Imaging Pearls ❯ Liver ❯ Inflammatory Disease
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- “The most frequent cause of focal calcified liver lesions is inflammation,with granulomatous disease being the most common cause. Most occurrences of granulomatous disease in the United States are attributed to histoplasmosis, sarcoidosis, and tuberculosis.”
Liver Calcifications and Calcified Liver Masses: Pattern Recognition Approach on CT Madhavi Patnana et al AJR 2018; 211:76–86 - “TB is one of the most prevalent causes of morbidity and death worldwide, partic- ularly in low- or middle-income countries [5]. Hepatic TB typically occurs from 11 to 50 years of age, with a peak occurrence in the second decade and a male-to-female ratio of 2:1 [6]. The best imaging examination for active hepatic TB diagnosis is contrast- enhanced CT [7]. There are ve patterns of hepatic TB as classi ed by Levine: military TB, concomitant lung and liver disease, primary (isolated) TB, tubercular hepatic abscess, and cholangitis.”
Liver Calcifications and Calcified Liver Masses: Pattern Recognition Approach on CT Madhavi Patnana et al AJR 2018; 211:76–86 - “ Some parasitic infections that can cause liver lesions with associated hepatic calcifications include hydatid disease, schistosomiasis, and fascioliasis.”
Liver Calcifications and Calcified Liver Masses: Pattern Recognition Approach on CT Madhavi Patnana et al AJR 2018; 211:76–86 - “Cystic echinococcosis can present as simple cysts or solid-appearing lesions [15]. Calcifi cations of the cyst can appear curvilinear, ringlike, or densely calcified [14, 19]. Four ra- diologic patterns have been described. Type I is a well-defined low-density simple-ap- pearing cyst lacking internal contents. Type II has three subtypes .”
Liver Calcifications and Calcified Liver Masses: Pattern Recognition Approach on CT Madhavi Patnana et al AJR 2018; 211:76–86
- “In Egypt, schistosomiasis was traditionally the most important public health problem and infection with Schistosoma mansoni the major cause of liver disease. From the 1950s until the 1980s, the Egyptian Ministry of Health (MOH) undertook large control campaigns using intravenous tartar emetic, the standard treatment for schistosomiasis, as community-wide therapy. This commendable effort to control a major health problem unfortunately established a very large reservoir of hepatitis C virus (HCV) in the country. By the mid-1980s, the effective oral drug, praziquantel, replaced tartar emetic a s treatment for schistosomiasis in the entire country.”
Liver disease in Egypt: hepatitis C superseded schistosomiasis as a result of iatrogenic and biological factors.
Strickland GT
Hepatology 2006 May;43(5):915-22. - Schistosomiasis: Facts
- Schistosomiasis, also known as bilharzia, is a disease caused by parasitic worms. Although the worms that cause schistosomiasis are not found in the United States, more than 200 million people are infected worldwide. In terms of impact this disease is second only to malaria as the most devastating parasitic disease. Schistosomiasis is considered one of the neglected tropical disease
- Facts from CDC - Schistosomiasis: Facts
- The parasites that cause schistosomiasis live in certain types of freshwater snails. The infectious form of the parasite, known as cercariae, emerge from the snail, hence contaminating water. You can become infected when your skin comes in contact with contaminated freshwater. Most human infections are caused by Schistosoma mansoni, S. haematobium, or S. japonicum.
- Facts from CDC
- Abscess
1. Can be pyogenic, fungal, or parasitic.
2. Etiologies:
- Immunocompromised
- Biliary infection/Cholangitis
- GI tract infection with septic thrombophlebitis
- Iatrogenic
- Amebic or Echinococcal
- Radiation Hepatitis: Facts
- Develops 2 weeks to 4 months after radiation therapy
- It is a form of veno-occlusive disease
- Usually has a sharp boundary corresponding to the radiation ports, not vascular enhancement
- Key differential diagnosis are hepatic infarction and focal fatty infiltration
- Radiation Hepatitis: Facts
- Develops 2 weeks to 4 months after radiation therapy
- It is a form of veno-occlusive disease
- Usually has a sharp boundary corresponding to the radiation ports, not vascular enhancement
- Key differential diagnosis are hepatic infarction and focal fatty infiltration - Liver Abscess: CT findings
- Pyogenic abscesses most common in right lobe of liver
- Air fluid level makes the diagnosis straight forward though this occurs in less than 25% of cases
- "cluster sign" is felt to be classic on CT
- Abscess can be single or multiple - Liver Abscess: Facts
- May be pyogenic, fungal or amoebic in nature
- Approximately 85-90% of abscesses are pyogenic and E. coli most common in adults as etiology
- Clinical history usually helps with the dx as can simulate other lesions including malignant primary or metastatic lesions - Budd-Chiari Syndrome: CT Findings
Chronic phase
- Primary- membranous obstruction of hepatic venous outflow tract
- Secondary- due to thrombosis due to causes ranging from chemotherapy or radiation therapy, hypercoagability states, or hepatic or extra-hepatic tumors - Budd-Chiari Syndrome: CT Findings
Chronic phase
- Non visualization of IVC and hepatic veins
- Hyperdense nodules or regenerating nodules - Budd-Chiari Syndrome: CT Findings
Acute phase
- Early enhancement of caudate lobe and central portion of liver around IVC, with decreased enhancement of the rest of the liver
- Delayed enhancement of peripheral portions of liver and central portion of low density (called flip-flop appearance)
- Narrow hypodense hepatic veins and IVC with dense walls - Budd-Chiari Syndrome: Facts
- AKA hepatic veno-occlusive disease
- Hepatic venous outflow obstruction and may be global or segmental
- May be acute or chronic in nature
- Regenerating nodules are every common ( and these vascular nodules can simulate an hepatoma) - HIV-Related Cholangitis: Facts
"Preliminary results suggest that in patients with cirrhosis and early HCC, perfusion CT is a feasible technique for noninvasive assessment of tumor vascularity."
Perfusion Computed Tomographic Assessment of Early Hepatocellular Carcinoma in Cirrhotic Liver Disease: Initial Observations
Ippolito D et al.
J Comput Assist Tomogr 2008;32:855-858 - HIV-Related Cholangitis: Facts
- Biliary tract involvement occurs in patients with markedly depressed immune function, with a CD4 count less than 100/mm3
- AIDS cholangiopathy is a form of secondary sclerosing cholangitis and can result from direct invasion of biliary epithelium by the HIV virus itself
- Papillary stenosis and long strictures are common - Bacterial Acute Cholangitis: Complications
- Sepsis
- Hepatic abscesses
- Portal vein thrombosis
- Bile peritonitis - Bacterial Acute Cholangitis: Causes
- Obstruction of the CBD by stones is most frequent cause occurring in 6-9% of patients admitted for gallstone disease
- Choledocholithiasis accounts for up to 80% of cases of acute cholangitis
- Malignancies in some series can account for up to 30% of causes - Bacterial Acute Cholangitis: Causes
- Bacterial
- Parasitic (ascariasis)
- Viral
- fungal "Development of bacterial acute cholangitis requires biliary bacterial contamination, stagnant bile, and increased intrabiliary pressure (= 20cm H2O) ."
Biliary Infections:Spectrum of Imaging Findings and Management
Catalano OA et al
RadioGraphics 2009; 29:2059-2080"Imaging plays a pivotal role in diagnosis of infectious cholangitis, helps identify predisposing causes, and demonstrates complications. Moreover, interventional radiology provides tools to treat acute life threatening biliary infections, chronic entities, and complications."
Biliary Infections:Spectrum of Imaging Findings and Management
Catalano OA et al
RadioGraphics 2009; 29:2059-2080- Primary Sclerosing Cholangitis: facts
- Male predominance
- 60-80% of patients have associated IBD especially ulcerative colitis
- Cholangiocarcinoma develops in 10% of patients with PSC
- "Our results suggest that CT findings of colonic wall thickening in end stage liver disease should be considered benign, and colonoscopy is unnecessary for the evaluation of malignancy or colitis unless it is clinically indicated."
Colonoscopy Findings in End Stage Liver Disease Patients with Incidental CT Colonic Wall Thickening
Ormsby EL et al.
AJR 2007; 189:1112-1117
- "The colonoscopy changes primarily ranged from mild mucosal edema to increased vascularity and telangiectasia, probably from hypoproteinemia or portal hypertension."
Colonoscopy Findings in End Stage Liver Disease Patients with Incidental CT Colonic Wall Thickening
Ormsby EL et al.
AJR 2007; 189:1112-1117
- "Our results suggest that CT findings of colonic wall thickening in end stage liver disease should be considered benign, and colonoscopy is unnecessary for the evaluation of malignancy or colitis unless it is clinically indicated."
Colonoscopy Findings in End Stage Liver Disease Patients with Incidental CT Colonic Wall Thickening
Ormsby EL et al.
AJR 2007; 189:1112-1117
- "The colonoscopy changes primarily ranged from mild mucosal edema to increased vascularity and telangiectasia, probably from hypoproteinemia or portal hypertension."
Colonoscopy Findings in End Stage Liver Disease Patients with Incidental CT Colonic Wall Thickening
Ormsby EL et al.
AJR 2007; 189:1112-1117
- Portal Venous Air: Differential Diagnosis
- Pneumatosis Intestinalis (malignant)
- Sepsis
- Severe enteritis
- Cholangitis
- Pancreatitis
- Diverticulitis
- After GI surgery
- Hepatic Abscesses: Categories
- Pyogenic abscess
- Amebic abscess
- Parasitic abscess
- Fungal abscess
- Granulomatous disease
- Other etiologies (bacillary angiomatosis)
- Hepatic Abscesses: Pyogenic Abscess
- Caused by hematogenous spread from GI tract, ascending cholangitis, or superinfection of necrotic tissue
- E. coli is the most common agent
- Clinical presentation is fever, right sided abdominal pain or even weight loss, as well as elevated LFT's
- Pyogenic Abscess: CT Findings
- Single or multiple in number and may involve one portion of the liver of be diffuse
- Range from a few millimeters to several centimeters
- Rim enhancement may occur
- May contain septations or gas within the abscess
- Hepatic Abscesses: Amebic Abscess
- Most common extraintestinal manifestation of amebiasis (8.5% of cases)
- More common in India, Far East, Africa, South America
- Usually very sick with high fevers
- Travel hx is critical
- Amebic Abscess: CT Findings
- Cystic lesion often with enhancing rim
- Zone of edema around border of the lesion
- Lesions usually solitary but may be multiple
- Hepatic Abscesses: Parasitic Abscess-Hydatid
- E Granulosus (hydatid Cyst) endemic to Mediterranean basin and other sheep raising areas
- Humans acquire disease from eating contaminated food
- Eosinophilia is common
- Parasitic Abscess-Hydatid Cyst: CT Findings
- Cystic with daughter cysts (75% of cases)
- Rim calcification common (50% of cases)
- Can be single or multiple
- Hepatic Abscesses: Fungal Abscess
- Common in patients with hematologic malignancies or comprimised immunologic system
- Abscesses may also involve the spleen and kidney
- Common agents are candida, cryptococcus, and aspergillosis
- Fungal Abscess-Candidiasis: CT Findings
- Microabscesses usually under 1 cm
- Multi-organ involvement common
- Key is clinical hx
- Hepatic Abscesses: Granulomatous Disease
- Commonly associated with sarcoidosis, TB, and histoplasmosis
- TB is the most common and usually associated with miliary TB
- CT findings in TB include hypodense lesions and eventually calcified lesions
- Granulomatous Disease: CT Findings
- Hypodense lesions common
- Calcified lesions not uncommon
- Hepatomegaly may be the finding in either TB or histoplasmosis
- "In patients suspected of having hepatic fungal infection, arterial phase CT depicts significantly more hepatic lesions than does CT performed during the other phases, and it reveals more lesions with enhancement patterns suggestive of infection. Arterial phase CT should be performed in addition to portal venous phase CT in patients suspected of having hepatic fungal infection."
Fungal Liver Infection in Immunocomprimised Patients: Depiction with Multiphasic Contrast Enhanced Helical CT Metser U et al. Radiology 2005; 235:97-105