Hepatobiliary System: Scanning Techniques

Practice 28 MSc (CT) Part 1 2005

Aims & Objectives



Aims
To review the hepatic blood supply & present an overview of the scanning techniques currently used for CT of the liver and GB

Objectives
Discuss the phases of contrast enhancement in the liver Evaluate different protocols used for CT liver & GB Have a knowledge of the clinical indications for each protocol Discuss the application of CT in patients awaiting OLT

Edel Thomas

University College Dublin 2005

Introduction


CT is 1 used in the evaluation of liver lesions CT offers a valuable insight into a range of other diseases US frequently requires further evaluation by CT/MR MSCT is rapidly replacing RNI

Edel Thomas

University College Dublin 2005

Edel Thomas

University College Dublin 2005

Edel Thomas

University College Dublin 2005

Hepatic Contrast Enhancement

 

All tumours have an arterial blood supply Tumour enhancement is also determined by contrast diffusion into the interstitium Contrast media may be:
Via intra-arterial injection or Via intra-venous injection

Edel Thomas

University College Dublin 2005

Hepatic Contrast Enhancement

What are the different phases of contrast enhancement for the liver? What is each phase used to evaluate? What factors affect the onset & duration of each phase?

Edel Thomas

University College Dublin 2005

Hepatic Contrast Enhancement



Arterial Phase
Little enhancement of normal liver Hepatic arteries are strongly enhanced Hypervascular tumours enhance Signs of malignancy on this phase:
 

Peripheral rim enhancement Heterogeneous enhancement

Cavernous haemangioma detection Pre-op evaluation of arterial variants

Edel Thomas University College Dublin 2005 8

Hepatic Contrast Enhancement



Portal Venous Phase

Parenchyma displays maximum enhancement Portal vein enhancement exceeds that in Aorta Early venous phase & HVP (20 secs after) Hypovascular tumours - hypoattenuating to liver parenchyma due to their arterial supply Small lesions & Hypervascular tumours may be missed on this phase

Edel Thomas

University College Dublin 2005

Hepatic Contrast Enhancement



Portal Venous Phase

Signs of malignancy:
   

Hypoattenuating lesions Heterogenous enhancement Cystic lesions with irregular borders Bulls-eye phenomenon

Hypoperfusion may simulate a malignancy

Edel Thomas

University College Dublin 2005

10

Hepatic Contrast Enhancement



Equilibrium Phase
Interstitial phase Contrast in extravascular & intravascular spaces Lesions may become inconspicuous Not useful for lesion detection


Exceptions: Tumours that have a large extracellular space or fibrous components

Hypervascular tumours may be detected

Edel Thomas University College Dublin 2005 11

Imaging Objectives for CT

    

 

ID presence of disease ? Focal or Diffuse Maximise lesion detection Characterisation of disease Lesion localisation with a view to resectability Assessing vessel patency Documentation of extrahepatic disease
University College Dublin 2005 12

Edel Thomas

Indications


Indications:
Assessment of Colorectal liver mets OLT Hepatoma Cirrhosis Non cirrhotic patients 1 liver tumours Mets

Edel Thomas

University College Dublin 2005

13

Technique: General Points

     

Oral or Water prep 18 G cannula IV contrast Limit scan range to ROI Optimise contrast resolution Make use of different windowing techniques to fully evaluate the liver

Edel Thomas

University College Dublin 2005

14

Technique
PARAMETER
Patient position Scan range Windows Slice thickness
Patient

SSCT

MSCT 16 slice

symmetrical in centre of gantry Arms raised above head Right hemi-diaphragm ASIS 300400 / 35-40; 180 / 90 (liver) 5-8mm

0.75mm

Edel Thomas

University College Dublin 2005

15

Technique
PARAMETER
Detector collimation Feed/rotation kVp mA Scan Time Reconstruction Inc Algorithm Field of view
Edel Thomas University College Dublin 2005

SSCT
5 - 7.5mm or 8-12mm 120

MSCT 16 slice
0.75mm

12.0 mm

180 200 or Dose modulation 0.5 -1 sec Equal to slice thickness Standard Skin surface
16

Liver protocols performed in CT

    

Arterial phase Portal Venous phase CTAP / CTHA Dual phase CT Lipiodol

Edel Thomas

University College Dublin 2005

17

Non-Contrast
Are there any indications for non-contrast scanning of the liver?

Edel Thomas

University College Dublin 2005

18

Non-Contrast Scan
  

Slice thickness & pitch may be increased Windows ? 3PH Liver note the following table positions :
Top and bottom of liver SMA SMV at 3 cms below the pancreas

Edel Thomas

University College Dublin 2005

19

Arterial Phase
  

Hypervascular lesions are more evident What are the windowing considerations? Arterial phase scanning requires fast injection rates and large volumes and short delays Arterial vascular mapping

Edel Thomas

University College Dublin 2005

20

Portal Venous Phase



1st stage in assessing resectability in CRCa: 150

mls @ 3mls/sec with 70 second scan delay

   

 

Otherwise 90 mls @ 2mls/sec with 70 sec delay Film on wide & narrow abdominal windows Image analysis on abnormal areas ?Colorectal Ca, ensure that there are no lung (CXR) / liver mets (US) Scan to level of SMV for Sx planning Venous vascular mapping
Edel Thomas University College Dublin 2005 21

CT Arterial Portography (CTAP)



The main step in pre-op staging of colorectal mets & focal tumours in non-cirrhotic liver Disadvantages
Low specifity Cost Invasive Time consuming

Edel Thomas

University College Dublin 2005

22

CTAP
   


Indirect splenic & mesenteric portography 5F Catheter placed in SMA or SA Niopam NC scan
80 mls of Niopam 300 is diluted with 80 mls of saline (160mls of a 150mg/ml solution) 30 mg Papaverine HCl injected prior to scan Arterial phase scan:
150mls, 3 mls/sec, 35 second delay
23

 

Edel Thomas

University College Dublin 2005

CTAP


If there are unequivocal mets present:

A further 75mls Niopam is injected

Delayed high dose CT 4-6 hours later:

More sensitive Scan range dome of diaphragm to inferior margin of liver Narrow liver windows

Edel Thomas

University College Dublin 2005

24

Dual Phase CTAP



  

Pre-op staging of hepatomas & focal tumours in cirrhotic livers Delayed high dose CT is not suitable for cirrhotic livers as hepatocellular function is poor 5F catheter is placed in SMA or SA in angio NC scan performed 40 mls of Ultravist 300 is diluted in 80mls of sterile saline (120 mls of a 150mgI/ml) 30 mg Papavarine HCL injected
Edel Thomas University College Dublin 2005 25

Dual Phase CTAP



Arterial phase scan performed:

100 mls of solution, 3mls/sec , 35 sec scan delay Repeat scan range 10-18 seconds later in caudocranial direction

Round deep lesions are considered to be tumour Perfusion defect:

Wedge-shaped peripheral area of low attenuation seen on arterial phase Absent or less visible on phase 3
Edel Thomas University College Dublin 2005 26

Lipiodol CT


There is increased retention of iodised oil within highly vascular & abnormal hepatic tissue Reasons include:
Permeability of the tumour vessels Trapped oil in tumour vessels Slow clearance of oil (absence of lymphatics and Kupffer cells)

 

HCC lesions appear as hyperattenuating areas Best for hypervascular lesions > 2 cm
Edel Thomas University College Dublin 2005 27

Lipiodol CT
    

Catheter is placed into HA 6-8 mls lipiodol CT performed 10 days later No oral or IV Limitations
Small subtypes of HCC are overlooked Non-specific retention of oil HCC previously treated by percutaneous ethanol injections
Edel Thomas University College Dublin 2005 28

Pathology that requires additional scans to CT Liver



Colorectal liver mets:

Thorax / Pelvis / Brain

Non-cirrhotic liver ? hypervascular mets:

Pelvis

Cholangiocarcinoma:
Delayed liver

Breast Ca ? mets:
Thorax / Pelvis / Brain
University College Dublin 2005 29

Edel Thomas

Orthotopic Liver Transplant (OLT)

 

Therapy for acute & chronic liver diseases Split liver donation or living donor donation
Non-invasive CT has a role to play in the evaluation of both donor & recipient

Evaluation of living donors

Hepatic arterial anatomy to the graft lobe Venous and biliary anatomy Liver volume

Edel Thomas

University College Dublin 2005

30

Orthotopic Liver Transplant



Evaluation of recipients
Exclusion of intra/extrahepatic malig Venous thrombosis Perihepatic varices Coeliac stenosis Splenic artery aneurysm GB

Edel Thomas

University College Dublin 2005

31

IND Colorectal liver mets OLT Hepatoma cirrhotic Noncirrhotic 1 liver tumour ? mets

PO Y N N N N N N

IV 140 3/s 150 4/s 150 4/s 150 4/s 150 4/s 150 4/s 150 4/s

NC N Y Y Y Y Y Y

ART N Y Y Y N Y Y

PV Y Y Y Y N Y Y

CTAP Y ? N N Y N N

Dual phase N N Y Y N N N

Lipiodo l N N Y N N N N

Edel Thomas

University College Dublin 2005

32

In Summary


A good knowledge of hepatic blood flow & anatomy is essential for CT liver Correct technique & careful timing of bolus delivery will maximise lesion detection and characterisation Multiphasic examinations can be acquired and exactly times with modern scanners Minimise dose and scan range to the patient at all times during these multiphasic examinations
Edel Thomas University College Dublin 2005 33