肝脏解剖与常见病影像诊断课件

TheHepaticLesion:RadiologicAssessment

TheAffiliatredhospitalofNBUWangJIANHUAwoxingw@2014-12-29TheHepaticLesion:2014-12-29CASECASE肝脏解剖与常见病影像诊断课件肝脏解剖与常见病影像诊断课件肝脏解剖与常见病影像诊断课件ObjectivesNormalliveranatomyImagingtechniquesCommondiseasesimagingdiagnosisDiffusediseasesFocaldiseases

ObjectivesNormalliveranatomyAnatomyoftheliversegments

Twodifferentaspects:morphologicalanatomyandfunctionalanatomy.

C.Couinaud(1957)dividedtheliverintoeightfunctionallyindepedentsegments.

Thisclassificationwillbepresentedherewithseveralillustrations.Anatomyoftheliversegments

Couinaudclassification

Dividestheliverintoeightfunctionallyindepedentsegments.

Eachsegmenthasitsownvascularinflow,outflowandbiliarydrainage.

Inthecentreofeachsegmentthereisabranchoftheportalvein,hepaticarteryandbileduct.

Intheperipheryofeachsegmentthereisvascularoutflowthroughthehepaticveins.Couinaudclassification

DividePortahepatisSecondPortahepatisPortahepatisSecondPortahepa肝脏解剖与常见病影像诊断课件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肝脏解剖与常见病影像诊断课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肝脏解剖与常见病影像诊断课件肝脏解剖与常见病影像诊断课件肝脏解剖与常见病影像诊断课件肝脏解剖与常见病影像诊断课件肝脏解剖与常见病影像诊断课件HepaticCystHepaticCystCT、MRIFeaturesRoundandquasi-circularSharpdemarcatationNonenhancingUniformdensityorsignal

CT：lowdensity(waterdensity0-15HU）T1WI：verylowsignalintensityT2WI：veryhighsignalintensityHepaticCystCT、MRIFeaturesHepaticCystHepaticAbscessBacterialandamebicliverabscessPathology：Pus/Necrosis/Fibertissue，InflammatorycellsinfiltrationEdemaImagingFeaturesSingleormultiplelowdensitylesionRoundorovalCircumferential[sə,kʌmfə'renʃəl]wall/enhancementfluildorgas-fluidlevelMRI：T1WI:hypo-intensityT2WI:hyper-intensityHepaticAbscessBacterialanda肝脏解剖与常见病影像诊断课件肝脏解剖与常见病影像诊断课件InflammatorygranulationtissueEdemaareaNecrosisTargetsignInflammatorygranulationtissu肝脏解剖与常见病影像诊断课件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肝脏解剖与常见病影像诊断课件HemangiomaHemangioma肝脏解剖与常见病影像诊断课件肝脏解剖与常见病影像诊断课件肝脏解剖与常见病影像诊断课件FNH影像特征平扫密度信号与肝实质接近强化明显内部瘢痕假包膜少见FNH影像特征平扫密度信号与肝实质接近肝腺瘤Hepatocelluaradenoma女,18岁增强：强化明显肝腺瘤Hepatocelluaradenoma女,1男,22岁易出血男,22岁易出血女性、23岁，MRI扫描征象：包膜、脂肪女性、23岁，MRI扫描征象：包膜、脂肪肝脏解剖与常见病影像诊断课件肝细胞癌我国最常见的恶性肿瘤之一发病率居恶性肿瘤的第2或第3位恶性程度高，5年生存率低于5%肝细胞癌我国最常见的恶性肿瘤之一肝细胞癌中国85%左右的HCC与病毒性肝炎肝硬化有关10％的中国人感染乙型肝炎病毒日本70％左右的HCC与丙型肝炎有关美国30-50％左右的HCC与丙型肝炎有关肝细胞癌中国肝细胞癌大体病理分型块状型直径大于5厘米，大于10厘米为巨块型结节型癌结节直径小于5厘米，单发或多发弥漫型癌结节小，弥漫分布小肝癌单发结节小于3厘米，或2个病灶直径之和小于3厘米肝细胞癌大体病理分型肝细胞癌临床表现右上腹痛消瘦乏力，进行性加重腹胀、腹泻、恶性、纳差黄疸发热AFP升高>400ug/L，持续4周以上，除外妊娠、活动性肝炎或生殖细胞肿瘤。肝细胞癌临床表现肝脏解剖与常见病影像诊断课件肝脏解剖与常见病影像诊断课件肝细胞癌肝细胞癌肝细胞癌肝细胞癌肝细胞癌肝细胞癌小肝细胞癌的定义国际胃肠病学会（1994年）单个病灶直径小于等于2厘米两个病灶，其直径之和小于等于2厘米日本Okuda单个病灶直径小于等于4.5厘米四个以内病灶，直径之和小于等于3.5厘米中国肝癌病理协作组？？单个病灶直径小于等于2厘米两个病灶，其直径之和小于等于2厘米小肝细胞癌的定义国际胃肠病学会（1994年）小肝细胞癌CT-CCT+C动脉期CT+C门脉期小肝细胞癌CT-CCT+C动脉期CT+C门脉期丙型肝炎合并小肝癌丙型肝炎合并小肝癌胆管癌伴肝内子灶胆管癌伴肝内子灶肝脏解剖与常见病影像诊断课件BulleyesignBulleyesign肝脏解剖与常见病影像诊断课件intrahepaticmetastasis

APatientwithcoloncarcinomahistoryintrahepaticmetastasisAPatie食管静脉曲张脐血管再通食管静脉曲张脐血管再通肝脏解剖与常见病影像诊断课件肝脏解剖与常见病影像诊断课件肝脏解剖与常见病影像诊断课件肝脏解剖与常见病影像诊断课件肝脏解剖与常见病影像诊断课件肝脏解剖与常见病影像诊断课件肝脏解剖与常见病影像诊断课件77%95%77%95%ThankyouThankyouTheHepaticLesion:RadiologicAssessment

TheAffiliatredhospitalofNBUWangJIANHUAwoxingw@2014-12-29TheHepaticLesion:2014-12-29CASECASE肝脏解剖与常见病影像诊断课件肝脏解剖与常见病影像诊断课件肝脏解剖与常见病影像诊断课件ObjectivesNormalliveranatomyImagingtechniquesCommondiseasesimagingdiagnosisDiffusediseasesFocaldiseases

ObjectivesNormalliveranatomyAnatomyoftheliversegments

Twodifferentaspects:morphologicalanatomyandfunctionalanatomy.

C.Couinaud(1957)dividedtheliverintoeightfunctionallyindepedentsegments.

Thisclassificationwillbepresentedherewithseveralillustrations.Anatomyoftheliversegments

Couinaudclassification

Dividestheliverintoeightfunctionallyindepedentsegments.

Eachsegmenthasitsownvascularinflow,outflowandbiliarydrainage.

Inthecentreofeachsegmentthereisabranchoftheportalvein,hepaticarteryandbileduct.

Intheperipheryofeachsegmentthereisvascularoutflowthroughthehepaticveins.Couinaudclassification

DividePortahepatisSecondPortahepatisPortahepatisSecondPortahepa肝脏解剖与常见病影像诊断课件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肝脏解剖与常见病影像诊断课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肝脏解剖与常见病影像诊断课件肝脏解剖与常见病影像诊断课件肝脏解剖与常见病影像诊断课件肝脏解剖与常见病影像诊断课件肝脏解剖与常见病影像诊断课件HepaticCystHepaticCystCT、MRIFeaturesRoundandquasi-circularSharpdemarcatationNonenhancingUniformdensityorsignal

CT：lowdensity(waterdensity0-15HU）T1WI：verylowsignalintensityT2WI：veryhighsignalintensityHepaticCystCT、MRIFeaturesHepaticCystHepaticAbscessBacterialandamebicliverabscessPathology：Pus/Necrosis/Fibertissue，InflammatorycellsinfiltrationEdemaImagingFeaturesSingleormultiplelowdensitylesionRoundorovalCircumferential[sə,kʌmfə'renʃəl]wall/enhancementfluildorgas-fluidlevelMRI：T1WI:hypo-intensityT2WI:hyper-intensityHepaticAbscessBacterialanda肝脏解剖与常见病影像诊断课件肝脏解剖与常见病影像诊断课件InflammatorygranulationtissueEdemaareaNecrosisTargetsignInflammatorygranulationtissu肝脏解剖与常见病影像诊断课件TargetsignAftertreatmentInflammatorygranulationtissueNecrosisedemaareaTargetsignAftertreatmentInflHemangioma

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