28. Liver MRI protocol
• Examination of the liver with MRI requires numerous sequences and imaging at multiple times
after the administration of gadolinium. Many variations exist, but a typical protocol would include:
• Pre-contrast
• T2
• T2 fat sat
• T1 weighted gradient echo in and out of phase
• T1 2D or 3D gradient echo equences (e.g. VIBE)
• Post-contrast
• T1 2D or 3D gradient echo equences (e.g. VIBE) at
• arterial phase: 20-25 seconds
• portal venous phase: 60-70 seconds
• equilibrium phase: 3-5 minutes
• hepatobiliary delayed phase: 10-30 minutes with and without fat sat
• later delayed phase: 1 hour +/- 3 hours in some institutions
45. irregular mucosa and stricture narrowing ascending
colon.,shortening of colon and terminal ileum pushed up..its
Ileocecal TB .DD is crohns,CA
46. Double duct sign..CBD and pancreatic duct
both dilated ..DD is pancreatic CA,ampullary
CA and stone at distal ampulla
47. Narrowing at confluence of hepatic ducts and proximal
CBD..klatskin tumor..DD is enlarged lymph nodes..Here
GB is not seen bcz its full of sludge..ovoid dark area
52. • what is the difference between infective cirrhosis
and the cirrhosis due to PSC??
• The end result of PSC is cirrhosis which is
usually characterised by a markedly distorted
biliary tract with atrophy of the entire liver with
the exception of the caudate lobe which is
hypertrophied in almost all cases (68-98%)
Atrophy involving the left lobe is a feature which
somewhat distinguishes it from cirrhosis from
other causes, in which the left lobe is usually
hypertrophied
54. Thickened gastric walls with transpyloric spread and no
perigastric involvement..lymphoma..Difference between
lymphoma and CA?
55. Gastric lymphoma vs adenocarcinoma
• 1)Preservation of the perigastric fat planes at CT is more likely to
be seen in lymphoma than in adenocarcinoma, particularly in the
presence of a bulky tumor
• 2)the stomach remains pliable even with extensive lymphomatous
infiltration, and the lumen is preserved, making gastric outlet
obstruction a rather uncommon feature However, non-Hodgkin
gastric lymphoma should be recognized as another cause of linitis
plastica, an appearance that results from dense infiltrates of
lymphomatous tissue in the gastric wall without associated fibrosis .
• 3) Although transpyloric spread is more common in gastric
lymphoma than in carcinoma,
• 4)Adenopathy is seen with both adenocarcinoma and lymphoma,
but if it extends below the renal hila or the lymph nodes are bulky,
lymphoma is more likely
• Complications such as obstruction, perforation, or fistulization can
occur as a result of the disease itself or of treatment and can be
detected with CT and barium studies.
58. • What is difference between technique of
barium enema done if hirschprung is
suspected?
• we dont inflate baloon bcz it obscures
view and go for lateral view
59. Enlarged pancreatic soft tissue shadow with diffuse
calcifications...alcoholic pancreatitis bcz in other chronic
pancreatitis size of pancreas is reduced.In cystic fibrosis
this also can happen
60. Spot film barium follow thru ..small bowel outlined by contrast normally
upto cecum..ascending,transverse,descending and sigmoid colon not
outlined by contrast but rectum is outlined..Fistula between cecum and
rectum
61. Irregular stricture narrowing of terminal ileum,cecum and ascending
colon,contracted,distorted cecum,ulcers,pseudopolyps...TB bcz the
lesion is continuous not skip lesions. The gap between diseased gut
and normal that is marked by arrow is due to thickness of gut loop.
62. Like previous image gap between gut loops due to wall thickening..but see here
due to wall thickness lumen is not narrowed and there are few ulcers on outer
margin shown by arrow.DD is lymphoma,crohns ...TB didnt appear like this it
gives luminal narrowing early
67. Mid part of CBD not seen..GB also not
seen ..no history of surgery,its gallbladder
CA infiltrated CBD
68. Cutoff at level of confluence of hepatic ducts and proximal
CBD..Klatskin tumor.. Further cross scetional imaging..If u do PTC in
this patient what will u do different?left side PTC to relieve pts
symptoms
71. Giant hemangioma with peripheral nodular
enhancement..complication is kasaback meritt
syndrome.Giant hemangiomas not resected they are
embolized.
72. lesion enhancing on arterial phase with delayed enhancement of
scar FNH ..its not FLC bcz that wash out on portovenous phase but
see its hyperdense on delayed phase.
73. Celiac angiogram..see tumor blush in rt lobe..Most common
treatment of HCC in pakistan is trans arterial catheter
embolization TACE..but only selective branch which supply tumor
is embolized otherwise hepatic ischemia will result if main hepatic
artery embolized.
78. MRI liver standard sequences..1st row. from left 1 is T2W see renal pelvis fluid
and csf giving high signals..second image is T2 fatsat see fat supressed but fluid
high..Third image is T1 out of phase imaging see chemical shift artifact..ow first image is
T1 inphase bcs fluid and fat both dark..second image is post contrast T1 arterial phase fat
supressed image and last is portovenous phase
