1. Fatty Liver: Imaging Patterns and Pitfalls DR MAHIPAL REDDY INDUR CT SCAN &MRI

2. Introduction The image-based diagnosis of fatty liver usually is straightforward, but fat accumulation may bemanifested with unusual structural patternsthat mimic neoplastic, inflammatory, or vascular conditions. Leading to :Unnecessary diagnosis test and Invasive procedure 3. Table of content

Risk Factors and Pathophysiologic Features

Imaging-based Diagnosis of Fatty Liver

Patterns of Fat Deposition

Differential Diagnosis

Pitfalls

4. Risk Factors and Pathophysiologic Features HistologicallyFatty liver: Triglyceride accumulation within the cytoplasm of hepatocytes. Termfatty infiltration of the liveris misleading because fat deposition is characterized by accumulation of discretetriglyceride doplets in hepatocytesand rarely, in other cell types. The term fatty liver is more accurate. 5. Conditions Associated with Fatty Liver 6. Pathophysiologic Features

Triglyceride accumulation (steatosis) within hepatocytes by altering

the hepatocellular lipid metabolism ,

in particular, by causing

defects in free fatty acid metabolic pathways .

7. Pathophysiologic Features

Hepatocytes in the center of the lobule (near the central vein) are tend to accumulate lipid earlier than periphery.

In advanced cases, there is diffuse, relatively homogeneous involvement of the entire lobule.

Steatosismay progress tosteatohepatitis ( with inflammation, cell injury, or fibrosis accompanying steatosis) andcirrhosis .

8. Pathophysiologic Features

To grade steatosis, pathologist visually estimate thefraction of hepatocytes that contain fat droplets.

0%, 1-5%, 6-33%, 34-66%, 67%.

Size of fat droplets is not considered.

9. Prevalence of Fatty Liver

General population about 15%.

Higher in

• 40% of consume large quanities of alcohol (>60g /day)

• 50% of Hyperlipidemia

• 75% of Obesity (BMI> 30 kg/m 2 )

• 95% of Both obesity and high alcohol consumption

10. Imaging-basedDiagnosis of Fatty Liver

Diagnosis at US

Diagnosis at CT

Diagnosis at MR Imaging

11. Diagnosis at US

Normal Liver

Echogenicity of the normal liver equals or minimally exceeds that of the renal cortex or spleen.

Intrahepatic vessels are sharply demarcated

Posterior aspects of the liver are well depicted

Fatty liver

Liver echogenicity exceeds that of renal cortex and spleen

Poor delineation of the intrahepatic architecture

Loss of definition of diaphragm

12. Normal Liver Fatty Liver To avoid false-positive interpretations, fatty liver should not be considered present if only one or two of these criteria are fulfilled 13. Diagnosis at CT

Normal Liver

The normal liver has slightly greater attenuation than the spleen and blood.

Intrahepatic vessels are visible as hypoattenuated structures

Fatty liver

Unenhanced CT

Attenuation of the liver is at least 10 HU less than that of the spleen or attenuation of fatty liver is less than 40 HU

In severe cases, intrahepatic vessels may appear hyperattenuated relative to fat-containing liver tissue.

14. Normal Liver 15. Fatty Liver 16. Normal Liver Fatty Liver

At enhanced CT, the comparison of liver and spleen attenuation value is not reliable.

Fatty liver can be diagnosed at contrast-enhanced CT if absolute attenuation is less than 40 HU,but this threshold has limited sensitivity .

17. Diagnosis at MR Imaging

Normal Liver

The signal intensityof the normal liver parenchyma issimilaron in-phase and opposed-phase images

Fatty liver The signal intensity loss on opposed-phase imagesin comparison with in-phase images. Chemical shift gradient-echo(GRE) imagingwithin-phaseandopposed-phaseacquisitions is the most widely used MR imaging technique for the assessment of fatty liver. 18.

Normal Liver

The signal intensity of the normal liver parenchyma is similar on in-phase and opposed-phase images

Chemical shift gradient-echo(GRE) imaging within-phase and opposed-phase 19.

Fatty liver

The signal intensity loss on opposed-phase imagesin comparison with in-phase images.

Chemical shift gradient-echo(GRE) imaging within-phase and opposed-phase 20. Chemical shift gradient-echo(GRE) imaging opposed-phasein-phase 21. Accuracy for Detection and Grading of Fat Deposition

Sensitivity Specificity

US 60-100% 77-95%

NECT 43-95% 90%

Chemical shift

GRE MRI 81% 100%

22. Patterns of Fat Deposition

Diffuse Deposition.

Focal Deposition and Focal Sparing.

Multifocal Deposition.

Perivascular Deposition.

Subcapsular Deposition.

23. Diffuse Deposition

Diffuse fat deposition in the liver is themost frequently encountered pattern .

Liver involvement usually ishomogeneous .

The image interpretation is straightforward if the rules specified earlier are applied

24. Diffuse Deposition 25. Diffuse Deposition 26. Diffuse Deposition 27. Focal Deposition and Focal Sparing

Slightly less common

More difficult to diagnosis because mayresemble mass lesions .

28. Focal Deposition and Focal Sparing

Fat content

Locationin areas characteristic of fat deposition or sparing

Absence of a mass effecton vessels and other liver structures

Ageographic configurationrather than a round or oval shape

Poorly delineated margins

Contrast enhancement that issimilar to or less thanthat of the normal liver

Imaging findings suggestive offatty pseudolesionsrather than true masses include the following: 29. Focal Deposition and Focal Sparing

Adjacent to thefalciform ligament

In theporta hepatis

In thegallbladder fossa

focal fat deposition or focal fat sparing characteristically occurs in specific areas: Focal fat deposition adjacent toinsulinoma metastases , probably due to local insulineffects on hepatocyte triglyceride synthesis and accumulation. 30. Focal Deposition and Focal Sparing

Focal fat accumulation in the liver at US. Transverse image.

31. Focal Deposition and Focal Sparing

Focal fat accumulation in the liver at CT. Axial contrast-enhanced image obtained during the portal venous phase.

32. Focal Deposition and Focal Sparing

Diffuse fat accumulation with focal sparing at US and CT.

33. Multifocal Deposition

Uncommon pattern.

In this pattern, multiple fat foci are scattered in atypical locations throughout the liver.

The foci may be round or oval and closely mimic true nodules.

Correct diagnosis isdifficult , especially in patients with a known malignancy . 34. Multifocal Deposition

Other clues indicative of multifocal fat deposition ;

Lack of a mass effect

Stability in size over time

Contrast enhancement similar to or less than that in the surrounding liver parenchyma.

For this purpose, chemical shift GRE imaging is more reliable than CT or US. 35. Multifocal Deposition

Multifocal fat accumulation in the liver at CT and MR imaging in a 48-year-old woman with breast cancer.(a)Unenhanced CT image shows multiple hypoattenuated 1-cm nodules (arrows).(b, c)T1-weighted GRE MR images show nodules (arrows) with a signal intensity slightly higher than that of the normal liver parenchyma on the in-phase image(b)but with a signal intensity loss on the opposed-phase image(c) .

36. Multifocal Deposition

Confluent foci of fat accumulation in the liver at MR imaging. Axial T1-weighted MR images

37. Perivascular Deposition

This pattern is characterized by halos of fat that surround the hepatic veins, the portal veins, or both hepatic and portal veins.

The configuration istramlikeor tubular for vessels with a course in the imaging plane andringlikeor round for vessels with a course perpendicular to the imaging plane.

38. Perivascular Deposition

An unequivocal signalintensity loss on opposed-phase imagesin comparison with that on in-phase images.

Thelack of a mass effecton the surrounded vessels are.

Indicative of the diagnosis The pathogenesis of perivascular fat deposition in the liver is unknown. 39. Perivascular Deposition 40. Perivascular Deposition Periportal fat accumulation in a patient with a chronic hepatitis B infection.Axial unenhanced and late portal venous phase 41. Subcapsular Deposition

In patients with renal failure and insulin-dependent diabetes, insulin may be added to the peritoneal dialysate during kidney dialysis.

This route of insulin administration exposes subcapsular hepatocytes to a higher concentration of insulin than that to which the remainder of the liver is exposed.

Administration of insulin results in a subcapsular pattern of fat deposition, which may be manifested as discrete fat nodules or a confluent peripheral region of fat.

42. Differential Diagnosis

Primary Lesions and Hypervascular Metastases.

Hypovascular Metastases and Lymphoma.

Perfusion Anormalies.

Periportal Abnormalities.

The diagnosis of diffuse fat deposition in the liver tends to be straightforward. 43. Primary Lesions and Hypervascular Metastases

A mass effect.

Tend to show vivid or heterogeneous enhancement.

May contain areas of necrosis or hemorrhage

Primary hepatic lesionseg, hepatocellular carcinoma, hepatic adenoma, and focal nodular hyperplasia. 44. Primary Lesions and Hypervascular Metastases

A mass effect.

Tend to show vivid or heterogeneous enhancement.

May contain areas of necrosis or hemorrhage

Infiltrativehepatocellular carcinomais anotable exception On CT images, this tumor may exerta minimal mass effect , showlittle evidence of necrosis , show thesame degree of enhancement as the normal liver parenchyma , andclosely resemble heterogeneous fat deposition .Correct diagnosis is usually possible withMR imaging , but thecorrelation of imaging findings with serum biomarkersmay be helpful. 45. Periportal fat accumulation in a patient with a chronic hepatitis B infection.Axial unenhanced and late portal venous phase Axialopposed-phase Axial in-phase Differentiation of adenoma from fatty deposition in the liver in a woman with a long history of oral contraceptive use. T1-weighted GRE images obtained before and during the hepatic arterial phase 46. P ortal venous phase Axial unenhanced CT Differentiation of hepatocellular carcinoma from fatty deposition in the liver. 47. Differentiation of metastases from fatty liver deposition in a woman undergoing chemotherapy for breast cancer. 48. Hypovascular Metastasesand Lymphoma

The differentiation of focal or multifocal fat deposition from hypovascular metastases and lymphoma in the livermay be difficult .

The clinical manifestations and imaging features such aslesion morphology ,location , andmicroscopic fat contentusually permit a correct diagnosis.

Chemical shift GRE imagingmay be necessary to assess the amount of intralesional fat.

49. Perfusion Anormalies

Resemble fat deposition but visible only during the arterial and portal venous phases.

Not detectable on unenhanced images or equilibrium phase images.

50. the upper mediastinum The level of the liver Differentiation of superior vena cava syndrome from fatty liver deposition. 51. Differentiation of hepatic venous congestion from fatty liver deposition. 52. CT images obtained at the same level in the liver.Iatrogenic postbiopsy arteriovenous fistula 53. Periportal Abnormalities

The US- and CT-based differential diagnosis of periportal fat deposition is broad and includes edema, inflammation, hemorrhage, and lymphatic dilatation.

Edema, inflammation, and lymphatic dilatationtend to affect the portal triads symmetrically.

Hemorrhagecharacteristically involves the portal triads asymmetrically and may be associated with laceration or other signs of injury.

Thus, if chemical shift imaging is performed, a signal intensity loss of perivascular tissue on opposed-phase images permits the correct diagnosis of fat deposition

54. Differentiation of periportal inflammation from fatty liver deposition. Axial contrast-enhanced CT images obtained during the portal venous phase and the equilibrium phase. 55. Pitfalls

Fat-containing Primary Tumors.

Low-Attenuation Lesions.

Focal Sparing that Mimics an Enhanced Tumor.

56. Fat-containing Primary Tumors

Hepatic adenomas, hepatocellular carcinomas, and, rarely, focal nodular hyperplasiasmay have microscopic fat content.

Hence, a finding of intralesional fatdoes not help exclude these entities , andclinical findingsas well asimaging featuressuch as morphologic structure, mass effect, and enhancement characteristics must be considered.

57. Differentiation of a fat-containing tumor from fat deposition in the liver. 58. Differentiation of metastases from fat deposition in the liver.

the mass effect

predominant round shape,

the thrombus in the superior mesenteric vein

and numerous heterogeneous lymph nodes

59. Summary

Fatty liver is a common imaging finding, with a prevalence of 15%95%, depending on the population.

The diagnostic standard of reference is biopsy with histologic analysis,

Fat deposition in the liver may be diagnosed noninvasively with US, CT, or MR imaging if established criteria are applied.

The most common imaging pattern is diffuse and relatively homogeneous fat deposition.

Less common patterns include focal deposition, diffuse deposition with focal sparing, multifocal deposition, perivascular deposition, and subcapsular deposition.

These patterns may mimic neoplastic, inflammatory, or vascular conditions, leading to confusion and to unnecessary diagnostic tests and invasive procedures.

Assessment of the lesion fat content, location, morphologic features, contrast enhancement, and mass effect usually permits a correct diagnosis.

Chemical shift GRE imaging is more reliable than US or CT for assessing intralesional fat and may be necessary when findings are equivocal.

60. The end. The end.