3 Radio-Frequency (RF) Ablation 373

11.4 Laser-Induced Interstitial Therapy (LITT) 376

11.5 Cryotherapy 378

11.6 Loco-Regional Drug Application 378

11.6.1 Percutaneous Ethanol Injection (PEI) 378

11.6.2 Regional Transarterial Chemoembolization (TACE) 379

11.7 Multimodality Treatment of Hepatic Lesions 385

References 387

12 MR Angiography in Liver Disease 389

12.1 Introduction 389

12.2 Technique 389

12.2.1 Time-of-Flight MRA 390

12.2.2 Phase-Contrast MRA 390

12.2.3 Contrast-Enhanced MRA 390

12.3 Imaging of the Arterial System 391

12.3.1 Normal Anatomy and Variants 391

12.3.1.1 Celiac Artery (CA) 391

12.3.1.2 Superior Mesenteric Artery (SMA) 391

12.3.1.3 Inferior Mesenteric Artery (IMA) 391

12.4 Imaging of the Portal-Venous System 397

12.4.1 Normal Anatomy and Variants 397

12.4.2 Clinical Implications 397

12.4.3 Evaluation in Liver Transplantation 399

12.4.4 Portal Vein Thrombosis and Cavernous Transformation 399

12.4.5 Tumor Encasement 399

12.5 Imaging ofthe Venous System 403

12.5.1 Normal Anatomy and Variants 403

12.5.2 Budd-Chiari Syndrome / Veno-Occlusive Disease 403

12.6 Evaluation of Living Donors in Liver Transplantation 403

12.7 Segmental Anatomy of the Liver 403

References 405

Subject Index 407

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