肝臟解剖與常見(jiàn)病影像診斷課件

TheHepaticLesion:RadiologicAssessment

TheAffiliatredhospitalofNBUWangJIANHUAwoxingw@2014-12-29TheHepaticLesion:2014-12-29CASECASE肝臟解剖與常見(jiàn)病影像診斷課件肝臟解剖與常見(jiàn)病影像診斷課件肝臟解剖與常見(jiàn)病影像診斷課件ObjectivesNormalliveranatomyImagingtechniquesCommondiseasesimagingdiagnosisDiffusediseasesFocaldiseases

ObjectivesNormalliveranatomyAnatomyoftheliversegments

Twodifferentaspects:morphologicalanatomyandfunctionalanatomy.

C.Couinaud(1957)dividedtheliverintoeightfunctionallyindepedentsegments.

Thisclassificationwillbepresentedherewithseveralillustrations.Anatomyoftheliversegments

Couinaudclassification

Dividestheliverintoeightfunctionallyindepedentsegments.

Eachsegmenthasitsownvascularinflow,outflowandbiliarydrainage.

Inthecentreofeachsegmentthereisabranchoftheportalvein,hepaticarteryandbileduct.

Intheperipheryofeachsegmentthereisvascularoutflowthroughthehepaticveins.Couinaudclassification

DividePortahepatisSecondPortahepatisPortahepatisSecondPortahepa肝臟解剖與常見(jiàn)病影像診斷課件Righthepaticveindividestherightlobeintoanteriorandposteriorsegments.

CrosstransversePortalveindividestheliverintoupperandlowersegments.

Middlehepaticveindividestheliverintorightandleftlobes(orrightandlefthemiliver).ThisplanerunsfromtheinferiorvenacavatothegallbladderfossaLefthepaticveindividestheleftlobeintoamedialandlateralpart.RighthepaticveindividestheTheimageonthefarleftisattheleveloftherightportalvein.Atthisleveltherightportalveindividestherightlobeoftheliverintosuperiorsegments(7and8)andtheinferiorsegments(5and6).

Theleveloftherightportalveinisinferiortotheleveloftheleftportalvein.Atthelevelofthesplenicvein,whichisbelowtheleveloftherightportalvein,onlytheinferiorsegmentsareseen(rightimage).TheimageonthefarleftisaCounterclockwiseCounterclockwise1CaudatelobeSegment1Segment4aSegment8Segment72Leftlateraluppersagment8Rightanterioruppersagment4Leftmedialsagment7RightposterioruppersagmentSegment21CaudatelobeSegment1SegmentLeftlateraluppersagmentLeftlateraluppersagmentLeftlaterallowsegmentLeftlaterallowsegmentLeftmedialsegmentLeftmedialsegmentRightposterioruppersegmentRightposterioruppersegmentRightanteriorupperdegmentRightanteriorupperdegmentRightanteriorlowdegmentRightanteriorlowdegmentRightposteriorlowsegmentRightposteriorlowsegmentLiveranatomyLiveranatomyImagingtechniquesUS:firstchoice,screening,difficulttocharacterizethelesionsCT:importanttechniqueMRI:problemresolvingtechniqueGoodmethodsofdecidingpositionandpredictingthenatureofthemassImagingtechniquesUS:firstchCTtechniquesCTtechniques7090120CTenhancedtechniques7090120CTenhancedtechniquesTheliverhasadualbloodsupplyfromthehepaticarteryandportalvein.Hepaticartery:1/3Portalvein:2/3TheliverhasadualbloodsupPortalveinphase60-70secafterborustracking-Hepaticmetastatictumor3minutesPortalveinphase-HepaticmetWhydoweneedmultiple-phaseenhancdmentIncreasethecontrastbetweennormalparenchymaandthelesionsothatincreasethedetectionrateUnderstandingthecharacteristicsofbloodsupplyandspeculatingthepathologicalchangesforthequalitativediagnosisWhydoweneedmultiple-phaseCASECASEMultiple-phaseenhancementMultiple-phaseenhancementMRIadvantagesMRIisoftenusedasaproblem-solveingtechniquetogiveadditionalinformationtoUSandCTExcellenttechniquefoedemonstratingtumoursImagescanbeobtainedincoronalandsagittalplanesIntravenuouscontrastisusedtoimprovevisualizationandhelpcharccterizelesions.Newliver-specificagents:SometakenbythehepatocytessomebythereticuloendothelialcellMRIadvantagesMRIisoftenuseMRIMRIMRCPMRCPMultiple-phaseEnhancementMultiple-phaseEnhancementArterialphaseEquilibriumphaseDelayedphase90minMultihance

liver-specificagents:specificallytakenbythehepatocytesPortalveinphaseArterialphaseEquilibriumphasHepatocarcinomacan’ttaketheagentmultihanceHepatocarcinomamultihanceCommonliverdiseasesimagingDiffusediseases:

fattyliver,cirrhosisFocaldiseases:

Benign：Livercyst,absecess,hemangiomaFocalnodulehyperplasia(FNH)adenoma

Malignant:heptocellularcarcinomacholangiocarcinomametastasistumorsCommonliverdiseasesimagingDFattyliverRelativelyfrequentfindingHypercholesterolaemiaobesityordiabetes,alcoholaddictandpatientsonchemotherapyorhormonotherapyDiffuseorlocalFattyinfiltrationleadstoareductionintheattenuationoftheaffectedparenchymacausinglowdensityonCTscansFattyliverRelativelyfrequent肝臟解剖與常見(jiàn)病影像診斷課件局灶性脂肪肝局灶性脂肪肝FattyliverFattyliverCirrhosisPathology:Livercelldegenerationandnecrosis,extensivefibrosisnodularregeneration----liverstructureandbloodcirculationsystemreconstructionImagingFeatures:Xray：esophagus,thebottomofthestomachvaricesCirrhosisPathology:LivercellCT、MRI

findings1/Shapemorphology：hepatomegaly/atrophic,liverloberatiochange,outerconcavecontour，parenchymalnodularregeneration2/Density:Inhomogeneousattenuation3/ContrastEnhancement(CE):inhomogeneousdegreeofenhancement,intrahepaticarterioportalfistulas4/Extrahepaticfindings:varices，scites,splenomegaly.5/Thedifferentialdiagnosis：

HepatocellularcarcinomaCT、MRI

findings1/Shapemorphol肝臟解剖與常見(jiàn)病影像診斷課件肝臟解剖與常見(jiàn)病影像診斷課件肝臟解剖與常見(jiàn)病影像診斷課件肝臟解剖與常見(jiàn)病影像診斷課件肝臟解剖與常見(jiàn)病影像診斷課件HepaticCystHepaticCystCT、MRIFeaturesRoundandquasi-circularSharpdemarcatationNonenhancingUniformdensityorsignal

CT：lowdensity(waterdensity0-15HU）T1WI：verylowsignalintensityT2WI：veryhighsignalintensityHepaticCystCT、MRIFeaturesHepaticCystHepaticAbscessBacterialandamebicliverabscessPathology：Pus/Necrosis/Fibertissue，InflammatorycellsinfiltrationEdemaImagingFeaturesSingleormultiplelowdensitylesionRoundorovalCircumferential[s?,k?mf?'ren??l]wall/enhancementfluildorgas-fluidlevelMRI：T1WI:hypo-intensityT2WI:hyper-intensityHepaticAbscessBacterialanda肝臟解剖與常見(jiàn)病影像診斷課件肝臟解剖與常見(jiàn)病影像診斷課件InflammatorygranulationtissueEdemaareaNecrosisTargetsignInflammatorygranulationtissu肝臟解剖與常見(jiàn)病影像診斷課件TargetsignAftertreatmentInflammatorygranulationtissueNecrosisedemaareaTargetsignAftertreatmentInflHemangioma

Pathology：BenignlesionCavernoushemangioma(mostly)/capillary/hemangioendotheliomaAtypeofbloodvesselmalformation(hemangioma)thathasrelativelylargeblood-filledspaces(cavities)Nocontaintissueoftheorganinwhichtheyaresituated.ImagingFeatures:Singleormultiplelowdensitylesion(CTvalue:30-40HU)Roundoroval,Sharpmargin,no

capsule

Contrast:earlyperipheralnodularenhancement,graduallyfillinginovertimeMRI：T1WI:hypo-intensityT2WI:hyper-intensityHemangioma

Pathology：BenignlHemangiomaHemangioma肝臟解剖與常見(jiàn)病影像診斷課件HemangiomaHemangioma肝臟解剖與常見(jiàn)病影像診斷課件肝臟解剖與常見(jiàn)病影像診斷課件肝臟解剖與常見(jiàn)病影像診斷課件FNH影像特征平掃密度信號(hào)與肝實(shí)質(zhì)接近強(qiáng)化明顯內(nèi)部瘢痕假包膜少見(jiàn)FNH影像特征平掃密度信號(hào)與肝實(shí)質(zhì)接近肝腺瘤Hepatocelluaradenoma女,18歲增強(qiáng)：強(qiáng)化明顯肝腺瘤Hepatocelluaradenoma女,1男,22歲易出血男,22歲易出血女性、23歲，MRI掃描征象：包膜、脂肪女性、23歲，MRI掃描征象：包膜、脂肪肝臟解剖與常見(jiàn)病影像診斷課件肝細(xì)胞癌我國(guó)最常見(jiàn)的惡性腫瘤之一發(fā)病率居惡性腫瘤的第2或第3位惡性程度高，5年生存率低于5%肝細(xì)胞癌我國(guó)最常見(jiàn)的惡性腫瘤之一肝細(xì)胞癌中國(guó)85%左右的HCC與病毒性肝炎肝硬化有關(guān)10％的中國(guó)人感染乙型肝炎病毒日本70％左右的HCC與丙型肝炎有關(guān)美國(guó)30-50％左右的HCC與丙型肝炎有關(guān)肝細(xì)胞癌中國(guó)肝細(xì)胞癌大體病理分型塊狀型直徑大于5厘米，大于10厘米為巨塊型結(jié)節(jié)型癌結(jié)節(jié)直徑小于5厘米，單發(fā)或多發(fā)彌漫型癌結(jié)節(jié)小，彌漫分布小肝癌單發(fā)結(jié)節(jié)小于3厘米，或2個(gè)病灶直徑之和小于3厘米肝細(xì)胞癌大體病理分型肝細(xì)胞癌臨床表現(xiàn)右上腹痛消瘦乏力，進(jìn)行性加重腹脹、腹瀉、惡性、納差黃疸發(fā)熱AFP升高>400ug/L，持續(xù)4周以上，除外妊娠、活動(dòng)性肝炎或生殖細(xì)胞腫瘤。肝細(xì)胞癌臨床表現(xiàn)肝臟解剖與常見(jiàn)病影像診斷課件肝臟解剖與常見(jiàn)病影像診斷課件肝細(xì)胞癌肝細(xì)胞癌肝細(xì)胞癌肝細(xì)胞癌肝細(xì)胞癌肝細(xì)胞癌小肝細(xì)胞癌的定義國(guó)際胃腸病學(xué)會(huì)（1994年）單個(gè)病灶直徑小于等于2厘米兩個(gè)病灶，其直徑之和小于等于2厘米日本Okuda單個(gè)病灶直徑小于等于4.5厘米四個(gè)以?xún)?nèi)病灶，直徑之和小于等于3.5厘米中國(guó)肝癌病理協(xié)作組？？單個(gè)病灶直徑小于等于2厘米兩個(gè)病灶，其直徑之和小于等于2厘米小肝細(xì)胞癌的定義國(guó)際胃腸病學(xué)會(huì)（1994年）小肝細(xì)胞癌CT-CCT+C動(dòng)脈期CT+C門(mén)脈期小肝細(xì)胞癌CT-CCT+C動(dòng)脈期CT+C門(mén)脈期丙型肝炎合并小肝癌丙型肝炎合并小肝癌膽管癌伴肝內(nèi)子灶膽管癌伴肝內(nèi)子灶肝臟解剖與常見(jiàn)病影像診斷課件BulleyesignBulleyesign肝臟解剖與常見(jiàn)病影像診斷課件intrahepaticmetastasis

APatientwithcoloncarcinomahistoryintrahepaticmetastasisAPatie食管靜脈曲張臍血管再通食管靜脈曲張臍血管再通肝臟解剖與常見(jiàn)病影像診斷課件肝臟解剖與常見(jiàn)病影像診斷課件肝臟解剖與常見(jiàn)病影像診斷課件肝臟解剖與常見(jiàn)病影像診斷課件肝臟解剖與常見(jiàn)病影像診斷課件肝臟解剖與常見(jiàn)病影像診斷課件肝臟解剖與常見(jiàn)病影像診斷課件77%95%77%95%ThankyouThankyouTheHepaticLesion:RadiologicAssessment

TheAffiliatredhospitalofNBUWangJIANHUAwoxingw@2014-12-29TheHepaticLesion:2014-12-29CASECASE肝臟解剖與常見(jiàn)病影像診斷課件肝臟解剖與常見(jiàn)病影像診斷課件肝臟解剖與常見(jiàn)病影像診斷課件ObjectivesNormalliveranatomyImagingtechniquesCommondiseasesimagingdiagnosisDiffusediseasesFocaldiseases

ObjectivesNormalliveranatomyAnatomyoftheliversegments

Twodifferentaspects:morphologicalanatomyandfunctionalanatomy.

C.Couinaud(1957)dividedtheliverintoeightfunctionallyindepedentsegments.

Thisclassificationwillbepresentedherewithseveralillustrations.Anatomyoftheliversegments

Couinaudclassification

Dividestheliverintoeightfunctionallyindepedentsegments.

Eachsegmenthasitsownvascularinflow,outflowandbiliarydrainage.

Inthecentreofeachsegmentthereisabranchoftheportalvein,hepaticarteryandbileduct.

Intheperipheryofeachsegmentthereisvascularoutflowthroughthehepaticveins.Couinaudclassification

DividePortahepatisSecondPortahepatisPortahepatisSecondPortahepa肝臟解剖與常見(jiàn)病影像診斷課件Righthepaticveindividestherightlobeintoanteriorandposteriorsegments.

CrosstransversePortalveindividestheliverintoupperandlowersegments.

Middlehepaticveindividestheliverintorightandleftlobes(orrightandlefthemiliver).ThisplanerunsfromtheinferiorvenacavatothegallbladderfossaLefthepaticveindividestheleftlobeintoamedialandlateralpart.RighthepaticveindividestheTheimageonthefarleftisattheleveloftherightportalvein.Atthisleveltherightportalveindividestherightlobeoftheliverintosuperiorsegments(7and8)andtheinferiorsegments(5and6).

Theleveloftherightportalveinisinferiortotheleveloftheleftportalvein.Atthelevelofthesplenicvein,whichisbelowtheleveloftherightportalvein,onlytheinferiorsegmentsareseen(rightimage).TheimageonthefarleftisaCounterclockwiseCounterclockwise1CaudatelobeSegment1Segment4aSegment8Segment72Leftlateraluppersagment8Rightanterioruppersagment4Leftmedialsagment7RightposterioruppersagmentSegment21CaudatelobeSegment1SegmentLeftlateraluppersagmentLeftlateraluppersagmentLeftlaterallowsegmentLeftlaterallowsegmentLeftmedialsegmentLeftmedialsegmentRightposterioruppersegmentRightposterioruppersegmentRightanteriorupperdegmentRightanteriorupperdegmentRightanteriorlowdegmentRightanteriorlowdegmentRightposteriorlowsegmentRightposteriorlowsegmentLiveranatomyLiveranatomyImagingtechniquesUS:firstchoice,screening,difficulttocharacterizethelesionsCT:importanttechniqueMRI:problemresolvingtechniqueGoodmethodsofdecidingpositionandpredictingthenatureofthemassImagingtechniquesUS:firstchCTtechniquesCTtechniques7090120CTenhancedtechniques7090120CTenhancedtechniquesTheliverhasadualbloodsupplyfromthehepaticarteryandportalvein.Hepaticartery:1/3Portalvein:2/3TheliverhasadualbloodsupPortalveinphase60-70secafterborustracking-Hepaticmetastatictumor3minutesPortalveinphase-HepaticmetWhydoweneedmultiple-phaseenhancdmentIncreasethecontrastbetweennormalparenchymaandthelesionsothatincreasethedetectionrateUnderstandingthecharacteristicsofbloodsupplyandspeculatingthepathologicalchangesforthequalitativediagnosisWhydoweneedmultiple-phaseCASECASEMultiple-phaseenhancementMultiple-phaseenhancementMRIadvantagesMRIisoftenusedasaproblem-solveingtechniquetogiveadditionalinformationtoUSandCTExcellenttechniquefoedemonstratingtumoursImagescanbeobtainedincoronalandsagittalplanesIntravenuouscontrastisusedtoimprovevisualizationandhelpcharccterizelesions.Newliver-specificagents:SometakenbythehepatocytessomebythereticuloendothelialcellMRIadvantagesMRIisoftenuseMRIMRIMRCPMRCPMultiple-phaseEnhancementMultiple-phaseEnhancementArterialphaseEquilibriumphaseDelayedphase90minMultihance

liver-specificagents:specificallytakenbythehepatocytesPortalveinphaseArterialphaseEquilibriumphasHepatocarcinomacan’ttaketheagentmultihanceHepatocarcinomamultihanceCommonliverdiseasesimagingDiffusediseases:

fattyliver,cirrhosisFocaldiseases:

Benign：Livercyst,absecess,hemangiomaFocalnodulehyperplasia(FNH)adenoma

Malignant:heptocellularcarcinomacholangiocarcinomametastasistumorsCommonliverdiseasesimagingDFattyliverRelativelyfrequentfindingHypercholesterolaemiaobesityordiabetes,alcoholaddictandpatientsonchemotherapyorhormonotherapyDiffuseorlocalFattyinfiltrationleadstoareductionintheattenuationoftheaffectedparenchymacausinglowdensityonCTscansFattyliverRelativelyfrequent肝臟解剖與常見(jiàn)病影像診斷課件局灶性脂肪肝局灶性脂肪肝FattyliverFattyliverCirrhosisPathology:Livercelldegenerationandnecrosis,extensivefibrosisnodularregeneration----liverstructureandbloodcirculationsystemreconstructionImagingFeatures:Xray：esophagus,thebottomofthestomachvaricesCirrhosisPathology:LivercellCT、MRI

findings1/Shapemorphology：hepatomegaly/atrophic,liverloberatiochange,outerconcavecontour，parenchymalnodularregeneration2/Density:Inhomogeneousattenuation3/ContrastEnhancement(CE):inhomogeneousdegreeofenhancement,intrahepaticarterioportalfistulas4/Extrahepaticfindings:varices，scites,splenomegaly.5/Thedifferentialdiagnosis：

HepatocellularcarcinomaCT、MRI

findings1/Shapemorphol肝臟解剖與常見(jiàn)病影像診斷課件肝臟解剖與常見(jiàn)病影像診斷課件肝臟解剖與常見(jiàn)病影像診斷課件肝臟解剖與常見(jiàn)病影像診斷課件肝臟解剖與常見(jiàn)病影像診斷課件HepaticCystHepaticCystCT、MRIFeaturesRoundandquasi-circularSharpdemarcatationNonenhancingUniformdensityorsignal

CT：lowdensity(waterdensity0-15HU）T1WI：verylowsignalintensityT2WI：veryhighsignalintensityHepaticCystCT、MRIFeaturesHepaticCystHepaticAbscessBacterialandamebicliverabscessPathology：Pus/Necrosis/Fibertissue，InflammatorycellsinfiltrationEdemaImagingFeaturesSingleormultiplelowdensitylesionRoundorovalCircumferential[s?,k?mf?'ren??l]wall/enhancementfluildorgas-fluidlevelMRI：T1WI:hypo-intensityT2WI:hyper-intensityHepaticAbscessBacterialanda肝臟解剖與常見(jiàn)病影像診斷課件肝臟解剖與常見(jiàn)病影像診斷課件InflammatorygranulationtissueEdemaareaNecrosisTargetsignInflammatorygranulationtissu肝臟解剖與常見(jiàn)病影像診斷課件TargetsignAftertreatmentInflammatorygranulationtissueNecrosisedemaareaTargetsignAftertreatmentInflHemangioma

Pathology：BenignlesionCavernoushemangioma(mostly)/capillary/hemangioendotheliomaAtypeofbloodvesselmalformation(hemangioma)thathasrelativelylargebloo