Gastrointestinal System Nuclear

medicine part 1

Liver Imaging
General review

The liver is a important organ and the largest

gland in the body. It occupies most of the
epigastrium and the right hypochondrium. It has
a large right ,small left lobes.It is situated below
the diaphragm and above the stomach , right
kidney , gallbladder ,the duodenum ,and part of
the colon .
 It is held in place by a series of fibrous
ligaments . The basic structure is hepatic
lobules ,each of which contains a central
vein and has four portal canals around its
periphery. The hepatic artery brings
oxygenated blood to the liver ;
hepatic plate
hepatic sinusoid
biliary system
biliary system
 The portal vein brings blood containing
nutrients from the gut to the liver and
constitutes a large part of the total liver
blood flow .In the liver the hepatic artery
and the portal vein both subdivide into
numerous branches which carry the
essential nutrients ,amino acids ,fats , and
oxygen to the liver cells .
The capillaries from the hepatic artery and
the portal vein empty into the central vein
of each lobule. From there the depleted
blood is then drained from the liver by the
hepatic vein returned via the inferior vena
cava to the heart.
 The bile is formed by the hepatic cells and
contains waste materials such as the
products of red-cells destruction and salts . It
is excreted through the biliary system , but is
also important for the emulsification of fats in
the small intestine.
 There are many tests about the function of the
liver . The nuclear medicine
examinations concerning the liver provide a
noninvasive method and will demonstrate
some parameters of liver function and may
locate intra-hepatic lesion.
Liver imaging is an accurate noninvasive method
to delineate overall organ size, the presence of
focal lesions, and/or the degree of hepatocellular
dysfunction in diffuse liver disease.
Liver scans help diagnose disorders such as
cirrhosis, hepatitis, tumors and other problems
in the digestive tract.
 Principle

Kupffer cells （ the reticuloendothelial

cells in the liver) constitute 15% of the
hepatic mass. They phagocytose
foreign particles and they can be
imaged with colloid tracers such as 99m
Tc-sulphur colloid or 99m Tc-phytate.
 Radionuclide Liver scans are performed after
intravenous administration of 99mTc labled to a
colloid that is trapped by the reticuloendothelial
cells, most of which are located in the
liver,spleen,and bone marrow . the radiocolloid
liver scan provides an image of the functional
behavior of reticuloenedothelial cells that depends
on cell numbers, distribution, integrity, and
blood supply.
Under normal conditions approximately 80%
of the radiolabelled colloid particles are
phagocytosed by the liver Kupffer cells,
12% by the spleen and the rest are
phagocytosed throughout the bone marrow.
 Normally the bone marrow is not imaged on liver
scans because of insufficient activity location .
However , in the presence of portal hypertension or
liver disease, blood may be shunted from the portal
to the systemic circulations, resulting in increased
99m
Tc -colloid flowing to bone marrow and increased
uptake sufficient for marrow visualization on routine
images. In hepatocellualar disease, changes in hepatic
and splenic size and shape are also seen on the scan.
 Particles between 0.3 and 1.0 microns are
predominantly phagocytized by the Kupffer
cells of the liver. Small particles (less than 0.1
micron) distribute primarily to the bone
marrow. Particles larger than 1 micron
distribute mostly to the spleen, while very
large particles will be deposited in the lungs.
 Uptake of the tracer reflects
distribution of hepatic perfusion and
functioning of the reticuloendothelial
cells in the liver (Kupffer cells) & spleen.
Although Kupffer cells make up less
than 10% of the liver cell mass, they are
distributed uniformly throughout the
liver.
Radiopharmaceuticals and Dosage

 99m Tc-sulfur colloid : (dose 5mCi)

Tc-Phytatedodeca sodium,Phy: ( dose 3-

 99m

5mCi)
 Tc-phytate is not colloid itself , but
99m

after intravenous injection it reacts with the

serum calcium and makes colloid which is
taken up rapidly by the reticulendotherial
system of the body. The liver image can be,
therefore, obtained with 99mTc- phytate.
Average particle size of a colloid must be
between 0.1 to 1 micron.The preparation
should not be used if it is over 6 hours
old due to particle agglomeration.
 Indications:

Liver scanning has a wide application and can be

used:

1. To assess the configuration (it’s sise , shape,

location and the relation to other organs)of the
liver and see if there is a normal anatomical
variation.
2. To detect the presence, number, location
and size of space-occupying lesions, such
as cysts, abscesses, and tumors (primary
or secondary), and to locate a site for
liver biopsy.
3. To assist in the diagnosis of diffuse liver
disease, such as cirrhosis, hepatitis etc.
 A liver scan is usually ordered after
blood studies and other imaging procedures
have shown a liver abnormality. It is most
often used to further evaluate masses or
tumors. These may be benign growths in
the liver, or cancer which has developed in
the liver or has spread (or metastasized)
from another organ.
 A liver scan may also be helpful in
diagnosing specific disorders, by detecting
features which are characteristic of a
disorder, such as cirrhosis of the liver.
This study may also be part of the battery
of tests used to evaluate potential candidates
for liver transplant.
 Procedures

There is no patient preparation

necessary, and following the injection

of the radioactive colloid, scanning

may be commenced after 15 minutes.

 Image acquisition

The patient is placed supine on the γ-

camera or SPECT table to get planar
imaging (anterior ,posterior and right
lateral planar imaging) and tomograms
are recorded with a 3600 acquisition at 60
increments .
 Transverse tomograms therefore are
reconstructed by filtered back-projection
at about 1-2 cm interval. Sagittal and
coronal images are reconstructed for
interpretation.
 Normal imaging
Under normal conditions the distribution
of the tracer in the liver is homogeneous and
the right lobe concentrates more than the
left lobe (L-R ratio normal 0.3 / 0.5).
Homogeneous distribution of activity
throughout both liver and spleen with no
focal defects.
The ratio of spleen/liver activity should be
about equal. Increased relative splenic uptake,
especially if accompanied visualization of bone
marrow reticuloendothelial uptake, indicates at
least some degree of hepatocellular dysfunction.
 Abnormal imaging

 1. Abnormal location
 2. Abnormal shape,
 3. Abnormal size,
 4. Abnormal radioactive distribution.
Abnormal radioactive distribution includes:
1. Focal Hepatic “cold” Spot( solitary or
multiple).
2. Focal Hepatic “Hot Spot”.
3. Diffuse abnormal radioactive distribution.
(inhomogeneous tracer distribution)
4.Anatomical variance.
Most focal lesions in the liver will have
less activity （ scarce or defect) than the
liver.
Focal nodular hyperplasia may have activity
equal to or greater than the surrounding
liver in about 50% of patients. Finding
normal activity or increased activity in a
lesion is very suggestive of focal nodular
hyperplasia.
 Clinical usage
Liver scans are sensitive in detecting liver metastases
and primary liver tumors imaged as regions of poor
or absent radiocolloid. In addition, liver scans is
useful in localizing focal hepatic defects caused by
abscesses, cysts, and trauma, as well as in confirming
the absence of focal disease in patients found to have
enlarged liver on physical examination.
Thus, a focal defect on the liver scan is nonspecific
finding.
 Reported sensitivity for detecting focal hepatic
abnormalities by scintigraphy range from 50 to 95%
and specificity from 46 to 97%, and scintigraphy report
wildly varying results . this variation partly reflects
differences in populations selected for study,
differing criteria for interpretation, variability in
equipment for all modalities, variability in
experimental design, and bias.
 Scintigraphic Patterns

Colloid Shift:
With a loss of functioning hepatic parenchyma
(or liver blood flow) a "shift" in phagocytic
function will result in enhanced colloid uptake by
other reticuloendothelial tissue, especially the
spleen and bone marrow.
In severe hepatic failure, uptake in the lungs
may occur. A spleen to liver ratio of greater than
2:1 is considered evidence of colloid shift.
 Colloid shift is a non-specific finding and may be
due to hepatocellular dysfunction (cirrhosis,
passive congestion, chemotherapy), infection
( hepatitis, mononucleosis, sepsis), or marrow
activation. Some authors differentiate colloid shift
(prominent splenic and bone marrow activity)
from simple shift (reversal of the normal liver to
spleen ratio).
Focal Hepatic Hot Spot:
In the presence of (superior cava vein , SVC ) or
innominate vein obstruction a bolus injected into the
basilic vein can travel via collaterals and deliver a large
amount of activity to the anterior mid portion of the liver
(quadrate lobe- inferior portion of the medial segment of
the left lobe), usually as a result of recanalization of
the umbilical vessels. This may have the appearance of
gallbladder activity. Injection in the foot will result in a
normal scan.
 Disease can cause Focal Hepatic Hot Spot:

Budd-Chiari syndrome (Hepatic vein

thrombosis): Caudate lobe (posterior)
SVC obstruction: Quadrate (anterior)
Hemangioma
Focal nodular hyperplasia
Cirrhosis (Regenerating nodules)
Solitary Cold Lesion includes:
Met (esp. colon.)
Cyst
Hepatoma (esp. if assoc. cirrhosis)
Hematoma
Hemangioma
Abscess
Pseudotumor (Cirrhosis)
Diffuse and Infiltrative Disorders
Early in the disease course the liver may be normal or
enlarged with diffusely decreased activity due to
alcoholic hepatitis ,infection hepatitis or fatty infiltration.
A mottled pattern due to recurrent injury, scarring ,
and regeneration can also be seen. Colloid shift
and splenomegaly are typically noted. If ascites is present
there will be displacement of the right lobe from lateral
abdominal wall and diaphragm, and indistinctness of liver
margin.
 The right lobe is frequently more affected by
the process and as the disease progresses . It will
become smaller due to parenchymal scarring. The
left lobe will appear relatively enlarged as a
result. In cirrhosis colloid shift is felt to be
secondary to intrahepatic shunting as the scan
often fails to become normal even after the portal
hypertension is alleviated. The amount of colloid
shift to the spleen, however, is not a reflection
of the degree or presence of portal hypertension.
Scintigraphic findings early in the disorder are
characterized by a diffusely mottled tracer uptake
in the liver. Over time this will progress to
diffusely decreased activity. The caudate lobe will
usually enlarge and show relatively increased
activity as a result of its separate venous drainage
directly into the IVC. If inferior vena caval
obstruction is present, the scan will show diffuse
hepatocellular dysfunction.
 In diffuse hepatic disease the shape and size of the
liver may be abnormal and the distribution of tracer
is less homogeneous.
In acute hepatitis (viral, bacterial, auto immune
or drug induced) liver scintigrams are either normal
or show mild hepatomegaly with slight
inhomogeneity of tracer distribution.
Mild splenomegaly may be noted on radiocolloid
imaging .
 In patients with fulminant hepatitis the
liver may appear small, with inhomogeneous
tracer distribution, and colloid shift
(increased tracer accumulation in the spleen
and bone marrow).
Colloid shift is an important indicator of
impaired liver function in a non-specific
manner.
In chronic hepatitis the liver is usually normal in size
with or without enlargement of the left lobe. There
may be normal or increased tracer accumulation
in the spleen and bone marrow.

In cirrhosis of the liver, there may be atrophy of the

right lobe with compensatory hypertrophy of left
lobe, and a "mottled" appearance of the tracer
distribution.
 In some patients the inhomogeneity is so
marked that it appears like a focal defect
"Pseudotumour". The spleen is enlarged
with splenic uptake much more than the
liver and there is marked uptake in the
bone marrow (vertebrae and ribs). This
provides firm evidence of hepatic
decompensation and portal hypertension.
 In hepatic vein thrombosis, there is a diffuse
decreased uptake of colloid except the caudate
lobe, which shows increased uptake.
This is attributed to the separate venous
drainage of the Caudate lobe through accessory
veins while all three main tributaries of the
hepatic vein may be thrombosed.
Etiologies of diffusely diminished hepatic
activity include:
 Normal variant (large pt)
 Hemochromatosis
 Diffuse hepatocellular dz (Hepatitis)
 Fatty infiltration
 Mets (Infiltrative mets, such as lung or breast,
produce a coarse inhomogeneous pattern)
 Lymphoma
 Amyloidosis
SPECT
Normal imaging
Normal imaging
Normal imaging
Normal Anatomical variants
Leftup: Transverse
tomography

Up : Coronal tomography

Left: Sagittal tomography

Multiple cold spots
Leftup: Transverse
tomography

Up : Coronal tomography

Left:Sagittal tomography
 polycystic liver

Leftup: Transverse tomography

Up : Coronal tomography

Left:Sagittal tomography
long thin right lobe, Riedel's lobe
Normal variants in liver shapes
Injury diaphragmatic hernia
 Liver
abscesses
Space occupying lesion
polycystic liver
Liver cirrhosis
Liver cirrhosis
Liver cirrhosis
Primary hepatic cancer
Primary hepatic cancer
Primary hepatic cancer huge mass pattern
Primary hepatic cancer Nodular pattern
Epigastria mass intraliver or extraliver

Fetal fringe sign

Focal Nodular Hyperplasia
Advantage and disadvantage
Ultrasonography is the preferred imaging
modality for the liver since it also evaluates the
surrounding organs and the diaphragm as well. It
is good at detecting focal lesion. CT/MRI provide
exquisite anatomic resolution of focal lesions, but
their contribution to evaluation of diffuse liver
disease is less than scintigraphy which provides
unique information of colloid shift.
 99m
Tc-colloid liver scans are not used
primarily in the work up a solitary liver
mass because CT, ultrasound and MRI are
much more sensitive. But these modalities
lack specificity because they rely on
anatomical distortion caused by the mass
for diagnosis.
 Liver scan is useful for cavernous
hemangiomas. Because they are
nonspecifice (most lesions are "cold" on
Liver scan). In the hemangioma case, the
lack of Kupffer cells, the plethora of blood
and the sluggish blood flow. So,we must to
take liver blood pool imaging to diagnosis it
late.
 Summarizing briefly
IV 99mTc-colloid is rapidly removed from the blood
by reticuloendothelial cells. （ Kupffer
cells ） Under normal physiologic conditions,
these cells are uniformly distributed throughout
the liver, thus imaging using the radionuclide
attached to colloid would show a complete,
homogeneous liver expressing its position, size and
contour.
If an area lacks Kupffer cells, for example,
replacement of normal tissue by space-
occupying lesions like cysts, abscesses,
metastases or tumors, that area would
not take up the radionuclide and would
show as a "cold" spot.
 Some lesions can take up radionuclide
normally, or even take up more, thus
showing as a "hot" spot. Focal nodular
hyperplasia can be distinguished from a
benign adenoma because the former can
take up normal to increased amounts of
radionuclide, whereas adenomas do not.
 Diffuse liver disease, for example, cirrhosis
or hepatitis, causes a heterogeneous uptake
pattern of radionuclide. There is usually a
decreased total amount of radionuclide
uptake by the liver and thus there is more
taken up by the spleen and bone marrow.
 These findings give clues as to possible
diagnoses, but nothing is absolutely
diagnostic. Hepatic vein obstruction, more
specifically though, does show as decreased
uptake by the liver uniformly except in the
caudate lobe because of its unique drainage
into the inferior vena cava.
 Peripheral marginal indentations in the liver
may normally be produced by the lateral rib
margins, the xiphoid, the gallbladder, the right
kidney, the suprahepatic veins, the heart, or
intrathoracic abnormalities that affect the
diaphragmatic configuration.
A defect is commonly seen in many anterior scans
due to attenuation of the photons by overlying
breast tissue.
General Aspects Normal variants in liver shapes:
long thin right lobe,
Riedel's lobe
prominent quadrate lobe
To be continued