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GALLBLADDER portions of the duodenum are labeled in

white.
 functions as a reservoir for bile produced  at the head of the pancreas, the common
by the liver. It is 7-10 cm long, 3 cm wide bile duct meets the pancreatic duct, and
at its broadest measure, and has a they exit into the second part of the
capacity of 30-50 mL duodenum, forming the hepatopancreatic
ampulla (ampulla of Vater)

 divided into 3 regions: fundus, body, and


neck

 bile produced by the left and right portions


of the liver travel through the right and
left hepatic ducts (1-2 mm in diameter).
These two ducts join to form the common
hepatic duct
 the common hepatic duct lies anterior to
the portal vein and to the right of hepatic
artery
 the common hepatic duct descends
roughly 3 cm before the cystic duct (3-4
cm long) from the gallbladder joins it from
the right

Adenomyomatosis
 one of the many causes for gallbladder
wall thickening
 pathologically, it is identified by
proliferation of the gallbladder mucosa
with diverticular outpuochings known as
Rokitansky-Aschoff sinuses
 typically cholesterol deposits are seen
within the gallbladder wall and cause a
 the common bile duct passes posterior to comet tail artifact
the first portion of the duodenum. It then
descends via a groove on the Causes of GB wall thickening
superolateral portions of the posterior
 biliary causes include:
head of the pancreas sometimes traveling
-acute cholecystitis, gall bladder
through the pancreas head. The four
carcinoma, polyps, as well as adenomyomatosis
 nonbiliary causes include:
-CHF, hepatitis, pancreatitis as well as
AIDs cholangiopathy

Acute Acalculous Cholecystitis


 represents inflammation of the gallbladder
in the absence of demonstrated calculi
 the disease process is distinct from the
calculous variety, in which the primary
initiating event is believed to be
obstruction of the cystic duct
 typically occurs as a secondary event in  gallbladder wall thickening
patients who are hospitalized and acutely  mucosal irregularity
ill from another cause  luminal distention
 increased bile density (biliary sludge)
Pathophysiology
 intramural or intraluminal gas
 at least 3 mechanisms
 intraluminal hemorrhage
a. systemic mediators of inflammation and
trauma  localized pericholecystic fluid collections
b. biliary stasis  inflammatory infiltration of pericholecystic
c. generalized or localized ischemia fat
 in turn, the mechanisms often result in  indistinctiveness of the liver-gallbladder
functional or secondary mechanical interface
obstruction of the cystic duct from
inflammation and bile viscosity Acute Cholecystitis
 sonographic criteria for acute cholecystitis
Sonographic signs compatible with acalculous -a thickened gallbladder wall (normal GB
cholecystitis wall- <3 mm)
 other sonographic findings
-gallstones
-positive Murphy’s sign
-pericholecystic fluid as well as
sonolucencies within the gallbladder wall
(indicates gallbladder wall edema)

Complications
 empyema
 gangrene
 perforation

 gallbladder wall thickening Epigastric Pain


 sonographically localized tenderness over
the GB
 subserosal edema
 pericholecystic fluid
 gallbladder distention
 biliary sludge
 presence of gas

CT findings
Chronic Cholecystitis with GB polyps
 chronic inflammation of the gallbladder
results from recurrent attacks of acute
cholecystitis
 fibrotic reaction usually causes the
gallbladder to become small and
contracted

Diffuse Wall Thickening


 most frequent gallbladder wall  75-80% of gallstones are of the cholesterol
abnormality detected by ultrasound type
 the wall is >3mm thick  10-25% of gallstones are bilirubinate of
 this appearance is neither sensitive nor either black or brown pigment
specific for an inflammatory process  in Asia, pigmented stones predominate,
although recent studies have shown an
Case increase in cholesterol stones in the Far
-patient is a 72-year old woman who presents East
with nausea and vomiting

Porcelain Gallbladder
 has been termed calcifying cholecystitis,
cholecystopathia chronic calcaria, or
calcified gallbladder
 are 5 times more common in women than
in men
 most often considered a sequel of low-
grade chronic inflammation Complications
 some have postulated that it is secondary  biliary colic- 56 %
to intramural hemorrhage or an imbalance  acute cholecystitis- 36 %
in calcium metabolism  acute pancreatitis- 4 %
 choledocholithiasis- 3 %
 gall bladder cancer- 0.3 %
 cholangitis- 0.2 %

Gall Stones

 appear as single or multiple filling defects


within the gallbladder and are densely
calcified, rim calcified, laminated, or have
a central nidus of calcification

Cholelithiasis
 is the pathologic state of stones or calculi
within the gallbladder lumen
 associated with chronic gallbladder
inflammation and gall stones in 95 % of
cases
 it appears as an echogenic arc with dense
posterior shadowing

Carcinoma of the Gallbladder


 the most common primary hepatobiliary
carcinoma
 the fifth most common malignancy of the
GI tract
 stones also may present as a soft-tissue  predominantly affects older persons with
density or a lucent filling defect within the long-standing cholecystolithiasis
bile. Some stones may contain air  GB epithelial tumors tend to behave
similarly to other GI adenocarcinomas
 most gallstones have no signal on MRI and  GB tumors occur in the fundus in 60 % of
present as signal void-filling defects within patients, in the body in 30 %, and neck 10
the gallbladder %
 early lymphatic spread occurs to the
retroperitoneal, right celiac, and
pancreaticoduodenal nodes
 direct invasion of the liver, extrahepatic
biliary ducts, and duodenum, and colon
occurs
 intraperitoneal seeding may occur

Ultrasound findings
 GB wall thickening
 single or multiple intraluminal mass
 extraluminal mass extending to the liver
 on T2-weighted sequences where signal-  polyps larger than 1 cm in diameter
void stones are contrasted against high-
signal bile Extraluminal mass extending to the liver
 on T1 weighted sequences, bile usually  this often is accompanied by a large mass
shows a homogenous low signal replacing the GB fossa
 the mass often is complex with areas of
necrosis visible
 this is the most common manifestation of
GB carcinoma, accounting for 40-65 % of
GB carcinomas

 signal-void stones also may be apparent


on T1-weighted images
 high signal may be seen occasionally on
T2-weighted images within stones that  US shows echogenic mass adherent to
contain bile within clefts gallbladder fundus (arrows). CT shows
 stones with high fatty acid content may enhancing mass within the gallbladder
demonstrate high signal on T1-weighted (arrows) with involvement of the liver
images (arrow head)

Porcelain gallbladder along with


distention and filled with sludge and
calculi
3-Left inferior lateral subsegment
4a-Left superior medial subsegment
4b-Left inferior medial subsegment
5-Right inferior anterior subsegment
6-Right inferior posterior subsegment
7-Right superior posterior subsegment
8-Right superior anterior subsegment

Bacterial (Pyogenic) Abscess


 80-85 % of all abscesses are bacterial in
origin
 bacteria gain access to liver via the portal
LIVER or biliary system. Possible causes are
iatrogenic, biliary disease, diverticular
disease, trauma, and inflammatory bowel
disease
 E. coli and anaerobes are the two most
common offending agents in pyogenic
abscess
 most pyogenic abscesses occur in the
right lobe

Radiogrpahic Findings (US)


 heterogenous, rounded masses with
irregular, thickened walls and poor
peripheral definition
 unique in having a dual blood supply  fluid and debris inside the abscess can
- 75 % originating from the portal venous create internal echoes
system and  gas-containing lesion also has acoustic
-25 % arising from the hepatic artery shadowing
 the hepatic veins are responsible for
drainage of filtered blood from the liver CT
into the IVC

3 Functional Lobes
 right
 left
 caudate

 the right and left lobes are further divided


into 2 segments each:
-the anterior and posterior
segments of the right lobe
-the medial and lateral segments of  heterogenous lesion with irregular margin
the left lobe (arrowhead) and possible peripheral
enhancement
Segments  internal septations or papillary projections
 20 % contain gas

Amebic Abscess
 trnasmitted by fecal-oral route
 the organism, E. histolytica, first infects
the colon, then gains access to the liver
via portal venous system
 patients generally present with right upper
quadrant pain

Radiographic Findings (US & CT)


1-Caudate lobe  indistinguishable from bacterial abscess.
2-Left superior lateral subsegment Tends to be peripheral in location
Diffuse Hepatic Disease
CT Findings
Cirrhosis

Causes
 alcohol
 alpha 1-antitrypsin
 postnecrotic (hepatitis)
 metabolic disease: Wilson,
hemochromatosis, glycogen storage
disease
 congestive heart failure

Pathology
 hepatocyte necrosis
 fibrosis
 nodular regeneration

Radiographic Findings

Signsof advanced necrosis


 generally non specific including:  liver surface nodularity
 a peripherally based, round or oval low  contracted liver with ascites
density lesion which often demonstrates a
 atrophy of the posterior segments (VI, VII)
peripheral rim of slightly higher of the right lobe
attenuation
 enlarged caudate lobe (I) and lateral
 the peripheral rim will often enhance with segments (II, III) of the left lobe
contrast administration
 prominent umbilical vein
 irregular enhancement
Echinococcal Abscess
 dogs are the main intermediate hosts of
hydatid disease
 eggs get ingested, hatch in the stomach
and duodenum, travel to the liver via
portal venous drainage, encyst in the liver
and grow slowly
 the cysts can exert mass effect on the
surrounding liver and biliary system. The
right lobe of the liver is most frequently
involved
 the cysts can rupture into the pleural  US- advanced cirrhotic liver appears to be
cavity, peritoneal cavity, alimentary canal, nodular, irregular, and contracted with
or biliary tree, causing profound shock, relatively enlarged caudate lobe (C) and
peritonitis, and anaphylaxis lateral segment (L) of the left lobe. Fatty
infiltration and fibrosis give a coarse
Radiographic Findings (US) echotexture of the liver parenchyma

 double-layered cyst, “classic” double-line


sign, water lily sign, racemose
Diffuse Fatty Infiltration
 Contrast CT: areas of fibrosis and
 a reversible process in which triglyceride
regeneration may become isodense to
accumulates diffusely in hepatocytes
parenchyma. The surface of the liver may
causing abnormal appearance on imaging
be very nodular in cirrhosis
 normally, less than 5 % of the liver is
composed of fat. In diffuse fatty infiltrated
liver, fat can make up to 50 % of the liver
tissue
 commonly seen in acute or chronic alcohol
abuse (most common), obesity, diabetes,
cystic fibrosis, tetracycline, steroids,
chemotherapy, malnutrition, and
hyperalimentation
 clinically, patients are asymptomatic. Liver
can be enlarged but without splenomegaly

 development of collateral vessels in portal Radiographic Findings (US)


hypertension
 splenomegaly and the presence of ascites

 the liver has increased focal or diffuse


echogenicity when compared to the
surrounding organs such as the kidneys

 Noncontrast CT- the liver looks hypodense


to the spleen due to fatty infiltration,
making the hepatic vasculature more
prominent

Hemochromatosis
 iron overload leads to deposition in the idiopathic, usually asymptomatic and
liver. The liver can be enlarged variable in size. They cannot be
 primary hemochromatosis: an autosomal distinguished from cysts that arise from
recessive disease that has abnormal prior hematomas or abscesses
absorption of iron in the intestine and thus  they can be associated with other disease
causes iron to be deposited in processes such as tuberous sclerosis and
hepatocytes, spleen, pancreas, and the polycystic kidney disease
myocardium  40 % of patients with polycystic kidney
 secondary hemochromatosis: caused by diseae have liver cysts
multiple transfusions with deposition of  60 % of patients with multiple liver cysts
iron in the reticuloendothelial cells of the have polycystic kidney disease
liver and the spleen. However, the
pancreas is not usually involved. If the Radiographic Findings
pancreas is involved, the
hemochromatosis is usually of the primary
type

US (95-99 % accurate)
 anechoic
 posterior enhancement (increased
transmitted sound)
 well-defined or imperceptible walls
 CT: hyperdense liver (>75 HU). There are
similar findings in Wilson’s disease,
amiodarone toxicity, and previous
thorotrast exposure

 Non-contrast CT: density of less than 20


HU, well-defined margins, no perceptible
wall (arrow)
 T1 and T2 weighted MRI: liver and spleen
are hyperintense (very dark liver)  Contrast CT: no enhancement after
compared with adjacent muscles owing to contrast administration
paramagnetic effect. Normally, the signal
intensity of the liver parenchyma is equal MRI
to or slightly greater than that of muscle

Simple Cysts
 the most common liver masses
 may be solitary or multiple
 cysts are found in 2-10 % of population,
has increased frequency with age and is
more common in females aged 50-70
 true hepatic cysts have bile duct origin
and cuboidal epithelial lining. They are
 US: hyperechoic and well-defined
 T1 weighted- homogeneously hypointense
(arrowhead)

 T2 weighted- homogeneously
hyperintense (arrow) due to water
property (comparable to the intensity of
CSF or gallbladder bile

Differential Diagnosis
 cystic liver mass with internal echoes,
thick septations, or a perceptible wall  T1 weighted MRI- hypointense to liver
noted on US include (arrows). If gadolinium-diethylenetriamine
-hemorrhagic cyst penta-acetic acid (Gd-DTPA) is used,
-abscess peripheral enhancement is seen initially
-echinococcal cyst with central enhancement within 15-30
-biliary cystadenoma minutes. Enhancement is persistent
-cystic metastasis (e.g. ovarian)
-HCC with necrosis

Hemangioma
 is a benign proliferation of vascular tissue
lined with endothelium which has slow
hepatic arterial blood flow
 two types are capillary (more common)
and cavernous
 occurs in the right lobe
 can easily be confused with metastases or  T2-weighted MRI- hyperinetense to the
hepatoma liver (just like a cyst; arrows). Looks as
bright as a light bulb! Intensity is as high
 the most common cause of a hyperechoic
as that of pure fluid (CSF or bile)
liver mass on US
 large hemangioma may appear
heterogenous. There may be thrombosis
Focal Nodular Hyperplasia
or a central stellate scar with a giant  most likely seen in young women (3 %)
hemangioma
Pathology
 a non-capsulated nodular mass
 was thought to be a
vascular/hamartomatous malformation
 is composed of normal hepatocytes,
Kupffer cells, and bile ducts but arranged
abnormally
 is less than 5 cm in diameter, most
commonly found peripherally in the right
lobe
 classic appearance: solitary, well-
circumscibed mass with a central stellate
scar of fibrosis even though the central
scar is seen in only 20 % of the cases

Hepatocellular Carcinoma (HCC)

• the most common primary hepatic tumor


and
• one of the most common cancers
 Non-contrast- the lesion has low worldwide
attenuation (arrows) compared with the
• a primary malignancy of hepatocyte origin
normal liver. The central stellate scar may
also show low attenuation
3 Growth Patterns of HCC
 Contrast CT: the lesion shows homogenous
enhancement early in arterial phase • Solitary mass – often large
(arrows) with prompt wash out. The • Multifocal or Nodular Pattern – multiple
central stellate scar will not enhance. nodules
• Diffuse – multiple, small foci scattered
diffusely throughout liver

US Findings

• Small HCCs can be homogenously


hyperechoic and can mimic hemangioma.
This can result when a large proportion of
fat is present in the tumor
• Small HCCs can appear hypoehcoic with
larger HCCs frequency mixed in
echogenicity.

 T1-weighted MRI: The lesion is hypo-


isointense to the normal liver. The central
scar enhances with Gd-DTPA.

 T2-weighted MRI: The lesion is isointense


to slightly hyperintense to liver. The
central scar is hyperintense to the liver
(arrows). (In contrast to hypointense
appearance of the central scar in large
hemangioma)

In the Portal Venous Phases

• Small lesions may be isodense or


hypodense and difficult to see, since the
remainder of the liver increases in
attenuation.
• Larger lesions with necrotic regions remain • In children the most common liver
hypodense. metastases are from a neuroblastoma,
Wilm’s tumor or leukemia.

Contrast CT: dense diffuse non-uniform


enhancement in arterial phase; some lesions are
hypervascular
Causes of Echogenic Metastases

• Mucinous adenocarcinoma of the colon,


Pancreatic carcinoma (usually hypoechoic
but possibly becoming echogenic as
calcification occurs), Gastric carcinoma
(usually hypoechoic), HCC,
Neuroblastoma, Cholangiocarcinoma,
Treated Breast Carcinoma, Renal cell
Carcinoma, Carcinoid, Choriocarcinoma,
Pancreatic Islet Cell tumors, Wilm’s Tumor
(usually spread to the lungs), Kaposi
sarcoma, Myeloma deposit, Hepatic
MRI chloroma

• T1-weighted: usually hypointense to


normal liver. When fatty change, fibrosis,
or copper is present, variable signal can
be seen.
• With Gd-DTPA, hypervascular lesions
enhance early in the arterial phase.

Causes of Hypoechoic Metastases

• Lymphoma (especially AIDS related), HCC,


Pancreatic carcinoma, Lung (particularly
adenocarcinoma), Cervix, Melanoma,
Nasopharyngeal carcinoma, Kaposi
sarcoma (rare, most are hyperechoic),
Myeloma deposits, Cystic liver
metastases, Mucinous
Liver Metastasis cystadenocarcinoma colon,
Cystadenocarcinoma ovary.
• The liver is the most commonly involved Cystadenocarcinoma pancreas,
organ by metastatic disease, after the Leiomyosarcoma, Squamous cell
lymph nodes. carcinoma, Testicular CA, Carcinoid,
• The most common primary sites are the Graunulosa cell ovarian tumor.
eye, colon, stomach, pancreas, breast and
lung. Cystic metastases
Two groups of patients tend to get cystic
metastases:

(1) Patients who have a primary neoplasm


with a cystic component such as a
mucinous cystadenocarcinoma of the
colon, stomach, pancreas, or ovary and,
(2) Patients with metastases that are
undergoing central necrosis, when low-
level echoes and wall irregularity is seen.
Squamous cell carcinoma,
leiomyosarcoma, melanoma, and Portal Vein Thrombosis
testicular carcinoma, have a propensity to
undergo extensive central necrosis. Five causes of portal vein thrombosis:
Causes of Bull’s Eye or Target, Metastases 1. Pancreatitis
2. Cirrhosis
• The halo is most probably related 3. Hepatic or biliary surgery
to a combination of compressed 4. Hepatoma with tumor thrombus
normal hepatic parenchyma around 5. Hypercoagulable states
the mass and a zone of cancer cell
proliferation CT: example of carcinoma in the hepatic vein
• The presence of a halo usually
suggests aggressive behavior
• Bronchogenic carcinoma
• Breast and colon as well as
• Primary malignant liver neoplasms
(eg. HCC) and
• Benign liver neoplasms (eg.
Adenoma in glycogen storage
disease)

Causes of heterogeneously Echogenic Liver


Metastases

• Breast, colon and/or rectum, stomach


(especially anaplastic lesions) and cervix
• Other causes of heterogeneously liver
metastases include the ff: HCC (especially
when complicated with hemorrhage), PANCREAS
carcinoid, melanoma, and bronchogenic Acute Pancreatitis
carcinoma.
• Common cause of pancreatitis include
alcohol abuse, choledolithiasis,
hypergylceridemia and hypercalcemia.
Acute pancreatitis usually presents as an
acute episode of upper abdominal pain,
with or without accompanying GI
symptoms.

• Other symptoms may include fever,


hypotension, pulmonary edema or shock.
Laboratory values reveal elevated WBC,
serum amylase and pancreatic lipase.
Initial treatment of pancreatitis includes
NPO, NG suction, analgesics, parenteral or
jejunal feeding. Prophylactic antibiotics
may also be of benefit.
Ranson’s score estimates the life threatening associated with associated with
complications or death in patients with acute pancreatic fat acute pancreatitis
pancreatitis using several factors at the time of infiltration
admission and during the first 48 hours
thereafter. Grad Single fluid
eD collection
Ranson’s Score
Grad Two or more fluid
Values at Admission First 48 Hours eE collections.

Age>55 Hct fall >10%

WBC >16,000/ml Ca >8mEq/L

Glucose >200mg/dl BUN rise > 5mg/dl

LDH>350 U/L PaO2 < 60mmHg

AST > 250 U/L Base defect > 4 mEq/L

Fluid sequestration > Nausea, vomiting with abdominal pain that


6L radiates to the back

Number of Criteria Mortality

0-2 <5%

3-4 15-20%

5-6 40%
Acute Necrotizing Pancreatitis
≥7 >99%
• Pancreatic necrosis is a known
complication of acute pancreatitis.
• Areas of necrosis are usually multifocal
Balthazar et al developed a classification system and rarely involve the entire gland.
for patients with acute pancreatitis based on • Necrosis develops earl in severe
radiologic findings pancreatitis and is usually established
within 96 hours of the onset of clinical
symptoms.

Balthazar et al Radiographic Grading of


Acute Pancreatitis

G Radiographic Prognosis
rade Findings

Grad Normal appearing


eA pancreas
Pancreatic Pseudocysts
Grad Focal or diffuse Mild,
eB enlargement of the uncomplicated • The most common cystic lesions of the
pancreas accounting for 75-80% of such
pancreas course
masses
Grad Pancreatic gland High risk of • A collection of amylase-rich, lipase-rich,
eC abnormalities complications and enterokinase-rich fluid
• Most frequently located in the lesser Pancreatic Cancer
peritoneal sac in proximity to the pancreas
• Large pseudocysts can extend to the • The findings of an invasive hypodense
paracolic gutters; pelvis; mediastinum mass in the had of the pancreas which
• Some are loculated involves the SMV and SMA along with
enlarged lymph nodes are most
Most Common Etiologies suggestive of pancreatic CA
• The 5th most common cause of cancer
• Chronic pancreatitis deaths
• Acute pancreatitis and • It is approximately twice as common in
• Pancreatic trauma males compared to females
• In addition, pseudocysts are associated • Patients are usually greater than 50
with pancreatic ductal obstruction and years old
pancreatic neoplasms • Greater than 90% of pancreatic
cancers are ductal adenocarcinoma
US Findings and its variants
• Most of the remaining 5-10% are islet
• An anechoic structures associated with cell tumors
acoustic enhancement • Arises in the head of the pancreas 70%
• Well defined and round or oval, and they of the time, in the body 20%, and in
are contained within a smooth wall the tail 10%.
• During the early phases, the more • Abdominal pain and weight loss are
complex, with varying degrees of internal present in greater than 75% of
echoes patients with pancreatic cancer, and
• Usually, this appearance results from the jaundice is present in greater than
presence of necrotic pancreatic and 80% of patients with pancreatic heat
peripancreatic debris and is more common tumors secondary to biliary obstruction
in pseudocysts that form as a result of
acute necrotizing pancreatitis than in CT
others. The debris is cleared over time.
• The pseudocysts can appear more • The best modality for imaging the
complex in 2 other instances: when pancreas
hemorrhage occurs in the cyst or when • A mass deforming the size and contour of
infection of the cyst complicates the the pancreas is the most common finding
clinical course for ductal cell carcinomas occurring in
• Color Doppler or duplex scanning should 96% of the cases
always be performed in cystic lesions to • A central zone of decreased attenuation is
ensure that the lesion in question is not a present in 83% of pancreatic head and
giant pseudoaneurysm 60% of pancreatic body carcinomas
• Abdominal CT is an excellent choice for • CT can be used for staging purposes with
imaging acute fluid collections and the findings of the retroperitoneal
pancreatic pseudocysts extension, major vascular involvement,
• CT characteristics of an acute fluid invasion of contiguous organs, ascites, LN
collection include low attenuation and a and distant metastases suggesting
homogenous appearance unresectability.
• CT attenuation values may measure
greater than 20-30 HU because of the Adenocarcinoma
presence of necrotic pancreatic or
peripancreatic debris or blood within the • The fourth most common cancer
confines of the acute fluid collection. • The prognosis of the disease is poor and
very few patients survive longer than one
year
• Major role of imaging once the primary
diagnosis has been made is to “stage” the
disease to determine operability
• The loss of the fat plane indicates
encasement of the artery making the
patient uncurable
CT Findings of Pancreatic CA • Visualization of the nodule with irregular
borders of the septae and calcification
• Alteration in the morphology of the gland which is curvilinear or punctate and
with abnormalities of CT attenuation confined to the cyst wall or septa
values • CECT show enhancement of the cyst wall,
• Obliteration of peripancreatic fat internal septations, mural nodules, and
• Loss of sharp margins with surrounding other intracavitary projections
structures • CT may also allow the identification of
• Involvement of adjacent vessels and solid components associated with cystic
regional lymph nodes elements, which are features of borderline
• Pancreatic ductal dilatation or malignant tumors but not benign
• Pancreatic atrophy and, variants. MCN’s develop predominantly in
the tail of the pancreas (>90%)
• Obstruction of the common bile duct
(CBD) • CT more clearly demonstrates
enhancement of the cystic walls and septa
Mucinous Cystic Neoplasm
US Features

• Usually larger than 5cm


• The walls are composed of thick, fibrous
stroma sometimes containing dystrophic
calcification
• A large cystic mass sometimes with
numerous septa and debris
• The tumor may be 2-23cm, and they
usually have sharply marginated walls and
smooth borders
• Typically show a multilocular, fluid-
containing mass with good transmission
and strong acoustic enhancement
Mucinous Cystic Tumors • Compared with serous cystic tumors, the
cysts in MCNs are larger (>20mm in
• So called macrocystic cystadenomas or, diameter) and less numerous (usually
cystadenocarcinomas. <6). CT-guided aspiration of the cyst can
provide further diagnostic clues and
• Predominate in the body and tail of
enable their differentiation from other
pancreas, have a strong female
pancreatic cystic masses (eg, pseudocyst,
predilection
serous cystadenoma, and solid and
• Most common of cystic pancreatic tumors,
pseudopapillary neoplasm)
accounting for 45-50% of tumors
• MCN cyst fluid typically has a high
• Multiloculated tumors with a characteristic
viscosity, low amylase levels, and high
smooth glistening surface CEA and carbohydrate antigen (CA) 72-4
• Arise from oversecretion of the mucus of levels, and they may show malignant
the hyperplastic columnar lining of the
ducts. The cysts contain thickened viscous
material, which can also be hemorrhagic
• Nonenhanced CT scans show a well-
defined unilocular or multilocular,
externally smooth, round-to-ovoid mass
with fluid attenuation
• The attenuation values of the multilocular
cysts vary according to the degree of
hemorrhage or protein in the mucoid cysts
• Larger cysts may demonstrate small
daughter cysts along its internal surface. cytology in patients with mucinous
Typically, they show a well defined, cystadenocarcinomas. Periodic Acid-Schiff
multilocular cystic mass with thick internal (PAS) and May Grunwald/Giemsa (MGG)
mass septae separating the separating the stains are usually positive for extracellular
different cystic cavities of varying sizes. as well as intracellular mucin.
The cysts are 2-26cm.
Mucinous Cystic Neoplasm

Intraductal Papillary Mucous Neoplasm

• Papillary neoplasm that arises within the


MPD or its branches
• The tumor hypersecretes mucin, which
often leads to duct dilatation and/or
chronic obstructive pancreatitis
• Are premalignant and may histologically
demonstrate areas ranging from
hyperplasia to carcinoma within in a single
tumor
• The tumors generally show intraluminal,
longitudinal growth but is usually slow to
invade periductal tissues radially and slow
to metastasize.
• Most commonly localized to the head of
the pancreas, but they may occur at any
site along the pancreatic ductal system
• Ductal dilatation is often impressive any
may mimic MCNs on CT scans
• Is recognized as predominantly a solid Hypervascular tumor in the pancreatic tail with
tumor with a central cyst. The cystic sunburst calcification. Note the Swiss-cheese
variety consists microscopically of cyst like enhancement.
spaces with papillary protrusions.

Intraductal Papillary Mucinous Tumor

SPLEEN
Accessory Spleens

• Or splenculi, are relatively commonly


In these cases, the findings on ERCP may be encountered “normal” anatomic variants
diagnostic. Rarely, segmental pancreatic duct • Estimated to be present in approximately
dilatation may acquire a cystic appearance, 10% of the population
• May be single or multiple in occurrence
whereas the MPD and the rest of the pancreas
• Are most frequently discovered in the
appears normal.
vicinity of the splenic hilum or elsewhere
within the gastrosplenic ligament
Microcystic Adenoma
• They may, however, be found along the
omentum, or anywhere else within the
• Cystic mass in the region of the tail of the
peritoneal cavity
pancreas.
CT Findings
• Attenuation and contrast-enhancement
characteristics that are identical to those
of normal spleen
• Measures approximately 1.0-1.5cm in
diameter, but may range in size a few
millimeters to several centimeters (2.3)
• Resection of all accessory spleens is
recommended at the time of the
splenectomy, as cases of accessory-
splenic hypertrophy have been described
subsequent to removal of the “main” • An example of calcified splenic cyst shown
spleen first on plain radiograph (left) with a
coronal CT construction (right). Note the
clear demarcation of the calcified cyst
capsule.

Accessory Spleen (s)

Metastases: the axial CT images demonstrates


multiple hypoenhancing lesions in the spleen
consistent with metastatic CLL.

Splenic Cysts

Images of splenic metastasis visualized on US.


• The differential diagnosis of large splenic Careful ultrasound examination can determine if
cysts should include posttraumatic cysts these are cysts with increased through
(most common), epidermoid cysts, transmission of echoes versus solid metastatic
abscess, pancreatic pseudocyst, lesions.
echinococcal cysts, lymphoma, infarction
or cystic lymphangiomas (less common).
Splenic cyst shown below as imaged on
US.
o Opportunistic infection in AIDS
patients (Pneumocystis carinii)
• Traumatic
• Vascular
o “phleboliths”
o Post-ischemic/infarction

The plain film shown demonstrates numerous


round calcifications diffusely distributed
specifically within the spleen. The likely etiology
of the calcified granulomata is Histoplasmosis,
Lymphoma which have this characteristic appearance in
comparison to microabscess.
• Lymphomas is the most common
malignant tumor of the spleen. Typically,
lymphatic drainage to the spleen serves
as the primary mechanism by which
extranodal lymphomas of varying types by
which extranodal lymphomas of varying
types disseminates to the spleen. Of the
two broad types of lymphoma (B vs. T
cell), B cell lymphomas Hodgkin’s and non
Hodgkin’s disease are often diagnosed
from splenic imaging. Primary splenic
lymphoma (PSL) is a rare malignancy with
a reported incidence of less than 1% of all Case
lymphomas.
33-year old woman with fever of unknown origin.
Patient is HIV +.

Case

Twenty-three year old woman with non-Hodgkin’s


lymphoma.
Pneumocystis carinii infection in the
spleen

• Important cause of pneumonia in an


immunocmporomised host
• Common sites of dissemination include
lymph nodes, liver, bone marrow, and
spleen.
• Splenic pneumocystic carninii infections
have been described typically as low
Splenic Calcifications attenuation lesion which may contain
internal calcifications.
• Infectious
o Previous granulomatous disease Differential diagnosis of cystic lesions
(tuberculosis, histoplasmosis)
• Post traumatic
• Epidermoid
• Epithelial and
• Echinococcal cyst
• Abscess
• Lymphoma and
• Metastatic lesions may also appear as
regions of decreased attenuation in the
spleen that may mimic cystic lesions

Splenomegaly

• lymphoma
• leukemia
• cirrhosis
• portal hypertension