RADIOLOGY

Liver and Gallbladder

LIVER
-Easy to identify in the RUQ
Upper surface outlined by diaphragm
-Inferior surface of right lobe is visible on plain radiograph (box)

-lower margin of left lobe not visible

-Riedels lobe (encircled)
-Normal variant
-Commonly seen in thin-waisted sexy females
-Tongue- like projection
-normal size: <13 cm (MCL)

ULTRASOUND OF THE LIVER

-Inexpensive
-Must go hand in hand with
other modalities like CT
-Require scanning
technique to demonstrate
the liver parenchyma.

Ultrasonogram Findings:
Unremarkable right liver
lobe parenchyma
MHV- Middle Hepatic Vein
RHV- Right Hepatic Vein

Legend:
PV- Portal Vein
CL-Caudate Lobe
VC- Inferior Vena Cava

CT-SCAN OF THE LIVER

Appreciate the
relationship of liver
-Cephalocaudal diameter is not smaller than 12 cm with:
-enlarged if >15.5 cm (accuracy of 87%) -Gallbladder (GB)
(green)
Anatomic Segments of the Liver -Pancreas (Orange)
-Stomach (with
COUINAUDS Segments
contrast media)
-Spleen (spleen)
CT Findings: -Kidneys (pink)
Spleen (Yellow) -Vertebra (violet)
Stomach (Orange)
Inferior Vena Cava (green)
Abdominal Aorta (pink)
CL- Caudate Lobe/ Segment 1

Hepatomegaly
-Ultrasound is already sufficient to diagnose hepatomegaly.
Possible changes
-downward displacement of hepatic flexure
-stomach is displaced to left and posteriorly

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 RADIOLOGY
SIMPLE CYST
-inferior displacement of left kidney (not common) Ultrasonogram of
-lower edge of liver crosses right psoas shadow the Right Liver
-displacement of duodenal bulb to left of midline or below body of L2 Lobe (RLL):
-elevation of right hemidiaphragm (MC displaced superiorly) There is a well-
circumscribed,
Radiographic Findings: anechoic, fluid-
-A very big sub tissue mass containing, unilocular
(triangle) in the right upper lesion without
abdomen displacing the colon septations and solid
inferiorly parts in the right liver
-Case of a patient who has lobe
HEPATOBLASTOMA -Posterior acoustic
- Malignant tumor involving the enhancement (box)
liver (all fluid containing
-Right lobe enlarged lesions will appear
with this artifact)

COMPLEX CYST
There is a well-
circumscribed
Causes of Hepatomegaly cyst with
A. METABOLIC septations and
Fatty infiltration (or fatty steatosis/ fatty liver) multiloculations.
o alcoholism (MC cause) (Harder to drain
o fatty diet bec of septations)
o chronic exposure to anesthetics
Amyloid deposition Most probably fluid
bec there is
Wilsons disease
posterior
Gauchers disease enhancement.
Neimann-Picks disease
Weber-Christian disease
Galactosemia
B. MALIGNANCY
lymphoma
diffuse metastasis
HEPATOCELLULAR CA (MC PRIMARY CA)
HEMANGIOMA
angiosarcoma
UTZ Findings:
C. INFLAMMATION AND INFECTION There is a solitary, hyperechoic,
hepatitis solid nodule with no posterior
miliary TB shadowing. (arrow)
*Posterior shadowing appears if
histoplasmosis the lesion is calcified. ie: stones
sarcoidosis -Mimics a metastasis or
malaria hepatocellular CA
leptospirosis -Solitary lesion
-Might present with posterior
D. VASCULAR acoustic enhancement
-Chronic passive congestion (CPC) -Benign but follow up after 6 months is recommended
-MC cause is congestive heart failure
-Detected by ultrasound and other modalities as intrahepatic vein CYSTS ON CT-SCANOGRAM
distention.
Smaller cyst on the left
E. OTHERS liver lobe
Early cirrhosis Larger cyst on the right
liver lobe
Polycystic liver disease
Tx: Put drain or
manually aspirate OR
CAUSES OF FOCAL LIVER LESIONS sclerose with alcohol
A.1 SOLITARY BENIGN
-Simple Cyst (MC, not more than 5cm)
-cavernous hemangioma
-hematoma/traumatic cyst
-abscess
-adenoma
-Focal Nodular Hyperplasia (FNH) is common in females
-Focal fatty change -segment IV-b is the most common site A.2. SOLITARY MALIGNANT
-Hepatoma (Hepatocellular Carcinoma)
-Metastasis
-Peripheral cholangiosarcoma (tumors that come from bile ducts)

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HEPATOCELLULAR CARCINOMA
CT-Scanogram Findings:
There is a large solitary, well-
delineated, iso dense mass on
the posterior segment of the
Right Liver Lobe. (Encircled)
Do biopsy.
B.1. MULTIPLE BENIGN
-these lesions are non-specific, we need other studies to confirm
simple cysts
cavernous hemangioma
polycystic liver disease
multiple abscesses
adenoma
regenerating nodules in cirrhosis
MULTIPLE BENIGN CAVERNOUS HEMANGIOMA
Triphasic CT-Scanogram
Findings:
Arterial phase:
pathognomonic finding of
hemangioma on CT is
PERIPHERAL NODULAR
ENHANCEMENT (arrows)
Good to know:
Special technique to evaluate
liver lesions that acquires
images at 3 different times
following the administration of contrast media. This assesses the double
blood supply of the liver (arterial phase after 18-25sec, portal phase
after 45sec and venous phase aka equilibrium phase after 65sec)
after acquiring a plain non-contrast image. A delayed-phase is warranted
for filling in of hemangioma.
B.2 MULTIPLE MALIGNANT
Metastasis: most common malignant liver tumor
o proven history of carcinomaliver, lungs
Multifocal hepatoma
Lymphoma
METASTASIS
Triphasic CT-Scanogram
(Venous/Delayed-phase)
findings:
Multiple HYPO DENSE
LESIONS scattered in the entire
liver consistent with metastasis
from a primary breast
carcinoma. Note the affectation
of the spleen.
*Colon Cancer Metastasis may
present as HYPERDENSE OR
HYPODENSE
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RADIOLOGY
Ultrasonogram Findings:
MULTIPLE HYPER ECHOIC
NODULES consistent with
CHRONIC METASTASIS FROM
LUNG CA (Hyperechoic bukolation)
GALLBLADDER AND BILIARY TRACT
Plain Abdominal Study
-GB rarely visualized (normal)
If enlarged: mass along the undersurface of the liver
-Gallbladder not seen unless enlarged on PLAIN IMAGING
Calcification in Gallbladder Wall
-Oval-shaped density
corresponding to size and
shape of gallbladder
(porcelain gallbladder)
-highly premalignant
(progression to
adenocarcinoma)
-high incidence of CA in
porcelain gallbladder,
prophylactic
cholecystectomy is
warranted
CT-Scanogram Finding:
Hyper dense gallbladder wall
(arrow)
The gallbladder should not
contain any solid particles
Gallbladder Stones (Cholecystolithiasis)
-Chief constituent: cholesterol (adults)
-Only 15% radiopaque (85- 90%-radiolucent)
-Seen in x-ray vs. renal stones: 90%
-90% of gallstones have mixed component but do not have enough
calcium to be visible radio graphically
- (calcium makes stones visible)
-Stone maturation- more calcium will be deposited over time thats why it
grows bigger (calcified stones)
-Opaque gallstones may vary in appearance but in general have a dense
outer rim and more transparent center
-If multiple, may be faceted (many planar areas/ sides)
-larger stones often laminated (many layers)
-Mercedes
Benz or
Crow-foot
sign: stellate
fissure of the
center; seen
in larger
opaque
stones
(arrows)
-Must be differentiated with other causes of localized calcification in the
RUQ:
(1) Calcification of the costal cartilages
(2) Calcified foci in the liver
(3) Calcified LN
(4) Renal stones
(5) Warts and moles on the skin surface
(6) Film artifacts and foreign material in the GIT
-Rotate patient in an oblique position or obtain lateral film to
differentiate gallstone from renal stone

X-RAY GALLSTONES
-Plain abdomen/plain
film -GB outline is
delineated
UTZ Findings:
Dense, hyperechoic structure with posterior shadowing
Smaller stones get stuck easier in
the CBD causing enlargement of
the gallbladder
There is almost always posterior
shadowing (very important
feature)
-Gallbladder with multiple filling
defect- multiple stones
UTZ Findings:
Solitary hyperechoic cholecystolith with
posterior shadowing.
Let the patient move from side to side (mobile
shadowing lesion)
UTZ Findings:
Multiple hyperechoic stones with posterior
shadowing in the gallbladder
Cholecystolithiasis- more appropriate term
UTZ Findings:
Multiple, aggregated,
confluent stones with
posterior shadowing
Enlarged swollen GB (almost
considered as hydrops)
-Can be mobile shadowing lesion
-Stones tend to form layers (heavy) localizing to the most dependent
layer of the GB
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RADIOLOGY
UTZ Findings:
Hyperechoic cylindrical structure
inside the gallbladder fossa highly
suggestive of PARASITIC
INFECTION (ASCARIASIS)
-Hx of biliary stasis secondary to
parasites
-Chronic ascariasis may lead to
obstructive jaundice
CHOLECYSTITIS
-Inflammation of GB wall (>5 MM THICKNESS confirms diagnosis)
Calculous cholecystitis
-Sonographic Murphys
sign (elicit cholecystitis by
doing murphys sign with
the transducer)
-Denser outer rim
-Wall is edematous and
thickened
-Pericystic fluid is
present
UTZ Findings:
-Thickened
hyperechoic
gallbladder wall
(arrow)
-Solitary
hyperechoic
cholecystolith with
posterior
enhancement
***Tiny stones may
be missed on CT
CT Finding:
Large hyper dense
stone in the gallbladder
fossa (arrow)
Outline of GB is hardly
seen
Incidental finding:
Polycystic kidneys
(encircled)
PNEUMOBILIA
Previously known as AEROBILIA (obsolete term)
-Gas in the gallbladder/ biliary tract (always abnormal)
-Gas may enter the gall bladder from the intestinal tract because of a
fistula between the two, as a result of surgical anastomosis or
because of a patulous sphincter of Oddi
-common cause: ulceration of a large gallstone through the wall into
the adherent duodenum
-gallstone ileus: impacted stone in small bowel (almost always)
-Y-shaped translucent shadow in the RUQ corresponding to the
common, left and right hepatic duct position (centrally located)
 RADIOLOGY
-Infection with gas-forming organisms may cause gas within the gall 11. Epithelial cyst
bladder, within its walls or both (MC is E.Coli but can be caused by 12. Mucocele
Clostridium) 13. Congenital defects
14. Malignant tumors (most common)
CT-Scanogram 15. Carcinoma, carcinoid, sarcoma, metastasis
Findings:
Air in the biliary tract Cholesterolosis
(hypo dense) pointed
by black arrow -small, round translucent
defects attached to the gall
bladder wall (cholesterol
containing lesions)
-lipid gall bladder or
strawberry gall bladder
-cholesterol polyp: small
collection of cholesterol
crystals beneath mucosa;
may form a sessile mass
or stalk (attached to the GB
Assignment: wall, differentiate from
RIglers Triad (Gallstone Ileus) polyps)
Presence of:
-Pneumobilia (red Adenomyoma
box) due to the -At the fundus, smoothly elevated or sessile mass often with a central
passage of a large dimple when viewed in tangent.
gallstone, usually
(but not always) Adenomyomatosis
through a
cholecystenteric -characterized by presence of Rokitansky-Aschoff sinuses or
fistula resulting to diverticula
Small Bowel -In septated gall bladder
Obstruction (yellow -RA sinuses consists of tiny diverticular out-pouching when filled with
box) contrast medium
-have symptoms of gall bladder disease
-cause is unknown
-Sometimes very difficult to see
-Multiple hyperdense with comet tail artifacts -no shadowing

Comet tail artefact can tell you that you are

EMPHYSEMATOUS CHOLECYSTITIS dealing with adenomyomatosis or plainly
cholesterolosis. These are just cholesterol
-rare entity deposits that dont move and without
-acute infection of the gall bladder shadowing.
-common in patients with uncontrolled diabetes
-Caused by Clostrium welchii or E. coli UTZ Finding:
-Gas within the gall bladder, walls or pericholecystic tissues Comet tail artifact aka Reverberation Artifact
denoting adenomyomatosis (same with image
In UTZ, air reflects the sound waves resulting to non- below)
visualization of the structures due to air artifacts
Gas in Portal Vein (Periportal)
-associated with necrosis of the small bowel secondary to mesenteric
thrombosis then necrosis
-linear translucent streaks in periphery of liver
-grave prognosis
-portal vein gas

CT-Scanogram Findings: Multifocal hyperdense streaks due to air in

the smaller portal veins at the peripheral regions of the liver

Tumor and Tumor-like Conditions of the Gallbladder Adenoma

CLASSIFICATIONS: -True benign tumor
1. Polypoid (non-tumorous) -sessile or pedunculated
- Cholesterol polyp -Solitary or multiple
-cholesterolosis when multiple -Fixed

2. Inflammatory polyp, hyperplastic polyp (may look like cholesterol

stones but not mobile)
3. adenomyoma, adenomyomatosis
4. benign epithelial tumors
5. papilloma
6. adenoma
7. fibroma
8.hemangioma
9. lipoma
10. cyst-like

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 RADIOLOGY
Absent GB
MISCELLANEOUS CONDITIONS OF THE GALLBLADDER congenital absence is very rare
hypoplasia occurs in 30% of patients with MUCOVISCIDOSIS
Hydrops

-More than 5cm diameter (measure the axial diameter)

-Enlarged but almost 5cm could be termed as hydropic GB

Milk of Calcium Bile

-GB is filled with an
accumulation of bile containing
a high percentage of calcium
carbonate.
- Follows obstruction of the
cystic duct
-opacified gall bladder in
absence of contrast material

CONGENITAL ANOMALIES OF THE GB

Phrygian cap
like the cap of
the dwarfs of
Snow White

-incomplete
septum
extends across
the fundus (the
real anomaly
here is the
septum not
the fundus)
-fundus
appears folded
over the body

-no clinical significance

Hourglass GB
partial septum in its midportion

Double GB
bifurcated with both sacs emptying into a common cystic duct
or with two individual cystic ducts
rare

Intrahepatic GB
gallbladder lies within gall bladder substance

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