Postoperative Changes, Liver

Published on 18/07/2015 by admin

Filed under Radiology

Last modified 18/07/2015

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 Consider iatrogenic infarction of hepatic mass or liver parenchyma

image Consider retained absorbable oxidized cellulose (Surgicel)
• Embolized, iodinated, poppyseed oil (Ethiodol, Lipiodol)

image May mimic calcified or hypervascular mass on plain radiography or CT, respectively
• Treated tumor often undergoes progressive volume loss and fibrosis

image May simulate focal confluent fibrosis, peripheral cholangiocarcinoma, or cirrhosis
• Consider prior resection of portions of liver

image May have similar appearance to congenital absence or hypoplasia of hepatic segments
• Iatrogenic arterioportal (AP) fistula

image Complication of percutaneous liver biopsy
image May simulate other vascular lesions, including tumor
• Small peripheral AP shunts are common, spontaneous findings in cirrhotic liver

TOP DIFFERENTIAL DIAGNOSES

• Pyogenic abscess
• Portal venous gas with bowel infarction
• Focal confluent fibrosis
• Cholangiocarcinoma (peripheral)
• Regenerative and dysplastic nodules
• Cirrhosis
• Hepatic angiomyolipoma
• Other causes of transient hepatic attenuation (THADs) and intensity (THIDs) differences
• Congenital absence of hepatic segments
image
(Left) Axial CECT shows several viable enhancing liver metastases image and 2 masses with gas and necrotic debris image that are the result of percutaneous radiofrequency ablation.

image
(Right) Axial CECT shows a collection of gas image but very little fluid in the cholecystectomy bed, mimicking an abscess. Note the surgical clips image. This is bioabsorbable oxidized cellulose (Surgicel), which was used as a hemostatic agent to control bleeding from the operative bed during cholecystectomy.
image
(Left) Axial CECT shows an absence of enhancement of the left lobe with a straight line of demarcation image and portal venous gas image, all due to hepatic arterial ligation during attempted resection of a peripheral cholangiocarcinoma.

image
(Right) Axial CECT shows a metallic coil image in the right hepatic artery, with a wedge-shaped collection image of gas and fluid “downstream.” Needle aspiration and drainage of this collection showed an infected hepatic infarction.

TERMINOLOGY

Definitions

• Iatrogenic changes to hepatic morphology that may cause or simulate pathologic conditions

IMAGING

Imaging Recommendations

• Best imaging tool

image Imaging test that shows morphology and hemodynamic characteristics of hepatic lesion
• Protocol advice

image Correlate with medical records and history of prior intervention

CT Findings

• Gas collection in hepatic or perihepatic lesion

image Abscess is primary concern, but also consider iatrogenic causes
image Iatrogenic infarction of hepatic mass or liver parenchyma

– Sudden death of hepatic (or other) tissue releases gas, ± coexisting infection

image Examples: Radiofrequency ablation, hepatic arterial chemoembolization, hepatic arterial occlusion (intentional or not)
– Gas released from sudden death of tissue

image Does not imply infection of tissue
image Clinical syndrome (fever, pain, leukocytosis) may mimic sepsis
image Retained absorbable oxidized cellulose (Surgicel)

– May be placed intraoperatively and left in place to control bleeding
– Appears as spherical, sponge-like collection of gas bubbles with little or no fluid component

image Tightly packed gas bubbles ± linear arrangement; no enhancing wall
image Fixed location and appearance on sequential exams
image Highly echogenic mass on US with posterior reverberation artifact
• Iatrogenic causes of portal venous gas

image Any procedure resulting in sudden death of hepatic parenchyma may release hepatic parenchymal ± portal venous gas

– Examples: Surgical ligation or transcatheter occlusion of hepatic artery (deliberate or unintentional)
– Might be used to devascularize hypervascular liver mass, benign (e.g., focal nodular hyperplasia or adenoma) or malignant
• 

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